An unusual preinduction arrhythmia resulting from the presence of a Mahaim fiber

A potentially life-threatening arrhythmia appeared on the preinduction electrocardiogram of an asymptomatic young woman prior to spine surgery. The patient was evaluated by electrophysiology and had a rare accessory pathway, a Mahaim Fiber.

Ensuring appropriate timing of antimicrobial prophylaxis

BACKGROUND

Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established.

METHODS

All patients at our institution are subjected to a surgical "time-out" protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, "piggybacked" onto our existing time-out verification checklist. In addition, we compared compliance during the study period with compliance during a three-month period prior to institution of this protocol and compliance for eighteen months after institution of this protocol.

RESULTS

The average time (and standard deviation) between the antibiotic administration and the incision was 26 +/- 12 minutes for all patients. The protocol was effective in ensuring antibiotic administration at the optimal time to 316 (99.1%) of the 319 patients. Analysis of a group of forty patients who had undergone total hip or knee replacement during the three months prior to the beginning of the study demonstrated a compliance rate of 65%. The difference between this baseline compliance rate and the rate during the study period was significant (p < 0.0001). The compliance rate was 97% for 160 patients who underwent similar procedures during the eighteen months after completion of the study. Independent audits demonstrated continuation of the significantly better compliance with timing of antibiotic prophylaxis for patients undergoing total hip and knee arthroplasty since the implementation of the protocol in our institution.

CONCLUSIONS

Piggybacking of verification of prophylactic antibiotic administration onto the wrong-site-surgery time-out protocol is an effective, cost-free, and easy-to-adopt method to ensure compliance with appropriate timing of prophylactic antibiotics.

Surface stimulation to determine needle direction and angle when performing an infraclavicular brachial plexus block

The infraclavicular approach to the brachial plexus is a safe and reliable technique for surgery of the upper extremity. When performing the block, the anesthesiologist must appreciate three variables: needle direction, needle angle to the chest wall, and needle depth. Surface stimulation is an easy technique that can reliably predict both needle direction and needle angle.

Safety and Efficacy of the Infraclavicular Nerve Block Performed at Low Current

It has recently been suggested that peripheral nerve or plexus blocks performed with the use of a nerve stimulator at low currents (<0.5 mA) may result in neurologic damage. We studied the infraclavicular nerve block, performed with the use of a nerve stimulator and an insulated needle, in a prospective evaluation of efficacy and safety. During a one-year period, 248 patients undergoing infraclavicular nerve block were evaluated for block success rate and incidence of neurologic complication. All blocks were performed with the use of a nerve stimulator and an insulated needle at < or =0.3 mA. Success rate was 94%, which increased to 96% with surgical infiltration of local anesthetic. There were no intraoperative or immediate postoperative complications noted. After one week, only one patient had a neurologic complaint, and this was surgically related, referable to surgery performed on the radial nerve. We conclude that infraclavicular nerve blocks performed at low currents (< or =0.3 mA) are safe and effective.

Smallpox in the 21st century

The viral disease, smallpox, was well known through the end of the 20th Century. Because it has been eradicated from natural populations, the present clinical experience with managing the disease is limited. Similarly, research in the pathophysiology, treatment, and prevention of the disease has recently become a priority. Concerns regarding smallpox as a weapon of bioterrorism have led to the implementation of a new prophylactic vaccine program, a renewal in variola vaccine research, and treatment regimens against variola infection.

The Fascia Iliaca Block For Postoperative Pain Relief After Knee Surgery

The fascia iliaca nerve block provides excellent postoperative pain relief after knee surgery. It is easy to perform, needle insertion is not directly next to nerves or vessels, and it is associated with minimal side effects. Instructive case reports as well as a description and discussion of the technique are presented.

Epidemiology, Pathophysiology, and Management of Complex Regional Pain Syndrome

Complex regional pain syndromes (CRPS) are challenging neuropathic pain states quite difficult to comprehend and treat. Although not yet fully understood, advances are being made in the knowledge of the mechanisms involved with CRPS. Patients often present with incapacitating pain and loss of function. Patients suffering from these disorders need to have treatment plans tailored to their individual problems. A comprehensive diagnostic evaluation and early and aggressive therapeutic interventions are imperative. The therapeutic approach often calls for a combination of treatments. Medications such as antiepileptics, opioids, antidepressants, and topical agents along with a rehabilitation medicine program can help a major portion of patients suffering from these disorders. Implantable devices can aid those patients with CRPS. While progress is being made in treating patients with CRPS, it is important to remember that the goals of care are always to: 1) perform a comprehensive diagnostic evaluation, 2) be prompt and aggressive in treatment interventions, 3) assess and reassess the patient's clinical and psychological status, 4) be consistently supportive, and 5) strive for the maximal amount of pain relief and functional improvement. In this review article, the current knowledge of the epidemiology, pathophysiology, diagnostic, and treatment methodologies of CRPS are discussed to provide the pain practitioner with essential and up-to-date guidelines for the management of CRPS.

What's new in practical patient monitoring and support equipment

The author discusses state-of-the-art technology for patient monitoring in office-based anesthesia. New technology includes bispectral index monitoring to evaluate the depth of anesthesia, signal extraction for more accurate oxygen saturation monitoring, and online S-T segment analysis for monitoring multiple electrocardiographic leads.

Reducing post-traumatic morbidity with pain management

Since significant pain can adversely affect multiple organ systems, many anesthesiologists believe that effective pain control can decrease perioperative and post-trauma morbidity. To achieve the goal of attenuating the physiological stress response associated with trauma, modalities such as patient-controlled analgesia, epidural infusions and peripheral nerve blocks are being utilized. This article will review the physiological response to pain, the new strategies and techniques for providing pain relief, and recent literature that evaluates the effect of the newer pain modalities on perioperative morbidity.

Hip fracture in the elderly: the effect of anesthetic technique

Seven hundred forty-nine community-dwelling, previously ambulatory, elderly patients who sustained a femoral neck or intertrochanteric fracture underwent prospective follow-up to determine whether anesthetic technique (spinal or general) had an effect on inpatient morbidity and mortality, or 1-year mortality. One hundred seven patients were excluded from the study as the anesthetic technique was "predetermined" based on a underlying medical condition. Of the remaining 642 patients, 362 (56.4%) received general and 280 (43.6%) received spinal anesthesia. Twenty (3.1%) patients died during hospitalization; 73 (11.4%) patients developed one or more postoperative medical complications. The 1-year mortality rate was 12.1%. There was no difference in inpatient morbidity and mortality, or 1-year mortality rates between patients receiving general or spinal anesthesia.

Ensuring early discharge following major surgery: orthopedic surgery

Managed care, critical pathways, and length of stay issues have a major impact on current hospital policy and patient care. In orthopedic surgery, significant strides have been made in improving efficiency, decreasing costs, and reducing length of stay. Use of vertical pathways, especially the first day of admission, the day of surgery, is important for efficient patient care. As anesthesiologists involved in the process, we must be certain that patient care is not compromised in an attempt to save money or achieve early discharge. In many studies, pain management, type of anesthesia, and amount of blood loss are not significant factors in length of hospital stay. These factors must be approached as quality-of-life issues and appropriate decisions made.

Functional outcome after hip fracture. Effect of general versus regional anesthesia

The effect of anesthetic technique on ambulation and functional recovery after hip fracture was studied in a series of 631 community dwelling, elderly patients. Functional recovery at followup was determined by an 11-item functional rating scale. In univariate analysis, recovery of ambulatory ability and percent functional recovery were significantly higher at 6 months for patients who had general anesthesia. When controlling for potential confounding variables, however, no differences were observed in recovery of ambulatory ability or percent functional recovery between the two groups at 3, 6, or 12 months after hip fracture.

Does blood transfusion increase the risk of infection after hip fracture?

OBJECTIVE

To determine whether allogeneic red blood cell transfusion is a predictor for developing an in-hospital postoperative urinary tract, respiratory, or wound infection.

STUDY DESIGN

Prospective, consecutive.

METHODS

Six hundred eighty-seven community-dwelling, ambulatory, geriatric hip fracture patients were prospectively followed; all patients had operative fracture treatment and received perioperative antibiotics.

RESULTS

Sixty-eight patients had a culture-positive infection before operative treatment. One hundred thirty-four of the remaining 619 patients (21.6%) developed a postoperative infection, primarily a urinary tract infection. The infection rate was 26.8% in transfused patients compared with 14.9% in nontransfused patients (p = 0.001). When stratifying by the type of infection, only the risk of urinary tract infection was statistically significant (p = 0.001). After controlling for the effect of patient age, sex, number of preinjury medical comorbidities, American Society of Anesthesiologists (ASA) rating of operative risk, fracture type, surgical delay, type of surgery, type of anesthesia, operative time, and blood loss, the relationship between allogeneic red blood cell transfusion and postoperative urinal tract infection remained statistically significant.

CONCLUSIONS

Geriatric hip fracture patients who receive allogeneic red blood cell transfusions are at higher risk for developing a postoperative urinary tract infection than are those patients who are not transfused.

Accidental needlesticks: do anesthesiologists practice proper infection control precautions?

Anesthesiologists as well as patients are at risk for acquiring blood-borne infections such as hepatitis and AIDS. We surveyed 2,530 anesthesiologists, a 10% random sample of the members of the American Society of Anesthesiologists, with a response rate of 57.1%, to determine the incidence of accidental needlestick exposure among anesthesia personnel and whether anesthesiologists are adhering to infection control guidelines to protect themselves and their patients from exposure to infectious diseases. Eighty-eight percent of respondents reported at least 1 accidental needlestick in the past 10 years; 21% received a needlestick from a high-risk patient and 4.5% a needlestick from a known HIV-positive patients. Residents reported significantly more accidental needlesticks from known HIV-positive patients (8.5%). Mucous membrane, open cut, eye, or other significant exposure to HIV-contaminated blood or body fluids was sustained by 8.34% of respondents in the past 10 years. Sixty percent of respondents reported they almost never reuse common syringes now compared with a 40.8% non-reuse rate (P < 0.001) in a similar survey on infection control practices conducted in 1990. Sixty-three percent reported they almost never reuse a vasopressor syringe compared with the 1990 non-reuse rate of 52.5% (P < 0.001). In the current survey, 39% of anesthesiologists reported reusing syringes from one patient to another and 36% reported reusing the same vasopressor syringes for different patients.(ABSTRACT TRUNCATED AT 250 WORDS)