Patients' concerns and perceptions of anesthesia-associated risks at University Hospital: A cross-sectional study.

BACKGROUND/AIM: The expectation of undergoing general anesthesia triggers fear in many individuals, and such anxiety can even exceed anxiety about surgery. The only opportunity patients usually have to express their concerns and ask questions is during a preoperative visits to their anesthesiologist. Therefore, a good anesthesiologist-patient relationship is important to reduce patients' anxiety. Achieving this end requires information on patients' attitudes and concerns regarding anesthesia. This study aimed to assess patients' knowledge, attitudes, and concerns about preoperative assessment and fear associated with anesthesia at University Hospital, Jeddah, Saudi Arabia. METHODS: This cross-sectional study used a self-administered questionnaire distributed to 399 outpatients. Data were collected on patient's characteristics, perceptions about anesthesiologists, preferences for anesthetic management, and preoperative concerns regarding anesthesia. RESULTS: Most patients thought that anesthesiologists spent only 3 years in medical school and 2 years in a residency program. Survey participants had several misconceptions about anesthesiologists' role, but it did not affect ratings of their importance. Although, the confidence of patients in anesthesiologists was high, it was significantly lower than their confidence in surgeons. The most common concern expressed by the patients was based on whether anesthesiologists had sufficient experience and qualifications. CONCLUSIONS: Discussing anesthetic forms preoperatively can help decrease patients' anxiety. More efforts should be made preoperatively to address patients' high level of fear about rare side effects and discuss common side effects they tend to ignore. Preoperative preparation must allow the anesthesiologists enough time to reassure patients about their concerns, as they obtain patients' informed consent.

Variability in risk tolerance and adherence to guidelines in "go or no-go" decisions among anesthetists in Saudi Arabia.

BACKGROUND: Anesthetists deal with many situations where they decide whether proceeding with anesthesia is safe or not. These are termed "go or no-go" decisions. Although guidelines have been developed to ensure safe anesthesia, many factors affect anesthetists' decision in practice. Therefore, we aimed to assess the variability in risk tolerance when making "go or no-go" decisions among anesthetists in Saudi Arabia. MATERIALS AND METHOD: A questionnaire-based study that included anesthetists practicing in Saudi Arabia from 1--14th October 2017 was conducted. The questionnaire presented 11 clinical scenarios that involved deviation from guidelines, followed by four questions where the participants were asked to decide whether they would proceed with administering anesthesia, write a comment explaining their decision, to predict whether a colleague would make the same decision, and if they had a previous similar experience. RESULTS: A total of 124 anesthetists responded, of which 56.5% were consultants. There was no absolute consensus over the decision to proceed in any scenario. Most of the respondents who would proceed (67.35%) expected a colleague to make the same decision. Anesthetists who encountered a previous similar experience were more likely to proceed (P = 0.000). There was no significant difference among the respondents' decisions according to years of experience (P = 0.121). Analysis of the comments showed that procedure urgency and presence of alternatives to deficient resources were the most frequent factors that dictated anesthetists' decision. CONCLUSION: There is a wide variation in risk tolerance among anesthetists. Further simulation-based studies are needed to identify and address factors that affect anesthetists' decisions.

Role of academic anesthesiology department in introducing patient safety module into medical school curriculum: 5 years-experience at King Abdulaziz University, Saudi Arabia.

BACKGROUND: Medical schools' curricula face increasing number of must to add-on components. Although the World Health Organization has emphasized integrating teaching patient safety and quality improvement in medical curricula, only few medical schools have responded and included these topics in their curricula. OBJECTIVE: This article aimed to describe the process of foundation and integration of patient safety module led by academic anaesthesiology department at King Abdulaziz's Faculty of Medicine. It also describes the main achievements and the most important challenges faced during implementation of this module during the last 5 academic years to guide other aspiring academic anaesthesiology departments in other medical schools for them to replicate the success. METHODS AND SUBJECTS: Patient safety module was designed to be interprofessional and multidisciplinary module that depends on evidence-based approach to patient safety. It was offered during the 6th year medical study started in 2011-2012 as part of an integrated, hybrid, system-based curriculum at King Abdulaziz's Faculty of Medicine. The mode was delivered through interactive lecture (15% of the module contact hours), e-learning (15%), and practical sessions (70%). Student's assessment during the module included written exams and presentation of a patient safety advocacy project on group base. RESULTS: The module committee continuously assessed the outcome measures of the module that included results of student's assessment, student's satisfaction, as well as student's self-reported learning of the module outcome. The module committee continuously revised the module in the light of these outcomes. CONCLUSION: Today medical school curricula aspire to graduate market-place ready safe and efficient future physicians. This requires implementation of effective programs that help students to recognize and show appropriate clinical and patient safety skills early and continuously in their professional education.

Risk of fatigue among anesthesia residents in Saudi Arabia.

OBJECTIVES: To quantify fatigue risk and sleepiness among anesthesia residents in Saudi Arabia (SA). Methods: Between April 2014 and April 2015, all anesthesia residents training in western, central, and eastern regions in SA were invited to fill a survey. We conducted a cross-sectional self-reporting survey that included demographic data, the Epworth sleepiness scale (ESS), and 2 other scales to assess fatigue risk: a Checklist for Individual Strength (CIS) and a predefined comprehensive fatigue risk assessment previously developed by the Australian Medical Association (AMA). Results: We received 102 responses, and more than half of the individuals in the sample were at elevated risk of fatigue according to both fatigue scales. Approximately 70% reported being excessively sleepy during the day.  Conclusion: All 3 scales used in our survey suggested that local anesthesia residents in SA are sleepy and at risk of becoming fatigued. This could be multifactorial, explained by long shifts, or cultural and lifestyle habits.

Learner-Centered Debriefing for Health Care Simulation Education: Lessons for Faculty Development.

STATEMENT: Better debriefing practices may enhance the impact of simulation-based education. Emerging literature suggests that learner-centered debriefing may be effective in helping instructors identify and address learner needs while building learner's engagement and sense of responsibility for learning. This contrasts with instructor-centered approaches to debriefing, where instructors maintain unilateral control over both the process and content of the debriefing, thus limiting input and direction from learners. Although different approaches to debriefing for simulation-based education exist, the simulation literature is largely mute on the topic of learner-centered debriefing. In this article we will (1) compare and contrast learner- versus instructor-centered approaches to teaching; (2) provide a rationale for applying more learner-centered approaches to debriefing; (3) introduce a conceptual framework that highlights the key dimensions of learner- versus instructor-centered debriefing; (4) describe key variables to consider when managing the balance between learner- and instructor-centered debriefing; and (5) describe practical learner-centered strategies for various phases of debriefing.

Anesthesia for tracheostomy for huge maxillofacial tumor.

Providing sedation for patients with compromised upper airway is challenging. A 19-year-old female patient with huge maxillofacial tumor invading the whole pharynx scheduled for elective tracheostomy under local anesthesia due to compromised airway. The patient had gastrostomy tube for feeding. Venous cannulation was totally refused by the patient after repeated trials for exhausted sclerosed veins. Pre-operative mixture of dexmedetomidine with ketamine was administered through the gastrostomy tube with eutectic mixture of local anesthetics cream application over the planned tracheostomy site. The patient was sedated with eye opening to command. Local infiltration followed by tracheostomy was performed without patient complaints or recall of operative events.

Major complications related to epidural analgesia in children: a 15-year audit of 3,152 epidurals.

BACKGROUND: Complications associated with epidural analgesia in children have a reported incidence of 40-90 in 10,000 epidurals. We sought to determine the incidence of major complications with the use of continuous epidural analgesia that occurred in our centre over the past 15 years and to describe the nature of these complications. METHODS: The Acute Pain Service database at a tertiary care academic pediatric hospital was reviewed retrospectively over a 15-year period. Data were categorized according to patient age (neonate, infant, child one through eight years, and child > eight years), mode of insertion of the epidural (caudal, transsacral, lumbar, thoracic), complication type, and complication severity. RESULTS: Over the 15-year period, 3,152 epidurals were performed. The use of caudal-thoracic epidurals in neonates and infants has increased since 2007. Twenty-four major complications were identified (incidence, 7.6 in 1,000 epidurals). The rate of complications in neonates was 4.2% compared with 1.4% in infants, 0.5% in children aged one through eight years, and 0.8% in children over eight years of age. The two most common complications were local skin infection and drug error. CONCLUSIONS: Our incidence of major complications and our finding that complications were more common in neonates and infants are both consistent with previously published data. The two most common types of complications are potentially preventable.

The use of botulinum toxin and epidural analgesia for the treatment of spasticity and pain in a patient with maple syrup urine disease.

A 7-year-old boy, weighing 18 kg, was diagnosed with maple syrup urine disease (MSUD). He suffered from spasticity of the lower limbs and pain that did not respond to oral medications. Injections of botulinum toxin A (BTX-A) at 10 sites and epidural analgesia with 0.125% bupivacaine were used to treat spasticity with good results. We conclude that BTX-A combined with epidural analgesia may be a useful treatment option for incapacitating, painful spasticity related to MSUD. This treatment modality allowed a comprehensive rehabilitation program to be completed and it lasted longer than 9 months.

An experiential teaching session on the anesthesia machine check improves resident performance.

PURPOSE: A preoperative machine check is imperative, yet machine faults are missed despite experience. We hypothesized that a simulation training session would improve junior residents' ability to perform a machine check beyond the level of final year residents who received only didactic training. METHODS: In 2005, an experiential machine check training session was introduced into residency training at the postgraduate year 1 (PGY-1) level. Three weeks later, the simulation residents were asked to perform a machine check and detect ten preset faults. The control group consisted of PGY-5 residents who had received a didactic anesthesia machine lecture during their residency; these control residents were asked to perform the same machine check as the simulation residents. Data were collected from 2005 to 2008 with each cohort of incoming PGY-1 residents and graduating PGY-5 residents. When the first group of PGY-1 residents became PGY-5 residents in 2009, they were invited to return for a retention test. In all tests, the number of faults detected was recorded, and the machine check was evaluated using a checklist. RESULTS: Thirty-seven simulation residents and 27 control residents participated in the study. Simulation residents had significantly higher checklist scores than the control residents, and they identified more machine faults (both P < 0.001). Twenty-one simulation residents repeated the study in their senior year, and they continued to achieve higher checklist scores and identify more machine faults than the control residents (both P < 0.001). CONCLUSION: Our results suggest that an experiential training session allowed junior residents to achieve skills superior to those of senior colleagues after a five-year residency. This training was retained for two to four years as they continued to outperform their comparative controls.

Broncho-pleuropericardial fistula complicating staphylococcal sepsis.

This is a rare case of broncho-pleuropericardial fistula in a 12-year-old female who presented with fever, painful joint swelling, and pleural and pericardial effusion secondary to disseminated methicillin-sensitive Staphylococcus aureus infection. The pleural and pericardial effusion were drained, however, air leak was observed from both tubes and was synchronous with mechanical inspiration. A broncho-pleuropericardial fistula was suspected and confirmed with computed tomography. This case report demonstrated that disseminated S. aureus bacteremia could result in broncho-pleuropericardial fistula. The ability of disseminated staphylococcal infection to produce pnemopericardium should be added to the list of other complications associated with disseminated staphylococcal sepsis.

Reduced hemodynamic responses to tracheal intubation by the Bonfils retromolar fiberscope: a randomized controlled study.

The Bonfils retromolar intubation fiberscope is a rigid endoscope designed to enable glottic visualization and facilitate intubation under endoscopic vision. Theoretically, avoiding direct-vision laryngoscopy and thus could produce less stimulation during intubation than the conventional direct laryngoscopic procedure. This prospective randomized study was designed to compare the effect of tracheal intubation with direct vision laryngoscopy (Macintosh blade) and the Bonfils retromolar intubation fiberscope on the hemodynamic responses in ASA I patients. Forty patients scheduled for elective surgery and requiring endotracheal intubation were randomly allocated to one of two groups according to the intubating tool under sevoflurane nitrous oxide Anaesthesia (n=20 each). The retromolar group received tracheal intubation with the Bonfils retromolar fiberscope, while the direct laryngoscopy group received tracheal intubation by the direct vision laryngoscope (Macintosh blade). Heart rate and arterial blood pressure (systolic BP, diastolic BP, mean ABP) were recorded before induction of Anaesthesia, 3 minutes after induction of Anaesthesia (before intubation) and 5 successive recordings at one-minute interval after intubation. All the systolic BP, diastolic Bp, mean ABP and heart rate values in the direct laryngoscopy group were significantly higher in the 5 successive minutes after intubation in comparison with the retromolar group (P = 0.00). This might be attributed to the gentle intubating technique, by the Bonfils retromolar fiberscope, which allows quick endotracheal intubation without manipulations of the base of the tongue or epiglottis.