Search

Purpose: Peripheral nerve blocks (PNBs) provide excellent perioperative analgesia but can increase the risk of severe postoperative pain once the block wears off. Poor adherence to discharge instructions may increase this risk. Panda-Nerve Block (Panda) is an app that alerts the patient to assess their PNB, score their pain, and take scheduled pain medication. We assessed the usability and feasibility of Panda for assisting patients after receiving a PNB. Methods: Twenty-nine patients tested Panda in three rounds, for two to seven days, postoperatively to assess and manage their pain and PNB. Feedback was provided via phone interview and the Computer System Usability Questionnaire (CSUQ). Additionally, each user’s usage log was analyzed for parameters such as alert response times. Feasibility was determined by alert responses that occurred before the next alert, with a goal of greater than 50%. User adherence was measured as percentage compliance with alerts within one hour; usability and user satisfaction were determined from the CSUQ and interviews. Results: A median [interquartile range (IQR)] of 68 [34–93]% responded before the next alert during the first 48 hr of app use, and 83 [54–92]% responded before the next alert with 87 [75–96]% of these within one hour. There were no significant differences in usage between rounds. Ninety-three percent of patients reported Panda to be easy to use and helpful, and 79% of patients would use Panda again. Critical themes included changes to the layout and appearance, clarification of the language of the PNB check, and requests for dynamic adjustments to the medication schedule based on user responses. Conclusion: Panda-Nerve Block is a feasible method for PNB patients to manage postoperative pain with a high response rate. Future work should include providing two-way communication for patients and clinicians and assessing its effect on pain outcomes. Trial registration: www.clinicaltrials.gov(NCT03369392); registered 5 December 2017.

Purpose: Processed electroencephalography (EEG) monitors support depth-of-hypnosis assessment during anesthesia. This randomized-controlled trial investigated the performance of the NeuroSENSE electroencephalography (EEG) monitor to determine whether its wavelet anesthetic value for central nervous system (WAVCNS) index distinguishes consciousness from unconsciousness during induction of anesthesia (as assessed by the anesthesiologist) and emergence from anesthesia (indicated by patient responsiveness), and whether it correlates with changes in desflurane minimum alveolar concentration (MAC) during maintenance of anesthesia. Methods: EEG was collected using a fronto-temporal bilateral montage. The WAVCNSwas continuously recorded by the NeuroSENSE monitor, to which the anesthesiologist was blinded. Anesthesia was induced with propofol/remifentanil and maintained with desflurane, with randomized changes of −0.4, 0, or +0.4 MAC every 7.5 min within the 0.8–1.6 MAC range, if clinically acceptable to the anesthesiologist. During emergence from anesthesia, desflurane was stepped down by 0.2 MAC every five minutes. Results: Data from 75 patients with a median [interquartile range] age of 41[35-52] yr were obtained. The WAVCNSdistinguished consciousness from unconsciousness as assessed by the anesthesiologist, with area under the receiver operating characteristic curve of 99.5% (95% confidence interval [CI], 98.5 to 100.0) at loss of consciousness and 99.4% (95% CI, 98.5 to 100.0) at return of consciousness. Bilateral WAVCNSchanges correlated with desflurane concentrations, with −8.0 and −8.6 WAVCNSunits, respectively, per 1 MAC change in the 0.8–1.6 MAC range during maintenance of anesthesia and −10.0 and −10.5 WAVCNSunits, respectively, in the 0.4–1.6 MAC range including emergence from anesthesia. Conclusion: The NeuroSENSE monitor can reliably discriminate between consciousness and unconsciousness, as assessed by the anesthesiologist, during induction of anesthesia and with a lower level of reliability during emergence from anesthesia. The WAVCNScorrelates with desflurane concentration but plateaus at higher concentrations, similar to other EEG monitors, which suggests limited utility to titrate higher concentrations of anesthetic vapour. Trial registration: clinicaltrials.gov, NCT02088671; registered 17 March, 2014.

Purpose: The Pain assessment using a novel digital application (Panda) is a smartphone application that contains the digital versions of the visual analogue scale (VAS-100) and numeric rating scale (NRS-11). This study aimed to investigate if the Pandaversions of these two pain scales are equivalent to the paper versions in adult patients. Methods: This was a prospective, randomized, cross-over-controlled trial of subjects aged 19–75 yr undergoing procedures with anticipated post-surgical pain. Each subject used both the Pandaand paper versions of VAS-100 or NRS-11 pain scores after emergence from anesthesia and after meeting postanesthesia care unit (PACU) discharge criteria. Correlations between the two tools were analyzed, and Bland-Altman agreement was calculated. The smartphone and paper versions were considered equivalent at each time point if the differences (and their 95% confidence interval [CI]) between them were less than 20 points for the VAS-100 and 2.1 for NRS-11. Results: The two versions of the VAS-100 correlated strongly after emergence (Pearson’s r = 0.93; P< 0.001) and upon meeting discharge criteria (r = 0.94; P< 0.001); the mean (standard deviation [SD]) Pandascore after emergence was 35 (27) compared with the paper score of 37 (26) (mean difference, − 2; 95% CI, − 22 to 19). The mean (SD) VAS-100 Pandascore upon meeting discharge criteria was 21 (20) compared with the paper score of 23 (21) (mean difference, − 2; 95% CI, − 17 to 13). For the NRS-11, Pandaagain correlated strongly with the original tool scores after emergence (r = 0.93; P< 0.001) and upon meeting discharge criteria (r = 0.96; P< 0.001); the mean (SD) Pandaand paper scores after emergence were both 4 (3) (mean difference, 0.05; 95% CI, − 1.87 to 1.96). The mean (SD) NRS-11 Pandaand paper scores upon meeting PACU discharge criteria were both 3 (2) (mean difference, − 0.08; 95% CI, − 1.41 to 1.26). Conclusion: Following emergence from anesthesia in adult patients, the digital Pandaversion of the NRS-11, but not the VAS-100, is equivalent to the validated paper version. In those who are ready for discharge from the PACU, the digital Pandaversions of both the VAS-100 and NRS-11 agreed adequately and can be used in place of the original paper versions.

Purpose: Opioids have a narrow therapeutic index and have the potential to cause significant harm. Developmental and pharmacogenetic factors put children, and especially infants, at increased risk of complications. We performed a retrospective root cause analysis to identify the factors associated with critical incidents in children receiving opioid infusions in a tertiary care children’s hospital. Methods: Following institutional ethical approval, we identified potential critical incidents during 2004 to 2009 from patient safety and pharmacy data. Patients’ medical charts were reviewed and a timeline of events that occurred before, during, and following each incident was generated. A safety assessment code score was assigned to each incident according to its severity and probability of recurrence, and incidents with a score ≥ 8 were selected for root cause analysis. Root causes were identified and classified, formal causal statements were written, and action plans were recommended. Results: One hundred and sixty-six medical charts were reviewed, and 58 of these included one (45/58) or more (13/58) relevant critical incidents. The resulting harms were of minor to moderate severity. Fourteen incidents were submitted for detailed analysis, from which 31 root causes were identified. The most frequent and significant root causes involved defects in pre-printed order sheets, lack of a nursing guidelines for infusions (rate, adjustment, weaning), and inadequate guidelines for monitoring and recording pain, vital signs, and arousal scores. Discussion: The root causes of a range of critical incidents have been identified, and these have been used to generate recommendations for improving both patient safety and quality of analgesia for children receiving opioid infusions for acute pain management.

Purpose: To determine whether detection of residual blockade is improved by using the accelerograph. A secondary objective was to compare acceleromyographic measurements with those obtained by electromyography. Methods: In a prospective, randomized, double-blind investigation, 22 anaesthetized children were studied during recovery from neuromuscular blockade following 0.1 mg· kg−1vecuronium iv. Assessments of depth of block began 10 min after injection and were repeated at one minute intervals using electromyography (Datex, Relaxograph) in one hand, and acceleromyography (Biometer, Tofguard) in the other, to measure responses of the adductor pollicis to train-of-four (TOF) stimulation of the ulnar nerve. Monitoring was stopped when no fade was visible and TOF ratio ≥0.7. The electromyographic (EMG) and acceleromyographic (AMG) data were compared with corresponding observations of the number of twitches and TOF fade in the visible responses of the thumb, made by the attending anaesthetist. The method of Bland and Altman was used to compare differences between AMG and EMG data. Results: During recovery from neuromuscular blockade, fade was no longer visible clinically 38.6 ± 10.4 min (mean ± SD) after the administration of vecuronium. This corresponded to TOF ratios of 0.40 ± 0.23 by AMG and 0.34 ± 0.21 by EMG. Usually, two twitches were visible before AMG detected the first twitch. The time to TOF ratio ≥0.7 by AMG and EMG was similar at 49.1 ± 10.5 and 50.9 ± 9.0 min, respectively. The bias between AMG and EMG was one minute, with limits of agreement from −10 to nine min. Conclusion: AMG is superior to visual assessment in detecting residual neuromuscular block and provides similar estimates of recovering block as the more cumbersome EMG.