Perioperative Pediatric Morbidity and Mortality

This case focuses on complications during a child’s surgery by asking the question: What are the rates of perioperative adverse events among children of different ages? This was a large study that provided estimates of the rates for adverse perioperative events among children. The study used data from 29,220 anesthetics collected from 1982 to 1987 and analyzed the rate of perioperative adverse events for children in five age groups. Overall, approximately 40% of children experienced at least one perioperative adverse event. Over the 6 years of the study, there was a decrease in the rate of postoperative events. Despite the number of perioperative adverse events, there was little parental dissatisfaction with the anesthetic experience.

Postdural Puncture Headache in Obstetrics: A Meta-analysis

This case focuses on how often postdural puncture headaches appear after using neuraxial blockage by asking the question: What are the frequency, onset, and duration of postdural puncture headache (PDPH) in the obstetric population after neuraxial blockade? This meta-analysis found that PDPH is a frequent complication, with an estimated incidence of 1.5% for epidurals and of 52.1% when dural puncture occurs. For spinals, the risk for PDPH varied depending on the type of spinal needle and ranged from 1.5% to 11.2%. The conclusions of this meta-analysis are consistent with prior recommendations that smallest diameter, atraumatic needles be used for spinal analgesia or anesthesia.

Epidural Glucocorticoid Injections for Spinal Stenosis

This case focuses on using an epidural on spinal stenosis by asking the question: What is the effectiveness of epidural injections of glucocorticoids plus anesthetic compared with injections of anesthetic alone in patients with lumbar spinal stenosis? This study demonstrated that epidural injection containing glucocorticoids for the treatment of lumbar stenosis offered minimal or no benefit over epidural injection of lidocaine alone at 6 weeks. Systemic absorption of glucocorticoids and suppression of the hypothalamic-pituitary axis were demonstrated among patients who received epidural injections containing glucocorticoids.

Postinjury Pain Hypersensitivity and NMDA Receptor Antagonists

This case focuses on pain hypersensitivity by asking the question: Are primary afferent-induced hypersensitivity states dependent on the activation of N-methyl-d-aspartate (NMDA) receptors, and is windup (perceived increase in pain intensity with a repeatedly delivered stimulus) a possible trigger for the production of central hypersensitivity? This study demonstrated that the induction and maintenance of central sensitization are dependent on NMDA receptor activation. NMDA receptor antagonists have been shown to prevent the manifestation of central sensitization as well as to decrease established hyperactivity in pain pathways. NMDA receptor antagonists play an important role in pain management.

Care Coordination

This case focuses on improving care coordination for patients who have been discharged from the hospital by asking the question: Is it possible to reduce the rate of repeat emergency department and hospital visits after discharge by improving care coordination? The study group included adults admitted to the general medicine service of an urban, academic medical center that serves an “ethnically diverse patient population.” Patients were assigned to nurse discharge advocates who provided the patients with delineated services and assistance during the hospitalization The Project Reengineered Discharge (RED) program substantially reduced repeat emergency department and hospital visits by improving care coordination at the time of hospital discharge.

Postoperative Oxygen Desaturation

This case focuses on the benefits of using regional anesthesia vs. continuous administration of opioids by asking the question: What are the effects of regional anesthesia vs. continuous administration of opioids on respiratory function following general anesthesia for major surgery? This study demonstrated that narcotic analgesia is an important cause of oxygen desaturation and ventilatory disturbances during sleep in postoperative patients. The transient nature of desaturations and ventilatory disturbances highlighted the need for continuous monitoring techniques in the postoperative period.

Prevention of Postoperative Nausea and Vomiting

This case focuses on the prevention of postoperative nausea and vomiting (PONV) by asking the question: What is the efficacy of six well-established prophylactic antiemetic strategies individually and in combination for the prevention of postoperative nausea and vomiting? Each of the three antiemetics in this study (ondansetron, dexamethasone, and droperidol) reduced the risk for PONV by approximately 26%; substituting propofol for volatile anesthetic reduced the risk by 19%; and substituting nitrogen (air) for nitrous oxide reduced the risk by 12%. A maximum reduction of 70% in the relative risk for PONV can be expected when total intravenous anesthesia is used with three antiemetics. The appropriate approach to the management of PONV depends on the patient’s baseline risk factors as well as the likelihood of adverse events and costs from the antiemetic medications.

Perioperative Medication Errors and Adverse Drug Events

This case focuses on medication errors and adverse drug events occurring during the perioperative period by asking the question: What are the rates, types, severity, and preventability of medication errors (MEs) and adverse drug events (ADEs) in the perioperative setting during anesthesia care? This prospective observational study reported that approximately 1 in 20 perioperative medication administrations, and every second operation, resulted in an ME and/or an ADE. These rates are markedly higher than those reported by prior retrospective surveys. Process- and technology-based solutions may address the root causes of MEs to reduce their incidence.

Intensive Insulin Therapy and Pentastarch Resuscitation in Sepsis

This case focuses on the use of intensive insulin therapy with sepsis by asking the question: What are the safety and efficacy of intensive insulin therapy compared with conventional therapy and hydroxyethyl starch (HES) compared with Ringer’s lactate in patients with severe sepsis or septic shock? This study demonstrated that critically ill patients did not benefit from intensive insulin therapy targeting blood glucose levels of 80–110 mg/dL vs. conventional insulin therapy nor from fluid resuscitation with HES vs. Ringer’s lactate. Neither intensive insulin therapy nor fluid resuscitation with HES is currently recommended in major sepsis guidelines.

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

This case focuses on detecting sepsis through early goal-directed therapies by asking the question: Does aggressive correction of hemodynamic disturbances in the early stages of sepsis improve outcomes? Early goal-directed therapies are aimed at restoring a balance between oxygen delivery and oxygen demand. Patients included in the study were adults presenting to the emergency room with severe sepsis or septic shock. Study results indicated that most patients with severe sepsis or septic shock should be managed with aggressive hemodynamic monitoring and support immediately on presentation in the emergency department (or, if this is not possible, in the intensive care unit) for 6 hours or until there is resolution of hemodynamic disturbances.