Design and Evaluation of a Wireless Electrocardiogram Monitor in an Operating Room: A Pilot Study

BACKGROUND: Wired electrocardiogram monitors are an important component of current perioperative monitoring. Wireless monitoring units could help reduce the number of cables attached to patients and thus improve anesthesia ergonomics and patient management. However, there is concern that electromagnetic interference generated by electrosurgical units may prevent effective wireless signals in the operating room. To evaluate the extent of this problem, we developed a Bluetooth electrocardiogram prototype monitor and compared its electrocardiogram traces to those captured with a standard wired electrocardiogram monitor in our operating room. METHODS: Bluetooth electrocardiogram and standard electrocardiogram traces captured from 10 patients undergoing surgical procedures that required use of an electrosurgical unit were compared by analysis of the durations of the P wave, QRS complex, and T wave and the position of the ST segment from the isoelectric line. The impact of the electrosurgical units on the Bluetooth electrocardiogram and S-electrocardiogram recordings was also assessed. RESULTS: There were no clinically relevant differences in P wave, QRS complex, or T-wave durations (0.006, 0.004, and 0.017 seconds, respectively) between Bluetooth electrocardiogram and standard electrocardiogram or in the position of the ST segment from the isoelectric line (0.02 mV). Mean differences were near zero, and Bland–Altman limits of agreement for individual differences were narrow (−0.035 to 0.047, −0.03 to 0.038, and −0.112 to 0.078 seconds for P wave, QRS complex, and T-wave durations, respectively, and −0.13 to 0.17 mV for ST segment position). Electrosurgical units use electrically disrupted Bluetooth electrocardiogram and standard electrocardiogram signals, but there was no electromagnetic interference effect on the Bluetooth electrocardiogram signals. CONCLUSIONS: Wireless electrocardiogram using Bluetooth can be reliably used in the operating room. The electrosurgical unit induces electric rather than electromagnetic artifacts, thus affecting wired and wireless electrocardiogram in a similar fashion. Accepted for publication November 1, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Philippe Ariès, MD, Department of Anesthesia and Intensive Care, Military Teaching Hospital "Clermont Tonnerre," Brest 29200, France. Address e-mail to philippe.aries@chu-brest.fr. © 2018 International Anesthesia Research Society

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Anticoagulation Management and Heparin Resistance During Cardiopulmonary Bypass: A Survey of Society of Cardiovascular Anesthesiologists Members

We surveyed Society of Cardiovascular Anesthesiologists members regarding anticoagulation practices for cardiopulmonary bypass and attitudes on heparin resistance. Of 550 respondents (18.5% response rate), 74.9% (95% CI, 71.3%–78.5%) used empiric weight-based dosing of heparin, and 70.7% (95% CI, 66.9%–74.5%) targeted an activated clotting time of either 400 or 480 seconds to initiate cardiopulmonary bypass. Of note, 17.1% (95% CI, 13.9%–20.2%) of respondents reported activated clotting time targets lower than those recommended by recent 2018 Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists/American Society of Extracorporeal Technology guidelines or failed to monitor heparin effects at all. When heparin resistance was encountered, 54.2% of respondents (95% CI, 50.0%–58.4%) administered antithrombin concentrates as a first-line therapy. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Accepted for publication November 13, 2018. Funding: This work was supported by Grifols, S.A., in the form of a research grant. The sponsor had no involvement in either data analysis or manuscript preparation. Conflicts of Interest: See Disclosures at the end of the article. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). Reprints will not be available from the authors. Address correspondence to Roman M. Sniecinski, MD, MSc, Department of Anesthesiology, Emory University Hospital, 1364 Clifton Rd, NE, Atlanta, GA 30322. Address e-mail to rsnieci@emory.edu. © 2018 International Anesthesia Research Society

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Development and Usability Testing of the Society for Pediatric Anesthesia Pedi Crisis Mobile Application

When life-threatening, critical events occur in the operating room, the fast-paced, high-distraction atmosphere often leaves little time to think or deliberate about management options. Success depends on applying a team approach to quickly implement well-rehearsed, systematic, evidence-based assessment and treatment protocols. Mobile devices offer resources for readily accessible, easily updatable information that can be invaluable during perioperative critical events. We developed a mobile device version of the Society for Pediatric Anesthesia 26 Pediatric Crisis paper checklists—the Pedi Crisis 2.0 application—as a resource to support clinician responses to pediatric perioperative life-threatening critical events. Human factors expertise and principles were applied to maximize usability, such as by clustering information into themes that clinicians utilize when accessing cognitive aids during critical events. The electronic environment allowed us to feature optional diagnostic support, optimized navigation, weight-based dosing, critical institution-specific phone numbers pertinent to emergency response, and accessibility for those who want larger font sizes. The design and functionality of the application were optimized for clinician use in real time during actual critical events, and it can also be used for self-study or review. Beta usability testing of the application was conducted with a convenience sample of clinicians at 9 institutions in 2 countries and showed that participants were able to find information quickly and as expected. In addition, clinicians rated the application as slightly above "excellent" overall on an established measure, the Systems Usability Scale, which is a 10-item, widely used and validated Likert scale created to assess usability for a variety of situations. The application can be downloaded, at no cost, for iOS devices from the Apple App Store and for Android devices from the Google Play Store. The processes and principles used in its development are readily applicable to the development of future mobile and electronic applications for the field of anesthesiology. Accepted for publication October 8, 2018. Funding: None. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website (https://ift.tt/KegmMq). †† The members of the secondary authors "The Pedi Crisis Application Working Group" are listed in the Appendix. Reprints will not be available from the authors. The REDCap electronic data capture tools are supported by a National Institutes of Health Clinical and Translational Science Award UL1TR000430 and hosted by the University of Chicago, Chicago, IL. Address correspondence to Anna Clebone, MD, Department of Anesthesiology and Critical Care Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637. Address e-mail to aclebone@gmail.com. © 2018 International Anesthesia Research Society

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Cardiac Emergencies in Children: A Practical Approach to Diagnosis and Management

No abstract available

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Narcolepsy, Anesthesia, and Sedation: A Survey of the Perioperative Experience of Patients With Narcolepsy

BACKGROUND: Patients with narcolepsy may be at increased perioperative risk due to the interactions among anesthesia, narcolepsy, and narcolepsy medications. This study sought to determine the perioperative experience of narcoleptic patients undergoing anesthesia or sedation, the frequency of perioperative counseling, and self-reported surgical complications. METHODS: A 22-question survey was developed by expert consensus and distributed by the Narcolepsy Network. Recruitment was via the Narcolepsy Network's list-serve and a Facebook link to the survey. One thousand and twenty respondents reported a diagnosis of narcolepsy and 1 or more procedures under anesthesia or sedation. Descriptive, comparative statistics and logistic regression were utilized. RESULTS: Respondents were mostly women (79.5%) and Caucasian (84.9%), with a mean age of 45 ± 16 years. Most respondents did not receive counseling regarding the possibility of increased sleepiness (70%), cataplexy (90%), or drowsy driving (59%) postanesthesia. More than half of respondents reported adverse events (medication withdrawal symptoms, inadequate pain relief, increased cataplexy). Subjects with cataplexy more frequently reported surgical complications (70% vs 31%; P = .03) and medication withdrawal symptoms (stimulant medications: odds ratio, 3.0 [95% CI, 1.9, 3.06]; P > .001 and antidepressant medications: odds ratio, 6.5 [95% CI, 2.1–19.5]; P = .001). Of the total sample, 18% indicated surgical complications. Undergoing 5 or more separate surgeries or procedures was associated with a 2-fold increase in self-reported complications (odds ratio, 2.2 [95% CI, 1.3–3.4]; P = .001), difficulty waking (odds ratio, 2.1 [95% CI, 1.45–3.06]; P = .001), and inadequate pain relief (odds ratio, 1.77 [95% CI, 1.01–3.13]; P

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Trends in the Mode of Delivery of Pregnant Women in Rural Guatemala from a Quality Improvement Database

Abstract

Purpose To evaluate trends and factors associated with mode of delivery in the rural Southwest Trifinio region of Guatemala. Description We conducted a retrospective analysis of self-reported antepartum factors and postpartum outcomes recorded in a quality improvement database among 430 women enrolled in a home-based maternal healthcare program between June 1, 2015 and August 1, 2017. Assessment Over the study period, the rates of cesarean delivery (CD) increased (from 30 to 45%) and rates of vaginal delivery (VD) decreased (70–55%) while facility-based delivery attendance remained stable around 70%. Younger age (23.5 years for VD vs. 21.6 years for CD, p < 0.001), nulliparity (25.1% for VD vs. 45.0% for CD, p < 0.001), prolonged/obstructed labor (2.4% for VD vs. 55.6% for CD, p < 0.001), and fetal malpresentation (0% for VD vs. 16.3% CD, p < 0.001) significantly influenced mode of delivery in univariate analysis. The leading indications for CD were labor dysfunction (47.5%), malpresentation (14.5%), and prior cesarean delivery (19.8%). The CD rate among the subpopulation of term, nulliparous women with singleton pregnancies in vertex presentation also increased from 20% of all CD in 2015, to 38% in 2017. Conclusion Among low-income women from rural Guatemala, the CD rate has increased above the World Health Organization (WHO) recommendations in a period of 3 years. Additional research on the factors affecting this trend are essential to guide interventions that might improve the appropriateness of CD, and to determine if reducing or stabilizing rates is necessary.

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Novel variants in SPTAN1 without epilepsy: An expansion of the phenotype

We describe two unrelated children with de novo variants in the non‐erythrocytic alpha‐II‐spectrin (SPTAN1) gene who have hypoplastic brain structures, intellectual disability, and both fine and gross motor impairments. Using agnostic exome sequencing, we identified a nonsense variant creating a premature stop codon in exon 21 of SPTAN1, and in a second patient we identified an intronic substitution in SPTAN1 prior to exon 50 creating a new donor acceptor site. Neither of these variants has been described previously. Although some of these patients' features are consistent with the known SPTAN1 encephalopathy phenotype, these two children do not have epilepsy, in contrast to reports about nearly every other patient with heterozygous SPTAN1 variants and in all patients with a variant near the C‐terminal coding region. Moreover, both children have abnormal thyroid function, which has not been previously reported in association with SPTAN1 variant. We present a detailed discussion of the clinical manifestations of these two unique SPTAN1 variants and provide evidence that both variants result in reduced mRNA expression despite different locations within the gene and clinical phenotypes. These findings expand the motor, cognitive, and behavioral spectrum of the SPTAN1‐associated phenotype and invite speculation about underlying pathophysiologies.

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