Response and Operating Room Preparation for the COVID-19 Outbreak: A Perspective From the National Heart Centre in Singapore.

The outbreak of coronavirus disease 2019 (COVID-19), a respiratory disease from a novel coronavirus that was first detected in Wuhan City, Hubei Province, China, is now a public health emergency and pandemic. Singapore, as a major international transportation hub in Asia, has been one of the worst hit countries by the disease. With the advent of local transmission, the authors share their preparation and response planning for the operating room of the National Heart Centre Singapore, the largest cardiothoracic tertiary center in Singapore. Protection of staff and patients, environmental concerns, and other logistic and equipment issues are considered.

Practical Considerations for Converting Operating Rooms and Post-anaesthesia Care Units into Intensive Care Units in the COVID-19 Pandemic - Experience from a Large Singapore Tertiary Hospital.

COVID-19 has spread globally, infecting and killing millions of people worldwide. The use of operating rooms (ORs) and the post-anaesthesia care unit (PACU) for intensive care is part of surge response planning. We aim to describe and discuss some of the practical considerations involved in a large tertiary hospital in Singapore. Firstly, considerations for setting up a level III intensive care unit (ICU) include that of space, staff, supplies and standards. Secondly, oxygen supply of the entire hospital is a major determinant of the number of ventilators it can support, including those on non-invasive forms of oxygen therapy. Thirdly, air flows due to positive pressure systems within the OR complex need to be addressed. In addition, due to the worldwide shortage of ICU ventilators, the US Food and Drug Administration has granted temporary approval for the use of anaesthesia gas machines for patients requiring mechanical ventilation. Lastly, planning of logistics and staff deployment needs to be carefully considered during a crisis. Although OR and PACU are not designed for long-term care of critically ill patients, they may be adapted for ICU use with careful planning in the current pandemic.

Achieving 100 percent compliance to perioperative antibiotic administration: a quality improvement initiative.

INTRODUCTION: Timely administration of prophylactic antibiotics within 60 minutes before surgical incision is important for reducing surgical site infections. This quality improvement initiative aimed to work towards achieving 100% compliance with perioperative antibiotic administration. METHODS: We examined the workflow in our Anaesthesia Information Management System (AIMS) and proposed interventions using cause-and-effect analysis of anonymised anaesthetic records from eligible surgical cases extracted from AIMS. This ultimately led to the implementation of an antibiotic pop-up reminder. The overall process was done in a few small plan-do-study-act cycles involving raising awareness, education and reorganisation of AIMS before implementation of the antibiotic pop-up reminder. Data analysis took place from August 2014 to September 2016. Compliance was defined as documented antibiotic administration within 60 minutes before surgical incision, or as documented reason for omission. RESULTS: The median monthly compliance rate, for 33,038 cases before and 28,315 cases after the reminder was implemented, increased from 67.0% at baseline to 94.5%. This increase was consistent and sustained for a year despite frequent personnel turnover. Documentation of antibiotic administration also improved from 81.7% to 99.3%, allowing us to identify and address novel problems that were initially not apparent, and resulting in several department recommendations. These included administering antibiotics later for cases with predicted longer-than-expected preparation times and bringing forward antibiotic administration in lower-segment Caesarean sections. CONCLUSION: The use of information technology and implementation of an antibiotic pop-up reminder on AIMS streamlined our work processes and brought us closer to achieving 100% on-time compliance with perioperative antibiotic administration.

Evaluation of partial carbon dioxide rebreathing cardiac output measurement during thoracic surgery.

OBJECTIVE: Noninvasive partial CO2 rebreathing (NICO; Novametrix Medical Systems, Inc, Wallingford, CT) is a relatively new alternative to thermodilution (TDCO) for measurement of cardiac output. This study compares the 2 methods during thoracic surgery and one-lung ventilation. DESIGN: A prospective, observational study. SETTING: A tertiary hospital. PARTICIPANTS: Twelve adult patients undergoing elective thoracotomy and one-lung ventilation in the lateral decubitus position. INTERVENTIONS: Paired measurements of cardiac output were performed during (1) 2-lung ventilation in the supine position (postinduction of anesthesia), (2) 10 minutes after initiation of one-lung ventilation in the lateral decubitus position with the nondependent chest open, and (3) after 30 minutes on one-lung ventilation. An average of 3 consecutive (10 mL 20 degrees C saline) TDCO measurements made during end-expiration was compared with corresponding NICO measurements. MEASUREMENTS AND MAIN RESULTS: The NICO showed a tendency to underestimate cardiac output compared with TDCO at all measurement times. Overall, bias was -0.29 L/min and limits of agreement -1.69 to 1.43 L/min. CONCLUSIONS: There was a moderate agreement between cardiac output measurements obtained with the NICO and TDCO. The present data suggest that the NICO technique may be useful during thoracic surgery.

Thoracoscopic thymectomy in a previous sternotomy.

A video assisted thoracoscopic surgery (VATS) thymectomy is a viable alternative to conventional open thymectomy in myasthenia gravis (MG). A previous operation in the same anatomical region is generally considered a relative contraindication to any minimally invasive approach in the same area. Few cases of VATS on previously operated chests have been reported. We report a case of a VATS thymectomy in a patient who had undergone two previous sternotomies for cardiac disease.

The effects of intravenous lidocaine on pain during injection of medium- and long-chain triglyceride propofol emulsions.

Propofol formulated in medium- and long-chain triglycerides (MCT/LCT) is thought to cause less pain on injection. In this study we sought to determine if adding lidocaine to propofol-MCT/LCT is more effective in decreasing pain compared with propofol-MCT/LCT alone or conventional propofol-lidocaine mixtures. Seventy-five patients were randomized into three groups. Group A received conventional propofol-lidocaine mixtures with 20 mg lidocaine, group B received propofol-MCT/LCT with saline, and group C received propofol-MCT/LCT with 20 mg lidocaine. The incidence of pain was 24% in groups A and B and 4% in group C. The number needed to treat to prevent pain was 5. We conclude that propofol-MCT/LCT-lidocaine mixtures significantly reduce pain.

The effects of remifentanil and thoracic epidural on oxygenation and pulmonary shunt fraction during one-lung ventilation.

OBJECTIVE: To compare the effects of remifentanil and thoracic epidural analgesia on the hemodynamic changes and pulmonary shunt fraction during one-lung ventilation (OLV) for thoracotomy. DESIGN: Prospective, single crossover design. SETTING: Tertiary care hospital. PARTICIPANTS: Thirty-four patients undergoing OLV for thoracic surgery. INTERVENTIONS: During general anesthesia with 2-lung ventilation, one-lung ventilation with remifentanil infusion, and one-lung ventilation with thoracic epidural anesthesia (TEA), hemodynamic parameters and arterial and mixed venous blood gases were taken from the radial and pulmonary artery catheters. During these 3 study periods, cardiac index (CI) was measured using thermodilution technique while shunt fraction (Qs/Qt), alveolar arterial oxygen gradient (A-a O(2)), and systemic (SVRI) and pulmonary vascular resistances indices (PVRI) were calculated. A p value <0.05 was taken to be statistically significant. MEASUREMENTS AND MAIN RESULTS: When OLV was instituted, there was a significant decrease in mean arterial blood pressure. Arterial oxygenation decreased, whereas CI and Qs/Qt increased during OLV, but there was no significant difference between remifentanil infusion and thoracic epidural analgesia. CONCLUSIONS: Both remifentanil infusion and TEA are suitable for analgesia during thoracic surgery when OLV is used. There was no significant difference in PaO(2) and Qs/Qt during each administration.

Predicting the depth of insertion of left-sided double-lumen endobronchial tubes.

OBJECTIVE: To analyze the parameters that predict the depth of insertion of a left-sided double-lumen tube (DLT) and to assess the accuracy of the parameters after intubation. DESIGN: Prospective. SETTING: Tertiary-care hospital. PARTICIPANTS: Patients undergoing 1-lung ventilation for thoracic surgery (n = 240). INTERVENTIONS: In the first 121 patients, the ideal depth of insertion was verified using fiberoptic bronchoscopy in the lateral position. Multiple regression analysis was used to find the correlation of this depth of insertion to the patients' height, weight, age, and the clavicular-to-carinal distance of the trachea measured from the chest radiograph. Another 119 patients were studied in whom the DLT was inserted blindly using the best regression line. The accuracy of the technique was assessed by fiberoptic bronchoscopy. MEASUREMENTS AND MAIN RESULTS: The depth of DLT insertion correlated significantly (p < 0.05) only with the height and clavicular-to-carinal distance of the trachea of the patients with the best regression line: Depth of insertion (cm) = 0.75 x clavicular-to-carinal distance of trachea (cm) + 0.112 x height (cm) + 6 with R(2) = 0.62 and p < 0.001. Using this best regression line, the DLT was placed in an acceptable position in 93 patients in the lateral position (positive predictive value of 78.2%) without further intraoperative adjustments. CONCLUSION: The ideal depth of insertion of the left-sided DLT correlated significantly with patients' height and clavicular-to-carinal distance of the trachea. The best regression line enabled the left-sided DLT to be placed in an acceptable position without complications nearly 80% of the time.