Anaesthetic Colleagues Research Articles

Achieving optimal cord management: a multidisciplinary quality improvement initiative

Optimal cord management (OCM), defined as waiting at least 60 seconds (s) before clamping the umbilical cord after birth, is an evidence-based intervention that improves outcomes for both term and...

868 Development & Implementation of a Patient Information Leaflet for Elective Daycase Laparoscopic Cholecystectomy – a Quality Improvement Project

Abstract Aim Daycase surgery reduces post-operative complications. Facilitating safe discharge is of paramount importance. One way of ensuring this is to enable patient access to reliable information. In this quality improvement project, we aimed to create and implement an information leaflet that would give succinct information to patients on what to expect on discharge, and signposting to further resources if required. It was felt that this would ultimately result in a better and safer patient experience. Method A leaflet was designed in conjunction with surgical, nursing, and anaesthetic colleagues, using information available from the Royal College of Surgeons and British Association of Day Surgery. This was then given to all relevant patients post-operatively. Subsequently, a cohort of patients were called and asked for feedback on the usefulness of this leaflet, using a questionnaire approach based on the psychometric Likert scale. Results A total of 15 patients were contactable, of which 14 (n = 15, 93%) reported having received the leaflet. A further 12 (n = 14, 86%) described the leaflet as useful, with comments such as ‘it was a comfort blanket’ and that ‘it allayed some anxieties I had about my recovery’. 2 people (n = 14, 14%) mentioned that some information was difficult to understand. Conclusions Information leaflets make a positive contribution to the post-operative patient experience. In future, we will look to conduct further study into whether the introduction of this leaflet has improved our day case rate, reduced re-admissions and whether patients have had an overall better experience of care.

Adoption of the Wide-Awake Local Anesthesia No Tourniquet Technique in Hand Surgery

» Wide-awake local anesthesia no tourniquet (WALANT) technique featuring tumescent infiltration of lidocaine with epinephrine at the operative site has broad application in hand surgery including both soft-tissue and bone procedures.» The advantages of wide-awake anesthesia include high patient satisfaction, preserved intraoperative finger and wrist motion, cost-effectiveness, improved operating room efficiency, fewer opioids during recovery, and improved access to hand surgery, which may be performed in an office-based setting without the need for anesthesia personnel.» In properly selected patients, use of lidocaine with epinephrine in the hand and fingers is safe. Rare postprocedure digital ischemia may be effectively treated with phentolamine rescue.» Barriers to adopting wide-awake anesthesia may be overcome by educating resistant stakeholders, including hospital administrators, nurse leaders, and anesthesia colleagues, about the advantages of the WALANT method.» The risk of postoperative complications after hand procedures may be mitigated by using the wide-awake technique instead of regional anesthesia with sedation or general anesthesia.

Letter: Integration of Veterans Affairs Medical Centers Into Neurosurgical Residency Programs.

To the Editor: We read with great interest the recent article published by Yearly et al1 highlighting the integration of Veterans Affairs (VA) Medical Center rotation into neurosurgery residency programs across the United States. The authors summarize succinctly the current state of affairs. At the University of Miami training program, our postgraduate year 3 (PGY3) residents rotate at the Bruce W. Carter VA Medical Center for 4 months. The VA rotation at our program has become known for its breadth through the wide skillset of contracted attendings, its innovation through the robust VA infrastructure, and its flexibility to continue training opportunities at the primary teaching site through its manageable clinical obligations. All these elements add to the findings of Yearly et al,1 affirming the formative nature of a VA rotation within neurosurgery training programs when possible. BREADTH There are 3 contracted attendings at our VA center, who specialize in complex spine, functional, tumor, and general cranial. Through this range of interests, the VA resident is exposed to these areas on a one-to-one basis with the attending because they are the sole resident on service. Our VA service make-up mirrors much of what Yearly et al1 report, in that spine surgeries are the most common, but within that, the complexities range from single-level laminectomy to multilevel cervical laminoplasties and lumbar fusions. Outside spine, a variety of procedures are also performed—a recent week's example includes spinal cord stimulator placement for pain, radiofrequency ablation for spinal metastasis, and endoscopic transsphenoidal resection for pituitary tumor. By having attendings who specialize in different areas, the VA rotation can provide the rotating resident exposure to a large breadth of surgical techniques. INNOVATION The infrastructure at the VA allows our department to incorporate new concepts and materials for the better of our patients. So much so that the invested interest from our anesthesia colleagues, operating room staff, and hospital managers has allowed the VA rotation to become known for better exposure to particular techniques than some of the other teaching sites within our program. This includes navigated single-position corpectomies and fusions and percutaneous spinal cord stimulator placements (Supplemental Figure 1,https://links.lww.com/NEU/D758). Furthermore, on the horizon for approval includes robotic spine surgery and stereotactic deep brain stimulation. Our experience therefore demonstrates the potential for the VA rotation within training programs to not only expose residents to standard operative techniques but also new and emerging ones too. FLEXIBILITY A normal week at the VA for our resident includes 2 operative days and 2 clinic days. Outside these clinical obligations, the vicinity of the primary teaching hospital allows the VA resident to participate in other clinical activities at the primary site. This can include further operative time and pursuing research interests which are both encouraged pending the resident's preference. A unique aspect of our VA center is its close proximity to the primary teaching hospital of our program—across the road. This location allows the VA resident to participate in all primary site learning activities (both in the morning and in the evening), as well as talk in-house overnight call at the primary site. Although not all VA centers are located so close to the primary teaching sites, our experience demonstrates that within a flexible set of obligations, a VA rotation is not a compromise in operative and academic opportunities if appropriate arrangements and schedules can be made ahead of time. At the University of Miami training program, the VA rotation has become a key and much looked forward to rotation among the residents. This is because of both the reasons Yearly et al1 highlight, as well as the elements we detail above. The VA rotation can be a pivotal experience for neurosurgery residents in their training, and maximizing where possible its breadth, innovation, and flexibility is highly encouraged.

Comments on- Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted

To the Editor, I read the recent article “Time to Adequately Heed Acute Pain in the Emergency Department – More Regional Blocks Warranted” by Dr. Zundert, et al. with much interest [1]. The central argument of offering adequate multimodal acute pain control to our most vulnerable patients has been the core tenant of my clinical practice and research for the last 15 years. I completely agree that If we (as the field of medicine) hope to succeed in equitable acute pain management, leveraging the skill of numerous clinicians (emergency physicians, surgeons, orthopedics, etc.) to perform single injection regional blocks will be needed [2]. Like other skills (endotracheal intubation, lumbar puncture, central venous cannulation, etc.) that have been adapted from innovators in one field and then taught to the various other specialties, ultrasound-guided regional anesthesia needs to be brought from the expert regional anesthesiologists and to the clinicians who are at the bedside caring for this cohort of patients. Working at an academic trauma center in a low resource setting, we have had to build patient-centered pain pathways that both treat acute pain as well as ensure a reduction in opioid use. With the help of our anesthesia colleague at University of California, San Francisco, we have integrated ultrasound-guided regional blocks into our clinical practice for more than 10 years in the emergency department (ED). Just as Dr. Zundert has pointed out, this collaboration between our Anesthesia and Emergency Medicine colleagues has been an amazing success, leading to timely pain control in our acutely injured patients as well as improved patient care. For hip fractures specifically, we have worked with our anesthesia and orthopedic colleagues to develop a practice standard that asks our clinicians to perform a block in under 1 hour after recognition of a hip fracture [3]. This collaborative non-siloed based practice standard between all services dealing with acutely injured patients (trauma surgery, orthopedics, anesthesia and emergency medicine) has fostered interdepartmental education, multiple research publications and most importantly improved patient care [4, 5,6, 7].

126. An evaluation and comparison of front of neck access simulation training with animal tissue, 3d printed and combined models

Surgical trainees especially those working in the head and neck region need to be able to manage a difficult airway situation alongside their anaesthetic colleagues. To learn the surgical procedure of performing a surgical cricothyroidotomy/front of neck access (FONA), an animal model is used to learn the relevant anatomical landmarks. The aim was to develop a model which did not involve animal tissue the same tactile feedback and necessary practical skills in performing this task.

Evaluation of automated manufacture of ready-to-administer injections to improve medicines safety in emergency intubation

Abstract Introduction Within the clinical setting of emergency anaesthesia the lack of ready to administer preparations poses a high risk to patients. The CIVAS@IP5 Medicines hub were approached by Cardiff and Vale University Health Board in response to a quality improvement project to prepare ready to administer anaesthesia. To manufacture these medicines required the use of semi-automated technology and development of manufacturing techniques to meet the quantity and range of products required including Ketamine, Rocuronium and Fentanyl. These are some of the first products developed for manufacture using a Grifill 4.0 Semi-automated Medicines Pump within the UK. Aim To develop new ready-to-administer products or use in emergency intubation scenarios within critical clinical settings, manufactured using innovative and newly developed processes. The products would be presented with the Royal College of Anaesthetists label colour scheme and have extended shelf lives assigned to allow suitability of use. Methods The project required three separate stages of methodology. First within Cardiff and Vale UHB, a clinical agreement on standardised concentrations of Ketamine, Fentanyl and Rocuronium was required. Secondly, development within CIVAS@IP5 of a Semi-automated compounding process that had been fully process mapped, assessed via HAACP analysis. This process was then validated for microbiological integrity and efficiency using Gage R&R principles to prove repeatability and reproducibility of a quality product. The final stage involved collaborative development of the final presentation and facilitation of its use locally. Ethical approval was not required for this service development initiative and evaluation. Results The new methodology for semi-automated preparation of ready-to-administer injectable medicines gave the following capacity timings for the three agreed concentrations recommended by the Royal College of Anaesthetists. Fentanyl 250mcg in 5mL – 54 seconds per syringe (Batch size 200 syringes). Rocuronium 250mg in 10mL – 2 minutes per syringe (Batch size 50 syringes). Ketamine 100mg in 10mL – 1 minute 32 seconds per syringe (Batch size 40 syringes). These timings are compared to current documented preparations of 5 minutes 42 seconds for syringes made manually in pharmacy technical services settings. This meant Cardiff and Value UHB could be provided with their emergency intubation medication in a ready-to-use format within a pharmacy manufacturing capacity expenditure of 4 hours and 12 minutes per month when compared to the same manual preparation taking 26 hours. A literature search allowed extended shelf lives of up to 100 days to be applied to the products, and the labels designed in collaboration with anaesthetic colleagues in Cardiff and Vale UHB. The clinical impact is that for emergency intubation scenarios clinicians have ready-to-administer medications at the point of care. Discussion/Conclusion Use of semi-automation within Pharmacy Technical Services can greatly increase the production output of medicines allowing products where there is a current unmet demand to be prepared. The impact is an increased service capacity for the provision of well designed, clinically significant products to clinical areas improving efficiency, patient safety and clinical delivery of treatment in emergency situations.

REPLY: Reply to Kumar and colleagues.

The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.In their recent letter to the Editor, Kumar and colleagues1Kumar N. Flores A.S. Hussain N. Ganapathi A.M. Whitson B.A. Essandoh M.K. et al.Ensuring pulmonary artery patency in donor-recipient size mismatch: a collaborative challenge.J Thorac Cardiovasc Surg Tech. 2022; 15: 206-207Scopus (4) Google Scholar provided an important suggestion for additional evaluation of the pulmonary artery anastomosis after lung transplantation with transesophageal echocardiography (TEE) in the operating room. We thank Yokoyama and colleagues2Yokoyama Y. Chen-Yoshikawa T.F. Nakajima D. Ohsumi A. Date H. Various techniques for anastomosis of pulmonary arteries with size mismatch during lung transplantation.J Thorac Cardiovasc Surg Tech. 2021; 9: 192-194Scopus (7) Google Scholar for their previous article on anastomotic techniques that again highlight the importance of a technically optimal operation, which includes an unobstructed pulmonary artery anastomosis. The routine nature of thoracic transplantation might allow a suboptimal pulmonary artery anastomosis after heart or lung transplantation to go undetected as a potential cause of pulmonary graft dysfunction or donor heart right ventricular dysfunction.Kumar and colleagues' suggestion of TEE Doppler interrogation of the flow characteristics across the anastomosis after lung transplantation could provide early evidence of a technical problem. If TEE is not routinely used for lung transplant operations, the anticipation of important pulmonary artery size disparity should at least stimulate consideration with our anesthesia colleagues for insertion of a TEE probe for anastomotic examination. The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. In their recent letter to the Editor, Kumar and colleagues1Kumar N. Flores A.S. Hussain N. Ganapathi A.M. Whitson B.A. Essandoh M.K. et al.Ensuring pulmonary artery patency in donor-recipient size mismatch: a collaborative challenge.J Thorac Cardiovasc Surg Tech. 2022; 15: 206-207Scopus (4) Google Scholar provided an important suggestion for additional evaluation of the pulmonary artery anastomosis after lung transplantation with transesophageal echocardiography (TEE) in the operating room. We thank Yokoyama and colleagues2Yokoyama Y. Chen-Yoshikawa T.F. Nakajima D. Ohsumi A. Date H. Various techniques for anastomosis of pulmonary arteries with size mismatch during lung transplantation.J Thorac Cardiovasc Surg Tech. 2021; 9: 192-194Scopus (7) Google Scholar for their previous article on anastomotic techniques that again highlight the importance of a technically optimal operation, which includes an unobstructed pulmonary artery anastomosis. The routine nature of thoracic transplantation might allow a suboptimal pulmonary artery anastomosis after heart or lung transplantation to go undetected as a potential cause of pulmonary graft dysfunction or donor heart right ventricular dysfunction. Kumar and colleagues' suggestion of TEE Doppler interrogation of the flow characteristics across the anastomosis after lung transplantation could provide early evidence of a technical problem. If TEE is not routinely used for lung transplant operations, the anticipation of important pulmonary artery size disparity should at least stimulate consideration with our anesthesia colleagues for insertion of a TEE probe for anastomotic examination. Ensuring pulmonary artery patency in donor-recipient size mismatch: A collaborative challengeJTCVS TechniquesVol. 15PreviewThe vascular anastomoses of lung transplantation are a growing area of interest. Anastomosing the donor and recipient pulmonary artery (PA) segments is among the most delicate aspects of the surgery, and proper surgical technique is critical to allograft and patient survival. Obstruction of blood flow through the PA may cause graft ischemia, refractory hypoxemia, right ventricular dysfunction, and even death in affected patients.1 However, the importance of the PA anastomoses has yet to be critically examined in the lung transplant literature. Full-Text PDF Open Access

History of Law 6, 1991

Law 6 was enacted thirty years ago. Notwithstanding the fact that almost three decades have elapsed, with the exception of the regional and national leaders, many anesthesiologists are unaware of the existence of such law, of its contents or about which are the positive aspects for the specialty and for all anesthesia colleagues. There is a lack of awareness regarding the fact that the oversight committees are a valuable instrument to ensure excellence in the practice of anesthesia.
 This publication shall contribute to an share an overview of the efforts made to ensure the approval of the Law by the National Congress and of the Law among all anesthesiologists in the country. In this way, all practitioners will become acquainted with the information on the topic to take advantage of the provisions in the Law.

Prospective Elective Neurosurgical Theater Utilization Audit in Pakistan: Problems in a Public Tertiary Care Hospital and Proposed Solutions from Lower-Middle-Income Country.

Background In lower-middle-income countries such as Pakistan, public hospitals provide free healthcare but suffer from poor management and misgovernance, negatively impacting service provision. One aspect of this is operating theater time (OTT) utilization. In a 1,600-bed hospital with a 22 million catchment population, we noticed significant delays and inadequate OTT efficiency at the neurosurgery department of Jinnah Hospital, Lahore, Punjab, Pakistan. This audit aimed to analyze the neurosurgical OTT utilization, identify delays, and highlight managerial deficiencies and areas for improvement while comparing our workflow with contemporary international literature. Materials and Methods We prospectively audited OTT utilization at the neurosurgical department. All elective surgeries from January to April 2021 were included to identify delays concerning patient transfer, anesthesia team arrival, preparation and intubation time, operative time, and anesthesia extubation time. Results Fifty-six per cent of OTT was utilized operating. Sources of delay included the delayed arrival of anesthesia team (4.7%) and the delay in transferring patients to OT (9.7%). Anesthesia intubation and preparation time accounted for 23% of OT utilization and was significantly longer than the comparable international studies. Extubation time accounted for 5.7% of OT utilization. The issues surrounding transfer delays and prolonged anesthesia time were discussed, with strategies to address them developed with close vital input from our anesthesia colleagues and ward staff. Conclusion Gross delays relatively simple in nature were identified due to poor management and less than ideal interspecialty coordination. Most delays were avoidable and can be addressed by proper planning, optimization of patient transfer and resources, and, most importantly, improved communication between surgeons, anesthetists, and ward staff. This can ensure optimal use of theater time and benefit all specialties, including ancillary staff, and, most importantly, the patient. A reaudit is warranted to assess the impact of interventions on OTT utilization.

Bridging the Communication Gaps from Preop to Phase II

Background Information Lack of a standard process or tool to communicate patient information and parental concerns from Preop to PACU resulted in less than optimal care for a sometimes very complex patient population. Lack of a consistent process or tool for PACU resulted in incomplete handoffs from surgical and anesthesia colleagues. Lack of a standard process for handoff from PACU RN to Phase II RN also resulted in less complete movement of information with the potential to compromise care. Objectives of Project Develop a tool to •improve communication of patient information from Preop to PACU •provide prompts to obtain more complete PACU handoffs from surgery and anesthesia colleagues •provide structure for RN to RN handoffs downstream from PACU and therefore, improve parent and patient care and satisfaction, safety and efficiency. Process of Implementation Audit current process for passing information, surveyed staff pre and post implementation of tool regarding communication gaps and handoff challenges, developed a tool, trialed and reformatted the tool based on feedback from users and post-implementation audits of the new tool. Statement of Successful Practice The use of the tool has been well adopted by the staff and surveys indicate staff feel the quality of handoffs have improved with audits indicating good use of the tool to provide patient and parent information from the preop side and improved quality of handoffs on PACU arrival which flow down the line. Implications for Advancing the Practice of Perianesthesia Nursing In the age of electronic health records this easy to use tool captures targeted specific information and provides structure for handoffs from Preop to Phase II. Processes to improve communication have been shown to improve safety and efficiency. Lack of a standard process or tool to communicate patient information and parental concerns from Preop to PACU resulted in less than optimal care for a sometimes very complex patient population. Lack of a consistent process or tool for PACU resulted in incomplete handoffs from surgical and anesthesia colleagues. Lack of a standard process for handoff from PACU RN to Phase II RN also resulted in less complete movement of information with the potential to compromise care. Develop a tool to •improve communication of patient information from Preop to PACU •provide prompts to obtain more complete PACU handoffs from surgery and anesthesia colleagues •provide structure for RN to RN handoffs downstream from PACU and therefore, improve parent and patient care and satisfaction, safety and efficiency. Audit current process for passing information, surveyed staff pre and post implementation of tool regarding communication gaps and handoff challenges, developed a tool, trialed and reformatted the tool based on feedback from users and post-implementation audits of the new tool. The use of the tool has been well adopted by the staff and surveys indicate staff feel the quality of handoffs have improved with audits indicating good use of the tool to provide patient and parent information from the preop side and improved quality of handoffs on PACU arrival which flow down the line. In the age of electronic health records this easy to use tool captures targeted specific information and provides structure for handoffs from Preop to Phase II. Processes to improve communication have been shown to improve safety and efficiency.

Redesigning the Pre-Admission Testing Process in a Specialized Children's Hospital, Moving Towards a Model of Care Coordination

<h3>Background Information</h3> We serve a patient population which includes many complex pediatric and young adult patients, who often present for surgery with an extensive list of comorbidities. Our pre-admission testing process was deemed inefficient, task focused vs. process focused. Multiple nurses could potentially touch a chart, leading to several hand offs, with no way of determining patient acuity. Our team felt overwhelmed and understaffed. <h3>Objectives of the Project</h3> Our goal with our workflow redesign was to streamline our processes, thereby increasing efficiency in the department, minimizing patient/chart handoffs and assuring a safe surgical experience for our patients. <h3>Process of Implementation</h3> Our core PreAdmit Testing team met and mapped out our current processes. This clearly illustrated the complexity of our system and the redundancies that existed. We also identified areas within our system that worked well. Four members of our team formed a task force to redesign the workflow, moving towards a model of care coordination. A point based acuity scale was developed, classifying patients as "red", "yellow" or "green", depending on number of points. Points reflect their comorbidities, complex psychosocial situations, multiple medications or required medication weans and labs and/or imaging procedures ordered in conjunction with surgical procedures. Any patient classified as "red" is assigned to one core Pre-Admit Testing nurse, who is responsible for coordinating all aspects of pre-op preparation, thus reducing handoffs. Care for "yellow" patients is also coordinated by core Pre-Admit testing staff. Patients classified as "green" can be delegated to nurses floating to the Pre-Admit office to prepare the chart and complete the pre-op phone call with the family. We are able to monitor productivity via EMR reports. <h3>Statement of Successful Practice</h3> PreAdmit Testing for our most complex patients has been streamlined, thus minimizing hand offs and assuring comprehensive preparation for surgery. Staff feedback confirmed that efficiency in the PreAdmit Testing office has improved as well as team satisfaction. Anesthesia colleagues have also reported satisfaction with our processes. <h3>Implications for Advancing the Practice of Perianesthesia Nursing</h3> In the future, the patient's acuity score will be available in the EMR to help guide pre-op as well as post-op care. It is our belief that streamlining our processes will improve patient safety.

INTRA-ARTICULAR MORPHINE AND ROPIVACAINE INJECTION PROVIDES EFFICACIOUS ANALGESIA COMPARED TO FEMORAL NERVE BLOCK IN THE FIRST 24 HOURS POST-OPERATIVELY AFTER ACL RECONSTRUCTION WITH BTB IN AN ADOLESCENT COHORT

Background:Opioid consumption and patient satisfaction are influenced by a surgeon’s pain management protocol and the use of adjunctive pain mediators. Two commonly utilized adjunctive pain modifiers for anterior cruciate ligament (ACL) reconstruction include femoral nerve blockade and intra-articular injection; however, debate remains as to the most efficacious methodology.Hypothesis/Purpose:We hypothesize that intra-articular injection with ropivacaine and morphine is as efficacious as a femoral nerve block injection of ropivacaine, dexamethasone, and dexmedetomidine for post-operative pain management in the first 24 hours after bone-patellar tendon-bone (BTB) ACL reconstruction.Methods:Charts were retrospectively reviewed for a single pediatric orthopedic surgeon performing BTB ACL reconstructions from 2013-2019. One hundred sixteen patients were identified, of whom 58 received intra-articular injection and 58 received single shot femoral nerve block. All patients were admitted for 24 hours. Pain scores were assessed every 4 hours. Morphine milligram equivalents (MME) consumed were tabulated for each patient.Results:Opioid use was 24.3 MMEs in patients treated with intra-articular injection vs 28.5MMEs in those with peripheral block (p=0.108). Consumption of MMEs was greater in the intra-articular group in the 0-4 hours period (7.1 MMEs vs. 4.6 MMEs, p=0.008). There was significantly less MME consumption in patients receiving intra-articular injection compared with peripheral block at 16-20 and 20-24 hours (3.2 MMEs vs. 5.6 MMEs, p=0.01; 3.8 MMEs vs. 6.5 MMEs, p<0.001 respectively). Mean pain scores were not significantly different over the 24-hour period (peripheral block=2.7, intra-articular injection=3.0, p=0.19).Conclusion:Moving away from the use of peripheral nerve block as an analgesic modality may be challenging given the multidisciplinary role of pain management in these patients. However, as Ramlogan et al. succinctly noted in their recent editorial “Anterior cruciate ligament repair and peripheral nerve blocks: time to change our practice?” in the British Journal of Anesthesia, both orthopedic and anesthesia colleagues alike are beginning to recognize that it is a change that may benefit our patients. Our study strengthens this argument and shows that there is no significant difference in MME consumption between the femoral nerve block and intra-articular injection groups in the first 24 hours post-operatively. While peripheral block is associated with lower opioid consumption in the first 4 hours after surgery, patients receiving intra-articular block require less opioids 16-24 hours post-operatively. Given these findings, we propose that intra-articular injection is a viable alternative for analgesia in pediatric patients undergoing BTB ACL reconstruction.Figure 1.2.Morphine milligram equivalent consumption trend during 24-hour post-operative period. PB=peripheral nerve block; IA=intra-articular injection

P.36 Improving patient safety and the way we work: Obstetric anaesthetic records at Altnagelvin Hospital

Introduction: Documentation is the cornerstone of patient safety and provides the foundation necessary to deliver quality care. In our hospital an obstetric anaesthetic chart was in need of modernisation. There was a need for a robust document which would stand up against judicial review and provide a clear patient pathway.1 There is no standard anaesthetic obstetric chart in the UK or regionally in Northern Ireland. In December 2020 our anaesthetic chart underwent a complete overhaul with input from our anaesthetic and obstetric colleagues, the midwifery team, and reflects best current guidance.

Survey of Anesthesiologists on Topical Vasoconstrictors and Intravenous Tranexamic Acid for Endoscopic Sinus Surgery.

Topical vasoconstrictors and intravenous tranexamic acid (IV TXA) are safe and efficacious to decrease bleeding and improve the surgical field during endoscopic sinus surgery (ESS). The purpose of this study was to investigate practice patterns, awareness of clinical evidence, and comfort levels among anesthesia providers regarding these hemostatic agents for ESS. A total of 767 attending anesthesiologists, residents, and certified registered nurse anesthetists (CRNAs) at 5 United States academic centers were invited to participate in a survey regarding their experience with IV TXA and 3 topical vasoconstrictor medications (oxymetazoline, epinephrine, and cocaine) during ESS. 330 (47%) anesthesia providers responded to the electronic survey. 113 (97%) residents, 92 (83%) CRNAs, and 52 (68%) attendings managed 5 or fewer ESS cases per month. Two-thirds of providers had not reviewed efficacy or safety literature for these hemostatic agents. Oxymetazoline was perceived safest, followed by epinephrine, IV TXA, and cocaine. Respondents considered potential side effects over surgical field visibility when selecting agents. The majority of providers had no formal training on these agents for ESS, but indicated interest in educational opportunities. Many anesthesia providers are unfamiliar with safety and efficacy literature regarding agents used to improve hemostasis for ESS, highlighting a need for development of relevant educational resources. Rhinologic surgeons have an opportunity to communicate with anesthesia colleagues on the use of hemostatic agents to improve the surgical field during ESS.

Geriatrician perspectives on perioperative care: a qualitative study

BackgroundPerioperative medicine services for older surgical patients are being developed across several countries. This qualitative study aims to explore geriatricians’ perspectives on challenges and opportunities for developing and delivering integrated geriatrics perioperative medicine services.MethodsA qualitative phenomenological semi-structured interview design. All geriatric medicine departments in acute public hospitals across Australia and New Zealand (n = 81) were approached. Interviews were conducted with 38 geriatricians. Data were analysed thematically using a framework approach.ResultsGeriatricians identified several system level barriers to developing geriatrics perioperative medicine services. These included lack of funding for staffing, encroaching on existing consultative services, and competing clinical priorities. The key barrier at the healthcare professional level was the current lack of clarity of roles within the perioperative care team. Key facilitators were perceived unmet patient needs, existing support for geriatrician involvement from surgical and anaesthetic colleagues, and the unique skills geriatricians can bring to perioperative care. Despite reporting barriers, geriatricians are contemplating and implementing integrated proactive perioperative medicine services. Geriatricians identified a need to support other specialties gain clinical experience in geriatric medicine and called for pragmatic research to inform service development.ConclusionsGeriatricians perceive several challenges at the system and healthcare professional levels that are impacting current development of geriatrics perioperative medicine services. Yet their strong belief that patient needs can be met with their specialty skills and their high regard for team-based care, has created opportunities to implement innovative multidisciplinary models of care for older surgical patients. The barriers and evidence gaps highlighted in this study may be addressed by qualitative and implementation science research. Future work in this area may include application of patient-reported measures and qualitative research with patients to inform patient-centred perioperative care.

First-Trimester Abortion Complications: Simulation Cases for OB/GYN Residents in Sepsis and Hemorrhage

IntroductionSerious complications associated with first-trimester abortions are rare. The US mortality rate for these procedures is 0.7 per 100,000, primarily due to infection and hemorrhage. While complications are unlikely to arise during training, residents must be prepared to manage them in practice. To address this, we developed a 2-hour simulation-based abortion complication curriculum for OB/GYN resident learners.MethodsOB/GYN residents participated in three sessions: a case-based didactic reviewing institutional aspiration abortion practice and preop preparation; an in-vivo aspiration abortion hemorrhage simulation; and an interdepartmental postabortal sepsis simulation. Participants completed surveys before and after their participation that evaluated clinical knowledge, and self-rated competence in, and preparedness for, managing first-trimester abortion complications.ResultsResident learners (N = 26) represented all four classes of OB/GYN residents. Residents initially showed stronger clinical knowledge in managing postabortal hemorrhage than sepsis (90% vs. 62%, p < .001). Clinical knowledge improved following the sepsis simulation (62% to 91%, p < .001), and remained strong but unchanged after the hemorrhage simulation (90% to 87%, p = .3). Resident self-assessments of competence and preparedness were significantly improved after both the hemorrhage (p = .006) and sepsis (p = .002) simulations. Learners reported that the simulation increased their level of comfort in managing these complications in their future practice.DiscussionPostabortal hemorrhage and sepsis simulations increased OB/GYN residents' knowledge, comfort, and preparedness for managing rare complications of first-trimester abortions. In-vivo simulation and interdepartmental collaboration were novel aspects of these simulations that may facilitate increased preparedness and management skills.

Paracervical blocks facilitate timely brachytherapy amidst COVID-19

PurposeThe COVID-19 pandemic presents serious challenges for brachytherapists, and in the time-sensitive case of locally advanced cervical cancer, the need for curative brachytherapy (BT) is critical for survival. Given the high-volume of locally advanced cervical cancer in our safety-net hospital, we developed a strategy in close collaboration with our gynecology oncology and anesthesia colleagues to allow for completely clinic-based intracavitary brachytherapy (ICBT). Methods and MaterialsThis technical report will highlight our experience with the use of paracervical blocks (PCBs) and oral multimodal analgesia (MMA) for appropriately selected cervical ICBT cases, allowing for completely clinic-based treatment. Results18 of 19 (95%) screened patients were eligible for in-clinic ICBT. The excluded patient had significant vaginal fibrosis. 38 of 39 intracavitary implants were successfully transitioned for entirely in-clinic treatment utilizing PCBs and oral MMA (97% success rate). One case was aborted due to inadequate analgesia secondary to a significantly delayed case start time (PO medication effect diminished). 95% of patients reported no pain at the conclusion of the procedure. The median (IQR) D2cc for rectum and bladder were 64.8 (58.6–70.2) Gy and 84.1 (70.9–89.4) Gy, respectively. Median (IQR) CTV high-risk D90 was 88.0 (85.6–89.8) Gy. ConclusionsIn a multidisciplinary effort, we have successfully transitioned many ICBT cases to the clinic with the use of PCB local anesthesia and oral multimodality therapy in direct response to the current pandemic, thereby mitigating exposure risk to patients and staff as well as reducing overall health care burden.

Letter: Neurosurgery Residency in the COVID-19 Era: Experiences and Insights From Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

To the Editor: At Thomas Jefferson University, a 1000-bed quaternary care hospital in Philadelphia, Pennsylvania, our neurosurgical service has cared for numerous patients testing positive for the novel coronavirus and also presenting with neurosurgical conditions. The institution has created a university-wide tiered system of classifying cases based on urgency and implemented strict policies governing visitation to the hospital, and has taken decisions on the management of risk of exposure and utilization of personal protective equipment (PPE). NEUROSURGERY RESIDENT ROLE IN THE HOSPITAL Neurosurgery residents have a ubiquitous role in the hospital and are often first responders. Therefore, it is of utmost importance that neurosurgery residents have 24/7 access to adequate PPE. Since neurosurgeons are often near the head, it would be prudent to follow the same precautions as our anesthesia colleagues. Based on the current recommendations, the Department of Neurosurgery at Thomas Jefferson University Hospital has been given access to powered air-purifying respirators (PAPRs). NEUROSURGERY RESIDENT EDUCATION AND TEAM MORALE While in-person conferences have been formally canceled in order to comply with social distancing criteria, we have found a way to come together, despite being separated, using the many internet-based resources that facilitate virtual group interactions. Residents are not immune to the psychological effects of the COVID-19 pandemic. The suspension of all elective surgeries has drastically changed the daily schedule of many residents, who now find themselves with more free and unstructured time. Furthermore, the health and safety of the neurosurgery residents is the top priority of our department at Jefferson. The program leadership has fought for the residents to secure adequate PPE to allow residents to respond safely and promptly to any COVID + neurosurgical emergencies. To ensure coverage, the Chief Residents have devised a new call schedule with 2 teams to minimize exposures and mandated that residents who are not working stay home. This pandemic offers a tremendous opportunity for residents to grow and discover a professional voice and identity, which is most influenced during residency training. REDISTRIBUTION OF RESIDENTS IN A PANDEMIC SURGE Neurosurgery residents are inherently facile in stressful situations, particularly in the intensive care unit (ICU) setting. Therefore, neurosurgery residents are working alongside those of general surgery to be part of a “Line Service” to place central and arterial lines in all COVID patients throughout the ICUs in the hospital. While planning for the critical care and acute inpatient needs of patients, we realize that we cannot make our plans in a vacuum—every department and clinical unit is interdependent in some way and has to unite in the fight against COVID-19. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.

Letter: The Coronavirus Disease 2019 Global Pandemic: A Neurosurgical Treatment Algorithm.