Using educational video to enhance protocol adherence for medical procedures

Kandler, L. et al. British Journal of  Anaesthesia. 2016. 116 (5): pp.662-669.

Background: Better education of clinicians is expected to enhance patient safety. An important component of education is adherence to standard protocols, which are mainly available in written form. Believing in the potential power of videos, we hypothesized that the introduction of an educational video, based on an institutional standard protocol, would foster adherence to the protocol.

Methods: We conducted a prospective intervention study of 425 anaesthesia procedures and teams (202 pre-video and 223 post-video) involving 1091 team members (516 pre-video and 575 post-video) in seven individual operating areas (with a total of 30 operating rooms) in a university hospital. Failure of adherence to safety-critical tasks during rapid sequence anaesthesia inductions was assessed during systematic on-site observations pre- and post-introduction of an educational video demonstrating evidence-based and best practice guidelines.

Results: The odds for failure of adherence to safety-critical tasks between the pre- and post-intervention period were reduced, odds ratio 0.34 (95% confidence interval 0.27–0.42, P<0.001). The risk for failure of adherence was reduced significantly for eight of the 14 safety-critical tasks (allP<0.001).

Conclusions: This study provides empirical evidence for the effectiveness of an educational video to enhance adherence to a standard protocol during complex medical procedures. The introduction of a video can reduce failure of adherence to safety-critical tasks and contribute to patient safety. We recommend the introduction of videos to improve protocol adherence.

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The half-life of infusion fluids: An educational review.

Hahn, R. G. & Lyons, G. European Journal of Anaesthesiology. Published online 20 April 2016.

An understanding of the half-life (T1/2) of infused fluids can help prevent iatrogenic problems such as volume overload and postoperative interstitial oedema. Simulations show that a prolongation of the T1/2 for crystalloid fluid increases the plasma volume and promotes accumulation of fluid in the interstitial fluid space. The T1/2 for crystalloids is usually 20 to 40 min in conscious humans but might extend to 80 min or longer in the presence of preoperative stress, dehydration, blood loss of <1 l or pregnancy.

The longest T1/2 measured amounts to between 3 and 8 h and occurs during surgery and general anaesthesia with mechanical ventilation. This situation lasts as long as the anaesthesia. The mechanisms for the long T1/2 are only partly understood, but involve adrenergic receptors and increased renin and aldosterone release. In contrast, the T1/2 during the postoperative period is usually short, about 15 to 20 min, at least in response to new fluid.

The commonly used colloid fluids have an intravascular persistence T1/2 of 2 to 3 h, which is shortened by inflammation. The fact that the elimination T1/2 of the infused macromolecules is 2 to 6 times longer shows that they also reside outside the bloodstream. With a colloid, fluid volume is eliminated in line with its intravascular persistence, but there is insufficient data to know if this is the same in the clinical setting.

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Pain assessment in children

Anaesthesia & Intensive Care Medicine

Acute pain in children can occur following trauma and injury or secondary to medical and surgical intervention. Before acute pain can be effectively treated, it must be accurately assessed. In spite of many years of research to enhance our understanding of pain, the assessment of pain in children continues to be a challenge and is often inconsistent and suboptimal in many organizations.

B0009782 Losartan and Lidocaine
image shows micrograph of Losartan and Lidocaine. source: Lars Bech, Wellcome Images//CC BY-NC-ND 4.0

Pain and its perception are multi-factorial, hence an approach to pain assessment and treatment must also be multi-faceted and multidisciplinary. Painful experiences are dynamic, with huge inter- and intra-individual variation; therefore pain assessment tools must be adaptable, reproducible and accurate to accommodate such variation.

This article outlines the different tools available for pain assessment in infants and children.

Brand, K. & Thorpe, B. Pain assessment in children Anaesthesia & Intensive Care Medicine. Available online 20 April 2016.

Evidence-Based Guidelines for Management of Post-Op Pain Issued Jointly by APS, ASA and ASRA

Holzman, D.C. Anesthesiology News. Published online: 18 April 2016.

The American Pain Society, for the first time, has released a clinical practice guideline on managing postoperative pain.

The guideline was created with input from the American Society of Anesthesiologists (ASA) and was subsequently approved by the American Society for Regional Anesthesia and Pain Medicine (ASRA), and was based on the 23-member panel’s review of 6,500 scientific abstracts and primary studies.

Read the full news story here

Preoperative paracetamol improves post-cesarean delivery pain management

Ozmete, O. et al. Journal of Clinical Anesthesia. Volume 33, September 2016, pp. 51–57
Image source: Steve Smith // CC BY-NC 2.0

Study Objective: To evaluate the analgesic effect of preoperative single dose intravenous paracetamol on postoperative pain and analgesic consumption within 24 hours after elective cesarean surgery.

Design: Prospective, randomized, double-blind, placebo-controlled clinical trial.

Setting: University Teaching Hospital.

Patients: American Society of Anesthesiologists (ASA) I and II 60 patients between 18–40 years of age who were scheduled to undergo elective cesarean section.

Interventions: Patients were randomized into two groups to receive either intravenous 1 g paracetamol (100 mL) (Group P) or 0.9% NaCl solution (100 mL) (Group C) 15 minutes before the induction of general anesthesia. After delivery of newborn 0.15 mg kg-1 morphine was administered to all patients in both groups. Postoperative analgesia was provided with patient-controlled intravenous analgesia with morphine in the postoperative period.

Measurements: Pain which is the primary outcome measure was assessed at 15th, 30th minutes and 1st, 2nd, 4th, 6th, 12th, 24th hours by the Visual Analogue Scale. Patients’ demographics, hemodynamics, Apgar score, additional analgesic requirement, side effects, patients’ satisfaction and postoperative total morphine consumption within 24 hours were recorded.

Main Results: Median visual analogue scale for pain in Group P was significantly lower compared to Group C at all time points except for the score at 24th h postoperatively (P < .05). Additional analgesic requirement during postoperative first hour was lower in Group P (P < .05). Total morphine consumption was higher in Group C compared with Group P (P < .05). There was no difference between groups with respect to Apgar scores, side effects, and patient satisfaction (P > .05).

Conclusions: Preoperative use of single-dose intravenous 1 g paracetamol was found to be effective in reducing the severity of pain and opioid requirements within 24 hours after cesarean section.

Read the abstract here

AAGBI guidelines: the use of blood components and their alternatives 2016

Klein, A.A. et al. Anaesthesia. Published online: 8th April 2016.

Image source: Wellcome Images // CC BY-NC-ND 4.0

Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.

Read the full guidelines here