WHY ‘WORK HERE ONLY IF YOU WANT’ IS A BAD POLICY IN HEALTHCARE

🙍🏽♂️Some studies indicate that  the cost of turnover can average 150% of the employee's annual salary. 

🙍🏽♂️A staff, say an ICU nurse,  gets moulded, for the work pattern of  a particular ICU,  AFTER KEEN OBSERVATION OF 

🔃the course of various diseases that is commonly admitted in that ICU

🔃the pattern of other staff’s responses to various emergency situations which happens there commonly 

🔃the usual prescription pattern of the doctors there 

🔃the way of communication to caretakers followed in that ICU

🔃the medicolegal issues unique to that ICU etc. 

…FOR A LONG PERIOD OF TIME

🙍🏽♂️Many patients avoid a hospital because of inappropriate care resulting from ’too volatile’ staff pool (e.g. lack of awareness of a new nurse about patient’s requirements in a particular ward, a new doctor who doesn't communicate with nursing team unlike the previous person which may translate into poor awareness of the nursing team about the management plan and less confidence in them while talking to the caretakers etc)

🙍🏽♂️When employees leave, their duties are shifted to the remaining personnel who feel obligated to shoulder the additional burden. This decreases the quality of work by the remaining staff, till a replacement comes.

🙍🏽♂️All patients prefer to be cared for by the same members of a healthcare team each time they require treatment because of the already established relationships between the patient and the treating team ( This may be more obvious in case of doctors; but in reality this is equally important in case of all other performing staffs. For e.g. Seeing the same well behaving and caring front reception staff every time, will boost the level of comfort in the patient as soon as he or she enters the hospital and will add to the reputation about the hospital )

🙍🏽♂️Such relationships are important in the success of the institution,  especially in the present scenario where the same treatment/care can be received from various similar healthcare facilities 

🙍🏽♂️Creating an organizational environment that is dedicated to the retention of talented personnel is the first step in reducing employee turnover. 

🙍🏽♂️Determining why employees are leaving an organization is an important part of developing an effective strategy. One way this information can be obtained is by conducting detailed exit interviews. 

🙍🏽♂️Some employees may truly enjoy their jobs, but eventually decide that the challenges associated with completing their assigned responsibilities are simply too much to bear. For example, nurses may be drowning in mundane paperwork that never seems to end. This could result in nurses feeling unsatisfied and unrewarded for their work. A solution to this challenge could be to implement a new digital technology that streamlines the paperwork process. Or, you could hire additional clerks to transfer some of the overwhelming responsibility away from the nurses.

🙍🏽♂️A strategy for retainment is to provide various opportunities for your employee’s to learn or improve within their field. Along with that, if your employees know that their hard work will eventually pay off in the form of a promotion, they are far more likely to stay with your organization in the long-run.

🙍🏽♂️With a strong reputation, a particular hospital  can better attract the best new employees and better retain the current employees. Such information regarding reputation will silently flow between healthcare professionals working in various hospitals and whenever a crisis develops in their present workplace, they will be tempted to move to such hospitals with good reputation. 

🙍🏽♂️In the long term, such a policy will result in the hospital retaining a pool of good doctors, nurses and other staffs and will help the institution stand strong in adversities and help it retain a big pool of very loyal ‘customers’(=patients) 

Reference: Radiol Manage. 2004 Jul-Aug;26(4):52-5.Employee retention: an issue of survival in healthcare. Collins SK1, Collins KS., Healthcare Recruiters International: 4 Ways to Increase Healthcare Employee Retention

A FEW PROSPECTIVE TECHNIQUES TO MEASURE ANALGESIA INTRA-OPERATIVELY

🤖Current electroencephalogram (EEG)-derived measures like BIS, provide information on cortical activity and hypnosis but are less accurate regarding subcortical activity, which is expected to vary with the degree of antinociception. 

🤖Efforts to develop methods for monitoring these subcortical activities produced a few indices, which may provide some use intra-operatively 

🤖Recently, the neurophysiologically based EEG measures of cortical input (CI) and cortical state (CS) have been shown to be prospective indicators of analgesia/anti-nociception and hypnosis, respectively. Composite Cortical State (CCS) is an alternate measure of CS.

🤖Composite Variability Index (CVI) is another recently developed EEG-derived measure of antinociception  based on a weighted combination of BIS and estimated electromyographic activity.

🤖CCS and BIS show strong correlations, suggesting that they behave similarly as indicators of hypnosis.

Reference: Comparisons of Electroencephalographically Derived Measures of Hypnosis and Antinociception in Response to Standardized Stimuli During Target-Controlled 

Propofol-Remifentanil Anesthesia, Mehrnaz Shoushtarian, Marko M. Sahinovic, Anthony R. Absalom, Alain F. Kalmar, Hugo E. M. Vereecke, David T. J. Liley and Michel M. R. F. Struys, anesthesia-analgesia, February 2016 • Volume 122 • Number 2

☹️FIBROMYALGIA- AN OVERVIEW 🙍🏻♂️

🦂Is a common chronic pain condition, characterised by 

🖌Pain ( Spontaneous, widespread , diffuse, worse in the morning, hypersensitivity to all painful stimuli, >3 months duration, 11 out of 18 defined tender points produce tenderness on digital palpation)

🖌 Sleep disturbances

🖌 Fatigue 

🦂Pathophysiology may include 

🖌dysfunction of descending inhibitory pathways 

🖌abnormal neurotransmitter release

🖌central sensitisation etc

🦂Tricyclic antidepressants ( like Amitriptyline 5-10 mg ) may be effective in fibromyalgia as they reduce pain & fatigue and improve sleep

🦂Other therapies used:

🖌 Pregabalin

🖌Gabapentin

🖌Newer MAO inhibitors like pirlindole

🖌TENS

🖌Acupuncture 

🖌Intravenous lignocaine

🖌Injection of trigger points

🖌Cognitive Behavioural Therapy

🖌Warm bath

🖌Complimentary therapies

#pain , #fibromyalgia , #PainManagement

Reference: Dedhia JT, Bone ME. Pain and fibromyalgia. Contin Educ Anaesth Crit Care Pain. 2009; 9(5): 162–166.

PIN INDEX AND COLOUR CODING

ANESTHETIC CONCERNS IN TRANS SPHENOIDAL PITUITARY SURGERIES

🐨 Pituitary tumours can be hypo or hyper secretory : so they may exhibit Cushingoid status or cortisol deficiency. Accordingly the anesthetist has to look for diseases which are associated with these conditions

🐨 During the Pre Anesthetic Check up (PAC), we should screen for the presence of factors affecting airway management, like

✔️ Macroglossia

✔️ Soft tissue hypertrophy

✔️Obstructive Sleep Apnea (OSA)

And also for other associations like

✔️ DM

✔️ Systemic Hypertension 

✔️ Ischemic Heart Disease

✔️ Heart failure

✔️ Pulmonary Hypertension 

 🐨 If there is cortisol deficiency ( can be diagnosed by short synacthen test) glucocorticoid supplementation should be continued peri-operatively.

🐨 The trans nasal trans sphenoidal approach offers better visibility and lesser incidence of postoperative Diabetes Insipidus (DI). NB: Both DI and SIADH can occur as postoperative complications; but incidence of DI is much higher (upto 50%) compared to that of SIADH.

🐨Trans nasal surgery requires oro-tracheal intubation, insertion of a throat pack to prevent blood going to trachea and stomach and infiltration of the nasal mucosa with local anesthetic and vasopressor ( by surgeon )

🐨 Establishment of an arterial line will help to intervene promptly during hemodynamic fluctuations that happens with infiltration or intense surgical stimulation 

🐨 Surgeon may request various 'helps' from the anesthesiologist to make the suprasellar part of the tumor prolapse down into the sella, like:

✔️ Insertion of a lumbar drain and letting out of CSF

✔️ Maintenance of hypercapnea (upto 60 mm of Hg)

✔️ Fluid administration

🐨 As the patient is positioned with upper part of trunk and head elevated, there is chance for venous air embolism

🐨 Use of short acting drugs facilitate a rapid and smooth emergence which will help in neurological assessment 

🐨 Presence of blood in pharynx, nasal packs and preexisting OSA, pose additional problems in managing the airway

🐨 We can't apply a nasal CPAP mask in such cases as it can cause pneumocephalus, meningitis and air embolism

Reference: Lim M, Williams D, Maartens N. Anaesthesia for pituitary surgery. J Clin Neurosci. 2006; 13(4): 413–418.

HOW Hb S BECOMES A VILLAIN IN SICKLE CELL DISEASE (SCD) ❓

✔️ Inherited as Autosomal Dominant (Ⓜ️NEMO> Sickle Cell Disease is a SAD disease; S=SCD, AD=Autosomal Dominant)

✔️ A single DNA base change ( Beta chain) causes SCD

✔️ DNA base change is Adenine for Thymine & the resultant amino acid change is Valine for Glutamic Acid ( Ⓜ️NEMO> Addition of bases other than Thymine results in Valueless Goods )

✔️ Thus Hb S is produced. As Valine is hydrophobic, the deoxygenated Hb is less water soluble and gets precipitated & polymerized inside the RBC

✔️ This polymerization slightly reduces the overall affinity for O2; otherwise the affinity for O2 is same for Hb A and Hb S

✔️ These changes also make the RBS more rigid and contributes to sickling and microvascular occlusion

✔️ Regarding hypoxaemia, HbS will precipitate at a PO2 of 5–6 kPa (37-45 mm of Hg). As venous PO2 lies in this range, in case of homozygous individuals having only abnormal Hb will have continuous sickling

✔️ Patients with sickle cell trait experience sickling at much lower partial pressures (2.5–4 kPa / 19-30 mm of Hg )

✔️ Sickledex test produces a turbidity and becomes positive even with a very small amount of Hb S: so it CAN NOT differentiate between homo & heterozygous states

Reference: Smith T, Pinnock C, Lin T. Fundamentals of Anaesthesia, 3rd edn. Cambridge: Cambridge University Press, 2009; pp. 234–5 

#Anesthesia , #hematology , #medicine , #SickleCellDisease

INTRACRANIAL PRESSURE (ICP) & IT'S MEASUREMENT

🔸The ICP waveform is a modified arterial pressure tracing

🔸 It has 3 peaks: P1, P2 & P3

🔸 P1 is a result of transmitted pressure from choroid plexus

🔸 The amplitude of P2 changes with brain compliance. If compliance is poor, amplitude will be high ( can even exceed that of P1) and vice versa

🔸P3 represents the dicrotic notch

🔸 Lundberg (A) or Plateau waves are steep rise of ICP to over 50 mm of Hg and lasting for 5-20 minutes; then it falls abruptly. Are always pathological and indicates significantly reduced compliance

🔸 Lundberg (B) waves are oscillations occurring every 1-2 minutes where ICP rises to over 20-30 mm of Hg from baseline in a crescendo manner. They are supposed to be result of altered cerebral (B)lood volume and altered tone of cerebral (B)lood vessels 

🔸 Lundberg (C) waves are oscillations whose amplitude is less than that of B waves and are supposed to result because of interactions between cardiac and respiratory (C)ycles. They occur also in healthy individuals 

METHODS OF MEASUREMENT OF ICP

 Intraventricular catheter - ventriculostomy represents the "gold standard" for pressure measurement

 

✔️Normally placed in the frontal horn of lateral ventricle 

✔️Allows therapeutic CSF drainage 

✔️Creates a pathway for infection 

✔️Potential for accidental venting of CSF

✔️Possible subdural haemorrhage or upward brain herniation 

✔️ Catheter obstruction & ventricular haemorrhage may occur 

 Subdural bolt 

✔️ "Richmond Screw" or "Leeds device" inserted through a burr hole & an opening in the dura & arachnoid remains intact

 

✔️connects via a fluid couple to a transducer 

✔️ less invasive 

✔️ may underestimate high ICP and damping is a problem

 Subdural catheter 

✔️ Usually subdural space over frontal lobe of non-dominant hemisphere is selected

✔️ Prone to signal damping and calibration drift 

✔️ Potential risk of infection 

✔️ Doesn't require penetration of brain tissue

 Intracerebral transducer 

✔️Inability to check zero calibration & drain CSF 

✔️ Risk of infection

✔️Less reliable

🔸The incidence of infection ~ 2-7% with monitoring ≥ 5 days

🔸The risks are slightly greater with dural penetration 

🔸The zero reference point of the transducer is usually taken as the external auditory meatus 

🔸 Rather than the waveform type, the important factors appear to be the degree and duration of ICP elevation

A BIOPIC ABOUT THYROXIN

🚶🏻Tyrosine derived from thyroglobulin is combined with iodine to produce T3 & T4 (Thyroxin)

🚶🏻T3 is 5 times more active than T4, though T4 is produced in larger amounts 

🚶🏻'ACTIVITIES OF TSH'

✔️ Increase the size & number of thyroid gland cells

✔️ Increase iodide binding

✔️ Increase the release of thyroglobulin into the colloid of the gland

✔️Increase pinocytosis of colloid by the thyroid cells

✔️Increase hormone production 

✔️ Increase release of already produced hormone from the bound thyroglobulin and into the bloodstream 

🚶🏻In bloodstream the hormones are 99% protein bound. 

🚶🏻Thyroxin Binding Globulin (TBG) has the greatest affinity; but Albumin has the greatest capacity for binding the hormones. Thyroxine-binding prealbumin (TBPA) also bind them

🚶🏻REGULATION OF HORMONAL ACTIVITY

✔️ For regulation of the hormonal levels, the negative feedback is mediated by the unbound free fraction 

✔️ Stress inhibits production 

✔️ Warmth decreases production 

✔️ Cold increases production 

✔️ Glucocorticoids, dopamine & somatostatin inhibit TSH secretion

Reference: Smith T, Pinnock C, Lin T. Fundamentals of Anaesthesia, 3rd edn. Cambridge: Cambridge University Press, 2009; p. 474 .

#Thyroid , #Thyroxin , #Medicine , #Physiology

WHAT IS SURGICAL STRESS INDEX (SSI)❓

🔵 SSI is an index which measures the surgical stress response in patients under anesthesia

🔵 It assess the balance between the intensity of surgical stimulation and the level of antinociception (e.g. Opioid analgesia , neuraxial or nerve blockade)

🔵 SSI uses two continuous cardiovascular variables, both obtained from Photo Plethysmography (PPG) waveforms of SpO2 

(1) The interval between successive hearts beats (HBI) 

(2) PPG amplitude (PPGA) 

🔵Photoplethysmography (PPG), i.e. pulse oximetry, is primarily used to produce an estimation of the relative concentration of oxyhemoglobin in blood.

🔵 PPG is related to volume changes and contains information about the peripheral blood circulation, including skin vasomotion. Skin vasomotion is controlled by the sympathetic nervous system, which is activated during surgical stress.

🔵 Changes in PPG amplitude (PPGA) reflect changes in the peripheral vascular bed, controlled by the sympathetic nervous system . Increased PPGA response has been associated with nociception during general anesthesia.

🔵SSI values near 100 correspond to a high stress level, and values near zero to a low stress level.

🔵 In trials, SSI correlated positively with the intensity of painful stimuli and negatively with the analgesic concentration

🔵 SSI has been shown to be capable of differentiating decreases in HR achieved with opioid from those accomplished with a beta blocker (Ahonen et al. 2007). 

🔵 An optimal range for SSI during anesthesia has not yet been recommended.

Reference: Measurements of adequacy of anesthesia and level of consciousness during surgery and intensive care, Johanna Wennervirta, Department of Anesthesiology and Intensive Care Medicine, Helsinki University Hospital

#anaesthesia , #anaesthesiology , #anaesthesiologist

CAUDAL BLOCKS: A FEW FACTS

🎯 Most effective for children <20 Kg (~ under 6 years of age) and for dermatomes below T10

🎯Common side effects are weakness of legs, urinary retention etc

🎯 The incidence of epidural hematoma has been reported as 1 in 80000 cases

🎯 Because of this, sometimes a caudal block may necessitate overnight admission 

🎯 Dose calculation can be done using Armitage ( 0.5 mL/kg for lumbosacral & 1 mL/kg for lumbar blockade, with 0.25% levobupivacaine ) or Scott formulas

🎯 Additives used in caudal block:

💉 Preservative free Ketamine: Extend duration of analgesia; not used in infants <6 months of age due to fear of neurotoxicity 

 💉 Clonidine : Extend duration of analgesia; not used in preterm infants and neonates due to higher incidence of bradycardia and apnoea. Provides postoperative sedation also.

🎯 Opioids when used as additives produce side effects like respiratory depression, pruritus & PONV

#EpiduralBlock , #Anaesthesia , #Anesthesia

References: De Beer DAH, Thomas ML. Caudal additives in children: solutions or problems? Br J Anaesth. 2003; 90: 487–498. Patel D. Epidural analgesia for children. Contin Educ Anaesth Crit Care Pain. 2006; 6(2): 63–66.