Enhancing Patient Safety through Education in a Low-to-Middle-Income Country: Training in the Correct Application of Cricoid Pressure

Background

Cricoid pressure (CP) is applied to occlude the esophagus during endotracheal intubation in patients at an increased risk of aspiration of gastric contents. Evidence shows marked deficiencies in knowledge and skills for CP application among personnel responsible for this task. This study evaluated the effectiveness of CP training in improving knowledge and skills regarding CP application among anesthesiology technicians and critical care nurses and assessed the retention of skills after 2 months.

Methods

Five workshops were conducted on effective application of CP. Indications, relevant anatomy, physiology, and correct technique were taught using interactive sessions and videos and hands-on practice on a weighing scale, 50-mL syringe, and trainer model. Pre- and postworkshop tests were conducted for knowledge and skill. An assessment was repeated after 2 months to assess skill retention.

Results

Five workshops were conducted for 102 participants. Statistically significant improvements were seen in mean scores for knowledge in postworkshop assessments (12.32 ± 2.12 versus 7.12 ± 2.32; P < .01). Similarly, posttraining mean scores for skill assessment were significantly higher than pretraining scores (6.31 ± 0.96 versus 2.72 ± 2.00; P < .0005), indicating an overall 131% improvement. Seventy-four participants appeared for assessment of the retention of skills. A 20% decrement was observed compared with posttraining scores (5.15 ± 1.71 versus 6.45 ± 0.86; P < .0005).

Conclusions

A significant improvement was observed in both knowledge and skills immediately following training. However, this does not ensure long-term retention of clinical skills, as a 20% decrement was observed 2 months after the workshops. Formal training and regular practice are recommended to enable clinicians to perform CP effectively.

Ratio of height to thyromental distance: a comparison with mallampati and upper lip bite test for predicting difficult intubation in Pakistani population

OBJECTIVE

To compare the accuracy of three diagnostic tests in predicting difficult laryngoscopy using Cormack and Lehane grade as the gold standard.

METHODS

The cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from August 2014 to August 2015, and comprised patients who required endotracheal intubation for elective surgical procedures. The primary investigator used ratio of height to thyromental distance, upper lip bite test and the modified Mallampati test for assessing the airway correlated with laryngoscopic view based on Cormack and Lehane grading. Data was analysed using SPSS 19.

RESULTS

Of the 383 patients, 59(15.4%) were classified as difficult cases of laryngoscopy. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of ratio of height to thyromental distance were 84.7%, 90.1%, 60.9%, 97%, 89.3%; and those the corresponding values for the upper lip bite test were 83.1%, 89.2%, 58.3%, 96.7% and 88.3%. The values for the modified Mallampati test were 30.5%, 84.3%, 26.1%, 86.9% and 79.9% respectively. The area under receiver-operating characteristic curve for the first two tests was significantly more than for the modified Mallampati test (p<0.01).

CONCLUSIONS

RHTMD and ULBT both are acceptable alternatives for prediction of difficult laryngoscopy as a simple, single bed-side test.

Knowledge, training and practice of cricoid pressure application by the anesthesiologists of teaching hospitals of a developing country: A national survey

Objective: To assess the knowledge, training, and practices of cricoid pressure (CP) application among the anesthesiologists working in teaching hospitals of a developing country.Methodology: This cross-sectional study was conducted among the consultant anesthesiologists and anesthesia trainees with at least 18 months of anesthesia experience, working in teaching hospitals of four provinces of the country and one teaching hospital of the capital city. The survey was conducted through a validated questionnaire including questions regarding knowledge, training and practice of CP application among anesthesiologist working in teaching hospitals of the capital city and four provinces of Pakistan.Results: A total of 220 questionnaires were distributed, 212 were returned with a response rate of 96%. 36 (16.98%) participants made correct answers to all of the six ‘knowledge’ based questions. With respect to “training”, 116 participants (55.50%) responded that they had supervised instructions on anesthetized patients, 19 participants (9.1%) had training courses using manikins and 74 participants (35.4%) had received knowledge from books only. 210 participants responded to the questions regarding the “practice” of CP application. 197 participants (93.8%) routine practice CP.Conclusion: Based on our survey, the ‘knowledge’ of cricoid pressure application was poor among the anesthesiologists working in teaching hospitals. There are insufficient training opportunities for this important anesthesia-related skill. More specific education and simulation-based training should be made mandatory for enhancing clinical use ofcricoid pressure.Citation: Butt MN, Hoda MQ. Knowledge, training, and practice of cricoid pressure application by the anesthesiologists of teaching hospitals of a developing country: A national survey. Anaesth. pain & intensive care 2019;23(2):151-156

Bladder Distension as a Cause of Abdominal Compartment Syndrome

Abdominal compartment syndrome (ACS) is increasingly identified in critically ill patient and its harmful effects are well documented. The disparity among the pressure, volume in abdominal cavity and its contents, results in ACS. The actual incidence of ACS is not known. However, it has been observed predominantly in patients with severe blunt and penetrating abdominal trauma, ruptured abdominal aortic aneurysms, retro- and intra-peritoneal hemorrhage, pneumoperitoneum, neoplasm, pancreatitis, ascites and multiple bone fracture. We present a case of 40-year female who underwent emergency cesarean section and developed abdominal compartment syndrome due to urinary bladder distension secondary to blockade of urinary catheter with blood clots. This is a very unusual cause of ACS.

ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery

BACKGROUND

The development of supraglottic airway devices has revolutionized airway management during general anaesthesia. Two devices are widely used in clinical practice to facilitate positive pressure ventilation: the ProSeal laryngeal mask airway (pLMA) and the Classic laryngeal mask airway (cLMA). It is not clear whether these devices have important clinical differences in terms of efficacy or complications.

OBJECTIVES

To compare the effectiveness of the ProSeal laryngeal mask airway (pLMA) and the Classic LMA (cLMA) for positive pressure ventilation in adults undergoing elective surgery.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 3) in the Cochrane Library; MEDLINE (Ovid SP, 1997 to April 2017); Embase (Ovid SP, 1997 to April 2017); the Institute for Scientific Information (ISI) Web of Science (1946 to April 2017); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO host, 1982 to April 2017).We searched trial registries for ongoing studies to April 2017.We did not impose language restrictions. We restricted our search to the time from 1997 to April 2017 because pLMA was introduced into clinical practice in the year 2000.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared the effectiveness of pLMA and cLMA for positive pressure ventilation in adults undergoing elective surgery. We planned to include only data related to the first phase of cross-over RCTs.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration.

MAIN RESULTS

We included eight RCTs that involved a total of 829 participants (416 and 413 participants in the pLMA and cLMA groups, respectively). We identified six cross-over studies that are awaiting classification; one is completed but has not been published, and data related to the first treatment period for the other five studies were not yet available. Seven included studies provided data related to the primary outcome, and eight studies provided data related to more than one secondary outcome.Our analysis was hampered by the fact that a large proportion of the included studies reported no events in either study arm. No studies reported significant differences between devices in relation to the primary review outcome: failure to adequately mechanically ventilate. We evaluated this outcome by assessing two variables: inadequate oxygenation (risk ratio (RR) 0.75, 95% confidence interval (CI) 0.17 to 3.31; four studies, N = 617) and inadequate ventilation (not estimable; one study, N = 80).More time was required to establish an effective airway using pLMA (mean difference (MD) 10.12 seconds, 95% CI 5.04 to 15.21; P < 0.0001; I² = 73%; two studies, N = 434). Peak airway pressure during positive pressure ventilation was lower in cLMA participants (MD 0.84, 95% CI 0.02 to 1.67; P = 0.04; I² = 0%; four studies, N = 259). Mean oropharyngeal leak (OPL) pressure was higher in pLMA participants (MD 6.93, 95% CI 4.23 to 9.62; P < 0.00001; I² = 87%; six studies, N = 709).The quality of evidence for all outcomes, as assessed by GRADE score, is low mainly owing to issues related to blinding and imprecision.Data show no important differences between devices with regard to failure to insert the device, use of an alternate device, mucosal injury, sore throat, bronchospasm, gastric insufflation, regurgitation, coughing, and excessive leak. Data were insufficient to allow estimation of differences for obstruction related to the device. None of the studies reported postoperative nausea and vomiting as an outcome.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of either of the airway devices in terms of failure of oxygenation or ventilation because there were very few events. Results were uncertain in terms of differences for several complications. Low-quality evidence suggests that the ProSeal laryngeal mask airway makes a better seal and therefore may be more suitable than the Classic laryngeal mask airway for positive pressure ventilation. The Classic laryngeal mask airway may be quicker to insert, but this is unlikely to be clinically meaningful.

Prospective survey to study factors which could influence same-day discharge after elective laparoscopic cholecystectomy in a tertiary care hospital of a developing country

All laparoscopic cholecystectomy (LC) patients in our hospital setting are admitted overnight. This article assesses the contribution of factors like postoperative nausea and vomiting (PONV), postoperative pain and surgical complications to overnight stay after elective LC. This 1-year observational study included patients having normal liver functions undergoing elective LC before 1400 h. The collected data included patient demographics, co-morbidities, PONV, pain scores, complications, surgical time, anesthesia technique, use of prophylactic antiemetics, analgesics, patient satisfaction and desire to have this surgery as day case or in-patient procedure. From 930 LC done per annum, 45.2 % (430/950) patients were included in this study. Prophylactic antiemetic was given in 91.6 %, intraoperative narcotics in 94.2 % patients and multimodal analgesia in 85.3 %. The mean pain score in the recovery and ward was maintained to <4. In the ward, 99.1 % patients were able to start oral fluids after 6 h and were started on oral non-steroidal anti-inflammatory drugs and paracetamol, and none required parental opioid. The PONV score of more than 2 was observed in only 3.2 % of patients in the ward requiring parenteral antiemetic. Surgical complications in the form of bleeding, visceral injury and bile duct leak were observed in 2 % of patients, which was treated intra-operatively. Satisfaction was observed in 99.3 % and desire to stay overnight in 87.4 % of patients. Factors like postoperative pain, PONV and surgical complications were well managed and were not associated with significant morbidity to justify routine overnight admission. However, majority of the patients desired to stay overnight, which could be improved by counseling and education.

Prevention of hypotension associated with the induction dose of propofol: A randomized controlled trial comparing equipotent doses of phenylephrine and ephedrine

BACKGROUND AND AIMS

Propofol, the most commonly used intravenous (IV) anesthetic agent is associated with hypotension on induction of anesthesia. Different methods have been used to prevent hypotension but with variable results. The objective of this study was to evaluate efficacy of equipotent doses of phenylpehrine and ephedrine in preventing the hypotensive response to the induction dose of propofol.

MATERIAL AND METHODS

One hundred thirty five adult patients were randomised to one of the study groups: propofol-saline (PS), propofol-phenylephrine (PP) or propofol-ephedrine (PE) by adding study drugs to propofol. Anesthesia was induced with a mixture of propofol and the study drug. Patients were manually mask-ventilated for 5 min using 40% oxygen in nitrous oxide and isoflurane at 1%. A baseline mean arterial pressure (MAP) was recorded prior to induction of anesthesia. Systolic, diastolic and mean blood pressure and heart rate were recorded every minute for up to 5 min after induction. Hypotension was defined as a 20% decrease from the baseline MAP.

RESULTS

There were no significant demographic differences between the groups. Overall incidence of hypotension in this study was 38.5% (52/135). Rate of hypotension was significantly higher in group PS than group PP (60% vs. 24.4% P = 0.001) and group PE (60% vs. 31.1% P = 0.005). In contrast, a significant difference in rate of hypotension was not observed between groups PP and group PE.

CONCLUSION

In equipotent doses, phenylephrine is as good as ephedrine in preventing the hypotensive response to an induction dose of propofol.

Audit of an acute pain service in a tertiary care hospital in a developing country

The first anaesthesia based acute pain service (APS) was introduced in Pakistan at the Aga Khan University Hospital in July 2001, with the aim of patient safety and satisfaction. The American Society of Anesthesiologist task force guidelines were used for the introduction of APS. APS has managed 6810 patients during four and half years period. Common analgesic techniques used, were intravenous infusion (50%), patient controlled intravenous analgesia (18%) and epidural infusions (30%). Common reported side effects were nausea and vomiting with intravenous infusion (10%) and PCIA (10%) while motor block was noticed with epidural infusion (29%). This article aims to share experience with the initial setup of APS, difficulties faced after establishment of APS and an audit to show overall APS performance.

Comparison between tramadol and pethidine in patient controlled intravenous analgesia

OBJECTIVE

To compare the efficacy and side effects related to Tramadol with Pethidine in patient controlled intravenous analgesia (PCIA) after total abdominal hysterectomies.

METHODS

A total of 60 patients were randomized to receive either Tramadol or Pethidine by PCIA (30 in each group) after total abdominal hysterectomy. Pain assessments were recorded one hour after starting the PCIA and then at 6, 12, and 24 hours by using visual analogue scale (VAS). Nausea vomiting score and sedation score were also recorded. Good attempts, total attempts and total drug consumption was noted from PCIA pump at the end of the study period.

RESULTS

The analgesia achieved in Tramadol group was comparable to Pethidine. The incidence of nausea and vomiting was similar in both groups. Tramadol causes significantly less sedation than Pethidine (p < 0.05). Mean drug consumption, total attempts and good attempts were also significantly less in Tramadol group than Pethidine group (p < 0.05).

CONCLUSION

Tramadol produces equivalent analgesia and less sedation and can be used as an alternative to Pethidine in Patient Controlled Intravenous Analgesiafor postoperative pain relief after Total Abdominal Hysterectomy (TAH).

Unusual site of guide-wire entrapment during central venous catheterization

We are reporting a case of possible entrapment of guide wire in the region of tricuspid valve, which made it impossible to remove the guide wire from internal jugular (IJ) vein for a short while. Awareness about this rare complication is emphasized.

Drug related critical incidents

Drug related incidents are a common form of reported medical errors. This paper reviews the critical incidents related to drug errors reported from the main operating theatre suite in a teaching hospital in a developing country from January 1997 to December 2002. Each report was evaluated individually by two reviewers using a structured process. During this period, 44 874 anaesthetics were administered; 768 critical incidents were reported, 165 (21%) of which were related to drug errors. Underdosage, side-effect/drug reaction and syringe swap were the most common. A total of 76% were classified as preventable; 56% due to human error and 19% due to system error. High risk incidents accounted for 10% of all drug errors and most of these were related to the use of neuromuscular blocking drugs. This analysis has been found useful in addressing some issues about priorities.

Anaesthesia for surgical correction of scoliosis with spinal cord monitoring--a case series

OBJECTIVE

To share our experience of anaesthetic management of scoliosis with intra-operative somatosensory evoked potential monitoring and wake up test.

METHODS

All the cases of scoliosis surgery scheduled during a period of two years in which SSEP and intra-operative wake-up test was planned were included in the study. The patient in which intra-operative wake-up test was not planned were excluded from this case series.

RESULTS

We managed a series of sixteen cases of scoliosis in our hospital. Eleven patients were female and five were male with the age ranging from six to twenty two years. SSEPs were monitored throughout the procedure and wake up test was done intra-operatively after surgical manipulation of spinal cord. Intra-operative wake-up test was completed successfully in all the patients. None of the patients had any neurological damage and were also successfully extubated at the end of procedure.

CONCLUSION

Intra-operative wake up test and SSEP monitoring are reliable methods for detection of intra-operative spinal cord ischemia during scoliosis surgery.

Haemodynamic effects of unilateral spinal anesthesia in high risk patients

OBJECTIVE

To assess whether a unilateral spinal anaesthesia using 0.5% hyperbaric Bupivacaine will restrict the sympathetic block to avoid the undesired cardio vascular effects.

METHODOLOGY

In this study 40 ASA III and IV patients aged between 60-90 years undergoing unilateral lower limb surgery were included. All patients received unilateral spinal anaesthesia using hyperbaric 0.5% Bupivacaine (1.1-1.8 ml according to patient's height). Patients were placed in the lateral position with operated side down and kept in this position for 10 minutes. Motor and sensory levels were assessed, and haemodynamic alterations were monitored for 30 minutes after initiation of spinal anaesthesia.

RESULTS

Unilateral spinal anaesthesia is very effective in restricting the sympathetic block as all high risk patients showed minimal haemodynamic changes following the technique.

CONCLUSION

Unilateral spinal anaesthesia is effective in restricting the sympathetic block in high risk patients.

A prospective survey of intra-operative critical incidents in a teaching hospital in a developing country

Critical incident monitoring has the advantage of identifying a potential risk to the patient without it necessarily resulting in morbidity. An added advantage in developing countries is the low cost involved in introducing the programme. This paper analyses the incidents reported from the operating room suite in a teaching hospital in a developing country from August 1997 to 31 December 1999. During the period, 20 819 anaesthetics were administered and 329 incidents were reported (1.58% of the cases). Seventy-three per cent of the incidents were reported in patients of ASA grade 1 or 2. Thirty-nine per cent occurred during induction, 51% during maintenance and 10% during emergence. Human error was the cause in 41%, equipment error in 50% and system error in 8.5%. Twenty-two per cent of the incidents resulted in minor, and 13% in major physiological disturbance. The technique has been found useful in identifying trends and selecting issues to be discussed in departmental quality assurance meetings, but requires persistent motivation of the reporting staff.