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- Department of Anesthesia, Intensive Care, Pain and Palliative Care, Hamad Medical Corporation – Hamad General Hospital, Doha, Qatar [1]
- Hamad Medical Corporation, Anesthesia, ICU and Perioperative Medicine Department, P.O. Box. 3050, Doha, Qatar, E-mail: [email protected] [1]
- Hamad Medical Corporation, Clinical Radiology and Medical Imaging Department, P.O. Box. 3050, Doha, Qatar [1]
- Hamad Medical Corporation, ENT - ORL Department, P.O. Box. 3050, Doha, Qatar [1]
- Hamad Medical Corporation, Surgery Department, P.O. Box. 3050, Doha, Qatar [1]
- Tanta Faculty of Medicine, Anesthesia and SICU, Tanta, EG [1]
- Weill Cornell Medical College in Qatar, Clinical Anesthesiology, Doha [1]
- Weill Cornell Medical College in Qatar, Clinical ORL-HNS Otolaryngology, Doha, Qatar [1]
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Bed crisis and elective surgery late cancellations: An approach using the theory of constraints
Late cancellations of scheduled elective surgery limit the ability of the surgical care service to achieve its goals. Attributes of these cancellations differ between hospitals and regions. The rate of late cancellations of elective surgery conducted in Hamad General Hospital Doha Qatar was found to be 13.14% which is similar to rates reported in hospitals elsewhere in the world; although elective surgery is performed six days a week from 7:00 am to 10:00 pm in our hospital. Simple and systematic analysis of these attributes typically provides limited solutions to the cancellation problem. Alternatively the application of the theory of constraints with its five focusing steps which analyze the system in its totality is more likely to provide a better solution to the cancellation problem. To find the constraint as a first focusing step we carried out a retrospective and descriptive study using a quantitative approach combined with the Pareto Principle to find the main causes of cancellations followed by a qualitative approach to find the main and ultimate underlying cause which pointed to the bed crisis. The remaining four focusing steps provided workable and effective solutions to reduce the cancellation rate of elective surgery.
Management of critical tracheal stenosis with a straw sized tube (Tritube): Case report
Imminent upper airway obstruction due to life-threatening tracheal stenosis of any cause is a challenging situation. We present a challenging case of total thyroidectomy for a malignant invasive and highly vascularized thyroid carcinoma that has invaded the surrounding tissues including the sternum and mediastinum resulting in compression of the trachea with indentation. The patient presented with a significant symptomatic tracheal stenosis the narrowest area of that was 4 mm. Airway management in such cases presents a particular challenge to the anesthesiologists especially considering that the option of tracheostomy is very difficult most of the time due to the highly swollen thyroid and distorted anatomy. A meticulous history of the patient's illness had been taken and a comprehensive preoperative evaluation was conducted including construction of a 3D model airway virtual endoscopy and transnasal tracheoscopy. On the day of the surgery the airway was managed through spontaneous respiration using intravenous anesthesia and the high-flow nasal oxygen (STRIVE-Hi) technique. It was then secured with intubation using a straw endotracheal tube (Tritube®) with an internal diameter (ID) of 2.4 mm and an outer diameter of 4.4 mm with the help of a fiberscope and D-MAC blade of a video laryngoscope. At the end of the procedure the airway was checked with a fiber optic scope which showed an improvement in the narrowed area. This enabled us to replace the Tritube with an adult cuffed ETT of size 6.5 mm ID and the patient was transferred intubated to the surgical ICU. Two days later the patient's tracheal diameter was evaluated with the help of a fiberoptic scope and extubated successfully in the operating theater.