Protecting the Airway and the Physician: Lessons from 214 Cases of Endotracheal Intubation Litigation.

Objective: Medicolegal examination of an intervention as common as endotracheal intubation may be valuable to physicians in many specialties. Our objectives were to comprehensively detail the factors raised in litigation to better educate physicians on strategies for minimizing liability and augmenting patient safety. Methods: Publicly available court records were searched for pertinent litigation. Ultimately, 214 jury verdict and settlement reports were examined for various factors, including outcome, award, geographic location, defendant specialty, setting in which an injury occurred, patient demographics, and other causes of malpractice. Results: Ninety-two cases (43.0%) were resolved in the defendant's favor, with the remaining cases resulting in out-of-court settlement or a plaintiff's verdict. Payments from these cases were considerable, averaging $2.5 M. The most frequent physician defendants were anesthesiologists (59.8%) and emergency-physicians (19.2%), although other specialties were well represented. The most common setting of injury was the operating room (45.3%). Common factors included sustaining permanent deficits (89.2%), death (50.5%), and anoxic brain injury (37.4%). Injuries occurring in labor and delivery mostly involved newborns and had among the highest awards. Conclusions: Litigation involves injuries sustained in numerous settings. The most common factors present included sustaining permanent deficits, including anoxic brain injury. The presence of this latter injury increased the likelihood of a case being resolved with payment. Finally, deficits in informed consent were noted in numerous cases, stressing the importance of a clear process in which the physician explains specific risks (such as those detailed in this analysis), benefits, and alternatives.

Clinical Implications of Opioid Therapy.

Although opioids are potent central acting broad-spectrum analgesics, their effectiveness is diminished by various factors pertaining to their metabolism, drug interactions, genetic issues, adverse/side effects, and potential for abuse. All these factors present potential barriers to effective analgesia requiring specific considerations in clinical practice, which include monitoring and case-based intervention.

Gabapentin Does Not Appear to Improve Postoperative Pain and Sleep Patterns in Patients Who Concomitantly Receive Regional Anesthesia for Lower Extremity Orthopedic Surgery: A Randomized Control Trial.

In recent years, gabapentin has gained popularity as an adjuvant therapy for the treatment of postoperative pain. Numerous studies have shown a decrease in pain score, even with immediate postoperative activity, which is significant for early post-op ambulation and regaining functionality sooner. However, studies have been in conclusive in patients undergoing lower extremity orthopedic surgery. For this reason, we hoped to study the effect of gabapentin on postoperative pain in patients undergoing total knee arthroplasty, total hip arthroplasty, or a hip fracture repair. This was done in the setting of ensuring adequate postoperative analgesia with regional blocks and opioid PCA, as is protocol at our institution. Given the sedative effects of gabapentin and the potential for improving postoperative sleep patterns, we also studied the drug's effect on this aspect of our patient's postoperative course. We utilized the Pittsburg Sleep Quality Index and Visual Analog Scale for pain to obtain a more objective standardized score amongst our study population. Our results indicate that gabapentin does not offer any additional relief in pain or improve sleep habits in patients who have received either a femoral or lumbar plexus block for lower extremity orthopedic surgery. This trial is registered with NCT01546857.

Factors associated with preparedness of the US healthcare system to respond to a pediatric surge during an infectious disease pandemic: Is our nation prepared?

OBJECTIVE: Recent incidents have demonstrated that the US health system is unprepared for infectious pandemics resulting in a pediatric surge. Development of efficient plans and a structured and coordinated regional response to pediatric pandemic surge remains an opportunity. To address this gap, we conducted a literature review to assess current efforts, propose a response plan structure, and recommend policy actions. DESIGN: A literature review, utilizing MEDLINE and PubMed, through March 2017 identified articles regarding infectious disease pandemics affecting the US pediatric population. After review of current literature, a proposed response plan structure for a pediatric pandemic surge was designed. RESULTS: Inclusion and exclusion criteria reduced an initial screening of 1,787 articles to 162 articles. Articles ranged in their discussion of pediatric pandemic surge. Review of the articles led to the proposal of organizing the results according to 4 S's; (1) Structure, (2) Staff, (3) Stuff (Resources), and (4) Space. CONCLUSION: The review has supported the concern that the US health system is unprepared for a pediatric surge induced by infectious disease pandemics. Common themes suggest that response plans should reflect the 4Ss and national guidelines must be translated into regional response systems that account for local nuances.

Unrecognized arteriosclerosis is associated with wound complications after below-knee amputation.

BACKGROUND: Guillotine below-knee amputation (BKA) for wet gangrene is an unfortunate complication of poorly controlled diabetes. We examined risk factors associated with wound complications after amputation formalization in this patient population. METHODS: Retrospective data over a 4-year period were collected for patients undergoing guillotine BKA for wet gangrene followed by staged formalization. Patients with abnormal distal pulses underwent evaluation before formalization to stratify for peripheral arterial disease (PAD). Those patients with palpable pulses and no known PAD went to formalization without further investigation. Poor operative candidates underwent delayed formalization to allow for preoperative optimization. Patient history, interval between surgeries, pathology, and preformalization laboratories were tested for significance. Primary outcome was postformalization wound complication. RESULTS: Fifty-six amputations in 55 patients met inclusion criteria. Wound complications after formalization occurred in 18 cases, all BKAs (32%). A history of PAD was present in 19 patients (34.5%). On pathology, 23 patients (41%) had small-vessel atherosclerosis or arteriosclerosis. There was no association between wound complications and history of PAD (P = 0.4), preformalization albumin (P = 0.09), glucose (P = 0.9), white blood cell count (P = 0.4), or delayed versus expedited formalization (P = 0.8). Only the presence of microvascular disease on formal pathology was predictive of wound complications (P = 0.03). There was no association between microvascular disease on pathology and a history of PAD (P = 0.07). CONCLUSIONS: After formalization of lower extremity amputation for wet gangrene, traditional markers of PAD were not predictive of wound complications. Although formalization of guillotine BKA can safely be performed without significant delay, more thorough assessment of microvascular disease in the perioperative period may be useful in identifying patients at risk for wound failure.