Impact of diabetes mellitus on the frequency of post-operative complications after carotid endarterectomy.

BACKGROUND: There is significant controversy surrounding the link between diabetes mellitus and post-operative complications after carotid endarterectomy (CEA). The aim of this study was to identify the possible effects of diabetes on the frequency of post-operative complications after CEA. METHODS: This prospective study was conducted at the Dedinje Clinic for Vascular Surgery, Belgrade. The patients who underwent CEA were divided into two groups: group A (37.7%) included 98 (35.1%) insulin-dependent and 181 (64.9%) insulin-independent diabetic patients, and group B (62.3%) comprised non-diabetic subjects. RESULTS: The pre-operative characteristics were similar, except for a greater prevalence of dyslipidaemia in patients with diabetes. Post-operative cardiac events occurred more often in patients with diabetes (3.6%) than in non-diabetic patients (1.1%) (p = 0.039); post-operative neurological events among patients with diabetes were 3.6% and among non-diabetics, 0.9% (p = 0.009). Peri-operative mortality rate was 2.5% in the diabetic group and 0.9% in the non-diabetic group. The total percentage of post-operative complications was two or more times higher in the diabetic group than the non-diabetic group (8.5 vs 18.3%, p < 0.001). CONCLUSIONS: Diabetes mellitus increased the surgical risk of CEA. Higher rates of mortality and post-operative complications were observed in patients being treated with oral antidiabetics than in those on insulin.

Perioperative cardiac evaluation of simulated patients by practicing anesthesiologists is not consistent with 2007 ACC/AHA guidelines.

STUDY OBJECTIVE: To determine if practicing anesthesiologists recommend preoperative evaluations consistent with the 2007 ACC/AHA guidelines on perioperative care. DESIGN: Survey instrument. SETTING: Academic medical center. SUBJECTS: ASA membership. MEASUREMENTS: In this Web-based survey, participants were presented with 6 clinical scenarios characterized by surgical procedure and the patient's clinical condition (ie, clinical risk factors and functional capacity). Scenarios and possible recommendations were presented randomly. Participants were asked to select the recommendation they considered to be most consistent with the Guidelines. The percentage of participants selecting the recommendation most consistent with the 2007 Guidelines was recorded. MAIN RESULTS: Of the 22,504 actively practicing members of the ASA who were sent a survey, 1,595 actively practicing self-selected anesthesiologists responded. For one of 6 scenarios, patients with an active cardiac condition, the upper 95% confidence bound for the percent selecting a recommendation consistent with the Guidelines was 82%. For the remaining 5 scenarios, the upper 95% confidence bound for the percent of anesthesiologists with an appropriate recommendation did not exceed 40%. With the exception of the scenario describing a patient with an active cardiac condition, respondents were more likely to provide recommendations consistent with the Guidelines if they had been in practice less than 5 years or worked in a teaching environment. CONCLUSION: When evaluating simulated patients, practicing anesthesiologists who are ASA members did not recommend preoperative evaluations that were consistent with the 2007 ACC/AHA Guidelines.

Use of a cardiac algorithm in a preoperative evaluation clinic - a pilot study.

The preoperative evaluation is vital in providing information to reduce the risks associated with the anesthesia and surgery and improve the quality of care. In the VA Nebraska-Western Iowa Health Care System, we introduced a computer-based cardiac algorithm as part of the preoperative evaluation software. Following the pre-op examination and use of the algorithm, the provider completed a survey regarding their perceived usefulness of the algorithm software. The survey results showed that effective preoperative evaluation can be performed using a preoperative evaluation clinic, users are receptive to the computer-based format and, in most cases, prefer to have the algorithm software available for use in preoperative assessment.

Telementoring for airway management between a far forward special operations location to a major medical center using inexpensive telemedicine solutions.

Critically ill patients in remote settings have limited access to specialized care. Telemedicine/telementoring can improve access to quality care, although VTC equipment is costly. This study showed that an inexpensive internet telecom software program can be effectively employed in the intubation training of a remote trainee.

Using the Battlefield Telemedicine System (BTS) to train deployed medical personnel in complicated medical tasks - a proof of concept.

This work describes the use of Adobe Connect software along with algorithm software to provide the necessary audio visual communication platform for telementoring a complex medical procedure to novice providers located at a distant site.

A comparison of an integrated suction blade versus a traditional videolaryngoscope blade in the endotracheal intubation of a hemorrhagic cadaver model - a pilot study.

In this pilot study, we evaluated two types of videolaryngoscope blades (integrated suction vs. traditional) with the Storz CMAC videolaryngoscope in the intubation of a lightly embalmed hemorrhagic cadaver model. No significant differences were found between the devices in the success rates for the intubations. The study subjects indicated a preference for the integrated suction blade in hemorrhagic airway intubation.

Use of a malleable bougie and curved forceps with videolaryngoscopy in airway management training in a cadaver model - a pilot study.

The wider angle of view of videolaryngoscopy versus standard direct laryngoscopy requires an assessment of the adjunctive devices used to facilitate intubation. In this study, subjects performed malleable bougie-assisted intubation and curved forceps removal of a glottic foreign body using videolaryngoscopy on a lightly embalmed cadaver and completed a post-procedure questionnaire. All subjects valued access to the malleable bougie available at their hospitals and 82% valued access to the curved forceps. Malleable bougie and curved forceps seem well-suited to facilitate videolaryngoscopic airway management.

2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on perioperative cardiac evaluation are usually incorrectly applied by anesthesiology residents evaluating simulated patients.

BACKGROUND: The 2007 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines on Perioperative Cardiac Evaluation and Care for Noncardiac Surgery is the accepted standard for perioperative cardiac evaluation. Anesthesiology training programs are required to teach these algorithms. We estimated the percentage of residents nationwide who correctly applied suggested testing algorithms from the ACC/AHA guidelines when they evaluated simulated patients in common clinical scenarios. METHODS: Anesthesiology resident volunteers at 24 training programs were presented with 6 scenarios characterized by surgical procedure, patient's risk factors, and patient's functional capacity. Scenarios and 5 possible recommendations per scenario were both presented in randomized orders. Senior anesthesiologists at 24 different United States training programs along with the first author of the 2007 ACC/AHA guidelines validated the appropriate recommendation to this web-based survey before distribution. RESULTS: The 548 resident participants, representing 12% of anesthesiology trainees in the United States, included 48 PGY-1s (preliminary year before anesthesia training), 166 Clinical Anesthesia Year 1 (CA-1) residents, 161 CA-2s, and 173 CA-3s. For patients with an active cardiac condition, the upper 95% confidence bound for the percent of residents who recommended evaluations consistent with the guidelines was 78%. However, for the remaining 5 scenarios, the upper 95% confidence bound for the percent of residents with an appropriate recommendation was 46%. CONCLUSIONS: The results show that fewer than half of anesthesiology residents nationwide correctly demonstrate the approach considered the standard of care for preoperative cardiac evaluation. Further study is necessary to elucidate the correct intervention(s), such as use of decision support tools, increased clarity of guidelines for routine use, adjustment in educational programs, and/or greater familiarity of responsible faculty with the material.

Field use of the STORZ C-MAC video laryngoscope in intubation training with the Nebraska National Air Guard.

Previous studies have shown that the videolaryngoscope is an excellent intubation training tool as it allows the student and trainer to share the same anatomical view of the airway. Use of this training tool is limited; however, as many times intubation training must take place outside the hospital environment (as in the training of military health care providers). In this environment, the device can prove to be large and cumbersome. This study examined the use of the Storz CMAC, a compact video laryngoscope system, for intubation training in a simulated field hospital setting with the Nebraska National Air Guard. The study showed that the C-MAC was well-received by the trainees and would be useful in a deployment or hospital setting.

The combined use of Skype and the STORZ CMAC video laryngoscope in field intubation training with the Nebraska National Air Guard.

This study examined the feasibility of using Skype technology in basic manikin intubation instruction of Nebraska National Air Guard personnel at a Casualty Training Exercise. Results show that the Skype monitor provided clear sound and visualization of the airway view to the trainees and the combination of VoIP technology and videolaryngoscopy for intubation training was highly valued by study participants.

A comparison of videolaryngoscopic technologies.

Difficulty in managing the airway is a major contributor to the morbidity and mortality of the trauma patient. The video laryngoscope, with its camera at the distal tip of the intubation blade, allows the practitioner an improved view of the glottic opening during intubation. The image from this viewer is transmitted to a monitor, allowing the intubating practitioner to "see around the corner" of a patient's airway. The purpose of the present study was to assess and compare the video quality of commercially available video laryngoscopy systems. It was found that between the STORZ C-MAC and the Verathon GlideScope® there was little difference between the video quality; the difference came down to user preference.

Telemedicine using free voice over internet protocol (VoIP) technology.

Though dedicated videoteleconference (VTC) systems deliver high quality, low-latency audio and video for telemedical applications, they require expensive hardware and extensive infrastructure. The purpose of this study was to investigate free commercially available Voice over Internet Protocol (VoIP) software as a low cost alternative for telemedicine.