Increasing patient knowledge on the proper usage of a PCA machine with the use of a post-operative instructional card.

OBJECTIVES: The purpose of this study was to see if an instructional card, attached to the PCA machine following total hip arthroplasty describing proper use of the device, would positively affect subjects' understanding of device usage, pain scores, pain medication consumption and satisfaction. METHODS: Eighty adults undergoing total hip replacements who had been prescribed PCA were randomized into two study groups. Forty participants received the standard post-operative instruction on PCA device usage at our institution. The other 40 participants received the standard of care in addition to being given a typed instructional card immediately post-operatively, describing proper PCA device use. This card was attached to the PCA device during their recovery period. On post-operative day one, each patient completed a questionnaire on PCA usage, pain scores and satisfaction scores. RESULTS: The pain scores in the Instructional Card group were significantly lower than the Control group (p = 0.024). Subjects' understanding of PCA usage was also improved in the Instructional Card group for six of the seven questions asked. CONCLUSION: The findings from this study strongly support that postoperative patient information on proper PCA use by means of an instructional card improves pain control and hence the overall recovery for patients undergoing surgery. In addition, through improved understanding it adds an important safety feature in that patients and potentially their family members and/or friends may refrain from PCA-by-proxy. This article demonstrates that the simple intervention of adding an instructional card to a PCA machine is an effective method to improve patients' knowledge as well as pain control and potentially increase the safety of the device use.

Ketamine decreases postoperative pain scores in patients taking opioids for chronic pain: results of a prospective, randomized, double-blind study.

BACKGROUND: Patients prescribed opioids for chronic pain may suffer from inadequate postoperative pain control. Ketamine is an adjuvant demonstrating analgesic and opioid-sparing effects. We hypothesize that an intravenous ketamine infusion in addition to opioid-based patient-controlled analgesia (PCA) improves postoperative pain relief in this patient population. METHODS: We evaluated 64 patients with chronic pain taking opioids undergoing nononcologic surgery. Patients were randomized to receive either postoperative hydromorphone PCA and continuous ketamine (0.2 mg/kg/hour), or hydromorphone PCA and saline. Patients provided numeric rating scale (NRS) pain scores for "worst," "average," and "least" pain following surgery. The primary outcome measure was change in patients' postoperative NRS scores compared with baseline NRS. Secondary and tertiary outcomes included postoperative day one 24-hour opioid use and the amount of opioid used 24 hours prior to hospital discharge. RESULTS: Fifty-nine patients were included in the analysis. Baseline patient characteristics were similar with the exception of age. Patients using ketamine had decreased "average" pain scores (percent change between postoperative and preoperative NRS) after surgery (13.5% decrease in the ketamine group vs 15.5% increase in NRS in the placebo group, P = 0.0057). There were no differences in "worst" or "least" pain scores or postoperative opioid use. Side effects between groups were similar. CONCLUSIONS: Our study demonstrates that a postoperative ketamine infusion at 0.2 mg/kg/hour in addition to opioids results in a statistically significant reduction of "average" pain scores in patients undergoing surgery who take opioids for chronic pain. However, "least" and "worst" pain scores and the amount of opioid used postoperatively did not differ between groups. Thus, the use of a postoperative ketamine infusion at 0.2 mg/kg/hour provides limited benefit in improving pain management for this challenging population.

Extended infusion of dexmedetomidine to an infant at sixty times the intended rate.

Dexmedetomidine is an α2 adrenergic agonist which has recently been approved in the United States for procedural sedation in adults. This report describes an infant who inadvertently received an intravenous infusion of dexmedetomidine at a rate which was 60 times greater than intended. We describe the hemodynamic, respiratory, and sedative effects of this overdose.

Have personal statements become impersonal? An evaluation of personal statements in anesthesiology residency applications.

STUDY OBJECTIVE: To evaluate personal statements submitted to a major academic anesthesiology program to determine the prevalence of common features and overall subjective quality, and to survey anesthesiology program directors as to how they utilized these statements during the resident selection process. DESIGN: Structured analysis of de-identified personal statements and Internet-based survey of program directors. SETTING: Large academic anesthesiology training program. SUBJECTS: 670 applicant personal statements and academic anesthesiology program directors. MEASUREMENTS: Prevalence of 13 specific essay features and 8 quality ratings were calculated for the essays and correlated with other aspects of the residency application, as abstracted from the Electronic Residency Application Service (ERAS) files. A 6-question survey regarding use of personal statements was collected from program directors. MAIN RESULTS: 70 of 131 program directors queried responded to our survey. Interest in physiology and pharmacology, enjoyment of a hands-on specialty, and desire to comfort anxious patients were each mentioned in more than half of the essays. Candidates invited for an interview had essays that received higher quality ratings than essays of those not invited (P = 0.02 to P < 0.0001). Higher quality ratings were also strongly associated with graduation from a U.S. or Canadian medical school, applicant file screening score, female gender, and younger age. Interrater reliability was good (kappa 0.75-0.99 for structural features, and 0.45-0.65 for quality features). More than 90% of program directors found proper use of English to be a somewhat or very important feature of the essay. Only 41% found the personal statement to be very or somewhat important in selecting candidates for interview invitations. However, over 90% stated that they used the statements during actual interviews with invited applicants. CONCLUSION: The data showed a high prevalence of common features found within personal statements and a general ambivalence amongst those program directors for whom the statements were intended.

Obstructive sleep apnea is not a risk factor for difficult intubation in morbidly obese patients.

BACKGROUND: Morbid obesity (MO), obstructive sleep apnea (OSA), and neck circumference (NC) are widely believed to be independent risk factors for difficult tracheal intubation. In this study, we sought to determine whether these factors were associated with increased risk of difficult intubation in patients undergoing bariatric surgery. The predictive factors tested were OSA and its severity, as determined by apnea-hypopnea index (AHI), gender, NC, and body mass index (BMI). METHODS: All sequentially enrolled MO patients underwent preoperative polysomnography. Severity of OSA was quantified using AHI and the American Society of Anesthesiologists' OSA severity scale. All patients had a standardized anesthetic that included positioning in the "ramped position" for direct laryngoscopy. RESULTS: One hundred eighty consecutive patients were recruited, 140 women and 40 men. The incidence of OSA was 68%. The mean BMI was 49.4 kg/m(2). The mean AHI was 31.3 (range, 0-135). All the patients' tracheas were intubated successfully without the aid of rescue airways by anesthesiology residents. Six patients required three or more intubation attempts, a difficult intubation rate of 3.3%. There was an 8.3% incidence of difficult laryngoscopy, defined as a Cormack and Lehane Grade 3 or 4 view. There was no relationship between NC and difficult intubation (odds ratio 1.02, 95% confidence interval 0.93-1.1), between the diagnosis of OSA and difficult intubation (P = 0.09), or between BMI and difficult intubation (odds ratio 0.99, 95% confidence interval 0.92-1.06, P = 0.8). There was no relationship between number of intubation attempts and BMI (P = 0.8), AHI (P = 0.82), or NC (P = 0.3). Mallampati Grade III or more predicted difficult intubation (P = 0.02), as did male gender (P = 0.02). Finally, there was no relationship between Cormack and Lehane grade and BMI (P = 0.88), AHI (P = 0.93), or OSA (P = 0.6). Increasing NC was associated with difficult laryngoscopy but not difficult intubation (P = 0.02). CONCLUSIONS: In MO patients undergoing bariatric surgery in the "ramped position," there was no relationship between the presence and severity of OSA, BMI, or NC and difficulty of intubation or laryngoscopy grade. Only a Mallampati score of 3 or 4 or male gender predicted difficult intubation.