BMC anesthesiology
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Randomized Controlled Trial
Effects of an individualized analgesia protocol on the need for medical interventions after adenotonsillectomy in children: a randomized controlled trial.
It has been proposed that the dose of rescue opioids should be individually titrated to the severity of obstructive sleep apnea after adenotonsillectomy. However, a sleep study is not always available before adenotonsillectomy. This randomized, controlled and blinded trial evaluated a strategy of pain control individualized to the results of a fentanyl test, rather than the results of polysomnography, in children after adenotonsillectomy. ⋯ Compared with a conservative dosing approach, this individualized protocol may improve analgesia without a significant increase in respiratory adverse events.
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Mortality after intensive care discharge is a hot topic in critical care medicine. Many factors probably play a role: patient's comorbidities and severity of the disease may have great impact on mortality. However it should be taken into account also the level of care that characterizes the ward in which the patient is discharged to. A soft transition from intensive care units to the other hospital wards is desirable to avoid the traumatic step that the fragile post-ICU patient has to face with.
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Surgical options for patients vary with age and comorbidities, advances in medical technology and patients' wishes. This complexity can make it difficult for surgeons to determine appropriate treatment plans independently. At our institution, final decisions regarding treatment for patients are made at multidisciplinary meetings, termed High-Risk Conferences, led by the Patient Safety Committee. ⋯ Given that some change to the treatment plan was made for 12% of the patients discussed at the High-Risk Conferences, we conclude that participants of these conferences did not always agree with the original surgical plan and that the multidisciplinary decision-making process of the conferences served to allow for modifications. Many of the modifications involved reductions in procedures to reflect a more conservative approach, which might have decreased perioperative mortality and the incidence of complications as well as unnecessary surgeries. High-risk patients have complex issues, and it is difficult to verify statistically whether outcomes are associated with changes in course of treatment. Nevertheless, these conferences might be useful from a patient safety perspective and minimize the potential for legal disputes.
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The Massachusetts General Hospital is a large, quaternary care institution with 58 operating rooms, 164 anesthesiologists, 76 certified nurse anesthetists (CRNAs), an anesthesiology residency program that admits 25 residents annually, and 35 surgeons who perform laparoscopic, vaginal, and open hysterectomies. In March of 2018, our institution launched an Enhanced Recovery After Surgery (ERAS) pathway for patients undergoing hysterectomy. To implement the anesthesia bundle of this pathway, an intensive 14-month educational endeavor was created and put into effect. There were no subsequent additional educational interventions. ⋯ Implementing the anesthesia bundle of an ERAS pathway in a large anesthesia group with diverse providers successfully occurred using implementation science-based approach of intense interventions, and these results were maintained after the intervention ceased.
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Observational Study
Completeness of the operating room to intensive care unit handover: a matter of time?
Handovers of post-anesthesia patients to the intensive care unit (ICU) are often unstructured and performed under time pressure. Hence, they bear a high risk of poor communication, loss of information and potential patient harm. The aim of this study was to investigate the completeness of information transfer and the quantity of information loss during post anesthesia handovers of critical care patients. ⋯ Handover completeness is affected by time pressure, interruptions, and inappropriate surroundings, which increase the risk of information loss. To improve completeness and ensure patient safety, an adequate time span for handover, and the implementation of communication tools are required.