An Educational Module on Ultrasound Guided Endotracheal Tube Sizing and Placement Verification in the Pediatric Surgical Patient

Background: Traditionally, demographic-based formulas have been utilized to determine the appropriate endotracheal tube (ETT) size in pediatric patients. However, formulas, such as Cole’s age-based formula, vary widely in accuracy, resulting in an overestimated or underestimated ETT size. Implications of an inappropriately sized ETT include subglottic stenosis, ischemia, infection, and irreversible loss of connective tissue around the cartilage. Proper ETT sizing is pivotal for optimal general anesthesia. Ultrasonographic assessment of the subglottic diameter provides a real-time measurement for accurate ETT sizing in pediatric patients. This project aims to assess anesthesia provider knowledge and attitude toward ultrasonographic measurement of the subglottic diameter versus traditional age-based formulas for ETT sizing in pediatric patients. Methods: The Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and PubMed search engines were accessed via the Florida International University (FIU) library database. A comprehensive search was conducted for full-text, peer-reviewed research studies published within the last 10 years, which assessed using ultrasonographic measurement of the subglottic diameter to appropriately size ETTs in pediatric surgical patients. An online module will be implemented to anesthesia providers regarding ultrasonographic measurement of the subglottic diameter to approximate ETT size in pediatric surgical patients. A Qualtrics pre- and post-test will be used to assess anesthesia provider knowledge and attitude. Results: Knowledge improved on characteristic anatomical differences observed in the pediatric patient compared to the adult patient. All the participants (100.00%) agreed that ninety percent of subglottic stenosis results from tracheal intubation. Congenital heart disease was correctly selected by all participants (100.00%) as the special pediatric population that may require a larger ETT size than the calculated age-based size. Knowledge improved on initial placement of the high-resolution linear probe used for subglottic measurement of the pediatric airway. Attitude toward the accuracy of age-based formulas for calculating ETT size in pediatric patients declined in support. Improvement in attitude toward using point of care ultrasound (POCUS) to measure the subglottic diameter of a pediatric airway was observed. An increase in attitude was noted in agreement that ultrasound is a reliable tool to approximate ETT size in pediatric patients. Discussion: An increase in provider knowledge and attitude was observed regarding the utilization of ultrasound as a tool to approximate ETT size in pediatric surgical patients. Current evidence-based research emphasizes the influence anesthesia providers have on the direction of pediatric airway management. Specifics regarding special airway considerations of congenital disease populations showed improvement in the post-test. Participants identified understanding a need for special management of the pediatric airway. Providers\u27 attitudes changed following participation in the educational module. A small sample size contributed to limitations in drawing conclusions. The topic of pediatric anesthesia may have contributed to a niche/self limiting response. Potential implications exist for decreased responsiveness related to email bombardment. Future consideration for staggered project release dates. Implementing a QI project raises awareness of the topic and ignites the process of change

Regional Anesthesia for Bilateral Carpal Tunnel Release

Carpal Tunnel Syndrome is the most common nerve entrapment neuropathy with over 60% of diagnosed patients presenting with bilateral median nerve involvement.  Bilateral upper extremity surgery presents unique anesthesia challenges, yet surgeons are increasingly interested in performing simultaneous bilateral carpal tunnel release (BCTR) procedures. Regional anesthesia techniques traditionally employed for unilateral hand procedures are impractical, and general anesthesia is expensive and incurs added risk.  A cost effective and efficient anesthesia plan for BCTR is therefore needed. Objective:  Conduct a literature search to support the administration of an efficient and safe anesthesia technique for BCTR utilizing local infiltration and median nerve block.  Methods: Electronic searches were conducted for current pertinent information published in anesthesia, hand surgery and plastic surgery journals within the past 5 years.  Information gathered was assimilated to make an evidence based recommendation for a BCTR anesthesia technique.  Results: BCTR is a more cost effective and time efficient treatment for bilateral carpal tunnel syndrome than a staged unilateral approach.  Local anesthesia with median nerve block with or without sedation is a cost efficient and safe anesthesia strategy for BCTR

Regional development gaps in Argentina: A multidimensional approach to identify the location of policy priorities

Spatial inequalities within Latin American countries have historically attracted the interest ofacademics, policy-makers, and international agencies. This article aims to provide amultidimensional diagnosis of provincial development gaps in Argentina, in order to identifythe location of policy priorities. Therefore, we built a large database, which covers sevendevelopment dimensions, and applied multivariate analysis techniques to overcome someanalytical limitations of previous studies. Results show the stability of provincial developmentgaps between 2003 and 2013 and some heterogeneity within geographic regions. Instead,cluster analysis offers a better classification of Argentine provinces according to theirdevelopment gaps, which can help the government to prioritize the places wheredevelopment policies are strategic.Fil: Niembro, Andrés Alberto. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Patagonia Norte; Argentina. Universidad Nacional de Río Negro; ArgentinaFil: Sarmiento, Jesica Isabel. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - Patagonia Norte; Argentina. Universidad Nacional de Río Negro; Argentin

An Anesthesia Quality Improvement Plan to Improve Postoperative Pain Outcomes after Hysterectomy

An anesthesia quality improvement initiative implemented an evidence-based, preemptive, preventive multimodal analgesic regimen to improve perioperative pain outcomes for women undergoing hysterectomy.  Though statistical significance was not achieved, clinically significant decreases in Post Anesthesia Care Unit (PACU) narcotic usage, pain ratings, time in the PACU, and opioid related side effects were observed.  This analgesic regimen was easily implemented, readily modifiable, and suitable for expansion to multiple surgical populations to supplement customary anesthesia perioperative care