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1.  Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices 
World Journal of Surgery  2009;34(3):438-444.
Background
The burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis.
Methods
A pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects.
Results
Workers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries.
Conclusions
This pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries.
doi:10.1007/s00268-009-0229-6
PMCID: PMC2816796  PMID: 19795163
2.  Mobile anesthesia: Ready, set, pack, and go 
Avicenna Journal of Medicine  2012;2(2):40-44.
Introduction:
Although we get into the habit of thinking that anesthesia cannot be safely delivered without the availability of all equipments available in a state of the art Operating room, we find ourselves faced with situations where the availability and mobility of all this equipment is limited ; this results in the impetus to start a thought process of how we can perform mobile anesthesia with less technology. Disaster situations, such as earthquakes, floods, or armed conflicts, might happen in areas where access of a regular operating room might be hours away or not available at all.
Golden Hour:
Delivering mobile Anesthesia during the golden hour can be a totally different experience from customary anesthesia practices in a regular operating room.It requires setting up a field/forward surgical teams with its organization and structure. Total Intravenous anesthesia gained popularity in crisis and combat situations and has been documented as a safe method in crisis situations.Anesthesia configured medic bag: Is a modified medic bag that can be utilized to contain the most commonly used Anesthesia supply material in a portable way.
Conclusion:
In reviewing the knowledge of how to provide anesthesia in crisis and disaster situations we conclude that there is evidence that anesthesia can be safely and efficiently delivered in a remote areas with limited tools and technology.
doi:10.4103/2231-0770.99163
PMCID: PMC3507077  PMID: 23210021
Disaster anesthesia; field surgical team; mobile anesthesia; TIVA anesthesia
3.  Bispectral Index Monitor 
Executive Summary
The objective of this analysis was to evaluate the effectiveness and cost-effectiveness of the bispectral index (BIS) monitor, a commercial device to assess the depth of anesthesia.
Conventional methods to assess depth of consciousness, such as cardiovascular and pulmonary measures (e.g., heart rate, systolic/diastolic blood pressure, mean arterial pressure, respiratory rate, and level of oxygen in the blood), and clinical signs (e.g., perspiration, shedding of tears, and limb movement) are not reliable methods to evaluate the brain status of anesthetized patients. Recent progress in understanding the electrophysiology of the brain has led to the development of cerebral monitoring devices that identify changes in electrophysiologic brain activity during general anesthesia. The BIS monitor, derived from electroencephalogram (EEG) data, has been used as a statistical predictor of the level of hypnosis and has been proposed as a tool to reduce the risk of intraoperative awareness.
Anesthesia that is too light can result in the recall of events or conversations that happen in the operation room. Patients have recalled explicit details of conversations that happened while under anesthesia. This awareness is frightening for patients and can lead to post-traumatic stress disorder. Conversely, anesthesia that is too deep can cause hemodynamic disturbances necessitating the use of vasoconstrictor agents, which constrict blood vessels, to maintain normal blood pressure and cardiac output. Overly deep anesthesia can also result in respiratory depression requiring respiratory assistance postoperatively.
Monitoring the depth of anaesthesia should prevent intraoperative awareness and help to ensure that an exact dose of anaesthetic drugs is given to minimize adverse cardiovascular effects caused by overly large doses. Researchers have suggested that cerebral monitoring can be used to assess the depth of anesthesia, prevent awareness, and speed early recovery after general anesthesia by optimizing drug delivery to each patient.
Awareness is a rare complication in general anesthesia. The risk of intraoperative awareness varies among countries, depending on their anesthetic practices. In the United States, the incidence of intraoperative awareness is 0.1% to 0.2% of patients undergoing general anesthesia. The incidence of intraoperative awareness depends on the type of surgery. Trauma patients have reported the highest incidence of intraoperative awareness (11%–43%) followed by patients undergoing cardiac surgery (1.14%) and patients undergoing Cesarean section (0.9%).
The BIS monitor, licensed by Health Canada, is the first quantitative EEG index used in clinical practice as a monitor to assess the depth of anesthesia. It consists of a sensor, a digital signal converter, and a monitor. The sensor is placed on the patient’s forehead to pick up the electrical signals from the cerebral cortex and transfer them to the digital signal converter. A BIS score quantifies changes in the electrophysiologic state of the brain during anesthesia. In patients who are awake, a typical BIS score is 90 to 100. Complete suppression of cortical activity results in a BIS score of 0, known as a flat line. Lower numbers indicate a higher hypnotic effect. Overall, a BIS value below 60 is associated with a low probability of response to commands. There are several alternative technologies to quantify the depth of anesthesia, but only the BIS and SNAP monitors are licensed in Canada. The list price of the BIS monitor is $13,500 (Cdn). The sensors cost $773 (Cdn) for a box of 25.
Because intraoperative awareness and recall happen rarely, only 1 randomized controlled trial of all the studies reviewed, was adequately powered to show the impact of BIS monitoring. This was a large prospective, randomized, double-blinded, multicentre study that was designed to investigate if BIS-guided anesthesia reduces the incidence of intraoperative awareness. The study confirmed 2 cases of intraoperative awareness in the BIS group and 11 cases in the standard practice group. This difference was statistically significant (P =.022). There were 36 reports of possible awareness that were not confirmed by the study group (20 patients in the BIS group and 16 in the standard practice group).
Additionally, the results of small randomized controlled trials and prospective cohort studies show that, overall, BIS monitoring is relatively good at indicating the state of being alert; however, its algorithm does not accurately predict an unconscious state. BIS monitoring has low sensitivity for the detection of the state of being asleep, and it may show values higher than 60 in those already asleep. Therefore, an unknown percentage of patients will not be identified as being asleep and will receive anesthetics unnecessarily.
Based on the literature review, the Medical Advisory Secretariat concludes the following:
Prevention of awareness should remain a clinical decision for anesthesiologists to make based on their experience with intraoperative awareness in their practices.
Although BIS monitoring may have a positive impact on reducing the incidence of intraoperative awareness in the general population, its negative impact on individual patients may overshadow this positive outcome.
BIS monitoring is good at indicating an “alert” state, which is why it can reduce the incidence of intraoperative awareness; however, its algorithm does not accurately predict an “asleep” state. This means an unknown percentage of patients who are already asleep will not be identified because of falsely elevated BIS values. These patients will receive unnecessary dosage of anesthetics resulting in a deep hypnotic state.
Adherence to the practice guidelines will reduce the risk of intraoperative awareness.
PMCID: PMC3387745  PMID: 23074459
4.  Anesthesia equipment malfunction: origins and clinical recognition. 
Equipment malfunction is a problem of particular importance during anesthesia and resuscitation. A review of published reports shows that the most common clinical events involve endotracheal tubes, the inspired oxygen concentration, the volume of inspired anesthetic vapours and gases, and pressures in the breathing or ventilation system. It is concluded that protection of a patient from equipment malfunction depends on: (a) appropriate application of standards set by a national standards association; (b) careful evaluation of equipment prior to purchase; (c) comprehension of equipment function by the user; (d) conscientious routine servicing of all systems concerned with anesthesia and resuscitation, and checking after service and before clinical use; (e) preanesthesia testing of equipment, including the use of an oxygen analyser in the breathing circuit; (f) early inclusion of equipment malfunction in the differential diagnosis of events during anesthesia; and (g) rapid action that cannot present a new hazard to the patient to correct the results of apparatus malfunction.
PMCID: PMC1819256  PMID: 436069
5.  Various Strategies for Pain-Free Root Canal Treatment 
Iranian Endodontic Journal  2013;9(1):1-14.
Introduction: Achieving successful anesthesia and performing pain-free root canal treatment are important aims in dentistry. This is not always achievable and therefore, practitioners are constantly seeking newer techniques, equipments, and anesthetic solutions for this very purpose. The aim of this review is to introduce strategies to achieve profound anesthesia particularly in difficult cases. Materials and Methods: A review of the literature was performed by electronic and hand searching methods for anesthetic agents, techniques, and equipment. The highest level of evidence based investigations with rigorous methods and materials were selected for discussion. Results: Numerous studies investigated to pain management during root canal treatment; however, there is still no single technique that will predictably provide profound pulp anesthesia. One of the most challenging issues in endodontic practice is achieving a profound anesthesia for teeth with irreversible pulpitis especially in mandibular posterior region. Conclusion: According to most investigations, achieving a successful anesthesia is not always possible with a single technique and practitioners should be aware of all possible alternatives for profound anesthesia.
PMCID: PMC3881296  PMID: 24396370
Anesthesia; Inferior Alveolar Nerve; Irreversible Pulpits; Pain; Root Canal; Succe
6.  Cerebral oxygen saturation is improved by xenon anaesthesia during carotid clamping 
Introduction
The cerebral protective effect of xenon anesthesia could be of interest during carotid surgery. The purpose of this study was to compare the effects of xenon on cerebral oxygen saturation with those of propofol during carotid clamping.
Methods
After approval of Research Ethics Board and patient informed consent, 74 patients scheduled for carotid endarterectomy were enrolled. Patients were not randomized but were well matched by preoperative characteristics. Patients in the Xenon group were the ones scheduled for surgery in the operative theater equipped with the xenon anesthesia system. Anesthesia was started with a target control infusion of propofol and remifentanil. Patients were then divided into the control group (37 patients) with anesthesia maintained with target control infusion propofol and remifentanil and the Xenon group with anesthesia maintained with xenon (target inspired concentration of 60%) and target control infusion remifentanil. Remifentanil and xenon or propofol were stopped at the end of skin closure.
Results
A cerebral oxygen saturation decrease below 55% was less frequently observed in the Xenon group during carotid cross-clamping (7/37 patients vs 15/37; p=0.01). Compared with values observed before clamping, the decrease in cerebral oxygen saturation during clamping was significantly less important in the Xenon group (12±11% vs 17±14%, p=0.04). Blood pressure and heart rate were not different between groups during carotid clamping.
Conclusions
This pilot study suggests that xenon anesthesia may be associated to higher cerebral oxygen saturation values when compared to propofol anesthesia during cross-clamping for carotid endarterectomy.
PMCID: PMC3722342  PMID: 23888233
carotid surgery; general anesthesia; TCI; propofol; remifentanil; xenon; near-infrared spectrometry
7.  A psychoeducational intervention reduces the need for anesthesia during radiotherapy for young childhood cancer patients 
Background
Radiotherapy (RT) has become an important treatment modality in pediatric oncology, but its delivery to young children with cancer is challenging and general anesthesia is often needed.
Methods
To evaluate whether a psychoeducational intervention might reduce the need for anesthesia, 223 consecutive pediatric cancer patients receiving 4141 RT fractions during 244 RT courses between February 1989 and January 2006 were studied. Whereas in 154 RT courses corresponding with 2580 RT fractions patients received no psychoeducational intervention (group A), 90 RT courses respectively 1561 RT fractions were accomplished by using psychoeducational intervention (group B). This tailored psychoeducational intervention in group B included a play program and interactive support by a trained nurse according to age to get familiar with staff, equipment and procedure of radiotherapy.
Results
Group A did not differ significantly from group B in age at RT, gender, diagnosis, localization of RT and positioning during RT. Whereas 33 (21.4%) patients in group A got anesthesia, only 8 (8.9%) patients in group B needed anesthesia. The median age of cooperating patients without anesthesia decreased from 3.2 to 2.7 years. In both uni- and multivariate analyses the psychoeducational intervention significantly and independently reduced the need for anesthesia.
Conclusion
We conclude that a specifically tailored psychoeducational intervention is able to reduce the need for anesthesia in children undergoing RT for cancer. This results in lower costs and increased cooperation during RT.
doi:10.1186/1748-717X-3-17
PMCID: PMC2430970  PMID: 18522761
8.  Survey of oral and maxillofacial surgeons' offices in Virginia: anesthesia team characteristics. 
Anesthesia Progress  2004;51(4):122-125.
This survey assesses whether oral and maxillofacial surgeons in the state of Virginia are prepared for inspection of their offices. A survey asking pertinent questions on the availability of specific equipment and the educational qualifications of the anesthesia care team was developed and sent to 155 offices. Seven questions were asked regarding the availability of nurses, types of life support training, (formal or informal), the surgeons and anesthesia care personnel, and the presence of a defibrillator. Questionnaires were short and simple to encourage compliance with the study guidelines. A total of 128 (82.6%) questionnaires were returned. Only 42 of 128 (32.8%) offices employed nurses, and 6 of the 42 nurses were not considered as part of the anesthesia care team. Only 36 of 128 (28.1%) of the offices had assistants with formal anesthesia assistant course training from the American Association of Oral and Maxillofacial Surgeons (AAOMS) or the American Dental Society of Anesthesiology (ADSA). However, 93% of the assistants who participated in the anesthesia had current basic life support training (BLS) training, and 74% of the surgeons had current advanced cardiac life support (ACLS) training. The AAOMS Office Emergency Manual was present in 118 of 128 offices (92.2%), and 124 of 128 offices (96.9%) had defibrillators. The survey suggests that the surgeons are well prepared from the standpoint of having a defibrillator present and the AAOMS Office Emergency Manual available as a template for the team to use in order to answer questions that the inspection team may ask of the primary anesthesia care provider and surgeon. The majority of the surgeons had current ACLS certification, and the office anesthesia assistants had current BLS training. Most of the assistants did not have formal course training, which indicates that on-the-job training is probably the norm. Less than one third of the offices had nurses.
PMCID: PMC2007491  PMID: 15675260
9.  Sleep Apnea and Total Joint Arthroplasty under Various Types of Anesthesia 
Background and Objectives
The presence of sleep apnea (SA) among surgical patients has been associated with significantly increased risk of perioperative complications. Although regional anesthesia has been suggested as a means to reduce complication rates among SA patients undergoing surgery, no data are available to support this association. We studied the association of the type of anesthesia and perioperative outcomes in patients with SA undergoing joint arthroplasty.
Methods
Drawing on a large administrative database (Premier Inc), we analyzed data from approximately 400 hospitals in the United States. Patients with a diagnosis of SA who underwent primary hip or knee arthroplasty between 2006 and 2010 were identified. Perioperative outcomes were compared between patients receiving general, neuraxial, or combined neuraxial-general anesthesia.
Results
We identified 40,316 entries for unique patients with a diagnosis for SA undergoing primary hip or knee arthroplasty. Of those, 30,024 (74%) had anesthesia-type information available. Approximately 11% of cases were performed under neuraxial, 15% under combined neuraxial and general, and 74% under general anesthesia. Patients undergoing their procedure under neuraxial anesthesia had significantly lower rates of major complications than did patients who received combined neuraxial and general or general anesthesia (16.0%, 17.2%, and 18.1%, respectively; P = 0.0177). Adjusted risk of major complications for those undergoing surgery under neuraxial or combined neuraxial-general anesthesia compared with general anesthesia was also lower (odds ratio, 0.83 [95% confidence interval, 0.74–0.93; P = 0.001] vs odds ratio, 0.90 [95% confidence interval, 0.82–0.99; P = 0.03]).
Conclusions
Barring contraindications, neuraxial anesthesia may convey benefits in the perioperative outcome of SA patients undergoing joint arthroplasty. Further research is needed to enhance an understanding of the mechanisms by which neuraxial anesthesia may exert comparatively beneficial effects.
doi:10.1097/AAP.0b013e31828d0173
PMCID: PMC3932239  PMID: 23558371
10.  Essentials of Airway Management, Oxygenation, and Ventilation: Part 1: Basic Equipment and Devices 
Anesthesia Progress  2014;61(2):78-83.
Offices and outpatient dental facilities must be properly equipped with devices for airway management, oxygenation, and ventilation. Optimizing patient safety using crisis resource management (CRM) involves the entire dental office team being familiar with airway rescue equipment. Basic equipment for oxygenation, ventilation, and airway management is mandated in the majority of US dental offices per state regulations. The immediate availability of this equipment is especially important during the administration of sedation and anesthesia as well as the treatment of medical urgencies/emergencies. This article reviews basic equipment and devices essential in any dental practice whether providing local anesthesia alone or in combination with procedural sedation. Part 2 of this series will address advanced airway devices, including supraglottic airways and armamentarium for tracheal intubation and invasive airway procedures.
doi:10.2344/0003-3006-61.2.78
PMCID: PMC4068090  PMID: 24932982
Airway management; Oxygenation; Ventilation; Equipment; Devices
11.  Replacement of anesthesia machines improves intraoperative ventilation parameters associated with the development of acute respiratory distress syndrome 
BMC Anesthesiology  2014;14:44.
Background
The impact of anesthetic equipment on clinical practice parameters associated with development of acute respiratory distress syndrome (ARDS) has not been extensively studied. We hypothesized a change in anesthesia machines would be associated with parameters associated with lower rates of ARDS.
Methods
We performed a retrospective cohort study on a subset of data used to evaluate intraoperative ventilation. Patients included adults receiving a non-cardiac, non-thoracic, non-transplant, non-trauma, general anesthetic between 2/1/05, and 3/31/09 at the University of Michigan. Existing anesthesia machines (Narkomed IIb, Drager) were exchanged for new equipment (Aisys, General Electric). The initial subset compared the characteristics of patients anesthetized between 12/1/06 and 1/31/07 (pre) with those between 4/1/07 and 5/30/07 (post). An extended subset examined cases two years pre and post exchange. Using the standard predicted body weight (PBW), we calculated and compared the tidal volume (total Vt and mL/kg PBW) as well as positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), Delta P (PIP-PEEP), and FiO2.
Results
A total of 1,414 patients were included in the 2-month pre group and 1,635 patients included in the post group. Comparison of ventilation characteristics found statistically significant differences in median (pre v post): PIP (26 ± 6 v 21 ± 6 cmH2O,p < .001), Delta P (24 ± 6 v 19 ± 6 cmH2O, p < .001), Vt (588 ± 139 v 562 ± 121 ml, p < 0.001; 9.3 ± 2.2 v 9.0 ± 1.9 ml/kg predicted body weight, p < .001), FiO2 (0.57 ± 0.17 v 0.52 ± 0.18, p < .001). Groups did not differ in age, ASA category, PBW, or BMI. The two year subgroup had similar parameters. Risk adjustment resulted in minimal differences in the analysis. New anesthesia machines were associated with a non-statistically significant reduction in postoperative ARDS.
Conclusions
In this study, a change in ventilator management was associated with an anesthesia machine exchange. The smaller Vt and lower PIP noted in the post group may imply a lower risk of volutrauma and barotrauma, which may be significant in at-risk populations. However, there was not a statistically significant reduction in the incidence of post-operative ARDS.
doi:10.1186/1471-2253-14-44
PMCID: PMC4153007  PMID: 25187754
ARDS; Perioperative ventilation; Equipment upgrade; Study design
12.  Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration 
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is becoming a standard method for invasive mediastinal staging and for the diagnosis of paratracheal and peribronchial lesions. It is essential to understand the technical aspects of EBUS-TBNA to ensure safe and efficient procedures. In this review, we discuss the practical aspects to be considered during EBUS-TBNA, including anesthesia, manipulation of equipment, understanding mediastinal ultrasound images, target selection, number of aspirations needed per target, sample handling, and complications.
doi:10.4046/trd.2013.75.4.135
PMCID: PMC3833933  PMID: 24265641
Endobronchial Ultrasound; Bronchoscopy; Lung Neoplasms
13.  Effects of deep sedation or general anesthesia on cardiac function in mice undergoing cardiovascular magnetic resonance 
Background
Genetically engineered mouse models of human cardiovascular disease provide an opportunity to understand critical pathophysiological mechanisms. Cardiovascular magnetic resonance (CMR) provides precise reproducible assessment of cardiac structure and function, but, in contrast to echocardiography, requires that the animal be immobilized during image acquisition. General anesthetic regimens yield satisfactory images, but have the potential to significantly perturb cardiac function. The purpose of this study was to assess the effects of general anesthesia and a new deep sedation regimen, respectively, on cardiac function in mice as determined by CMR, and to compare them to results obtained in mildly sedated conscious mice by echocardiography.
Results
In 6 mildly sedated normal conscious mice assessed by echo, heart rate was 615 ± 25 min-1 (mean ± SE) and left ventricular ejection fraction (LVEF) was 0.94 ± 0.01. In the CMR studies of normal mice, heart rate was slightly lower during deep sedation with morphine/midazolam (583 ± 30 min-1), but the difference was not statistically significant. General anesthesia with 1% inhaled isoflurane significantly depressed heart rate (468 ± 7 min-1, p < 0.05 vs. conscious sedation). In 6 additional mice with ischemic LV failure, trends in heart rate were similar, but not statistically significant. In normal mice, deep sedation depressed LVEF (0.79 ± 0.04, p < 0.05 compared to light sedation), but to a significantly lesser extent than general anesthesia (0.60 ± 0.04, p < 0.05 vs. deep sedation).
In mice with ischemic LV failure, ejection fraction measurements were comparable when performed during light sedation, deep sedation, and general anesthesia, respectively. Contrast-to-noise ratios were similar during deep sedation and during general anesthesia, indicating comparable image quality. Left ventricular mass measurements made by CMR during deep sedation were nearly identical to those made during general anesthesia (r2 = 0.99, mean absolute difference < 4%), indicating equivalent quantitative accuracy obtained with the two methods. The imaging procedures were well-tolerated in all mice.
Conclusion
In mice with normal cardiac function, CMR during deep sedation causes significantly less depression of heart rate and ejection fraction than imaging during general anesthesia with isoflurane. In mice with heart failure, the sedation/anesthesia regimen had no clear impact on cardiac function. Deep sedation and general anesthesia produced CMR with comparable image quality and quantitative accuracy.
doi:10.1186/1532-429X-11-16
PMCID: PMC2689210  PMID: 19454023
14.  EQUIP: Implementing chronic care principles and applying formative evaluation methods to improve care for schizophrenia: QUERI Series 
Background
This paper presents a case study that demonstrates the evolution of a project entitled "Enhancing QUality-of-care In Psychosis" (EQUIP) that began approximately when the U.S. Department of Veterans Affairs' Quality Enhancement Research Initiative (QUERI), and implementation science were emerging. EQUIP developed methods and tools to implement chronic illness care principles in the treatment of schizophrenia, and evaluated this implementation using a small-scale controlled trial. The next iteration of the project, EQUIP-2, was further informed by implementation science and the use of QUERI tools.
Methods
This paper reports the background, development, results and implications of EQUIP, and also describes ongoing work in the second phase of the project (EQUIP-2). The EQUIP intervention uses implementation strategies and tools to increase the adoption and implementation of chronic illness care principles. In EQUIP-2, these strategies and tools are conceptually grounded in a stages-of-change model, and include clinical and delivery system interventions and adoption/implementation tools. Formative evaluation occurs in conjunction with the intervention, and includes developmental, progress-focused, implementation-focused, and interpretive evaluation.
Results
Evaluation of EQUIP provided an understanding of quality gaps and how to address related problems in schizophrenia. EQUIP showed that solutions to quality problems in schizophrenia differ by treatment domain and are exacerbated by a lack of awareness of evidence-based practices. EQUIP also showed that improving care requires creating resources for physicians to help them easily implement practice changes, plus intensive education as well as product champions who help physicians use these resources. Organizational changes, such as the addition of care managers and informatics systems, were shown to help physicians with identifying problems, making referrals, and monitoring follow-up. In EQUIP-2, which is currently in progress, these initial findings were used to develop a more comprehensive approach to implementing and evaluating the chronic illness care model.
Discussion
In QUERI, small-scale projects contribute to the development and enhancement of hands-on, action-oriented service-directed projects that are grounded in current implementation science. This project supports the concept that QUERI tools can be useful in implementing complex care models oriented toward evidence-based improvement of clinical care.
doi:10.1186/1748-5908-3-9
PMCID: PMC2278162  PMID: 18279505
15.  Medical simulation is needed in anesthesia training to achieve patient's safety 
Korean Journal of Anesthesiology  2013;64(3):204-211.
Many medical schools and hospitals throughout the world are equipped with a simulation center for the purpose of training anesthesiologists to perform both technical and non-technical skills. Because induction, maintenance, and emergence of general anesthesia are critical to patient welfare, various simulation mannequins and tools are utilized for the purpose of training anesthesiologists for safer patient care. Traditionally, anesthesia residency training mostly consisted of didactic lectures and observations. After completion of "traditional" training, anesthesia residents were allowed to perform procedures on patients under supervision. However, simulation would be a more effective training tool for which to teach anesthesiologists the skills necessary to perform invasive procedures, such as endotracheal intubation, central venous catheter insertion, and epidural catheter insertion. Recently, non-technical skills, such as the Anesthesia Non-Technical Skills developed by anesthesiologists from Aberdeen University, have been emphasized as an important training resource. Technical skills and non-technical skills can be learned by anesthesiology residents through a standardized and organized simulation program. Such programs would be beneficial in training anesthesia residents to work efficiently as a team in the operation room.
doi:10.4097/kjae.2013.64.3.204
PMCID: PMC3611068  PMID: 23560184
Anesthesia; Non-technical skill; Simulation; Simulator; Training
16.  Prevalence of Adverse Intraoperative Events during Obesity Surgery and Their Sequelae 
BACKGROUND
Adverse intraoperative events (AIEs) during surgery are a well-known entity. A better understanding of the incidence of AIEs and their relationship with outcomes is helpful for surgeon preparation and preoperative patient counseling. The goals of this study are to describe the incidence of AIEs during bariatric surgery and examine their impact on major adverse complications.
STUDY DESIGN
The study included 5,882 subjects who had bariatric surgery in the Longitudinal Assessment of Bariatric Surgery study between March 2005 and April 2009. Prospectively collected AIEs included organ injuries, anesthesia-related events, anastomotic revisions, and equipment failure. The relationship between AIEs and a composite end point of 30-day major adverse complications (ie, death, venous thromboembolism, percutaneous, endoscopic, or operative reintervention and failure to be discharged from the hospital within 30 days from surgery) was evaluated using a multivariable relative risk model adjusting for factors known to influence their risk.
RESULTS
There were 1,608 laparoscopic adjusted gastric banding, 3,770 laparoscopic Roux-en-Y gastric bypass operations, and 504 open Roux-en-Y gastric bypass operations. Adverse intraoperative events occurred in 5% of the overall sample and were most frequent during open Roux-en-Y gastric bypass (7.3%), followed by laparoscopic Roux-en-Y gastric bypass (5.5%) and laparoscopic adjusted gastric banding (3%). The rate of composite end point was 8.8% in the AIE group compared with 3.9% among those without an AIE (p < 0.001). Multivariable analysis revealed that patients with an AIE were at 90% greater risk of composite complication than those without an event (relative risk = 1.90; 95% CI, 1.26–2.88; p = 0.002), independent of the type of procedure (open or laparoscopic).
CONCLUSIONS
Incidence of an AIE is not infrequent during bariatric surgery and is associated with much higher risk of major complication. Additional study is needed to assess the association between specific AIEs and short-term complications.
doi:10.1016/j.jamcollsurg.2012.03.008
PMCID: PMC3569521  PMID: 22634116
17.  Laparoscopic Cholecystectomy Under Epidural Anesthesia: A Feasibility Study 
Background:
Laparoscopic cholecystectomy (LC) is normally performed under general anesthesia. But of late this operation has been tried under regional anesthesia successfully without any added complications like epidural anesthesia.
Aims:
The aim of the study was to study the feasibility of performing LC under epidural anesthesia in normal patients so that the benefits could be extended to those high-risk patients having symptomatic gallstone disease and compromised cardio-pulmonary status where general anesthesia is contraindicated.
Materials and Methods:
In all, 20 patients with the American Society of Anesthesiologist's class I or II were enrolled in the study. The level of epidural block and satisfaction score, both for the patient and the surgeon, were noted in the study.
Results:
The LC was performed successfully under epidural anesthesia in all but two patients who had severe shoulder pain in spite of giving adequate analgesia and were converted to general anesthesia.
Conclusions:
The LC can be performed safely under epidural anesthesia with understanding between patient and surgeon. However, careful assessment of complications in the patients should be done to make the procedure safer.
doi:10.4103/1947-2714.145468
PMCID: PMC4264291  PMID: 25535604
Cholecystectomy; Epidural anesthesia; Laparoscopic; Shoulder pain
18.  The Extended Surgical Time-Out: Does It Improve Quality and Prevent Wrong-Site Surgery? 
The Permanente journal  2010;14(1):19-23.
Purpose: To review the initial results of implementing an extended surgical time-out (STO) in pediatric surgery.
Methods: Starting in January 2006, all members of our surgical team implemented and used an extended STO, confirming the patient's identity, technical and anesthetic details, administered and available medications, and need for blood products and special equipment. To avoid disrupting work flow, the STO was initially after anesthesia induction. Starting in October 2007, the STO was done before anesthesia induction. Initial results, elapsed time to incision, and surgical team surveys were reviewed before and after implementing the preinduction STO.
Results: The elapsed time to incision was similar for elective and urgent operations before and after implementing the preinduction STO. All antibiotics were administered and confirmed during the STO. Four significant equipment findings were detected, altering the planned procedure (two before and two after implementing the preinduction STO). Operating room staff felt more confident and prepared for the operations because communication was improved. One near-miss occurred during the postinduction STO. One wrong-site operation occurred despite the preinduction STO, because of inadequate marking. Root-cause analysis demonstrated that this was due to a systems error.
Conclusions: Using the extended STO before anesthesia induction improved communication among the surgical team members and did not disrupt work flow. An extended STO may also have broader value, such as confirming timely antibiotic administration or meeting other quality measures. The extended STO did not eliminate wrong-site surgery. However, implementation of the STO placed the responsibility for wrong-site surgery with the whole team and system, rather than with the individual surgeon.
PMCID: PMC2912716  PMID: 20740127
19.  Time Management in the Operating Room: An Analysis of the Dedicated Minimally Invasive Surgery Suite 
Background:
Dedicated minimally invasive surgery suites are available that contain specialized equipment to facilitate endoscopic surgery. Laparoscopy performed in a general operating room is hampered by the multitude of additional equipment that must be transported into the room. The objective of this study was to compare the preparation times between procedures performed in traditional operating rooms versus dedicated minimally invasive surgery suites to see whether operating room efficiency is improved in the specialized room.
Methods:
The records of 50 patients who underwent laparoscopic procedures between September 2000 and April 2002 were retrospectively reviewed. Twenty-three patients underwent surgery in a general operating room and 18 patients in an minimally invasive surgery suite. Nine patients were excluded because of cystoscopic procedures undergone prior to laparoscopy. Various time points were recorded from which various time intervals were derived, such as preanesthesia time, anesthesia induction time, and total preparation time. A 2-tailed, unpaired Student t test was used for statistical analysis.
Results:
The mean preanesthesia time was significantly faster in the minimally invasive surgery suite (12.2 minutes) compared with that in the traditional operating room (17.8 minutes) (P=0.013). Mean anesthesia induction time in the minimally invasive surgery suite (47.5 minutes) was similar to time in the traditional operating room (45.7 minutes) (P=0.734). The average total preparation time for the minimally invasive surgery suite (59.6 minutes) was not significantly faster than that in the general operating room (63.5 minutes) (P=0.481).
Conclusion:
The amount of time that elapses between the patient entering the room and anesthesia induction is statically shorter in a dedicated minimally invasive surgery suite. Laparoscopic surgery is performed more efficiently in a dedicated minimally invasive surgery suite versus a traditional operating room.
PMCID: PMC3016833  PMID: 15554269
Laparoscopy; Operating room; Ergonomics; Efficiency; Minimally invasive surgery suite
20.  Basic Surgical Techniques in the Göttingen Minipig: Intubation, Bladder Catheterization, Femoral Vessel Catheterization, and Transcardial Perfusion 
The emergence of the Göttingen minipig in research of topics such as neuroscience, toxicology, diabetes, obesity, and experimental surgery reflects the close resemblance of these animals to human anatomy and physiology 1-6.The size of the Göttingen minipig permits the use of surgical equipment and advanced imaging modalities similar to those used in humans 6-8. The aim of this instructional video is to increase the awareness on the value of minipigs in biomedical research, by demonstrating how to perform tracheal intubation, transurethral bladder catheterization, femoral artery and vein catheterization, as well as transcardial perfusion.
Endotracheal Intubation should be performed whenever a minipig undergoes general anesthesia, because it maintains a patent airway, permits assisted ventilation and protects the airways from aspirates. Transurethral bladder catheterization can provide useful information about about hydration state as well as renal and cardiovascular function during long surgical procedures. Furthermore, urinary catheterization can prevent contamination of delicate medico-technical equipment and painful bladder extension which may harm the animal and unnecessarily influence the experiment due to increased vagal tone and altered physiological parameters. Arterial and venous catheterization is useful for obtaining repeated blood samples and monitoring various physiological parameters. Catheterization of femoral vessels is preferable to catheterization of the neck vessels for ease of access, when performing experiments involving frame-based stereotaxic neurosurgery and brain imaging. When performing vessel catheterization in survival studies, strict aseptic technique must be employed to avoid infections6. Transcardial perfusion is the most effective fixation method, and yields preeminent results when preparing minipig organs for histology and histochemistry2,9. For more information about anesthesia, surgery and experimental techniques in swine in general we refer to Swindle 2007. Supplementary information about premedication and induction of anesthesia, assisted ventilation, analgesia, pre- and postoperative care of Göttingen minipigs are available via the internet at http://www.minipigs.com10. For extensive information about porcine anatomy we refer to Nickel et al. Vol. 1-511.
doi:10.3791/2652
PMCID: PMC3197034  PMID: 21730947
21.  Techniques of rapid sequence induction and intubation at a university teaching hospital 
BACKGROUND:
Rapid sequence induction and intubation (RSII) is a medical procedure involving a prompt induction of general anesthesia by using cricoid pressure that prevents regurgitation of gastric contents. The factors affecting RSII are prophylaxis for aspiration, preoxygenation, drug and equipment preparation for RSII, ventilation after induction till intubation and patient condition. We sometimes saw difficulties with the practice of this technique in our hospital operation theatres. The aim of this study was to assess the techniques of rapid sequence induction and intubation.
METHODS:
Hospital based observational study was conducted with a standardized checklist. All patients who were operated upon under general anesthesia during the study period were included. The techniques of RSII were observed during the induction of anesthesia by trained anesthetists.
RESULTS:
Altogether 140 patients were included in this study with a response rate of 95.2%. Prophylaxis was not given to 130 patients (92.2%), and appropriate drugs were not used for RSII in 73 patients (52.1%), equipments for difficult intubation in 21 (15%), suction machines with catheter not connected and turned on in 122 (87.1%), ventilation for patients after induction and before intubation in 41 (29.3%), cricoid pressure released before cuff inflation in 12 (12.1%), and difficult intubation in 8 (5.7%), respectively. RSII with cricoid pressure was applied appropriately in 94 (67.1%) patients, but cricoid pressure was not used in 46 (32.9%) patients.
CONCLUSIONS:
The techniques of rapid sequence induction and intubation was low. Training should be given for anesthetists about the techniques of RSII.
doi:10.5847/wjem.j.issn.1920-8642.2014.02.005
PMCID: PMC4129883  PMID: 25215158
Rapid sequence; Induction; Intubation; Pulmonary aspiration; General anesthesia
22.  Evaluation of magnetic scope navigation in screening endoscopic examination of colorectal cancer 
Surgical Endoscopy  2011;26(3):632-638.
Background
Colorectal cancer is the most common cancer in Europe. Early diagnosis and treatment gives the patient a chance for complete recovery. Screening colonoscopies in the symptom-free patients are currently performed on a wide scale. The examinations are performed under local anesthesia which does not eliminate all discomfort and pain related to the examination. The aim of this study was to evaluate magnetic scope navigation in screening endoscopic examinations performed to detect early-stage colorectal cancer.
Methods
The study group consisted of 200 patients, aged 40–65 years, who were free from colon cancer symptoms. All patients underwent complete colonoscopy under local anesthesia. The equipment could be fitted with the scope that allows three-dimensional observation of instrument localization in the bowel. The examination was performed by three experienced endoscopists, each of whom performed over 5,000 colonoscopies. The patients were randomized to two groups: those whose equipment did not have 3D navigation (group I) and those whose equipment did have 3D navigation (group II). Each group consisted of 100 cases matched by gender, age, and BMI. The authors compared the duration of introducing instrument to cecum, the pulse rate before the examination and at the time the instrument reached the cecum, and subjective pain evaluation by the patient on the visual analog scale.
Results
Group I consisted of 54 women and 46 men with a mean age of 54.6 years and mean BMI of 27.8 kg/m2, and group II had 58 women and 42 men, mean age of 55.1 years and mean BMI of 26.4 kg/m2. The average time it took for the instrument to reach the cecum was 216s in group I and 181s in group II (P < 0.05). Pain measured on the 10-point VAS scale was 2.44 in group I and 1.85 in group II (P < 0.05). The results showed a significantly shorter time for the instrument to reach the cecum in group II and significantly lower pain intensity during the examination was reported by the group II patients. No significant differences were found in the pulse measurements between the groups (P = 0.5).
Conclusions
3D navigation during colonoscopy decreases the time for the instrument to reach the cecum and lowers pain intensity subjectively reported by the patients. The use of 3D and the possibility to observe instrument localization and maneuvers brings more comfort to the patients.
doi:10.1007/s00464-011-1930-8
PMCID: PMC3271220  PMID: 21959687
Colorectal cancer; Colonoscopy; Magnetic endoscopic imaging; Pain
23.  Risk Management Status of Waste Anesthetic Gases Using ECRI Institute Standards 
Iranian Journal of Public Health  2012;41(11):85-91.
Background
The aim of this study was assessment the risk management status of waste anesthetic gases in academicals hospitals in Iran to prevent from harmful effects of these gases on employees’ health.
Methods:
A descriptive-analytic study was designed in 2011. Standard structured checklist developed by ECRI institute (Emergency Care Research Institute) was applied. Checklists were filled onsite through direct observation and interviews with anesthesia personnel in 46 operating rooms at 4 hospitals from all of the hospitals under affiliation of Isfahan University of Medical Sciences. These hospitals were selected based on the number of surgical beds.
Results:
Total means score of WAGs risk management status was 1.72 from the scale of 3. In the studied operating rooms, only 28% complied with predetermined standards, 16% needed improvement and 56% had no compliance. Total mean scores of compliance in planning, training and evaluation and monitoring of waste anesthetic gases were weak and equipment and work activity was at medium level.
Conclusion:
The risk management status of waste anesthetic gases in the hospitals to be weak, therefore operating room personnel are exposed to medium to high level of these gases. The hospital mangers should prepare and apply scavenging equipment, development of control program, quality improvement, risk management and maintenance of anesthesia equipment. Finally, ongoing monitoring and evaluation, education to personnel and modification of policy and procedures and improvement of work activities should be considered.
PMCID: PMC3521891  PMID: 23304681
Risk management; Waste anesthetic gas; Assessment
24.  General anesthesia mediated by effects on ion channels 
Although it has been more than 165 years since the first introduction of modern anesthesia to the clinic, there is surprisingly little understanding about the exact mechanisms by which general anesthetics induce unconsciousness. As a result, we do not know how general anesthetics produce anesthesia at different levels. The main handicap to understanding the mechanisms of general anesthesia is the diversity of chemically unrelated compounds including diethyl ether and halogenated hydrocarbons, gases nitrous oxide, ketamine, propofol, benzodiazepines and etomidate, as well as alcohols and barbiturates. Does this imply that general anesthesia is caused by many different mechanisms Until now, many receptors, molecular targets and neuronal transmission pathways have been shown to contribute to mechanisms of general anesthesia. Among these molecular targets, ion channels are the most likely candidates for general anesthesia, in particular γ-aminobutyric acid type A, potassium and sodium channels, as well as ion channels mediated by various neuronal transmitters like acetylcholine, amino acids amino-3-hydroxy-5-methyl-4-isoxazolpropionic acid or N-methyl-D-aspartate. In addition, recent studies have demonstrated the involvement in general anesthesia of other ion channels with distinct gating properties such as hyperpolarization-activated, cyclic- nucleotide-gated channels. The main aim of the present review is to summarize some aspects of current knowledge of the effects of general anesthetics on various ion channels.
doi:10.5492/wjccm.v1.i3.80
PMCID: PMC3953864  PMID: 24701405
General anesthesia; Ion channels; γ-amino-butyric acid type A receptors; Hyperpolarization activated cyclic nucleotide; Potassium channels; Glutamatergic ion channels; Sodium channels
25.  Office Single Puncture Laparoscopy Sterilization with Local Anesthesia 
Background and Objectives:
Recently there has been a renewed interest in office based laparoscopy sterilization utilizing local anesthesia with conscious intravenous sedation. The safety of performing the procedure outside of a hospital environment has been questioned. The author attempts to determine the incidence of major complications with a review of the literature and a retrospective chart review of his personal cases.
Methods:
During the period from 1971 to 1995, the author performed 1,753 laparoscopic procedures, utilizing local anesthesia in 1,562 cases and general anesthesia in the remainder. The focus of this chart study is the 1,190 laparoscopy sterilization cases performed in an office exam room setting, utilizing local anesthesia and conscious intravenous analgesia. Conventional 10 mm single puncture laparoscopy equipment was used. Major complications were defined as requiring laparotomy, blood transfusion, cardiopulmonary resuscitation, or emergency transfer to the hospital.
Results:
The author's series contained one major complication, which was easily handled in the office environment. A review of the literature, including the author's series, revealed a major complication incidence of 5 out of 20,568 cases reviewed. None of these five complications would have required immediate laparotomy or blood transfusion to prevent a fatality.
Conclusion:
The author proposes that there is no documented evidence that office laparoscopy places the patient at increased risk for a life-threatening complication and should be considered by experienced gynecologic laparoscopists who are interested in cost containment.
PMCID: PMC3015231  PMID: 9876648
Laparoscopy sterilization; Local anesthesia; Safety; Office; Experienced gynecologic laparoscopist

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