Wake Up Safe in the USA & International Patient Safety.

Patient safety is the most important aspect of anesthetic care. For both healthcare professionals and patients, the ideal would be no significant morbidity or mortality under anesthesia. Lessons from harm during healthcare can be shared to reduce harm and to increase safety. Many nations and individual institutions have developed robust safety systems to improve the quality and safety of patient care. Large registries that collect rare events, analyze them, and share findings have been developed. The approach, the funding, the included population, support from institutions and government and the methods of each vary. Wake Up Safe (WUS) is a patient safety organization accredited by Agency for Healthcare Research and Quality. Wake Up Safe was established in the United States in 2008 by the Society for Pediatric Anesthesia. The initiative aims to gather data on adverse events, analyze these incidents to gain insights, and apply this knowledge to ultimately reduce their occurrence. The purpose of this review is to describe the patient safety approaches in the USA. Through a national patient safety database WUS. Similar approaches either through WUS international or independent safety approaches have been described in Australia-New Zealand, India, and Singapore. We examine the patient safety processes across the four countries, evaluating their incident review process and the distribution of acquired knowledge. Our focus is on assessing the potential benefits of a WUS collaboration, identifying existing barriers, and determining how such a collaboration would integrate with current incident review databases or systems.

Rapid-Onset Obesity, Hypothalamic Dysregulation, Hypoventilation, Autonomic Dysregulation, and Neuroendocrine Tumour: Rare Syndrome with Myriad Anaesthesia Implications.

Anaesthesia management of a child with rapid-onset obesity, hyperphagia, and hypothalamic dysfunction syndrome is complex due to the multisystem involvement, the most important features being morbid obesity, autonomic dysfunction, and dyselectrolytemia due to hypothalamic dysfunction. The acronym of the disease was amended in 2008 to rapid-onset obesity, hyperphagia, hypothalamic dysfunction neural crest tumour to include the risk of ganglioneuroma or ganglioneuroblastoma. Patients usually require removal of tumour in the prone position. Obstructive sleep apnea, difficult airway and intravenous access, and haemodynamic lability all add to the trials faced by the paediatric anaesthesiologist. Invasive haemodynamic monitoring, ultrasonography, bispectral index monitoring, and meticulous calculation of drug dosages help in smoothening the course of anaesthesia in the presence of constant vigilance.

The Preoperative Fasting Conundrum: An Audit of Practice in a Tertiary Care Children's Hospital.

OBJECTIVE: This article aimed to study preoperative fasting times in children undergoing elective surgery and to analyze the effect of active interventions conducted to promote compliance with current fasting guidelines. METHODS: An initial audit was performed in which 85 children up to 15 years of age posted for elective surgeries were surveyed. A question- naire was circulated among nurses, resident medical officers, and surgeons to assess their knowledge regarding recent fasting guidelines and its importance. The mean preoperative fasting times were found to be much longer than the recommended guidelines. Interventions were carried out to spread awareness about recent preoperative fasting guidelines. A re-audit was done 4 months after the initial audit. RESULTS: The initial audit revealed a mean preoperative fasting time for solids and water to be 9.43 hours and 6.64 hours, respectively. About 43.6% of hospital staff believed "fasting from midnight" regimen is the best method to prevent pulmonary aspiration. Incorrect orders by doctors (47%) and ward nurses (38%) were found to be important causes of non-adherence. After the intervention, mean preoperative fasting times for solids and water decreased to 7.7 hours and 2.6 hours, respectively. CONCLUSION: Adopting simple measures such as education and multidisciplinary teamwork can optimize fasting duration and children's experi- ences preoperatively.

Quality improvement and patient safety in India-Present and future.

India is a vast, populous and diverse country, and this reflects in the state of health care as well. The spectrum of healthcare services ranges from world class at one end, to a dearth of resources at the other. In the rural areas especially, there is a shortage of trained medical personnel, equipment, and medications needed to carry out safe surgery. Several initiatives have and are being made by the government, medical societies, hospitals, and nongovernment organizations to bridge this gap and ensure equitable, safe, and timely access to health for all. Training medical personnel and healthcare workers, accreditation of healthcare facilities, guidelines, and checklists, along with documentation and audit of practices will all help in improving services. This narrative review discusses the measures that have been taken, systems that have been established and the challenges involved in ensuring quality and patient safety in India.

Comparing postgraduate anaesthesia education in India and abroad: Strengths and scope.

The quality of training is a major contributor to workforce proficiency in healthcare, and there is a definite need to achieve a uniform level of knowledge and skill in medical education programmes. There is a paucity of literature comparing postgraduate anaesthesia medical education training structure and requirements across the globe. In a zeal to achieve uniform competencies and technical skills, the strengths and scope of training programmes need to be identified. In this article, we describe the core elements of postgraduate training in various countries while proposing an amalgamation of strengths of each programme and providing a roadmap to evolve further the competency-based comprehensive curriculum proposed by the National Medical Commission of India.

Perfusion index as a predictor of working pediatric caudal block under general anesthesia- A prospective observational study.

Background and Aims: Advances in pulse oximeter technology have enabled us to measure parameters such as perfusion index (PI). We aimed to ascertain the utility of PI in the lower limb for evaluating the onset and adequacy of the pediatric caudal block under general anesthesia. The primary objective was to monitor PI trends after caudal block. The secondary objective was to compare the role of PI, heart rate (HR), and mean arterial pressure (MAP) in detecting onset and adequacy of caudal block and to ascertain whether PI was an earlier indicator in detecting adequate block. Material and Methods: Twenty-five children between 1 and 6 years, who underwent general anesthesia (GA) with caudal block were included. Baseline PI, HR, and MAP were recorded prior to and post caudal block at 5, 10, 15, 20 min and on skin incision. The onset of adequate block was defined as 100% increase of PI from baseline, 15% decrease of MAP or HR from baseline. T-test was used to compare trends of PI with baseline and the number of patients who met or failed these criteria for each of these three parameters at various time intervals wasnoted. Results: PI increased at all time intervals in 23 of 25 patients with working caudal block (P < 0.0001). By 10 min all those with a working caudal showed a 100% increase in PI. In contrast, 15% decrease in HR was not attained until 15 min where only 8 out of 23 achieved the above criteria, reaching a maximum of 20 patients at the time of incision; a 15% decrease in MAP was observed only in one patient at 5 min, reaching a maximum of eight patients at the time of incision. Conclusion: PI is an earlier and more sensitive indicator of the onset of the caudal block under general anesthesia (GA) than HR and MAP.

Specialised training in paediatric anaesthesia: Need of the hour.

Paediatric anaesthesia is an upcoming speciality which is gaining wide interest and can be a career choice for the new trainees. The need to develop paediatric anaesthesia as a speciality was realised with the progress in the field of paediatric surgery. The profile of the 'patient' encountered by a paediatric anaesthesiologist spans from an extremely premature neonate on the fringes of survival, to a full-grown adolescent equivalent to an adult. Perioperative morbidity and mortality are 2-3 times higher in infants and neonates compared to adults particularly in middle and low-income countries. The anatomical, physiological, pharmacological variations and presence of congenital cardiac, pulmonary and metabolic diseases in young children make perioperative management challenging. Special expertise and training are required for anaesthetic management of these preverbal children. In India, 3-years DM and 1-year Fellowship courses in paediatric anaesthesia are now available for specialisation. An ideal paediatric anaesthesia training centre should have substantial paediatric and neonatal patient load with exclusive intensive care facility. Paediatric anaesthesiologists, having knowledge of several facets of paediatrics and anaesthesia are capable of coordinating with health care professionals performing procedures outside the operating room. Paediatric anaesthesia, as a career thus offers a great opportunity to enhance quality and safety of anaesthesia in this high-risk surgical population. Persistent coordinated team efforts improve patient outcomes, reduce stress at work and increase job satisfaction.

Challenges and Opportunities Facing Pediatric Anesthesia Providers in Low- and Middle-Income Countries (LMICs), India.

India is a vast, populous country with a huge variability in the standards of health care. While the cities have state of the art hospitals with trained doctors, rural areas where most of the population lives, have a severe shortage of resources. Children form nearly 40% of India's population, and there is a great demand for pediatric surgical and anesthesia services. Specialty training in pediatric anesthesia, however, is still in its infancy, with the majority of children being administered anesthesia by general anesthesiologists. This review discusses the reasons behind India's ailing healthcare system and the shortage of qualified pediatric anesthesiologists. Anesthesiologists face multiple challenges in their daily work including inadequate infrastructure, paucity of medications and working equipment, nonavailability of trained help, and poor remuneration. All these factors contribute to work-related stress. On the other hand, the dearth of anesthesiologists offers ample opportunities to serve the underserved, improve the safety and quality of perioperative care in the rural areas, and improve the self-image of the anesthesiologist. A paucity of data regarding anesthesia, surgery, and work-related issues makes writing an article like this very difficult. However, it highlights the need for professional bodies to take note of these facts and play an active role in encouraging documentation, data collection, and improving standards of teaching and practice.

The troublesome triumvirate: Temporomandibular joint ankylosis, Pierre Robin syndrome and severe obstructive sleep apnoea.

Managing the paediatric airway with a multitude of issues, poses a unique anaesthetic challenge. Thorough understanding of implications of the associated co-morbidities, meticulous planning to counter the anticipated difficulties with back-up plans and optimal utilisation of modern anaesthesia techniques are the cornerstones in ensuring success in such tricky situations.

Efficacy and safety of videolaryngoscopy-guided verbal feedback to teach neonatal and infant intubation. A prospective randomised cross over study.

BACKGROUND AND AIMS: Neonatal endotracheal intubation is challenging due to the miniature anatomy, which is distinct from adults and reserves only less oxygen and time before desaturation begins. As a result, teaching neonatal intubation becomes fraught with difficulties. This study aimed to determine the efficacy and safety of videolaryngoscopy-guided verbal feedback compared to conventional laryngoscopy verbal feedback in neonatal and infant intubation. METHODS: In this prospective randomised cross over study, 24 trainees were randomly allocated to two groups, video-assisted verbal feedback followed by conventional verbal feedback (V/C) and conventional verbal feedback followed by video-assisted verbal feedback (C/V). one hundred forty-four ASA grade I-II patients aged 1 day to 6 months requiring general anaesthesia with endotracheal intubation were included. Each trainee performed three intubations with one technique and switched to other technique to perform three more intubations. Primary outcome was first attempt success rate and secondary outcomes were time to best view, time to intubation, ease of intubation, manoeuvres used and complications. RESULTS: Overall first attempt intubation success rate was higher with video-assisted verbal feedbacks compared to conventional verbal feedback (83.3% vs. 44.4%, P value = <0.001). The time to best view (19.8 s vs. 26.8 s, P value = <0.001) and intubation (30 s vs. 41.7 s) was achieved faster with video-assisted part of the study. CONCLUSION: Our study results show that video-assisted verbal feedback to trainees resulted in high intubation success rate and reduced complications like oesophageal intubation and desaturation in neonatal and infant intubations.

Premedication and Induction of Anaesthesia in paediatric patients.

Perioperative anxiety has been associated with adverse clinical outcomes such as emergence delirium, increased analgesic requirements and negative postoperative behavioural changes such as sleep disturbance, separation anxiety, eating problems and new-onset enuresis. Predictors of preoperative anxiety have been identified, and these include, among other factors, the age and temperament of the child. Any plan for anaesthetic induction in a child must take into account these factors. The anaesthetic plan must be individualised for special situations, for example, the child with behavioural disorder or at risk of aspiration. This article details the pharmacological and nonpharmacological methods to minimise preoperative anxiety and the techniques of anaesthetic induction in infants and children undergoing surgery. The benefits and limitations of inhalational and intravenous induction and the current status of rapid sequence induction in children are discussed. MEDLINE database was searched for this narrative review using the keywords including preoperative anxiety, child, premedication, paediatric and anaesthetic induction. Search was restricted to articles in English, but without any publication date restrictions.

A novel use of ultrasound for the extraction of a fractured umbilical arterial catheter.

A 7-day-old 600 grams baby with a post-conceptual age of 29 weeks presented with features suggestive of hollow viscous perforation, and was posted for an emergency laparotomy. In addition, she had a fractured indwelling umbilical arterial catheter which was planned for extraction in the same sitting. Radiological imaging showed that the catheter extended into the stump of the umbilical cord. She underwent exploratory laparotomy and ileal resection anastomosis, following which the stump was explored. However, the catheter could not be identified, and we suspected that it had embolised into the aorta. Using ultrasound guidance, we identified the catheter within the aorta. The aorta was cross-clamped, and the catheter extracted through an aortotomy which was later sutured.

Effect of preoperative education on anxiety in children undergoing day-care surgery.

BACKGROUND AND AIMS: There have been various methods tested for reducing preoperative anxiety in children, but very limited literature is available in the Indian scenario. Our aim was to analyse the effect of an informative video about the anaesthetic technique on preoperative anxiety in children. METHODS: In all, 94 children were randomly allotted into two groups. Children in the study group were shown a peer modelling video depicting induction of general anaesthesia and recovery during the preanaesthetic check (PAC). Patients in the control group were given only verbal information during PAC. Anxiety was assessed on visual analog scale (VAS) for anxiety at two times. Baseline VAS score was recorded during PAC and preoperative VAS score was assessed prior to induction of anaesthesia. The VAS score was represented as median value. Data were analysed using the Mann-Whitney U-test for ordinal data and skewed quantitative data. Categorical data was analysed by using Chi-square test and t-test was applied for quantitative data. The significance threshold of P value was set at <0.05. RESULTS: The median (interquartile range) preoperative VAS score was significantly lower in the study group [1 (0-1.3)] when compared with the control group [5 (3-5)] (P < 0.001). The mean preoperative pulse rate, mean preoperative systolic blood pressure and mean preoperative diastolic blood pressure were significantly lower in the study group when compared with the control group (P < 0.001). CONCLUSION: Multimedia information in the form of a peer modelling video helped reduce preoperative anxiety in children between 7 and 12 years of age.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block versus local infiltration during paediatric laparoscopic surgeries.

BACKGROUND AND AIMS: The purpose of this study was to compare the analgesic efficacy of ultrasonography-guided transversus abdominis plane (TAP) blocks with local port site infiltration in children undergoing laparoscopic surgeries. METHODS: After ethics committee approval and informed consent, 92 children aged 2-12 years posted for laparoscopic surgeries were randomly divided into Group T and Group L. Port site infiltration was performed in Group L by the surgeon at the time of port placement and end of surgery with 0.4mL/kg of 0.25% bupivacaine. Bilateral TAP block was performed in Group T after induction of anaesthesia, under ultrasonographic guidance with a Logiq E7 GE portable ultrasound unit and a linear 5-10 MHz probe. A 22G hypodermic needle and 0.4 mL/kg of 0.25% bupivacaine were used on each side for the TAP block. The parameters recorded were intraoperative haemodynamics, opioid requirements, postoperative pain scores and the need for rescue analgesia in the first 6 h postoperatively. RESULTS: The median (interquartile range) pain scores were significantly lower in the TAP block group than the local infiltration group at 10 min [2 (0-2.5) vs 2 (3-4); P = 0.011], 30 min [1.5 (0-3) vs 3 (2-5);P < 0.001], 1 h [1.5 (0-2) vs 2 (2-3);P < 0.001] and 2 h [2 (0-2) vs 2 (1.5-2.5); P = 0.010] postoperatively. The need for intraoperative opioids and rescue analgesia was also significantly lower in the TAP block group (P < 0.001). CONCLUSION: TAP block is superior to local infiltration for intra- and immediate postoperative analgesia in paediatric laparoscopic surgeries.