ISSN NUMBER: 1938-7172
Issue 13.8

Editor:
Michael A. Fiedler, PhD, CRNA

Contributing Editors:
Mary A Golinski, PhD, CRNA
Dennis Spence, PhD, CRNA

Assistant Editor
Heather Whitten, MEd.


A Publication of Lifelong Learning, LLC © Copyright 2019

New health information becomes available constantly. While we strive to provide accurate information, factual and typographical errors may occur. The authors, editors, publisher, and Lifelong Learning, LLC is/are not responsible for any errors or omissions in the information presented. We endeavor to provide accurate information helpful in your clinical practice. Remember, though, that there is a lot of information out there and we are only presenting some of it here. Also, the comments of contributors represent their personal views, colored by their knowledge, understanding, experience, and judgment which may differ from yours. Their comments are written without knowing details of the clinical situation in which you may apply the information. In the end, your clinical decisions should be based upon your best judgment for each specific patient situation. We do not accept responsibility for clinical decisions or outcomes.

Table of Contents

GENERAL
Use of an anaesthesia workstation barrier device to decrease contamination in a simulated operating room

OBSTETRIC ANESTHESIA
Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study

REGIONAL ANESTHESIA
Is COMBIPECS the answer to perioperative analgesia for breast surgery? A double blinded randomized controlled trial

None of the editors or contributors have any real or potential conflicts of interest to disclose.

 

This program has been prior approved by the American Association of Nurse Anesthetists for 20 Class A CE credits; Code Number 1037484; Expiration Date 03/31/2022.

General
Use of an anaesthesia workstation barrier device to decrease contamination in a simulated operating room

Br J Anaesth 2017;118:870-5

DOI: 10.1093/bja/aex097

Hunter S, Katz D, Goldberg A, Lin HM, Pasricha R, Benesh G, Le Grand B, DeMaria S


Abstract

 

Purpose   The purpose of this study was to determine if using an anesthesia workstation barrier reduced contamination of the intraoperative environment.

 

Background   Nosocomial infections continue to be a significant problem in healthcare delivery. Anesthesia providers have been shown to have low adherence rates to hand hygiene guidelines. Even with good hand hygiene, however, contamination of the anesthesia workstation can still occur. Previous research has demonstrated that double gloving prior to intubation reduces contamination rates from 50.5% to 12.5% (P < 0.001). However, double gloving requires the anesthesia professional to remember to double glove. An alternative may be to place a physical barrier over the anesthesia workstation; this may help reduce cross-contamination because the clear barrier is present during a dirty portion of the anesthetic and could be discarded after induction. It also does not require the anesthesia professional to remember to double glove. The investigators hypothesized that a clear physical barrier would reduce the overall rate of contamination of the intraoperative environment between groups randomized to an anesthesia workstation barrier or no barrier.

 

Methodology   This was a randomized controlled trial of 42 residents and staff anesthetists conducted in a simulation center. Participants were randomized to conduct a simulated induction of anesthesia for a patient undergoing an appendectomy with or without a clear, physical barrier covering the anesthesia workstation. [Editor’s Note: a picture of the barrier is available at: https://bjanaesthesia.org/article/S0007-0912(17)30051-X/fulltext] The barrier was made out of waterproof clear plastic taped over the surface of the anesthesia workstation, manual ventilation bag, adjustable pressure limiting valve, ventilator switch, and ventilator/vital signs monitor.

 

Participants wore masks and gloves but were not provided with hand sanitizer. [Editor’s Note: the investigators did not state if participants were instructed or observed performing hand hygiene prior to entering the simulated environment.] Induction proceeded in a standard fashion with preoxygenation, a rapid sequence induction with propofol and succinylcholine, tracheal intubation, taping of the eyes and endotracheal tube, and maintenance of anesthesia with volatile anesthetic. Non-depolarizing agent administration was prompted by the surgeon asking for skeletal muscle relaxation. Then the surgical time out occurred. Participants randomized to the barrier group were instructed to remove the barrier when the surgical time-out occurred. At this time subjects were instructed to remove their gloves and the simulation continued for five more minutes. Participants were observed administering an analgesic via the stop-cock.

 

Before participants entered the room, 1 mL of fluorescent marker was placed in the oropharynx of the mannequin. Fourteen target sites were examined for the presence of contamination. Prior to every simulated case the room was cleaned with soap and water wipes to ensure complete removal of the dye. Statistical analysis and sample size calculations were appropriate. A P < 0.05 was considered significant.

 

Sites examined for the presence of Fluorescein dye included:

  • Manual ventilation bag
  • Vital signs monitor
  • Unused laryngoscope on workstation
  • Unused oral airway on workstation
  • Mannequin eyes
  • Adjustable pressure limiting valve
  • Anesthesia workstation drawers and handle
  • Ventilator circuit tubing
  • Ventilator switch
  • Drug cart drawers and handles
  • Anesthesia workstation surface
  • Ventilator monitor
  • IV stopcock
  • Drug cart surface

Result   The control group had 10 residents and 11 staff attending anesthetists and the barrier group had 13 residents and 8 staff attending anesthetists. In the control group, the staff attending anesthetists had a higher average rate of contamination compared to residents (36% vs. 4%, P = 0.001). Rates of contamination between attendings and residents in the barrier group were similar (21% vs. 18%, P = NS).

 

Site specific contamination rates were significantly different between the barrier and control group at 6 of the 14 sites. Sites with higher contamination rates in the control group included:

  • adjustable pressure limiting valve
  • manual ventilation bag
  • ventilator switch
  • anesthesia workstation
  • anesthesia circuit
    • (each of the above P<0.01)
  • IV stopcock (P = 0.029)

In the control group the greatest contamination was found on the manual ventilation bag, circuit, and the adjustable pressure limiting valve, each of which were contaminated >75% of the time.

 

Contamination at other locations were similar between groups (Figure 1).

 

Figure 1. Site Contamination: Control vs. Barrier

 

Conclusion   Results suggest use of a clear plastic barrier on the anesthesia workstation may reduce the risk of contamination of the intraoperative environment during induction of anesthesia.

 

Comment

 

At my facility we have been encouraged to double glove during induction of anesthesia. I have tried to do it but changing a habit (not double gloving) that is 20-years old is hard! So, when I saw this article I was intrigued. The results seem encouraging, but I think it would take quite a bit of time to get used to. Essentially your anesthesia workstation is covered with a plastic bag. I would be worried during a crisis the bag may get in the way. Also, from the picture I think it might be hard to see the monitors (see https://bjanaesthesia.org/article/S0007-0912(17)30051-X/fulltext). Therefore, I am not sure this intervention would be widely accepted.

 

So, what should we do? Well, try to remember to double glove. After induction of anesthesia (or whenever you contaminate a surface) take some time to wipe down all surfaces (including the bed control) with a cleaning wipe. Teach students this practice. And ALWAYS remember to do frequent hand hygiene. One of the main findings of this study was that attending anesthetists had higher rates of contamination compared to anesthesia residents. So maybe we can learn a thing or two from the young ones!

Dennis Spence, PhD, CRNA


Notes: The original article summarized here is available free full text at the following url: https://bjanaesthesia.org/article/S0007-0912(17)30051-X/fulltext

 

The views expressed in this article are those of the author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.

 


© Copyright 2019 Anesthesia Abstracts · Volume 13 Number 8, September 2, 2019




Obstetric Anesthesia
Operating room-to-incision interval and neonatal outcome in emergency caesarean section: a retrospective 5-year cohort study

Anaesthesia 2018;73:825-831

DOI: 10.1111/anae.14296

Palmer E, Ciechanowicz S, Reeve A, Harris S, Wong DJN, Sultan P


Abstract

 

Purpose   The purpose of this study was to determine what effect, if any, anesthetic technique and other factors had on the operating room - to - incision interval for cesarean section. A secondary purpose was to examine whether or not any of these factors were associated with APGAR scores less than 7.

 

Background   The need for an emergency cesarean delivery is defined by a compromise that is an immediate threat to the life of the mother or fetus. A decision - to - delivery interval (DDI) of no more than 30 minutes is recommended. The DDI includes transferring the mother to the operating room, starting anesthesia, and deliver of the fetus. The operating room - to - incision interval (ORII) is defined as the time from entering the operating room to the surgical incision. There is limited published data on the effect of anesthetic technique or other factors on ORII or neonatal outcomes.

 

Methodology   This was a retrospective cohort study at a single institution in the United Kingdom. Subjects were women who underwent emergency cesarean delivery between January 2010 and December 2014. Only women who had a singleton delivery with complete anesthetic technique data were included. The primary outcome was ORII and the secondary outcome was neonatal 5-min APGAR score ≥ 7.

 

Differences in ORII based on type of anesthetic technique; i.e. general anesthesia, spinal, epidural, or combined-spinal epidural. Statistical analysis controlled for covariates such as body mass index (BMI), age, parity, delivery hours, and gestational age. A lower hazard ratio represented a shorter time to delivery. To examine differences in the 5-min APGAR scores, the investigators used logistic regression to determine if anesthetic technique or other factors were associated with an APGAR score ≥ 7. Sample size calculations were not performed. Statistical analysis was appropriate. A P < 0.05 was significant.

 

Result   During the 5-year study period, there were 9,634 cesarean deliveries, with 832 (8.6%) being emergent. Of the emergency deliveries, n = 717 were included in the analysis. The type of anesthesia in cases included in the analysis was as follows:

  • epidural top-up 44% (n = 317)
  • spinal anesthesia 23% (n = 167)
  • general anesthesia 21% (n = 147)
  • combined spinal - epidural 6% (n = 46)

Demographics and clinical characteristics were similar between the anesthetic technique groups, except that combined spinal - epidural anesthesia was more commonly administered between 1800 hours - 0800 hours compared to the other groups (65% vs. 40-44%).

 

The epidural top up group was the largest group; all other groups were compared to it. The shortest operating room to incision interval was in the general anesthesia group (P<0.0001). The median time of the ORII was approximately 46% shorter than epidural top up in those undergoing general anesthesia, 21% longer for spinal anesthesia, and about twice as long for combined spinal-epidural anesthesia (all P < 0.05; Figure 1). Women that were underweight (BMI <18.5 Kg/m2) had a 36% shorter ORII. Overweight women (BMI 25 - 30 Kg/m2) had a 26% shorter ORII compared to normal weight women. Age, parity, delivery hours, and gestational age were not predictive of ORII.

 

Despite shorter ORII times, women who underwent general anesthesia were significantly more likely to deliver a baby with an APGAR score <7 compared to women who received an epidural top-up bolus. Administration of spinal anesthesia was not not associated with any difference in AGPAR scores ≥ 7 compared to epidural top-up boluses. Body mass index, age, parity, delivery hours, and gestational age were not predictive of APGAR scores. Additionally, the ORII time was not predictive of APGAR scores being ≥ 7.

 

Figure 1. Comparison of Operating Room-to-Incision Interval Times

NOTE: ORII time = operating room to delivery interval in minutes. Symbols are group medians. Horizontal bars are group range.

 

Conclusion   Administration of general anesthesia was associated with the fastest operating room - to - incision interval but was associated with poorer neonatal outcomes (AGPARS <7). Longer operating room - to - incision times were not associated with worse neonatal outcomes.

 

Comment

 

Epidural anesthesia is considered the gold-standard for labor analgesia and can be bolused to quickly achieve surgical anesthesia for an emergency cesarean delivery. Neuraxial anesthesia is safer for the mom because pregnancy increases the risk of aspiration and failed intubation that may occur during induction of general anesthesia. General anesthesia is associated with uterine atony and bleeding, and as this study found, worse neonatal outcomes (APGAR <7) when compared to an epidural top-up despite a more rapid operating room - to - incision interval.

 

When I get called for an emergency cesarean delivery in a woman with an existing epidural, I quickly check a level and then start quickly titrating in 20 mL of 2% lidocaine with 1:200K epinephrine. My goal is to have it all injected prior to moving the patient to the bed. We then quickly prep, drape, check and level (praying the level is adequate), and cut. If not the patient either gets intubated or I titrate in ketamine if the epidural is patchy. I always use a video laryngoscope to intubate. The challenge these days is at my facility we cannot leave any prefilled syringes out (let alone any syringes pre-labeled), so inducing general anesthesia can take a few minutes.

 

The limitations of this study are that we do not know the indication for cesarean delivery or what the local anesthesia practices were. The investigators claimed that controlling for operating room - to - incision time was a surrogate marker for urgency of cesarean delivery. I assume they started blousing the epidural prior to entering to operating room. But were they able to have drugs drawn up and ready to go if general anesthesia was required? Where there any long - term adverse neonatal outcomes other than a low APGAR score? What were the cord gases? These factors may have impacted the results.

 

Overall, I felt this was a very good study and provides us with further evidence that neuraxial anesthesia is the safest option for cesarean delivery.

 

Dennis Spence, PhD, CRNA


Notes: The original article summarized here is available free full text at the following url: https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14296

 

The views expressed in this article are those of the author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.

 


© Copyright 2019 Anesthesia Abstracts · Volume 13 Number 8, September 2, 2019




Regional Anesthesia
Is COMBIPECS the answer to perioperative analgesia for breast surgery? A double blinded randomized controlled trial

Indian J Anaesth 2019;63:530-536

DOI: 10.4103/ija.IJA_222_19

Khemka R, Chakrborty A, Agrawal S, Ahmed R


Abstract

 

Purpose   The purpose of this study was to determine if a COMBIPECS block (single injection PECS I and II block) provided better postoperative pain control compared to patient-controlled analgesia (IVPCA).

 

Background   Regional anesthesia techniques, such as a pectoral nerve block I and II, have been shown to provide more effective analgesia after breast cancer surgery compared to parental opioids. Opioids have been associated with reduced cellular and humoral immune function and may contribute to higher rates of cancer recurrence or metastasis. Similarly, opioids increase the incidence of postoperative nausea and vomiting (PONV). Breast cancer surgery, especially if it includes axillary dissection, requires blockade of the pectoral nerve, intercostobrachial, intercostals III, IV, V, VI and long thoracic nerve. This research group has previously demonstrated that a one-injection PECS I and II technique can provide effective analgesia (COMBIPECS); however, the combined technique has not been compared to parental opioids delivered via PCA in a randomized study.

 

Methodology   This was a prospective, randomized, controlled trial of ASA 1 and 2 patients scheduled to undergo unilateral breast surgery with axillary dissection. Patients were randomized into either a COMBIPECS group (Group P) or a control group (Group C). Group P received a COMBIPECS block after induction of anesthesia. Induction and postoperative analgesia regimens were standardized. All patients received morphine PCA with 1 mg/mL, 1 mL bolus every five minutes, maximum 10 doses/hour, no basal rate and IV acetaminophen 1 GM every eight hours.

 

The COMBIPECS block was performed with ultrasound guidance after induction of general anesthesia. The block needle was passed in a plane near the 3rd rib, striking the rib and then withdrawn a little above the serratus anterior. Next, 20 mL of 0.25% levobupivacaine was injected between the pectoralis major and minor and the needle withdrawn to lie between the pectoralis minor and serratus anterior where 10 mL of 0.25% levobupivacaine was injected.

 

The primary outcome was postoperative opioid consumption. The secondary outcome was pain scores for the first 24 hours after surgery (recovery room, 1, 4, 8, 12, and 24 hours). Sample size calculations were based on detecting a 5 mg difference in morphine consumption. Patients, data collectors, and nursing staff were blinded to group assignment. However, the anesthesia professional and surgeon were not. Most statistical analyses were appropriate; however, the investigators stated they were using a Student’s t-test to compare pain scores and opioid consumption at multiple time points. The more appropriate test would have been an analysis of variance (ANOVA) which would have adjusted for multiple comparisons. A P < 0.05 was considered significant.

 

Result   A total of N = 100 women completed the study. Groups were similar on most demographics and surgical characteristics except age. Subjects in Group P were approximately 4 years older (P = 0.02). Intraoperative opioid consumption was lower in Group P compared to Group C (mean difference = 5.12 mg); however, anesthesia professionals were not blinded to group assignment. The rate of PONV was significantly lower in Group P in the recovery room through 8 hours after surgery (P < 0.05). Mean pain scores were very slightly lower at all time points but the authors do not report standard deviations or P values. Opioid consumption was lower at 1, 4 and 8 hours after surgery but, again, the authors do not report standard deviations or P values. Results are presented in Figures 1 and 2.

 

Figure 1. Postoperative Pain Scores

Notes: VAS = visual analogue scale. Group P = COMBIPECS, Group C = Control.

 

Figure 2. Postoperative Opioid Consumption

Notes: Group P = COMBIPECS, Group C = Control.

 

Conclusion   The COMBIPECS block may have reduced postoperative pain scores and opioid consumption in patients undergoing breast cancer surgery with axillary dissection.

 

Comment

 

Pectoral nerve blocks (PECS I and II) are becoming popular blocks for breast cancer surgery. At my facility we do them for most cases, and if not, the surgeon directly infiltrates local anesthetic in the fascial planes between the pectoralis major and minor muscles. We are finding results similar to what the authors found in this study. The blocks are fairly easy to do once you are familiar with the ultrasound anatomy. The COMBIPECS block would probably be better on an awake patient because the block only requires a single injection.

 

The study design was appropriate; however, the statistical analysis for measuring repeated data, pain scores and opioid consumption, was inappropriate and there is a risk of a type I error (finding a difference when none truly exists). The authors did not report the standard deviation, so it is difficult to accurately assess the results. I suspect the standard deviation were quite large at 12 and 24 hours for postoperative opioid consumption because I would have expected to find significant differences at these time points with such a large mean difference (approximately 5 mg).

 

Nonetheless, I think the results suggest the COMBIPECS may be an option to consider for breast cancer surgery.

Dennis Spence, PhD, CRNA


Notes: The original article summarized here is available free full text at the following url: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6644204/

 

The views expressed in this article are those of the author and do not reflect official policy or position of the Department of the Navy, the Department of Defense, the Uniformed Services University of the Health Sciences, or the United States Government.


© Copyright 2019 Anesthesia Abstracts · Volume 13 Number 8, September 2, 2019