Faculty Bibliography

OBJECTIVES: To develop consensus recommendations for peri-operative tracheotomy care in pediatric patients. METHODS: Expert opinion by the members of the International Pediatric Otolaryngology Group (IPOG). The mission of the IPOG is to develop expertise-based consensus recommendations for the management of pediatric otolaryngologic disorders with the goal of improving patient care. The consensus recommendations herein represent the first publication by the group. RESULTS: Consensus recommendations including pre-operative, intra-operative, and post-operative considerations, as well as sedation and nutrition management are described. These recommendations are based on the collective opinion of the IPOG members and are targeted to (i) otolaryngologists who perform tracheotomies on pediatric patients, (ii) intensivists who are involved in the shared-care of these patients, and (iii) allied health professionals. CONCLUSION: Pediatric peri-operative tracheotomy care consensus recommendations are aimed at improving patient-centered care in this patient population.

SUMMARY: We reviewed the results of 4,723 day of sur- gery pregnancy tests performed at two of our institution's locations, our ambulatory surgery center and our acute orthopaedics hospital over a 23 month time period. All pa- tients were scheduled for elective orthopaedic surgery. There were seven positive results (0.15%) and one false negative result (0.02%). The cost per positive result for both hospital locations was $1,005.32. INTRODUCTION: Performing elective surgery on pregnant women can harm the mother and fetus. In order to minimize the likelihood of this happening, we administer a urine pregnancy test to each woman of childbearing age on the date of surgery. From November 2009 to September 2011, we performed 4,723 urine human chorionic gonadotropin (hCG) pregnancy tests on the day of surgery. We reviewed the results and cost of each pregnancy test. We then used these results to calculate the percentage of positive tests and the cost of diagnosing each pregnant female on the date of their surgery. METHODS: We obtained the records of all urine hCG preg- nancy tests performed from November 2009 to September 2011. Each test was reviewed to determine if the result was positive or negative. Costs were calculated using the charges incurred for a qualitative hCG pregnancy test. We then contacted each patient with a positive result to determine if the urine hCG test results were accurate. RESULTS: 4,723 pregnancy tests were reviewed over a 23 month period with 7 (0.15%) having a positive result. Over the 23 month time period, we were notified of one false nega - tive result (0.02%). The Positive Predictive Value (PPV) was 100% and the Negative Predictive Value (NPV) was 99.9%. The cost of a single urine hCG test was $1.49, the total cost for all 4,723 tests was $7,037.27. The cost of diagnosing 7 positive tests was $1,005.32. CONCLUSION: Routinely performing urine hCG pregnancy tests on the day of surgery is a cost effective method of pre- venting elective orthopaedic surgery on pregnant women. Of 4,723 women tested 7 had a positive result and 1 had a false negative result. The cost of $1,005.32 for each positive test must be compared with the benefit of not performing elective surgery on a pregnant female.

PURPOSE: To evaluate the utility of femoral nerve blocks in postoperative pain control after hip arthroscopy. METHODS: Forty consecutive patients scheduled for hip arthroscopy were randomized into 2 groups for postoperative pain control. Half were to receive routine intravenous narcotics for pain scores of 7 or above in the postanesthesia care unit (PACU), and the other half were to receive a femoral nerve block in the PACU for the same pain scores. Data were compared with respect to patient sex, patient age, traction times, type of procedure, nausea, overall patient satisfaction with analgesia, and duration of time in the PACU. RESULTS: Thirty-six patients had initial pain scores of 7 of 10 or greater on a visual analog scale. Of these patients, 16 were randomized to receive postoperative morphine and 20 to receive a femoral nerve block. There were no significant differences between the 2 groups with respect to sex, age, traction times, or type of procedure performed. Patients who received morphine had a significantly longer time to discharge from the PACU (216 minutes) than the femoral nerve block group (177 minutes). The morphine group was also significantly more likely to report postoperative nausea (75%) than the femoral nerve block group (10%). Patients receiving femoral nerve blocks were significantly more likely to be satisfied with their postoperative pain control (90%) than those who had received morphine (25%). All of the patients receiving a femoral nerve block stated that they would undergo the block again if they needed another hip arthroscopy. CONCLUSIONS: On the basis of all criteria studied (quality of pain relief, length of stay in the PACU, side effects, and patient satisfaction), a femoral nerve block is an excellent alternative to routine narcotic pain medication in patients undergoing hip arthroscopy. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

SUMMARY By all criteria studied (quality of pain relief, length of stay in the PACU, side effects and patient satisfaction), a femoral nerve block is an excellent alternative to routine narcotic pain medication in patients undergoing hip arthroscopy. DATA Purpose: To evaluate the utility of femoral nerve blocks in post-operative pain control after hip arthroscopy. Methods: Forty consecutive patients scheduled for hip arthroscopy were randomized into two groups for postoperative pain control. Half were to receive routine intravenous narcotics for pain scores of seven or above in the PACU, the other half were to receive a femoral nerve block in the PACU for the same pain scores. Data was compared with respect to patient sex, age, nausea, overall satisfaction with analgesia, and duration of time in the PACU. Results: Thirty-six patients had initial pain scores of seven or greater. Sixteen were randomized to receive post-operative morphine, and twenty to receive a femoral nerve block. There were no significant differences between the two groups with respect to sex or age of the patients. Patients who received morphine had a significantly longer time to discharge from the PACU (216 mins) than the femoral nerve block group (177 mins). The morphine group was also significantly more likely to report post-operative nausea (75%) than the femoral nerve block group (10%). Patients receiving femoral nerve blocks were significantly more likely to be satisfied with their post-operative pain control (90%) than those who had received morphine (25%). All of the patients receiving femoral nerve block stated that they would have the block again if they needed another hip arthroscopy

ABSTRACT: Simulation-based training is becoming an accepted tool for educating physicians before direct patient care. As ultrasound-guided regional anesthesia (UGRA) becomes a popular method for performing regional blocks, there is a need for learning the technical skills associated with the technique. Although simulator models do exist for learning UGRA, they either contain food and are therefore perishable or are not anatomically based. We developed 3 sonoanatomically based partial-task simulators for learning UGRA: an upper body torso for learning UGRA interscalene and infraclavicular nerve blocks, a femoral manikin for learning UGRA femoral nerve blocks, and a leg model for learning UGRA sciatic nerve blocks in the subgluteal and popliteal areas

Introduction: While it is well described that an Interscalene Nerve Block (ISB) results in phrenic nerve paralysis on the ipsilateral side (1,2), concern exists that this, in the presence of preexisting contralateral hemi-diaphragmatic paralysis, can result in significant respiratory distress after a nerve block is performed. While knowledge of an elevated hemi-diaphragm on the contralateral side, indicating paralysis, would be a consideration as to whether an ISB should be performed, it is not routine for patients to have a Chest X-Ray (CXR) prior to receiving an ISB for shoulder surgery. The frequency of an elevated hemi-diaphragm as an incidental CXR finding is not described in the literature. We undertook a retrospective review of CXRs on patients admitted to the NYU Langone Medical Center for reasons other than orthopedic surgery, to determine the percent of patients who have an undiagnosed elevated hemi-diaphragm to determine if routine CXR should be performed prior to a patient receiving an ISB. Methods: After obtaining IRB approval, the official report of 1029 random CXRs were reviewed. All X-rays were evaluated by a board certified radiologist specializing in Thoracic Imaging. CXRs were considered positive if the Radiologist documented an elevated hemi-diaphragm and a review of the patients' chart did not reveal a pre-existing diagnosis or condition that would explain the findings. Results: 21/1029 patients were found to have an elevated hemi-diaphragm on routine CXR (2.04%). While the reported incidence was higher on the right (n = 14) than left (n = 7), this did not reach clinical significance. Discussion: Our data indicate that the incidence of hemi-diaphragmatic paralysis is low (2.04%) Therefore we do not recommend preoperative CXR screening for its presence. However, while it is not a common occurrence it has a place in the differential diagnosis of respiratory distress in the OR or PACU in patients who have received an ISB. Anesthesiologists are in agreement that due to the near 100% incidence of a phrenic nerve block after an ISB the finding of an elevated hemi-diaphragm on a pre-operative CXR would be a consideration prior to performing the block. The literature was lacking when it came to the percent of patients who have an elevated hemi-diaphragm as an incidental finding on CXR. Our review demonstrates a low prevalence (2.04% total, 1.36% right, 0.68% left) and therefore a routine CXR is not justified. Because a small number of our patients will have an elevated hemi-diaphragm on the contralateral side prior to the performance of an ISB, this should be a consideration in the PACU

Tobacco use has been identified as a major risk factor for oral disorders such as cancer and periodontal disease. Tobacco use cessation (TUC) is associated with the potential for reversal of precancer, enhanced outcomes following periodontal treatment, and better periodontal status compared to patients who continue to smoke. Consequently, helping tobacco users to quit has become a part of both the responsibility of oral health professionals and the general practice of dentistry. TUC should consist of behavioural support, and if accompanied by pharmacotherapy, is more likely to be successful. It is widely accepted that appropriate compensation of TUC counselling would give oral health professionals greater incentives to provide these measures. Therefore, TUC-related compensation should be made accessible to all dental professionals and be in appropriate relation to other therapeutic interventions. International and national associations for oral health professionals are urged to act as advocates to promote population, community and individual initiatives in support of tobacco use prevention and cessation (TUPAC) counselling, including integration in undergraduate and graduate dental curricula. In order to facilitate the adoption of TUPAC strategies by oral health professionals, we propose a level of care model which includes 1) basic care: brief interventions for all patients in the dental practice to identify tobacco users, assess readiness to quit, and request permission to re-address at a subsequent visit, 2) intermediate care: interventions consisting of (brief) motivational interviewing sessions to build on readiness to quit, enlist resources to support change, and to include cessation medications, and 3) advanced care: intensive interventions to develop a detailed quit plan including the use of suitable pharmacotherapy. To ensure that the delivery of effective TUC becomes part of standard care, continuing education courses and updates should be implemented and offered to all oral health professionals on a regular basis.

The infraclavicular approach to the brachial plexus is a safe and reliable technique for surgery of the upper extremity. When performing the block, the anesthesiologist must appreciate three variables: needle direction, needle angle to the chest wall, and needle depth. Surface stimulation is an easy technique that can reliably predict both needle direction and needle angle

It has recently been suggested that peripheral nerve or plexus blocks performed with the use of a nerve stimulator at low currents (<0.5 mA) may result in neurologic damage. We studied the infraclavicular nerve block, performed with the use of a nerve stimulator and an insulated needle, in a prospective evaluation of efficacy and safety. During a one-year period, 248 patients undergoing infraclavicular nerve block were evaluated for block success rate and incidence of neurologic complication. All blocks were performed with the use of a nerve stimulator and an insulated needle at < or =0.3 mA. Success rate was 94%, which increased to 96% with surgical infiltration of local anesthetic. There were no intraoperative or immediate postoperative complications noted. After one week, only one patient had a neurologic complaint, and this was surgically related, referable to surgery performed on the radial nerve. We conclude that infraclavicular nerve blocks performed at low currents (< or =0.3 mA) are safe and effective