Management of a Patient with an Encapsulated Parapneumonic Empyema Complicated by the Intraoperative Development of an Acute Bronchopleural Fistula and ARDS

We report the use of independent lung ventilation (ILV) in a patient with severe underlying parenchymal disease who developed bronchopleural fistula (BPF) after thoracotomy and decortication of an empyema with subsequent development of acute respiratory distress syndrome (ARDS). While a great majority of patients with either ARDS or BPF can be successfully managed with conventional ventilation strategies, the additional management challenges presented by BPF in the setting of ARDS and sepsis often necessitate the utilization of alternative ventilation strategies such as ILV, high frequency ventilation (HFV), and extracorporeal support

Case Report on Morbidly Obese Patient with Cervical Spine Ankylosing Spondylitis Presenting with Acute Spinal Shock and Complex Airway Management

A 67 year old morbidly obese male presented to the ER with weakness in both lower extremities after a fall at home. The patient sustained a T12/ L1 unstable vertebral fractures and cord compression at the thoracolumbar junction with acute traumatic paraplegia. The patient arrived in the PACU on a backboard and with a cervical collar in place directly from the ER. The review of the patient’s chart revealed that he had a history of hypertension, PE / DVT on coumadin, hypothyroidism, NIDDM, bipolar disorder and cervical spine ankylosing spondylitis of his neck. On physical exam the patient was sleepy, but arousable and unable to move his lower extremities, with loss of bladder and bowel control. There was one 20 G IV in place. The airway exam revealed Mallampati Class 4. The patient was hemodynamically unstable with BP ~80/~40 mm HG; HR ~70’s/min; SpO2 ~86-88%. Resuscitation commenced immediately. The patient was started on face mask @ 10 l/m O2. One liter of normal saline was administered with minimal effect. A phenylephrine infusion was started. The blood pressure improved to SBP of 120’s mm Hg. The O2 saturation increased to 95%. A methylprednisone drip (30mg/kg iv bolus) was started for treatment of his spinal cord injury. For additional IV access, another 20G IV was placed. Two units of FFP were given to normalize the INR of 2.4. After multiple attempts, a right radial arterial catheter was successfully placed. A right internal jugular (RIJ) central venous catheter was inserted under ultrasound guidanc

Post-Anesthesia Evaluation: Using a Systems Based Team Approach to Achieve Compliance with CMS Interpretive Guidelines

Introduction: In December of 2009 the Center for Medicare and Medicaid Services (CMS) issued Revised Anesthesia Services Interpretive Guidelines. The revised post-anesthesia evaluation rules require assessment and documentation within 48 hours from the time the patient is moved into the recovery area for patients (includes outpatients prior to discharge as well as all inpatients). It applies to all patients who have had monitored anesthesia services, regional or general anesthesia. It must be performed and documented by a practitioner who is qualified to administer anesthesia and can be completed at any time and location as long as the patient has recovered sufficiently from anesthesia to answer the key questions related to the evaluation. Required key elements include assessment of mental status, pain, nausea and vomiting, temperature, hydration, respiratory and cardiovascular status. We describe the systems based team approach we used to achieve compliance with the 93% or higher post-anesthesia evaluation set by CMS and The Joint Commission. Background: UMass Memorial is a multi-campus medical center (A: Ambulatory Surgery Center (ASC), C: Tertiary University site, B: Memorial).Annually we provide anesthesia coverage for approximately 37,000 patients at 43 anesthetizing locations (44% inpatients and 56% outpatient procedures). The spread of Anesthesiology resources over three sites and the resident work hour restrictions posed a challenge to ensure compliance with CMS requirements for post-anesthesia evaluation and documentation. Methods: With input from the Anesthesiologists at all three sites we designed a template form that captured the required elements of the post-anesthesia evaluation and became part of the patient medical record (figure 1). We also modified the discharge process from the Post Anesthesia Care Unit (PACU). Previously our patients were discharged when the Alderete criteria were met using a standardized post-anesthesia order set. We modified this post-anesthesia order set to add post-anesthesia evaluation and documentation to the discharge criteria (figure 2). The Peri-anesthesia staff (PACU and Surgical Admission unit) was educated about these changes. We implemented a visual clue by the patient stretcher in the PACU when the patient was discharge ready. A member of the Anesthesia team completed the evaluation and documentation prior to patient discharge from the PACU. Patients who were admitted directly to the ICU or were not seen in the PACU were seen the following day by a member of the group. We used a systems based team approach with the help of the Anesthesiology staff and Peri-anesthesia nursing to implement this process across all three campuses. Random monthly chart audits were performed by our Quality department to assess our compliance with these CMS revised guidelines (20 charts at each site per month). Conclusion: We were able to achieve an average compliance rate of 82 to 93% across the medical center (figure 3)

Delayed Emergence from General Anesthesia

The incidence of perioperative morbidity associated with varying degrees of untreated thyroid disease is unknown, however major complications have been reported including severe hypotension or cardiac arrest, extreme sensitivity to opioids and anesthetics with prolonged unconsciousness, and myxedema coma. Myxedema coma is a rare and life-threatening illness the outcome of which has not been robustly studied in large numbers, partly due to its low incidence. This case illustrates the differential diagnosis of delayed emergence from general anesthesia and the value of a complete history and physical exam. Although delayed emergence from general anesthesia is not uncommon, recognizing the cause and instituting timely treatment is imperative in conditions where delayed therapy can increase morbidity and mortality

Patient Flow in Peri-Operative Services: Analysis of Factors that Impact OR Turn Over Time

Introduction: The University Campus of UMass Memorial Medical Center has 16 operating rooms. The average Turn Over Time (TOT), defined as patient out of OR to next patient in, is 43 minutes. This is a source of dissatisfaction for the surgeons and has an impact on the patient experience. We did an observational study to map and time patient flow from the Surgical Admission Unit (SACU) to the Operating Room and the process for OR turn over and arrival of the next patient. The goal was to assess how the process could be modified to enhance the patient experience and improve surgeon satisfaction. Methods: Observation and hand recording of three rooms in the University OR was performed from 6/13/2011 – 8/5/2011 (Orthopedic and Neurosurgery cases). Time points for all processes directly involving the patient were collected. Data collection was done by three undergraduate students. Support for the students was provided by Orthopedics, Anesthesiology and Peri-Operative Services. Results: See Figure 1 for patient flow and turn over process map. Subsequent figures show time intervals from SACU to OR case completion, call for cleaning, completion of cleaning and arrival of next patient. Cleaning was complete in 18 minutes but TOT was 43 minutes because nondependent tasks were being performed in series (Figure 5). Summary: Nondependent tasks are being performed in series in the SACU and during OR turn over. There is an opportunity to decrease patient length of stay in the SACU. By doing parallel practice OR TOT can be decreased from 43 to 19 minutes if the anesthesia team is allowed to bring the patient in the room once the room is clean. This process can enhance the patient experience and improve surgeon satisfaction

Physician Referral Rather than Proxy Referral to an Organ Procurement Organization Following Asystolic Death Results in Higher Tissue Donation Rates

Timely referral of patients following asystolic death to an organ procurement organization (OPO) may increase tissue donation rates. Notification of the OPO following asystolic death was formerly the responsibility of the admitting office. We hypothesized that changing the responsibility from the admitting department to the declaring physician for calling the OPO would increase timely referral and tissue donation rates. In 2006, the instructions accompanying the working copy of the death certificate were altered to require the patient’s physician to call the OPO within one hou r of death. From 10/2006 to 2/2007 intensive communication and in-servicing was carried out in all intensive care units. Timely referral and donation rates were tabulated before and after the intervention. Data were modeled longitudinally using Generalized Linear Mixed Models (SAS). There timely referral rates rose 2.1 fold on campus 1 (p\u3c0.05) and 1.3 fold on campus 2 (p= NS). The tissue donation rate rose significantly (2.6 fold, p\u3c0.05). In 2005, the donation rate was 21 cases/year and rose to 56 cases/year by 2008 (p\u3c0.05). The rate has held steady since that time (2009-2012). Physician referral rather than referral by other parties following asystolic death results in higher tissue donation rates

Testing a Novel Manual Communication System for Mechanically Ventilated ICU Patients

Introduction: Available communication methods for intubated patients in the ICU are insufficient to meet patient needs. Both ICU patients and their care providers report broadly unsuccessful communication attempts, resulting in less effective medical care and undue stress1,2. Use of existing methods - including letter boards, writing, and mouthing words - for mechanically ventilated (MV) patients has led to a consensus that new methods are required3. We report on the testing of a new system designed to address the communication needs of MV patients that is currently being tested in a low- to medium- acuity surgical ICU4. Methods: We have developed several generations of prototypes designed to address patient communication needs. Design of this device has focused on ICU-specific communication needs, including ICU-specific content, infection control, simple design, and capitalizing on motor movements that can be easily performed by most ICU patients. Initial testing, starting with non-MV patients able to give more detailed feedback, has begun in a low- to medium- acuity surgical ICU. Recently developed prototypes combine custom-built tablet software, focusing on the needs that nurses believe patients wish to express in the ICU setting, with a newly designed manually operated access device. The system produces visual and auditory output to allow patients to answer basic questions and effectively convey information. Results: Initial patient impressions are encouraging, particularly among patients who have recently experienced mechanical ventilation. Many patients are unfamiliar with tablet software or struggle with manual dexterity required to access the tablet screen directly, further indicating the need for an external access method as part of the system. The content suggested by nurses via a previously conducted survey has been confirmed by patients as relevant to their experience. Conclusions: A novel manually operated communication system has elicited both positive reviews and helpful feedback from patients

Principles of Augmentative and Alternative Communication System Design in the ICU Setting

Introduction: The ICU as a technology design setting requires specific and thoughtful awareness of patient-, caregiver-, and environment-related constraints. Designing an ICU-specific communication system involves an even deeper understanding of patient needs and desires, building on existing work exploring available technologies for use in this setting1,2. We report our initial experience from a pilot study with a novel communication device engineered specifically to allow mechanically ventilated ICU patients to communicate with caregivers3. Methods: We used a validated survey for nurses about communication purposes to explore relevant beliefs, attitudes, and desires of nurses4. Existing technologies available for communication assistance in the ICU – e.g., letter boards, writing on paper, and mouthing words – were analyzed. Suggestions about the content for an eventual communication system were collected. ICU-specific design requirements were noted, including adherence to infection control standards, accessibility to restrained patients, and availability to patients with motor weakness, contractures, edema, tremor, and/or neuropathy. In addition, the system must include a minimal learning curve, Results: Initial testing in the ICU has revealed additional considerations for technology design. For instance, many patients have visual impairments, so displays should be large and high-contrast. Furthermore, patients benefit from a very short teaching/demo process due to their short attention span. Additionally, leveraging interfaces with significant similarities to everyday systems appears to reduce confusion. Nurses also mentioned that the system should be accessible to at least some non-English-speaking patients. Finally, physical deficits that ICU patients experience require that manually operated devices be as flexible as possible in terms of type of manipulation required. Conclusions: ICU patients are in significant need of communication systems that meet their unique needs. Building such a system requires awareness of many different constraints, including both general heterogeneity of patient needs and capabilities and the constraints of the ICU setting itself

Effect of a Multidisciplinary Team Approach to Eradicate Central Line Associated Blood-Stream Infections (CLABSI)

Introduction: CLABSI remains a significant problem in the intensive care unit. Hypothesis: A multimodal approach for the insertion and care of CVC will prevent CLABSI. Methods: A Critical Care Operations Committee was formed to transform care in 8 intensive care units (ICU) in an academic medical center in 9/2004. One goal was to reduce CLABSI. Using evidence based medicine, a clinical practice guideline was developed that incorporated the use of maximum barrier precautions, chlorhexidine skin preparation, avoidance of the femoral insertion site, dedicated catheter cart, a check list, the tracking of high risk CVC, anti-septic or antimicrobial impregnated catheters, a recommendation to use ultrasound guidance when inserting CVC in the internal jugular vein, daily determination of the need for the CVC and treatment of CLABSI as a critical event.CLABSI were adjudicated by the hospital epidemiologist and CVC days were tracked. Rates of CLABSI were followed from 9/2004 through 7/2011. The Spearman correlation coefficient was used for statistical evaluation. A p Results: CLABSI rates (per 1000 catheter-days) declined dramatically from 2004 to 2011 (p Conclusions: A multimodal approach to CVC insertion and care reduces CLABSI by over 90%. Our ultimate goal is the complete eradication of CRBSI in our institution

Microvascular response to transfusion in elective spine surgery

AIM: To investigate the microvascular (skeletal muscle tissue oxygenation; SmO2) response to transfusion in patients undergoing elective complex spine surgery. METHODS: After IRB approval and written informed consent, 20 patients aged 18 to 85 years of age undergoing \u3e 3 level anterior and posterior spine fusion surgery were enrolled in the study. Patients were followed throughout the operative procedure, and for 12 h postoperatively. In addition to standard American Society of Anesthesiologists monitors, invasive measurements including central venous pressure, continual analysis of stroke volume (SV), cardiac output (CO), cardiac index (CI), and stroke volume variability (SVV) was performed. To measure skeletal muscle oxygen saturation (SmO2) during the study period, a non-invasive adhesive skin sensor based on Near Infrared Spectroscopy was placed over the deltoid muscle for continuous recording of optical spectra. All administration of fluids and blood products followed standard procedures at the Hospital for Special Surgery, without deviation from usual standards of care at the discretion of the Attending Anesthesiologist based on individual patient comorbidities, hemodynamic status, and laboratory data. Time stamps were collected for administration of colloids and blood products, to allow for analysis of SmO2 immediately before, during, and after administration of these fluids, and to allow for analysis of hemodynamic data around the same time points. Hemodynamic and oxygenation variables were collected continuously throughout the surgery, including heart rate, blood pressure, mean arterial pressure, SV, CO, CI, SVV, and SmO2. Bivariate analyses were conducted to examine the potential associations between the outcome of interest, SmO2, and each hemodynamic parameter measured using Pearson\u27s correlation coefficient, both for the overall cohort and within-patients individually. The association between receipt of packed red blood cells and SmO2 was performed by running an interrupted time series model, with SmO2 as our outcome, controlling for the amount of time spent in surgery before and after receipt of PRBC and for the inherent correlation between observations. Our model was fit using PROC AUTOREG in SAS version 9.2. All other analyses were also conducted in SAS version 9.2 (SAS Institute Inc., Cary, NC, United States). RESULTS: Pearson correlation coefficients varied widely between SmO2 and each hemodynamic parameter examined. The strongest positive correlations existed between ScvO2 (P = 0.41) and SV (P = 0.31) and SmO2; the strongest negative correlations were seen between albumin (P = -0.43) and cell saver (P = -0.37) and SmO2. Correlations for other laboratory parameters studied were weak and only based on a few observations. In the final model we found a small, but significant increase in SmO2 at the time of PRBC administration by 1.29 units (P = 0.0002). SmO2 values did not change over time prior to PRBC administration (P = 0.6658) but following PRBC administration, SmO2 values declined significantly by 0.015 units (P \u3c 0.0001). CONCLUSION: Intra-operative measurement of SmO2 during large volume, yet controlled hemorrhage, does not show a statistically significant correlation with either invasive hemodynamic, or laboratory parameters in patients undergoing elective complex spine surgery