Perioperative point-of-care ultrasound for diagnosis of acute lower extremity arterial thrombosis after total hip arthroplasty revision: a case report.

PURPOSE: Acute arterial thrombosis after hip arthroplasty is a rare event associated with potentially catastrophic complications. Early clinical diagnosis of progressive limb ischemia is often difficult in the immediate postoperative period because of residual neuraxial blockade and the nonspecific nature of signs. We describe the use of point-of-care ultrasound (POCUS) in the postanesthesia care unit (PACU) to diagnose this complication early and facilitate timely intervention. CLINICAL FEATURES: A 78-yr-old female patient underwent elective right hip revision arthroplasty under spinal anesthesia and postoperatively had an absent dorsalis pedis pulse on her operative leg as screened by an audible-only Doppler. No obvious clinical symptoms were present as the patient was still under subarachnoidal blockade. A bedside POCUS vascular evaluation was performed in the PACU and showed an absence of blood flow in the superficial femoral artery, expediting the confirmation of a surgical emergency. The patient underwent a successful open thrombectomy and made an uneventful postoperative recovery. CONCLUSION: Our case report highlights the novel use and impact of bedside POCUS to assess the presence or absence of distal limb arterial blood flow and, in this case, the level of arterial occlusion.

RéSUMé: OBJECTIF: La thrombose artérielle aiguë après arthroplastie de la hanche est un événement rare associé à des complications potentiellement catastrophiques. Le diagnostic clinique précoce de l'ischémie progressive du membre est souvent difficile à poser dans la période postopératoire immédiate en raison du bloc neuraxial résiduel et de la nature non spécifique des signes. Nous décrivons l'utilisation de l'échographie ciblée (POCUS) en salle de réveil (SDR) pour diagnostiquer cette complication rapidement et faciliter une intervention rapide. CARACTéRISTIQUES CLINIQUES: Une patiente de 78 ans a bénéficié d'une arthroplastie non urgente de révision de la hanche droite sous rachianesthésie; après l'intervention, le pouls pédieux, tel que dépisté par un Doppler uniquement sonore, était absent au niveau de la jambe opérée. Aucun symptôme clinique évident n'était présent alors que la patiente était toujours sous bloc sous-arachnoïdien. Une évaluation vasculaire d'échographie ciblée a été réalisée en salle de réveil et montrait l'absence de circulation sanguine dans l'artère fémorale superficielle, confirmant l'urgence chirurgicale. La patiente a bénéficié d'une thrombectomie ouverte réussie et s'est rétablie sans incident après l'opération. CONCLUSION: Notre présentation de cas met en évidence l'utilisation innovante et l'impact de l'échographie ciblée pour évaluer la présence ou l'absence du flux sanguin artériel distal et, dans ce cas, le niveau de l'occlusion artérielle.

Preprocedural ultrasound assessment does not improve trainee performance of spinal anesthesia for obstetrical patients: a randomized controlled trial.

STUDY OBJECTIVE: This randomized controlled trial was designed to evaluate the efficacy of additional information from preprocedure ultrasound examination to aid anesthesiology trainees performing spinal anesthesia for obstetric patients. DESIGN: Trainee residents were randomly allocated to landmark technique and anatomy demonstration via ultrasound examination or landmark technique only for spinal anesthetic placement. SETTING: Obstetric delivery suite. PATIENTS: Eighty healthy obstetric patients undergoing elective cesarean delivery. INTERVENTION: Ultrasound examination prior to spinal anesthetic placement. MEASUREMENTS: The primary outcome was the number of attempts for the spinal anesthetic. Secondary outcomes included placement duration; block height; and the incidence of need for staff intervention, paresthesia, and bloody tap. Subjective ease of placement was rated on a 100-mm visual analog scale. MAIN RESULTS: Baseline demographic data were similar between the patient groups. The median number of attempts with preprocedure ultrasound and landmark was 3 (interquartile range, 2-7). This was not significantly different from the number of attempts with landmark technique only of 3 (1-60) (P=.69). The median duration of spinal placement with ultrasound and landmark was 92 (51-140) seconds vs 75 (53-126) seconds with landmark only (P=.57). There was no statistical difference between the groups in spinal placement duration, need for staff intervention, paresthesia, bloody tap, lumbar interspace, or block height. There was no difference in subjective ease of spinal placement by the resident. CONCLUSIONS: In this study of junior anesthesia trainees performing obstetrical spinal anesthesia with preprocedure ultrasound and landmark technique or landmark technique only, no significant difference was observed in the number of attempts, duration of spinal placement, subjective ease of spinal placement, or any other measured secondary outcome.

The sum of the parts detracts from the intended whole: competencies and in-training assessments.

OBJECTIVES: Despite the fact that Canadian residency programmes are required to assess trainees' performance within the context of the CanMEDS Roles Framework, there has been no inquiry into the potential relationship between residents' perceptions of the framework and their in-training assessments (ITA). Using data collected during the study of ITA, we explored residents' perceptions of these competencies. METHODS: From May 2006-07, a purposive sample of 20 resident doctors from internal medicine, paediatrics, and surgery were interviewed about their ITA experiences. Data collection and analysis proceeded in an iterative fashion consistent with grounded theory. In April 2008, a summary of recurrent themes was presented during a focus group interview of another five residents to afford further elaboration and refinement of thematic findings. RESULTS: The in-training assessment report (ITAR) was perceived as a primary source of residents' information on CanMEDS. Residents' familiarity with the set of competencies appeared to be quite limited and they possessed narrow definitions of the roles. Several trainees questioned the framework's relevance and some appeared confused about the overlapping nature of the roles. Although residents viewed the central Medical Expert role as the most relevant and important competency, they incorrectly perceived it as only involving the acquisition of medical and scientific knowledge. A visual rhetorical analysis of a typical ITAR suggests that the visual features found within this assessment tool may be misrepresenting the framework and the centrality of the Medical Expert role. CONCLUSIONS: Resident doctors' knowledge of CanMEDS was found to be limited. The visual structure of the ITAR appears to be a factor in residents' apparent distortion of the CanMEDS construct from its original holistic philosophy.