Faculty Bibliography

BACKGROUND: Delivery of intravenous antibiotic prophylaxis within one hour prior to surgical incision is considered important in helping to decrease the incidence of surgical site infections, but methods to ensure compliance have not been established. METHODS: All patients at our institution are subjected to a surgical 'time-out' protocol to prevent wrong-site surgery. During a seven-week period, all patients undergoing spine surgery, total hip arthroplasty, or total knee arthroplasty had another safety initiative, that of ensuring that prophylactic intravenous antibiotics were administered at least one hour prior to incision, 'piggybacked' onto our existing time-out verification checklist. In addition, we compared compliance during the study period with compliance during a three-month period prior to institution of this protocol and compliance for eighteen months after institution of this protocol. RESULTS: The average time (and standard deviation) between the antibiotic administration and the incision was 26 +/- 12 minutes for all patients. The protocol was effective in ensuring antibiotic administration at the optimal time to 316 (99.1%) of the 319 patients. Analysis of a group of forty patients who had undergone total hip or knee replacement during the three months prior to the beginning of the study demonstrated a compliance rate of 65%. The difference between this baseline compliance rate and the rate during the study period was significant (p < 0.0001). The compliance rate was 97% for 160 patients who underwent similar procedures during the eighteen months after completion of the study. Independent audits demonstrated continuation of the significantly better compliance with timing of antibiotic prophylaxis for patients undergoing total hip and knee arthroplasty since the implementation of the protocol in our institution. CONCLUSIONS: Piggybacking of verification of prophylactic antibiotic administration onto the wrong-site-surgery time-out protocol is an effective, cost-free, and easy-to-adopt method to ensure compliance with appropriate timing of prophylactic antibiotics

PURPOSE: To ultrasonically identify the presence of septae within the neurovascular sheath and to assess their effect on local anesthetic spread when performing infraclavicular brachial plexus blocks. CLINICAL FEATURES: Thirty ASA status I and II patients scheduled for minor hand surgeries were enrolled in the study. Ultrasound guided infraclavicular brachial plexus blocks were performed on 28 patients. The images of the local anesthetic spread and the effect of the septum within the neurovascular sheath were analyzed. Septae were present in four of six patients where unilateral local anesthetic spread was seen. Septae were not visualized in the 22 patients with unrestricted local anesthetic spread after the initial injection. All 28 patients underwent their planned operations successfully with adequate anesthesia. CONCLUSIONS: Our study shows that the presence of septae within the neurovascular sheath may influence the pattern of local anesthetic spread associated with the infraclavicular approach to brachial plexus blocks

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

The viral disease, smallpox, was well known through the end of the 20th Century. Because it has been eradicated from natural populations, the present clinical experience with managing the disease is limited. Similarly, research in the pathophysiology, treatment, and prevention of the disease has recently become a priority. Concerns regarding smallpox as a weapon of bioterrorism have led to the implementation of a new prophylactic vaccine program, a renewal in variola vaccine research, and treatment regimens against variola infection