Unintended perioperative hypothermia.

BACKGROUND: Hypothermia, defined as a core body temperature less than 36°C (96.8°F), is a relatively common occurrence in the unwarmed surgical patient. A mild degree of perioperative hypothermia can be associated with significant morbidity and mortality. A threefold increase in the frequency of surgical site infections is reported in colorectal surgery patients who experience perioperative hypothermia. As part of the Surgical Care Improvement Project, guidelines aim to decrease the incidence of this complication. METHODS: We review the physiology of temperature regulation, mechanisms of hypothermia, effects of anesthetics on thermoregulation, and consequences of hypothermia and summarize recent recommendations for maintaining perioperative normothermia. RESULTS: Evidence suggests that prewarming for a minimum of 30 minutes may reduce the risk of subsequent hypothermia. CONCLUSIONS: Monitoring of body temperature and avoidance of unintended perioperative hypothermia through active and passive warming measures are the keys to preventing its complications.

Evaluating safety of handoffs between anesthesia care providers.

BACKGROUND: Anesthesia care providers frequently exchange care of patients among one another. This daily process of information exchange could be a potential source for adverse events. OBJECTIVES: Our objectives were to determine if the current handoff system is ineffective and if more standardized methods available for the exchange of patient information could improve the effectiveness of handoffs. METHODS: We distributed a survey to all anesthesia staff, residents, and nurse anesthetists. The survey queried the following: handoff adequacy, location for best handoff, method for best handoff, and need for inclusion in the electronic medical record. RESULTS: We received 80 completed initial surveys from anesthesia staff, residents, and nurse anesthetists. Of those surveyed, 20% found the existing handoff process inadequate. Most reported both giving and receiving a poor or incomplete handoff within the previous year (84% and 57%, respectively), and 25% related an adverse outcome to a poor handoff. An overwhelming majority, 89%, felt that standardization of this process could improve patient care; 68% reported that ideal handoffs would occur in the record, as well as in person; and 62% believed that handoffs should be incorporated into the electronic medical record. CONCLUSIONS: These data will be used to improve the method of the patient care handoff and have assisted us in devising techniques that can be incorporated into daily practice, advancing the safety of handoffs and decreasing complications. A handoff screen has been included on the electronic anesthesia record, encouraging a more formalized procedure for handoffs, thereby promoting patient safety.

Increase in venous complications associated with etomidate use during a propofol shortage: an example of clinically important adverse effects related to drug substitution.

Etomidate is a widely used intravenous induction agent that is especially useful for patients at risk for hypotension during anesthesia induction. Side effects limiting its use include adrenocortical suppression, acidosis, myoclonus, venous irritation, and phlebitis. The osmolality of etomidate prepared in propylene glycol appears to play a crucial role in causing phlebitis. The increased use of etomidate during the recent propofol shortage correlated with an increase in reported incidences of postoperative phlebitis and thrombophlebitis at Ochsner Clinic Foundation from October 2009 through April 2010. Several methods aim to prevent such occurrences, including pretreatment with lidocaine (and possibly esmolol), lower doses of etomidate, and injection into larger veins. The most compelling evidence suggests that using a lipid formulation of etomidate instead of the traditional propylene glycol preparation may dramatically decrease venous sequelae.

Operating room fire safety.

Operating room fires are a rare but preventable danger in modern healthcare operating rooms. Optimal outcomes depend on all operating room personnel being familiar with their roles in fire prevention and fire management. Despite the recommendations of major safety institutes, this familiarity is not the current practice in many healthcare facilities. Members of the anesthesiology and the surgery departments are commonly not actively involved in fire safety programs, fire drills, and fire simulations that could lead to potential delays in prevention and management of intraoperative fires.

Epidural Anesthesia for Cesarean Delivery in a Patient With Severe Pulmonary Artery Hypertension and a Right-to-Left Shunt.

A 38-year-old woman with severe pulmonary artery hypertension and a right-to-left shunt of unknown etiology presented at 32 weeks' gestational age. Determination of the cause of her pulmonary hypertension by transesophageal echocardiography was delayed until after delivery secondary to anesthetic risk. She was successfully anesthetized for cesarean delivery using epidural anesthesia. Systemic vascular resistance was maintained using phenylephrine hydrochloride before delivery and vasopressin after delivery. Transesophageal echocardiography after delivery revealed a patent foramen ovale, indicating a diagnosis of idiopathic pulmonary artery hypertension and a very poor prognosis. Differentiating between Eisenmenger syndrome and idiopathic pulmonary artery hypertension may not be important for determining the optimal anesthetic management of patients with pulmonary hypertension but is important in assessing long-term prognosis.

Spinal anesthesia for cesarean delivery in a patient receiving fondaparinux.

Fondaparinux sodium, a selective inhibitor of factor Xa, is a new anticoagulant being used for thromboprophylaxis in all patient populations. We outline a case of neuraxial anesthesia for cesarean delivery in a patient with recent fondaparinux use and discuss most recent literature recommendations.

Multidisciplinary approach to the management of placenta accreta.

Patients with placenta accreta have abnormally adherent placentas and are at risk for massive hemorrhage at delivery. We report 2 cases of cesarean hysterectomy in patients with placenta accreta. These patients were cared for by a multidisciplinary team consisting of a maternal fetal medicine specialist, gynecologic oncologist, anesthesiologist, neonatologist, interventional radiologist, and urologist. Favorable maternal and fetal outcomes resulted from the use of this team.

Intraoperative oxygen administration does not reduce the incidence or severity of nausea or vomiting associated with neuraxial anesthesia for cesarean delivery.

BACKGROUND: Supplemental oxygen may reduce postoperative nausea and vomiting after general anesthesia. We designed this study to evaluate the efficacy of supplemental oxygen administration for reducing nausea and vomiting in women having neuraxial anesthesia for cesarean delivery. METHODS: We conducted a prospective, randomized, double-blind study of women having standardized neuraxial anesthesia and postoperative analgesia for cesarean delivery. After umbilical cord clamp, women were randomized to receive either 70% or 21% oxygen for surgery. Nausea and vomiting were recorded at three time intervals: induction until delivery, delivery until the end of surgery, and at 24 postoperative hours. chi2 and Student's t-tests were used to determine significant differences. RESULTS: The study groups were similar with respect to demographic and procedural variables. There was no significant difference between groups in the overall incidences of nausea and vomiting. The incidence of severe nausea (rated by mothers) in the oxygen group predelivery, postdelivery, and postoperatively was 3%, 7%, and 9%, respectively, and in the medical air group was 3%, 9%, and 7%, respectively. Severe vomiting (>2 episodes) in both the oxygen and medical air groups were 0%, 2%, and 4% at the corresponding time intervals. These differences were not statistically significant. CONCLUSION: Administration of supplemental oxygen during cesarean delivery with neuraxial anesthesia does not decrease the incidence or severity of intraoperative or postoperative nausea or vomiting.

Incidence of concomitant surgery for pelvic organ prolapse in patients surgically treated for stress urinary incontinence.

OBJECTIVE: To examine the concomitant incidence of surgery for pelvic organ prolapse in patients undergoing a surgical procedure to correct stress urinary incontinence in both an academic and private urogynecology practices. STUDY DESIGN: A retrospective chart review was performed on all patients undergoing surgical correction of stress urinary incontinence over a 1-year period at 2 centers. RESULTS: Among 150 surgical procedures for stress urinary incontinence in the academic practice, 116 (77%) patients underwent at least 1 additional procedure for a pelvic support defect, and 72 (48%) patients required 2 or more concomitant reconstructive pelvic procedures. In the private urogynecology practice, 182 surgical procedures for stress urinary incontinence were performed, 153 (84%) patients required at least 1 additional procedure for a pelvic support defect, and 86 (47%) patients required 2 or more concomitant reconstructive pelvic procedures. CONCLUSION: Women who require surgical correction of stress urinary incontinence have a high incidence of concomitant pelvic support defects that require surgical repair. The incidence of concomitant surgery for pelvic organ prolapse between the 2 sites was not significantly different.

Abdominal sacral colpopexy mesh erosion resulting in a sinus tract formation and sacral abscess.

BACKGROUND: Complications associated with the use of synthetic mesh during an abdominal sacral colpopexy procedure include mesh infection and erosion into the vaginal vault and sacral osteomyelitis. CASE: This case report describes the management of an abdominal sacral colpopexy procedure that was complicated by postoperative vaginal mesh erosion, formation of a fistulous tract from the vaginal apex to the sacrum, and development of diskitis, osteomyelitis, and a sacral abscess. CONCLUSION: Treatment of a vaginal mesh erosion complicated by the formation of a sinus tract after abdominal sacral colpopexy should include extensive sinus tract resection in addition to complete mesh removal.