A 66-year-old man underwent a left minithoracotomy for pleural biopsies and thoracentesis. A left T3 paravertebral catheter was placed prior to induction of general anaesthesia, and a total of 20 mL of bupivacaine 0.25% administered. Postoperatively, ropivacaine 0.2% infusion was commenced at 10 mL/hour. Thirty-seven hours after the initial block, the patient developed convulsions without loss of consciousness. The ropivacaine infusion rate was unchanged and no further boluses had been given. He reported of perioral tingling, a burning sensation in his legs and penis and agitation. Ropivacaine infusion was ceased and a bolus of lipid emulsion (Intralipid 20%) administered, followed by an infusion. His symptoms (aside from mild agitation) resolved within an hour of cessation of the local anaesthetic and commencement of lipid rescue. The total serum concentration of ropivacaine during the event was 2.1 mg/L compared with a published toxic level of 2.2 mg/L in healthy human volunteers.

Massive transfusions guided by massive transfusion protocols are commonly used to manage critical bleeding, when the patient is at significant risk of morbidity and mortality, and multiple timely decisions must be made by clinicians. Clinical decision support systems are increasingly used to provide patient-specific recommendations by comparing patient information to a knowledge base, and have been shown to improve patient outcomes. To investigate current massive transfusion practice and the experiences and attitudes of anaesthetists towards massive transfusion and clinical decision support systems, we anonymously surveyed 1000 anaesthetists and anaesthesia trainees across Australia and New Zealand. A total of 228 surveys (23.6%) were successfully completed and 227 were analysed for a 23.3% response rate. Most respondents were involved in massive transfusions infrequently (88.1% managed five or fewer massive transfusion protocols per year) and worked at hospitals which have massive transfusion protocols (89.4%). Massive transfusion management was predominantly limited by timely access to point-of-care coagulation assessment and by competition with other tasks, with trainees reporting more significant limitations compared to specialists. The majority of respondents reported that they were likely, or very likely, both to use (73.1%) and to trust (85%) a clinical decision support system for massive transfusions, with no significant difference between anaesthesia trainees and specialists ( P = 0.375 and P = 0.73, respectively). While the response rate to our survey was poor, there was still a wide range of massive transfusion experience among respondents, with multiple subjective factors identified limiting massive transfusion practice. We identified several potential design features and barriers to implementation to assist with the future development of a clinical decision support system for massive transfusion, and overall wide support for a clinical decision support system for massive transfusion among respondents.

Background: Managing critical bleeding with massive transfusion (MT) requires a multidisciplinary team, often physically separated, to perform several simultaneous tasks at short notice. This places a significant cognitive load on team members, who must maintain situational awareness in rapidly changing scenarios.Similar resuscitation scenarios have benefited from the use of clinical decision support (CDS) tools. Study Design and Methods: A multicenter, multidisciplinary, user-centered design (UCD) study was conducted to design a computerized CDS for MT. This study included analysis of the problem context with a cognitive walkthrough, development of a user requirement statement, and co-design with users of prototypes for testing. The final prototype was evaluated using qualitative assessment and the System Usability Scale (SUS).Results: Eighteen participants were recruited across four institutions. The first UCD cycle resulted in the development of four prototype interfaces that addressed the user requirements and context of implementation. Of these, the preferred interface was further developed in the second UCD cycle to create a high-fidelity web-based CDS for MT. This prototype was evaluated by 15 participants using a simulated bleeding scenario and demonstrated an average SUS of 69.3 (above average, SD 16) and a clear interface with easy-to-follow blood product tracking.Discussion: We used a UCD process to explore a highly complex clinical scenario and develop a prototype CDS for MT that incorporates distributive situational awareness, supports multiple user roles, and allows simulated MT training. Evaluation of the impact of this prototype on the efficacy and efficiency of managing MT is currently underway.

Objective: Electronic communication mediums provide an opportunity for clinicians to enhance communication, collaboration, and sharing of clinical experience, especially via mobile devices. In 2016, the authors implemented a private online discussion forum in a tertiary-level anaesthesia department to improve communication and collaboration amongst members. The objective of this survey was to assess if these aims were met, to determine the degree of communication medium duplication incurred by its introduction, and to assess departmental communication practices more generally.Methods: A qualitative anonymous online survey was conducted 18 months following the introduction of the online discussion forum, over a two-month period. All 120 medical staff were invited via forum message and hard-copy invitation and responses were stratified by training status.Results: Forty-seven responses were collected (39% response rate), comprising 31 anaesthesia specialists and 16 anaesthesia trainees. Sixty-one percent of respondents reported that discussion had improved following the introduction of the online discussion forum, with no significant difference between specialists and trainees. Despite this, 57% overall maintained a preference for email discussion.Conclusions: This study demonstrated that the introduction of an online discussion forum resulted in a perceived improvement in overall departmental communication. However, it is important that workplaces considering implementation of a similar communication medium determine their employees’ cultural perspectives on technology, established communication preferences and aims of implementation to ensure success.