Multidisciplinary simulation of local anaesthetic systemic toxicity improves diagnostic and treatment skills and self-confidence for pain clinic procedural staff.

Local anaesthetic systemic toxicity (LAST) is a rare complication after outpatient interventional pain procedures, which can present as an emergent and life-threatening condition. Proficiency and confidence in managing this rare situation necessitates strategies to ensure team members can perform necessary tasks. The primary objective was to familiarse the pain clinic procedural staff-physicians, nurses, medical assistants, and radiation technologists-with concise and current instruction and an opportunity to practice in a controlled environment. A two-part series was designed and led by the pain physicians, with the assistance of the simulation centre and clinic staff. A 20 min didactic session was held to familiarise the providers with relevant details and information regarding LAST. Then, 2 weeks later, all team members participated in a simulation exercise intended to portray a LAST encounter, tasking participants to recognise and manage the condition in a team-based model. Before and after the didactic and simulation sessions, the staff was administered a questionnaire to assess knowledge of LAST signs, symptoms, management strategies, and priorities. Respondents were better able to identify signs and symptoms of toxicity and prioritise management steps, and felt more confident in recognising symptoms, starting treatment and coordinating care. Furthermore, participants emphasised the positive of debriefing, practicing a rare situation and learning strategies for effective communication, team dynamics and role clarity. FORMAT: Small group didactic session, simulation exercise in a clinical simulation lab. TARGET AUDIENCE: Attending, fellow, and resident physicians, medical students, registered nurses, certified medical assistants, and radiation technologists working in a pain clinic procedure suite. OBJECTIVES: To acquaint the pain clinic procedural staff with current training related to LAST and an opportunity to practice in a controlled environment.

Predictors and Impact of Low Diastolic Blood Pressure and Widened Pulse Pressure Following Transcatheter Aortic Valve Replacement.

BACKGROUND: The association between post-operative diastolic blood pressure (DBP) and pulse pressure (PP) with outcomes following transcatheter aortic valve replacement (TAVR) remains unclear. We sought to assess the prevalence, predictors, and impact of post-operative DBP and PP on presence of post-procedural aortic insufficiency (AI) and mortality in adults undergoing TAVR. METHODS: The study population included 194 patients who underwent TAVR from 2016 to 2017 at an academic tertiary medical center, of which 176 had invasive arterial pressures available postoperatively. Low DBP and widened PP were defined as ≤40 mmHg and ≥80 mmHg respectively on invasive arterial line on post-operative day 1. Clinical outcomes of interest included post-procedural AI and 1-year all-cause mortality. RESULTS: Post-operative low DBP and widened PP were noted in 32.4% and 58.5% of the study population. No significant association between post-operative AI and low DBP (p = 0.82) or widened PP (p = 0.32) was noted. There was a trend toward higher rates of mortality in patients with low DBP (19.3% vs 9.2%, p = 0.06) but no difference in mortality in patients with widened PP (10.7% vs 15.1%, p = 0.39) or those with ≥1+ post-procedural AI (16.7% vs 10.7%, p = 0.32). In multivariable analysis, low DBP was associated with a trend toward higher rates of 1-year mortality [odds ratio (OR) 2.43, 95% confidence interval (CI) 0.97-6.11, p = 0.06]. When excluding patients with a post-operative invasive systolic blood pressure < 80 mmHg, low DBP was associated with significantly higher risk-adjusted mortality at 1 year [OR 2.75, 95% CI (1.07-7.07), p = 0.04]. CONCLUSIONS: In this contemporary study of adults undergoing TAVR, low DBP and widened PP were widely prevalent post TAVR. Low DBP was associated with a trend toward higher rates of 1-year mortality but not with post-procedural AI.

Systematic Review of Novel Synovial Fluid Markers and Polymerase Chain Reaction in the Diagnosis of Prosthetic Joint Infection.

Prosthetic joint infection (PJI) may be underreported because of difficulty in making a diagnosis, especially in infections with low-virulence organisms. Reports of PJI cases misdiagnosed as aseptic loosening suggest that current screening and diagnostic tools are not sensitive enough to detect all infections and that PJI likely is underdiagnosed. We reviewed the literature on recently developed novel synovial biomarkers and polymerase chain reaction (PCR) technologies, of which several have proved promising as highly sensitive and specific tools for detecting PJI. We followed the recommendations of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Of 90 papers screened by title or abstract and then by full text, 15 met our inclusion criteria. Sensitivities reported in the included studies ranged from 63% to 100% for α-defensin, from 46.8% to 90.9% for interleukin 6, from 28.6% to 100% for leukocyte esterase, and from 67.10% to 95.7% for PCR. Specificities ranged from 95% to 100% for α-defensin, from 85.7% to 97.6% for interleukin 6, from 63.6% to 96.5% for leukocyte esterase, and from 12.3% to 97.8% for PCR. α-Defensin is a highly sensitive and specific screening tool that may help improve the accuracy of PJI detection, particularly in low-grade infections.