Anesthesiology Research and Practice The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Current Trends in Neuromuscular Blockade, Management, and Monitoring amongst Singaporean Anaesthetists Thu, 13 Oct 2016 05:53:19 +0000 Introduction. This survey aimed to investigate the attitudes/practice pertaining the use, management, and monitoring of neuromuscular blockade amongst Singaporean anaesthetists. Methods. All specialist accredited anaesthetists registered with the Singapore Medical Council were invited to complete an anonymous online survey. Results. The response rate was 39.5%. Neuromuscular monitoring (NM) was used routinely by only 13.1% despite the widespread availability of monitors. 82% stated residual NMB (RNMB) was a significant risk factor for patient outcome, but only 24% believed NMB monitoring should be compulsory in all paralyzed patients. 63.6% of anaesthetists estimated the risk of RNMB in their own institutions to be <5%. 63.1% always gave reversal. Neostigmine was predominantly used (85.1%), with 28.2% using sugammadex at least sometimes, citing unavailability and high costs. However, 83.8% believed in sugammadex’s benefits for patients’ safety and >50% said such benefits may be able to offset the associated costs. Conclusions. There is a significant need for reeducation about RNMB, studies on local RNMB incidences, and strengthening of current monitoring practices and guidelines. Strategies are discussed. As NM monitors appear widely available and reversal of NMB standard practice, it is hopeful that Singaporean anaesthetists will change and strive for evidence-based best clinical practice to enhance patient safety. Wendy H. Teoh, Thomas Ledowski, and Phillip S. Tseng Copyright © 2016 Wendy H. Teoh et al. All rights reserved. Time Trends and Predictors of Abnormal Postoperative Body Temperature in Infants Transported to the Intensive Care Unit Thu, 29 Sep 2016 08:57:40 +0000 Background. Despite increasing adoption of active warming methods over the recent years, little is known about the effectiveness of these interventions on the occurrence of abnormal postoperative temperatures in sick infants. Methods. Preoperative and postoperative temperature readings, patient characteristics, and procedural factors of critically ill infants at a single institution were retrieved retrospectively from June 2006 until May 2014. The primary endpoints were the incidence and trend of postoperative hypothermia and hyperthermia on arrival at the intensive care units. Univariate and adjusted analyses were performed to identify factors independently associated with abnormal postoperative temperatures. Results. 2,350 cases were included. 82% were normothermic postoperatively, while hypothermia and hyperthermia each occurred in 9% of cases. During the study period, hypothermia decreased from 24% to 2% () while hyperthermia remained unchanged (13% in 2006, 8% in 2014, ). Factors independently associated with hypothermia were higher ASA status (), lack of intraoperative convective warming () and procedure date before 2010 (). Independent associations for postoperative hyperthermia included lower body weight () and procedure date before 2010 (). Conclusions. We report an increase in postoperative normothermia rates in critically ill infants from 2006 until 2014. Careful monitoring to avoid overcorrection and hyperthermia is recommended. Hedwig Schroeck, Angela K. Lyden, Wendy L. Benedict, and Satya Krishna Ramachandran Copyright © 2016 Hedwig Schroeck et al. All rights reserved. Hypnosis in the Perioperative Management of Breast Cancer Surgery: Clinical Benefits and Potential Implications Sun, 21 Aug 2016 12:46:59 +0000 The aim of this review is to summarize data published on the use of perioperative hypnosis in patients undergoing breast cancer surgery (BCS). Indeed, the majority of BCS patients experience stress, anxiety, nausea, vomiting, and pain. Correct management of the perioperative period and surgical removal of the primary tumor are clearly essential but can affect patients on different levels and hence have a negative impact on oncological outcomes. This review examines the effect of clinical hypnosis performed during the perioperative period. Thanks to its specific properties and techniques allowing it to be used as complementary treatment preoperatively, hypnosis has an impact most notably on distress and postoperative pain. During surgery, hypnosis may be applied to limit immunosuppression, while, in the postoperative period, it can reduce pain, anxiety, and fatigue and improve wound healing. Moreover, hypnosis is inexpensive, an important consideration given current financial concerns in healthcare. Of course, large randomized prospective studies are now needed to confirm the observed advantages of hypnosis in the field of oncology. Arnaud Potié, Fabienne Roelants, Audrey Pospiech, Mona Momeni, and Christine Watremez Copyright © 2016 Arnaud Potié et al. All rights reserved. The Effect of Dexmedetomidine on Lumbar Epidural Injection for Failed Back Surgery Syndrome Wed, 17 Aug 2016 08:53:51 +0000 Purpose. Failed back surgery syndrome is a chronic pain condition requiring rapid, effective, and efficient management. This study evaluates the effect of adding dexmedetomidine to lumbar epidural steroids in patients with failed back surgery syndrome. Methods. Fifty patients suffering from failed back surgery syndrome were randomly assigned to one of two groups, receiving an epidural injection of 20 mL of either a mixture of betamethasone (14 mg) and bupivacaine 0.5 mg (group C) or a mixture of betamethasone (14 mg), bupivacaine 0.5 mg, and dexmedetomidine (0.5 μg/kg) (group D) adjusted to the volume with normal saline. The effect was evaluated using visual analogue scale (VAS), analgesic requirement, and Oswestry disability index 2 weeks, 4 weeks, 8 weeks, and 12 weeks after injection. Results. VAS and ibuprofen consumption showed a significant reduction in group D. The Oswestry disability index was significantly improved in group D. There were no records of hypotension, bradycardia, sedation, or hypoxemia in both groups. Conclusion. The present study demonstrated potential safe and effective usage of adding dexmedetomidine to epidural steroid to control pain in patients with failed back surgery syndrome. Ashraf Eskandr and Sadik Abdel Maseeh Copyright © 2016 Ashraf Eskandr and Sadik Abdel Maseeh. All rights reserved. Length of Stay in Ambulatory Surgical Oncology Patients at High Risk for Sleep Apnea as Predicted by STOP-BANG Questionnaire Tue, 16 Aug 2016 10:46:22 +0000 Background. The STOP-BANG questionnaire has been used to identify surgical patients at risk for undiagnosed obstructive sleep apnea (OSA) by classifying patients as low risk (LR) if STOP-BANG score < 3 or high risk (HR) if STOP-BANG score ≥ 3. Few studies have examined whether postoperative complications are increased in HR patients and none have been described in oncologic patients. Objective. This retrospective study examined if HR patients experience increased complications evidenced by an increased length of stay (LOS) in the postanesthesia care unit (PACU). Methods. We retrospectively measured LOS and the frequency of oxygen desaturation (<93%) in cancer patients who were given the STOP-BANG questionnaire prior to cystoscopy for urologic disease in an ambulatory surgery center. Results. The majority of patients in our study were men (77.7%), over the age of 50 (90.1%), and had BMI < 30 kg/m2 (88.4%). STOP-BANG results were obtained on 404 patients. Cumulative incidence of the time to discharge between HR and the LR groups was plotted. By 8 hours, LR patients showed a higher cumulative probability of being discharged early (80% versus 74%, ). Conclusions. Urologic oncology patients at HR for OSA based on the STOP-BANG questionnaire were less likely to be discharged early from the PACU compared to LR patients. Diwakar D. Balachandran, Saadia A. Faiz, Mike Hernandez, Alicia M. Kowalski, Lara Bashoura, Farzin Goravanchi, Sujith V. Cherian, Elizabeth Rebello, Spencer S. Kee, and Katy E. French Copyright © 2016 Diwakar D. Balachandran et al. All rights reserved. Intubation Success through I-Gel® and Intubating Laryngeal Mask Airway® Using Flexible Silicone Tubes: A Randomised Noninferiority Trial Sun, 10 Jul 2016 11:25:52 +0000 Introduction. The study aims to test whether flexible silicone tubes (FST) improve performance and provide similar intubation success through I-Gel as compared to ILMA. Our trial is registered in CTRI and the registration number is “CTRI/2016/06/006997.” Methods. One hundred and twenty ASA status I-II patients scheduled for elective surgical procedures needing tracheal intubation were randomised to endotracheal intubation using FST through either I-Gel or ILMA. In the ILMA group (), intubation was attempted through ILMA using FST and, in the I-Gel group (), FST was inserted through I-Gel airway. Results. Successful intubation was achieved in 36.67% (95% CI 24.48%–48.86%) on first attempt through I-Gel () compared to 68.33% (95% CI 56.56%–80.1%) in ILMA () (). The overall intubation success rate was also lower with I-Gel group [58.3% (95% CI 45.82%–70.78%); ] compared to ILMA [90% (95% CI 82.41%–97.59%); ] (). The number of attempts, ease of intubation, and time to intubation were longer with I-Gel compared to ILMA. There were no differences in the other secondary outcomes. Conclusion. The first pass success rate and overall success of FST through an I-Gel airway were inferior to those of ILMA. Latha Naik, Neerja Bhardwaj, Indu Mohini Sen, and Rakesh V. Sondekoppam Copyright © 2016 Latha Naik et al. All rights reserved. The Effect of Patient Weight and Provider Training and Experience on Dosing of Rocuronium Sun, 26 Jun 2016 11:49:43 +0000 Introduction. Maintenance dosing of neuromuscular blocking agents is complex and varies with patient, procedure, and clinical situation. With this in mind, we sought to identify factors impacting the maintenance dosing of neuromuscular blockers as a step toward identifying best practice with respect to minimizing residual neuromuscular blockade. Methods. Cases utilizing rocuronium from July 1, 2010, to June 30, 2014, at the sponsoring institution were analyzed. Using a mixed model to account for repeated measures, patients were analyzed by dose and weight category as defined by the World Health Organization (eight categories ranging from very severely underweight to very severely obese) as well as by the administering provider’s level of experience. Results. The study included 12,671 patients with a mean age of 49.7 (SD 16.7). Increasing weight category and higher levels of provider experience were associated with higher doses for rocuronium. There were no differences in initial dose or in frequency of maintenance dosing by weight category after controlling for case length. Discussion. The two dosing patterns identified, higher doses for overweight patients and higher doses administered by experienced providers, are modifiable factors that could enhance patient safety. N. C. Godwin, L. Rodriguez, S. Banks, B. T. Major, and Y. Rodriguez Copyright © 2016 N. C. Godwin et al. All rights reserved. Comparison of Medical Adhesive Tapes in Patients at Risk of Facial Skin Trauma under Anesthesia Sun, 12 Jun 2016 11:55:40 +0000 Introduction. Adhesive tapes are used for taping eyelids closed and securing endotracheal tubes during general anesthesia. These tapes can cause facial skin injury. We compared the incidence of facial skin injury and patient satisfaction with different tapes used. Methods. A total of 60 adult patients at risk of skin trauma were randomized to use 3M™ Kind Removal Silicone Tape or standard acrylate tapes: 3M Durapore (endotracheal tube) and Medipore (eyelids). Patients were blinded to tape used. Postoperatively, a blinded recovery nurse assessed erythema, edema, and denudation of skin. Anesthesiologist in charge also assessed skin injury. On postoperative day 1, patients rated satisfaction with the condition of their skin over the eyelids and face on a 5-point Likert scale. Results. More patients had denudation of skin with standard tapes, 4 (13.3%) versus 0 with silicone tape () and in anesthesiologist-evaluated skin injury 11 (37%) with standard versus 1 (3%) with silicone (). No significant differences were found in erythema and edema. Patient satisfaction score was higher with silicone tape: over eyelids: mean 3.83 (standard) versus 4.53 (silicone), Mann-Whitney test, ; over face: mean 3.87 (standard) versus 4.57 (silicone) (). Conclusion. Silicone tape use had less skin injury and greater patient satisfaction than standard acrylate tapes. Ling Antonia Zeng, Sui An Lie, and Shin Yuet Chong Copyright © 2016 Ling Antonia Zeng et al. All rights reserved. Effects of Addition of Systemic Tramadol or Adjunct Tramadol to Lidocaine Used for Intravenous Regional Anesthesia in Patients Undergoing Hand Surgery Mon, 30 May 2016 13:47:37 +0000 Intravenous regional anesthesia (IVRA) is used in outpatient hand surgery as an easily applicable and cost-effective technique with clinical advantages. The present study aimed to investigate the effects of addition of systemic tramadol or adjunct tramadol to lidocaine for IVRA in patients undergoing hand surgery. American Society of Anesthesiologists (ASA) I-II patients () who underwent hand surgery were included. For this purpose, only lidocaine (LDC), lidocaine+adjunct tramadol (LDC+TRA group), or lidocaine+systemic tramadol (LDC+SysTRA group) was administered to the patients for IVRA and the groups were compared in terms of onset and recovery time of sensory and motor blocks, quality of anesthesia, and the degree of intraoperative and postoperative pain. The onset time of sensorial block was significantly shorter in the LDC+TRA group than that in the LDC+SysTRA group. The motor block recovery time was significantly shorter in the LDC+SysTRA group than that in the LDC+TRA and LDC groups. Administration of tramadol as an adjunct showed some clinical benefits by providing a shorter onset time of sensory and motor block, decreasing pain and analgesic requirement, and improving intraoperative conditions during IVRA. It was determined that systemic tramadol administration had no superiority. Abdulkadir Yektaş, Funda Gümüş, Abdulhalim Karayel, and Ayşin Alagöl Copyright © 2016 Abdulkadir Yektaş et al. All rights reserved. Comparison of the Success of Two Techniques for the Endotracheal Intubation with C-MAC Video Laryngoscope Miller Blade in Children: A Prospective Randomized Study Sun, 15 May 2016 11:20:38 +0000 Background. Ease of endotracheal intubation with C-MAC video laryngoscope (VLS) with Miller blades 0 and 1 has not been evaluated in children. Methods. Sixty children weighing 3–15 kg with normal airway were randomly divided into two groups. Intubation was done with C-MAC VLS Miller blade using either nonstyletted endotracheal tube (ETT) (group WS) or styletted ETT (group S). The time for intubation and total procedure, intubation attempts, failed intubation, blade repositioning or external laryngeal maneuver, and complications were recorded. Results. The median (minimum/maximum) time for intubation in group WS and group S was 19.5 (9/48) seconds and 13.0 (18/55) seconds, respectively (). The median (minimum/maximum) time for procedure in group WS was 30.5 (18/72) seconds and in group S was 24.5 (14/67) seconds, respectively (). Intubation in first attempt was done in 28 children in group WS and in 30 children in group S. Repositioning was required in 14 children in group WS and in 7 children in group S (). There were no failure to intubate, desaturation, and bradycardia in both groups. Conclusion. Styletted ETT significantly reduces time for intubation and time for procedure in comparison to nonstyletted ETT. Renu Sinha, Ankur Sharma, Bikash Ranjan Ray, Ravinder Kumar Pandey, Vanlalnghka Darlong, Jyotsna Punj, Chandralekha Chandralekha, and Ashish Datt Upadhyay Copyright © 2016 Renu Sinha et al. All rights reserved. Development and Testing of Screen-Based and Psychometric Instruments for Assessing Resident Performance in an Operating Room Simulator Wed, 11 May 2016 07:08:22 +0000 Introduction. Medical simulators are used for assessing clinical skills and increasingly for testing hypotheses. We developed and tested an approach for assessing performance in anesthesia residents using screen-based simulation that ensures expert raters remain blinded to subject identity and experimental condition. Methods. Twenty anesthesia residents managed emergencies in an operating room simulator by logging actions through a custom graphical user interface. Two expert raters rated performance based on these entries using custom Global Rating Scale (GRS) and Crisis Management Checklist (CMC) instruments. Interrater reliability was measured by calculating intraclass correlation coefficients (ICC), and internal consistency of the instruments was assessed with Cronbach’s alpha. Agreement between GRS and CMC was measured using Spearman rank correlation (SRC). Results. Interrater agreement (GRS: ICC = 0.825, CMC: ICC = 0.878) and internal consistency (GRS: alpha = 0.838, CMC: alpha = 0.886) were good for both instruments. Subscale analysis indicated that several instrument items can be discarded. GRS and CMC scores were highly correlated (SRC = 0.948). Conclusions. In this pilot study, we demonstrated that screen-based simulation can allow blinded assessment of performance. GRS and CMC instruments demonstrated good rater agreement and internal consistency. We plan to further test construct validity of our instruments by measuring performance in our simulator as a function of training level. Richard R. McNeer, Roman Dudaryk, Nicholas B. Nedeff, and Christopher L. Bennett Copyright © 2016 Richard R. McNeer et al. All rights reserved. A Prospective Cohort Study Evaluating the Ability of Anticipated Pain, Perceived Analgesic Needs, and Psychological Traits to Predict Pain and Analgesic Usage following Cesarean Delivery Thu, 07 Apr 2016 08:43:36 +0000 Introduction. This study aimed to determine if preoperative psychological tests combined with simple pain prediction ratings could predict pain intensity and analgesic usage following cesarean delivery (CD). Methods. 50 healthy women undergoing scheduled CD with spinal anesthesia comprised the prospective study cohort. Preoperative predictors included 4 validated psychological questionnaires (Anxiety Sensitivity Index (ASI), Fear of Pain (FPQ), Pain Catastrophizing Scale, and Eysenck Personality Questionnaire) and 3 simple ratings: expected postoperative pain (0–10), anticipated analgesic threshold (0–10), and perceived analgesic needs (0–10). Postoperative outcome measures included post-CD pain (combined rest and movement) and opioid used for the 48-hour study period. Results. Bivariate correlations were significant with expected pain and opioid usage (), anticipated analgesic threshold and post-CD pain (), and perceived analgesic needs and post-CD pain (). Multiple linear regression analysis found that expected postoperative pain and anticipated analgesic needs contributed to post-CD pain prediction modeling (, ); expected postoperative pain, ASI, and FPQ were associated with opioid usage (, ). Conclusion. Preoperative psychological tests combined with simple pain prediction ratings accounted for 44% and 42% of pain and analgesic use variance, respectively. Preoperatively determined expected postoperative pain and perceived analgesic needs appear to be useful predictors for post-CD pain and analgesic requirements. Brendan Carvalho, Ming Zheng, Scott Harter, and Pervez Sultan Copyright © 2016 Brendan Carvalho et al. All rights reserved. Comparison of Ondansetron and Dexamethasone for Prophylaxis of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Surgeries: A Meta-Analysis of Randomized Controlled Trials Sun, 27 Mar 2016 11:49:29 +0000 Background. Postoperative nausea and vomiting (PONV) is a significant complication after laparoscopic surgeries. Ondansetron and dexamethasone are most commonly used drugs for PONV prophylaxis. Comparisons of these two drugs have not been systematically reviewed till date. Methods. PubMed, PubMed Central, and CENTRAL databases were searched with the following words: “dexamethasone,” “ondansetron,” “laparoscopy,” and “PONV” to identify randomized trials that compared ondansetron and dexamethasone for PONV prophylaxis after laparoscopic surgeries. Results. Data of 592 patients from 7 RCTs have been included in this meta-analysis. Incidence of postoperative nausea at 4–6 h is significantly lower when dexamethasone was used instead of ondansetron (; OR 0.49, 95% CI 0.24–0.98, M-H fixed). Incidence of nausea is similar at 24 hours (, OR 0.71, 95% CI 0.48, 1.05; M-H fixed); vomiting is also similar at 4–6 h (, OR 1.27, 95% CI 0.70–2.27; M-H fixed) and also at 24 h (, OR 0.92, 95% CI 0.73, 1.16; M-H fixed). Conclusion. Dexamethasone is superior to ondansetron in preventing postoperative nausea after 4–6 h of laparoscopic surgeries. However, both the drugs are of equal efficacy in preventing postoperative vomiting up to 24 h after surgery. However, results should be interpreted with caution due to clinical heterogeneity in the included studies. Souvik Maitra, Anirban Som, Dalim K. Baidya, and Sulagna Bhattacharjee Copyright © 2016 Souvik Maitra et al. All rights reserved. Percutaneous Nephrolithotomy: Current Clinical Opinions and Anesthesiologists Perspective Sun, 27 Mar 2016 11:33:53 +0000 Percutaneous nephrolithotomy (PCNL), a minimally invasive method for removal of renal calculi, was initially started in the 1950s but gained popularity about two decades later and has now become standard practice for management. There has been an immense improvement in technique and various guidelines have been established for treatment of renal stones. However, it has its own share of complications which can be attributed to surgical technique as well as anesthesia related complications. PubMed and Google search yielded more than 30 articles describing the different complications seen in this procedure, out of which 15 major articles were selected for writing this review. The aim of this review article is to describe the implications of the complications associated with PCNL related to the anesthesiologist. The anesthesiologist is as much responsible for the management of the patient perioperatively as the surgeon. Therefore, it is mandatory to be familiar with the various complications, some of which may be life threatening and he should be able to manage them efficiently. The paper also analyses the advantages and drawbacks of the available options in anesthesia, that is, general and regional, both of which are employed for PCNL. Indira Malik and Rachna Wadhwa Copyright © 2016 Indira Malik and Rachna Wadhwa. All rights reserved. Leakage Characteristics of Dual-Cannula Fenestrated Tracheostomy Tubes during Positive Pressure Ventilation: A Bench Study Thu, 17 Mar 2016 12:49:47 +0000 This study compared the leakage characteristics of different types of dual-cannula fenestrated tracheostomy tubes during positive pressure ventilation. Fenestrated Portex® Blue Line Ultra®, TRACOE® twist, or Rüsch® Traceofix® tracheostomy tubes equipped with nonfenestrated inner cannulas were tested in a tracheostomy-lung simulator. Transfenestration pressures and transfenestration leakage rates were measured during positive pressure ventilation. The impact of different ventilation modes, airway pressures, temperatures, and simulated static lung compliance settings on leakage characteristics was assessed. We observed substantial differences in transfenestration pressures and transfenestration leakage rates. The leakage rates of the best performing tubes were <3.5% of the delivered minute volume. At body temperature, the leakage rates of these tracheostomy tubes were <1%. The tracheal tube design was the main factor that determined the leakage characteristics. Careful tracheostomy tube selection permits the use of fenestrated tracheostomy tubes in patients receiving positive pressure ventilation immediately after stoma formation and minimises the risk of complications caused by transfenestration gas leakage, for example, subcutaneous emphysema. Thomas Berlet and Mathias Marchon Copyright © 2016 Thomas Berlet and Mathias Marchon. All rights reserved. Dexmedetomidine versus Magnesium Sulfate as Adjunct during Anesthesia for Laparoscopic Colectomy Wed, 09 Mar 2016 11:41:07 +0000 Objectives. To compare dexmedetomidine versus magnesium during laparoscopic colectomy. Patients and Methods. 51 patients were randomly allocated into 3 groups: group C (control) received saline infusion, group D dexmedetomidine 1 g/kg and then 0.4 g/kg/hr, and group M MgSO4 2 g and then 15 g/kg/min. Intraoperative hemodynamics were measured before and 1 min after intubation (T1 and T2), before and 5 min after peritoneal insufflation (T3 and T4), before and 5 min after 30° Trendelenburg position (T5 and T6), 5 min after resuming flat position (T7), 5 min after peritoneal deflations (T8), after extubation (T9), and at time of admission to PACU (T10). Recovery time and degree of sedation were assessed. Results. HR and MAP were significantly higher in T2, T4, and T6 compared to T1, T3, and T5, respectively, in all groups with lower measurements in groups D and M compared to group C. Mean of collective measurements was significantly higher in group C. Recovery time and sedation score were significantly higher in groups D and M. Time to Aldrete score of ≥9 was significantly longer in groups D and M. Conclusion. Both drugs ameliorate the pressor responses during LC with a nonsignificant difference. This study is registered with PACTR201602001481308. Pierre Zarif, Ahmed Abdelaal Ahmed Mahmoud, Mohamed Mohamed Abdelhaq, Hany M. S. Mikhail, and Ahmed Farag Copyright © 2016 Pierre Zarif et al. All rights reserved. Comparative Evaluation of Pain Scores during Periodontal Probing with or without Anesthetic Gels Mon, 29 Feb 2016 13:07:48 +0000 Context. The initial periodontal examination which includes full-mouth periodontal probing is one of the discomforting procedures for a patient. Aim. To evaluate the efficacy of two local anesthetic gels in the reduction of pain during periodontal probing using Florida probe in CGP patients in comparison with manual probing. Materials and Methods. Ninety systemically healthy patients with moderate to severe CGP patients were recruited. In each patient, the quadrants were randomly assigned to manual probing with UNC-15 probe, probing with Florida probe, and Florida probing with lidocaine 10% gel and with benzocaine 20% gel. In the quadrants undergoing probing with anesthetic gels, the sites were isolated and the gel was injected using syringe and a blunt-end cannula. Pain was measured using 10 mm horizontal VAS. Statistical Analysis. The analysis was carried out using SPSS version 18. The comparison of mean VAS scores was done using repeated measures ANOVA with post hoc Bonferroni test. Results. Mean VAS for manual probing was significantly more than Florida probing. Further, the mean VAS score for Florida probing was higher than the two gels. Conclusion. It is suggested that the gels might be useful in reducing pain experienced during full-mouth periodontal probing in patients with CGP. Ashank Mishra, Mandapathi Priyanka, Koppolu Pradeep, and Krishnajaneya Reddy Pathakota Copyright © 2016 Ashank Mishra et al. All rights reserved. Impact of an Innovative Classroom-Based Lecture Series on Residents’ Evaluations of an Anesthesiology Rotation Wed, 17 Feb 2016 14:04:48 +0000 Introduction. Millennial resident learners may benefit from innovative instructional methods. The goal of this study is to assess the impact of a new daily, 15 minutes on one anesthesia keyword, lecture series given by faculty member each weekday on resident postrotation evaluation scores. Methods. A quasi-experimental study design was implemented with the residents’ rotation evaluations for the 24-month period ending by 7/30/2013 before the new lecture series was implemented which was compared to the 14-month period after the lecture series began on 8/1/2013. The primary endpoint was “overall teaching quality of this rotation.” We also collected survey data from residents at clinical rotations at two other different institutions during the same two evaluation periods that did not have the education intervention. Results. One hundred and thirty-one residents were eligible to participate in the study. Completed surveys ranged from 77 to 87% for the eight-question evaluation instrument. On a 5-point Likert-type scale the mean score on “overall teaching quality of this rotation” increased significantly from 3.9 (SD 0.8) to 4.2 (SD 0.7) after addition of the lecture series, whereas the scores decreased slightly at the comparison sites. Conclusion. Rotation evaluation scores for overall teaching quality improved with implementation of a new structured slide daily lectures series. Pedro Tanaka, David Yanez, Hendrikus Lemmens, Adam Djurdjulov, Lena Scotto, Lindsay Borg, Kim Walker, Sylvia Bereknyei Merrell, and Alex Macario Copyright © 2016 Pedro Tanaka et al. All rights reserved. The Relationship of the Subclavius Muscle with Relevance to Venous Cannulation below the Clavicle Sun, 07 Feb 2016 14:21:46 +0000 Introduction. The catheter “pinch-off syndrome” has been described to be secondary to crimping of the catheter between the clavicle and the first rib, as well as entrapment of the catheter at the site of penetration of the subclavius muscle. The lateral insertion technique has been recommended to prevent catheter pinch-off, but it is unknown if this technique can prevent entrapment by the subclavius muscle. We undertook this study to evaluate the anatomical relationship of the subclavius muscle and the subclavian vein. Methods. Twenty-eight adult cadavers were studied on both right and left sides. The adherence between the subclavian vein and subclavius muscle was subjectively assessed and the distance between the two structures was measured in mm. Results. The subclavius muscle and subclavian vein were tightly adherent in 72% of specimens, partly adherent in 14% with a mean distance of 4.5 mm and loosely connected in 14% with a mean distance of 6.1 mm. Conclusions. The anatomical relationship between the subclavius muscle and vein was very close in the majority of specimens, suggesting that the lateral insertion technique may not prevent penetration of the muscle, which may contribute to catheter pinch-off. The real-time ultrasound-guided technique may prevent penetration of the subclavius muscle. Kyutaro Kawagishi, Joho Tokumine, and Alan Kawarai Lefor Copyright © 2016 Kyutaro Kawagishi et al. All rights reserved. Efficacy of Continuous S(+)-Ketamine Infusion for Postoperative Pain Control: A Randomized Placebo-Controlled Trial Tue, 02 Feb 2016 06:42:58 +0000 Aim. A double-blind, randomized, placebo-controlled trial was designed to evaluate the efficacy of continuous intraoperative infusion of S(+)-ketamine under intravenous anesthesia with target-controlled infusion of remifentanil and propofol for postoperative pain control. Methods. Forty-eight patients undergoing laparoscopic cholecystectomy were assigned to receive continuous S(+)-ketamine infusion at a rate of 0.3 mg·kg−1·h−1 (, intervention group) or an equivalent volume of saline at the same rate (, placebo group). The same target-controlled intravenous anesthesia was induced in both groups. Pain was assessed using a 0 to 10 verbal numeric rating scale during the first 12 postoperative hours. Pain scores and morphine consumption were recorded in the postanesthesia care unit (PACU) and at 4 and 12 hours after surgery. Results. Pain scores were lower in the intervention group at all time points. Morphine consumption did not differ significantly between groups during PACU stay, but it was significantly lower in the intervention group at each time point after PACU discharge (). At 12 hours after surgery, cumulative morphine consumption was also lower in the intervention group () than in the placebo group (). Conclusions. Continuous S(+)-ketamine infusion during laparoscopic cholecystectomy under target-controlled intravenous anesthesia provided better postoperative pain control than placebo, reducing morphine requirement. Trial Registration. This trial is registered with NCT02421913. Luiz Eduardo de Paula Gomes Miziara, Ricardo Francisco Simoni, Luís Otávio Esteves, Luis Henrique Cangiani, Gil Fernando Ribeiro Grillo-Filho, and Anderson Garcia Lima e Paula Copyright © 2016 Luiz Eduardo de Paula Gomes Miziara et al. All rights reserved. Improving Patient Safety through Simulation Training in Anesthesiology: Where Are We? Mon, 01 Feb 2016 13:03:53 +0000 There have been colossal technological advances in the use of simulation in anesthesiology in the past 2 decades. Over the years, the use of simulation has gone from low fidelity to high fidelity models that mimic human responses in a startlingly realistic manner, extremely life-like mannequin that breathes, generates E.K.G, and has pulses, heart sounds, and an airway that can be programmed for different degrees of obstruction. Simulation in anesthesiology is no longer a research fascination but an integral part of resident education and one of ACGME requirements for resident graduation. Simulation training has been objectively shown to increase the skill-set of anesthesiologists. Anesthesiology is leading the movement in patient safety. It is rational to assume a relationship between simulation training and patient safety. Nevertheless there has not been a demonstrable improvement in patient outcomes with simulation training. Larger prospective studies that evaluate the improvement in patient outcomes are needed to justify the integration of simulation training in resident education but ample number of studies in the past 5 years do show a definite benefit of using simulation in anesthesiology training. This paper gives a brief overview of the history and evolution of use of simulation in anesthesiology and highlights some of the more recent studies that have advanced simulation-based training. Michael Green, Rayhan Tariq, and Parmis Green Copyright © 2016 Michael Green et al. All rights reserved. A Posterior TAP Block Provides More Effective Analgesia Than a Lateral TAP Block in Patients Undergoing Laparoscopic Gynecologic Surgery: A Retrospective Study Thu, 28 Jan 2016 14:07:45 +0000 Background. There are a few papers that compared the lateral transversus abdominis plane (TAP) block with the posterior TAP block. Our study aimed to compare retrospectively the quality of analgesia after laparoscopic gynecologic surgery using the lateral TAP block with general anesthesia versus the posterior TAP block with general anesthesia. Method. Sixty-seven adult female patients were included in this retrospective study. Of these patients, thirty-four patients received the lateral TAP block with general anesthesia (lat. TAP group), and the rest of thirty-three patients received the posterior TAP block with general anesthesia (pos. TAP group). Pain scores both at rest and at movement and the use of additional analgesic drugs were recorded in the postoperative care unit within twenty-four hours after the operation. Postoperative complications were noted. Results. Patients who received pos. TAP reported lower visual analog scale (VAS) pain scores in all points, within twenty-four hours after the operation, than patients who received lat. TAP. Moreover, with the use of additional analgesic drugs, the incidence of nausea and vomiting during the first twenty-four hours after surgery was lower in the pos. TAP group than in the lat. TAP group. Conclusion. The posterior TAP block provided more effective analgesia than the lateral TAP block in patients undergoing laparoscopic gynecologic surgery. Sakatoshi Yoshiyama, Hironobu Ueshima, Ryomi Sakai, and Hiroshi Otake Copyright © 2016 Sakatoshi Yoshiyama et al. All rights reserved. Granisetron versus Granisetron-Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Pediatric Strabismus Surgery: A Randomized Double-Blind Trial Tue, 26 Jan 2016 13:07:50 +0000 Aim. Efficacy of granisetron and combination of granisetron and dexamethasone was evaluated for prevention of postoperative nausea and vomiting (PONV) in children undergoing elective strabismus surgery. Methods. A total of 136 children (1–15 years) were included. Children received either granisetron (40 mcg/kg) [group G] or combination of granisetron (40 mcg/kg) and dexamethasone (150 mcg/kg) [group GD]. Intraoperative fentanyl requirement and incidence and severity of oculocardiac reflex were assessed. PONV severity was assessed for first 24 hours and if score was >2, it was treated with metoclopramide. Postoperative analgesia was administered with intravenous fentanyl and ibuprofen. Results. The demographic profile, muscles operated, and fentanyl requirement were comparable. Complete response to PONV in first 24 hours was observed in 75% (51/68) of children in group G and 76.9% (50/65) of children in group GD, which was comparable statistically (, Fisher exact test; OR 1.11, 95% CI 0.50, 2.46). Incidence of PONV between 0 and 24 hours was comparable. One child in group G required rescue antiemetic in first 24 hours and none of the children had severe PONV in group GD. There was no significant difference in incidence or severity of oculocardiac reflex. Conclusion. Dexamethasone did not increase efficacy of granisetron for prevention of PONV in elective pediatric strabismus surgery. Registration number of clinical trial was CTRI/2009/091/001000. Renu Sinha, Dilip Shende, Souvik Maitra, Neeraj Kumar, Bikash Ranjan Ray, and Virender Kumar Mohan Copyright © 2016 Renu Sinha et al. All rights reserved. The Influence of Differences in Solvents and Concentration on the Efficacy of Propofol at Induction of Anesthesia Thu, 21 Jan 2016 12:19:10 +0000 Background. Propofol is a popular intravenous anesthetic and varieties of formulations were produced from different laboratories. The present study compared efficacy of propofol of different laboratories and different concentrations (1 and 2%) during induction of anesthesia. Methods. Seventy-five scheduled surgical patients were randomly allocated into three groups. The patients of group D1 received AstraZeneca Diprivan 1% (Osaka, Japan) at a rate of 40 mg kg−1 h−1. Group M1 was given 1% Maruishi (Maruishi Pharmaceutical, Osaka, Japan) and group M2 was given 2% formulation at the same rate of propofol. Achieving hypnosis was defined as failure to open their eyes in response to a verbal command and the venous blood sample was withdrawn. Results. The hypnotic doses of M2 were significantly larger (D1: , M1: , and M2:  mg, resp. (mean ± SD). ). Age and gender were selected as statistically significant covariates using general linear model-ANOVA. The blood concentration showed no significant difference among the groups (, , and  μg mL−1, resp.). Conclusion. The required dose of propofol was different among the formulations; however, the serum concentration showed no significant difference. This trial is registered with UMIN Clinical Trial Registry: UMIN000019925. Yukako Obata, Yushi U. Adachi, Katsumi Suzuki, Taiga Itagaki, Hiromi Kato, Maiko Satomoto, and Yoshiki Nakajima Copyright © 2016 Yukako Obata et al. All rights reserved. Designing and Implementing a Competency-Based Training Program for Anesthesiology Residents at the University of Ottawa Mon, 21 Dec 2015 08:31:08 +0000 Competency-based medical education is gaining traction as a solution to address the challenges associated with the current time-based models of physician training. Competency-based medical education is an outcomes-based approach that involves identifying the abilities required of physicians and then designing the curriculum to support the achievement and assessment of these competencies. This paradigm defies the assumption that competence is achieved based on time spent on rotations and instead requires residents to demonstrate competence. The Royal College of Physicians and Surgeons of Canada (RCPSC) has launched Competence by Design (CBD), a competency-based approach for residency training and specialty practice. The first residents to be trained within this model will be those in medical oncology and otolaryngology-head and neck surgery in July, 2016. However, with approval from the RCPSC, the Department of Anesthesiology, University of Ottawa, launched an innovative competency-based residency training program July 1, 2015. The purpose of this paper is to provide an overview of the program and offer a blueprint for other programs planning similar curricular reform. The program is structured according to the RCPSC CBD stages and addresses all CanMEDS roles. While our program retains some aspects of the traditional design, we have made many transformational changes. Emma J. Stodel, Anna Wyand, Simone Crooks, Stéphane Moffett, Michelle Chiu, and Christopher C. C. Hudson Copyright © 2015 Emma J. Stodel et al. All rights reserved. Web-Based Learning for Emergency Airway Management in Anesthesia Residency Training Wed, 16 Dec 2015 08:02:32 +0000 Introduction. Web-based learning (WBL) is increasingly used in medical education; however, residency training programs often lack guidance on its implementation. We describe how the use of feasibility studies can guide the use of WBL in anesthesia residency training. Methods. Two case-based WBL emergency airway management modules were developed for self-directed use by anesthesia residents. The feasibility of using this educational modality was assessed using a single cohort pretest/posttest design. Outcome measures included user recruitment and retention rate, perceptions of educational value, and knowledge improvement. The differences between pre- and postmodule test scores and survey Likert scores were analysed using the paired test. Results. Recruitment and retention rates were 90% and 65%, respectively. User-friendliness of the modules was rated highly. There was a significant improvement in perceptions of the value of WBL in the postsurvey. There was a significant knowledge improvement of 29% in the postmodule test. Conclusions. Feasibility studies can help guide appropriate use of WBL in curricula. While our study supported the potential feasibility of emergency airway management modules for training, collaboration with other anesthesia residency programs may enable more efficient development, implementation, and evaluation of this resource-intensive modality in anesthesia education and practice. Ada Hindle, Ji Cheng, Lehana Thabane, and Anne Wong Copyright © 2015 Ada Hindle et al. All rights reserved. Comparison of the Disposable Streamlined Liner of the Pharynx Airway and the Disposable I-gel in Anaesthetized, Paralyzed Adults: A Randomized Prospective Study Tue, 01 Dec 2015 07:01:25 +0000 Introduction. This study compared streamlined liner of the pharynx airway (SLIPA) and I-gel noninflatable, single-use, supraglottic airway device (SAD) performance in anesthetized, paralyzed adults. Methods. Eighty adults (ASA physical statuses I–III) who were undergoing elective procedures under general anesthesia with an SAD were enrolled in this prospective, randomized, single-blind study. Subjects were randomly and evenly assigned to the SLIPA or I-gel group for intraoperative airway management. Ease and number of insertions, insertion time, oropharyngeal sealing pressure, hemodynamic response, oxygen saturation (SpO2), end-tidal CO2 (EtCO2), and peri- and postoperative complications were examined. Results. The SLIPA and I-gel devices were successfully inserted in 100% and 95% of subjects, respectively. In two I-gel subjects (5%), ventilation was not possible after two attempts, but a size 55 SLIPA was successfully inserted in both cases. Forty-two and 38 patients were ultimately included in the SLIPA and I-gel groups, respectively. Insertion time was significantly shorter with the SLIPA ( s) than with the I-gel ( s, ). Oropharyngeal sealing pressure was significantly higher in SLIPA ( cmH2O) than in I-gel ( cmH2O) subjects (). Blood staining occurred more frequently in SLIPA (, 19.0%) than in I-gel (, 13.2%) patients (). Heart rate, mean arterial blood pressure, SpO2, and EtCO2 were not significantly different between groups. Conclusion. Although blood staining incidence was higher, SLIPA insertion was easier and faster than I-gel insertion. The SLIPA provided better airway sealing pressure. Both devices had similar mechanical ventilation and oxygenation characteristics and comparable hemodynamic stability. Both noninflatable SADs are useful, but SLIPA rapid insertion and good airway sealing make it an effective alternative to the I-gel. Khaled EL-Radaideh, Ala"a Alhowary, and Diab Bani Hani Copyright © 2015 Khaled EL-Radaideh et al. All rights reserved. Evaluation of Waste Anesthetic Gas in the Postanesthesia Care Unit within the Patient Breathing Zone Thu, 26 Nov 2015 13:28:36 +0000 Potential health hazards from waste anesthetic gases (WAGs) have been a concern since the introduction of inhalational anesthetics into clinical practice. The potential to exceed recommended exposure levels (RELs) in the postanesthesia care unit (PACU) exists. The aim of this pilot study was to assess sevoflurane WAG levels while accounting for factors that affect inhalational anesthetic elimination. In this pilot study, 20 adult day surgery patients were enrolled with anesthesia maintained with sevoflurane. Following extubation, exhaled WAG from the patient breathing zone was measured 8 inches from the patient’s mouth in the PACU. Maximum sevoflurane WAG levels in the patient breathing zone exceeded National Institute for Occupational Safety and Health (NIOSH) RELs for every 5-minute time interval measured during PACU Phase I. Observed WAGs in our study were explained by inhalational anesthetic pharmacokinetics. Further analysis suggests that the rate of washout of sevoflurane was dependent on the duration of anesthetic exposure. This study demonstrated that clinically relevant inhalational anesthetic concentrations result in sevoflurane WAG levels that exceed current RELs. Evaluating peak and cumulative sevoflurane WAG levels in the breathing zone of PACU Phase I and Phase II providers is warranted to quantify the extent and duration of exposure. Kenneth N. Hiller, Alfonso V. Altamirano, Chunyan Cai, Stephanie F. Tran, and George W. Williams Copyright © 2015 Kenneth N. Hiller et al. All rights reserved. Comment on “Depth of Anesthesia as a Risk Factor for Perioperative Morbidity” Wed, 11 Nov 2015 11:04:48 +0000 Marco Cascella Copyright © 2015 Marco Cascella. All rights reserved. Depth of Anesthesia as a Risk Factor for Perioperative Morbidity Tue, 02 Jun 2015 11:37:15 +0000 Introduction. The prognostic value of age, physical status, and duration of surgery on perioperative course has been extensively studied. However, the impact of deep hypnotic time (time when Bispectral Index values are less than 40) has not been well evaluated. Methods. We designed an observational study to clarify the relative influence of deep hypnotic time (DHT) on outcome. Eligible participants were mentally stable patients over 18 years old scheduled for elective major abdominal surgery. In total, 248 patients enrolled. Data were analyzed using Fisher’s exact test and multiple logistic regression. Results. Five variables (DHT, hypotension, age, comorbidity, and duration of surgery) showed statistically significant association with complications, when examined independently. However, when all variables were examined together in a multiple logistic regression model, age and comorbidity were no longer associated with outcome. DHT, hypotension, and duration of surgery were significant predictors of “complications,” and “hypotension” was a significant predictor of prolonged hospital stay .  Conclusion. Deep hypnotic time emerged as a new factor associated with outcome, and its impact compared to other factors such as age, surgery duration, hypotension, and comorbidity is redefined. Monitoring and managing depth of anesthesia during surgery are important and should be part of careful operation planning. Argyro Petsiti, Vassilios Tassoudis, George Vretzakis, Dimitrios Zacharoulis, Konstantinos Tepetes, Georgia Ganeli, and Menelaos Karanikolas Copyright © 2015 Argyro Petsiti et al. All rights reserved.