Complications of pediatric trauma: effects on pediatric trauma anesthesia

Pediatric trauma is a significant problem worldwide. The complications of pediatric trauma affect the emergency medical services provider, emergency physician, trauma surgeon, and anesthesiologist in different and challenging ways. Children have unique airway concerns, and require distinctive and safe approaches to protection of the airway. Moreover, the resuscitation of infants, children, and adolescents involved in trauma is complex and can be stressful for many caregivers. Therefore, the provision of anesthesia for acute pediatric trauma requires a synthesis of the usual issues of pediatric anesthesia with the overlying complications of trauma to effect an ideal anesthetic technique for each patient.

Deconstructing surgical education--teacher quality really matters: implications for attracting medical students to surgical careers

Delineating those factors that enhance a student's surgical experience during medical school may be important to attracting "the best and the brightest" to surgery programs. Therefore, understanding the differences between an excellent and poor student evaluation from the student perspective is critical to surgical education, yet it remains ill defined. We concurrently assessed comprehensive student evaluations from a surgical clerkship over a 2-year period. The purpose of this study is to report the results of this audit. Two years of student-directed evaluations were analyzed. Nine different surgical services were evaluated. Twenty-six data points were collected, including demographic, career, objective, and subjective information. Statistical analysis was performed using descriptive, chi2, and logistic regression tests. One hundred twenty-eight students rotated over 2 years, with 113 (88%) completing the assessment (61% men, 39% women). Men were more interested in surgical careers than women (4:1, P < 0.05). Medicine (22%) and surgical subspecialties (23%) were the most common career interests. Regression analysis demonstrated that age and gender were not predictors of outcome. The "highest rated and lowest rated" service were compared. Analysis demonstrated significant differences in three areas (operating room experience, and resident and faculty teaching.) The characteristics that separated the good teachers from the poor ones were the ability to challenge the student to think, providing useful feedback for their work, the ability to communicate ideas, and a positive attitude toward students/teaching. Student surgical evaluations underscore the role faculty and/or residents play in their education.

Monitoring intraoperative effectiveness of caudal analgesia through skin temperature variation

BACKGROUND/PURPOSE

A reliable noninvasive intraoperative marker of caudal analgesia effectiveness remains elusive. Caudal analgesia causes sympathetic inhibition resulting in vasodilatation, increased blood flow, and a resultant increase in temperature in the affected dermatomes. The authors hypothesize that this change in temperature between the affected and unaffected dermatomes is measurable and may represent a noninvasive method of monitoring effectiveness of caudal analgesia.

METHODS

Children undergoing lower abdominal surgery participated in the caudal or noncaudal (control) analgesia arm of the study. After induction of general anesthesia, 0.25% bupivicaine (1 mL/kg) was infiltrated for a field block in control patients or a caudal block in the experimental group. Temperature was measured at the C4 and L2 dermatomes starting after induction and 5 minutes before the caudal or field block and every 5 minutes after. T(o) is defined as the difference between the C4 and L2. Delta T (DeltaT) is the temperature variation between T(o). A change in the DeltaT is defined by an increase in the L2 temperature.

RESULTS

Forty-six families enrolled (36 experimental, 10 control). The DeltaT for controls was 0.2+/-0.09 degrees C (SEM). Each child in the experimental group had 2 temperature measurements before the caudal with an average DeltaT of 0.3+/-0.07 degrees C (SEM), thus, were internal controls. A marked increase in DeltaT at 5 minutes 0.5+/-0.06 degrees C (SEM) and at 10 minutes 0.6+/-0.07 degrees C (SEM; P <.05) was noted in the experimental group.

CONCLUSION

A significant transient change in temperature is observed after caudal analgesia and maybe a noninvasive marker of effectiveness. Further study may clarify its clinical utility.

Anaesthetic complications of acromegaly

The anaesthetic risks of acromegaly include difficulties in airway management, hypertension, and cardiac, gastrointestinal and renal problems. To estimate the incidence of major complications in this rare group of patients, we reviewed 28 patients with acromegaly who had pituitary tumour excision over a 10-yr period. Each patient was matched for age, weight and sex to a non-acromegalic patient undergoing transsphenoidal pituitary surgery. Acromegalic patients received significantly more fentanyl and midazolam and less thiopental and succinylcholine than controls (all P < 0.05). Mean arterial pressure (baseline, minimal and maximal values) was higher in acromegalic patients than in controls. There was no difference between groups in the use of vasoactive drugs. PaO2, FIO2 and PaCO2 were similar in both groups. Arterial pH was significantly lower (P = 0.015), blood glucose was higher (P < 0.001) and fluid intake minus output was higher (P = 0.04) in acromegalic patients than in controls. Airway difficulty and tongue enlargement were encountered more often in acromegalic patients (P = 0.002 and P = 0.001, respectively). Our data confirm that in acromegalic patients: airway difficulties occurred more frequently; severe haemodynamic instability did not typically occur during surgery for acromegaly; pulmonary gas exchange was not altered during operation; glucose intolerance may be an intraoperative problem; and fluid regulation may be altered.

Sharps disposal in the operating room: current clinical practices and costs

In the evolving medical environment, fiscal constraints on medical practice are becoming the norm. The new days of austerity have revived interest in the economics of medical practice. Economic measures, however, should not impinge on the quality of patient care. Waste disposal, in particular, is an area without any direct patient benefit but which carries both short- and long-term ecological costs. Much of how we dispose of waste is dictated in the United States by the Joint Commission for the Accreditation of Hospital Organization, Occupational Safety and Health Administration, state regulations, and individual hospital protocols. In an attempt to elucidate the waste in waste management, we examined the use of standard operating room sharp boxes. Full sharp boxes from three different operating sites were randomly saved. Boxes were weighed and opened, and contents were separated into appropriate sharps: loose needles, scalpels, syringes with uncapped needles, and other. Weight and volume assessments were performed on the nonsharps. True sharp values were derived from nonsharps data. Less than 50% of the contents were appropriate for sharps disposal, with empty glass vials constituting the greatest percentage by weight of nonsharps material. We believe that encouraging the appropriate use of sharps boxes is a potential source for savings.

IMPLICATIONS

Sharp boxes were randomly saved from university operating rooms and analyzed for content. The full boxes contained 14% appropriate sharps by weight and <50% appropriate sharps by volume. The largest fraction of nonsharps weight was found to be glass.