Thomas Caruso

All Publications

• A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients. Pediatric quality & safety Nye, A., Conner, E., Wang, E., Chadwick, W., Marquez, J., Caruso, T. J. 2019; 4 (6): e246

  Abstract

  Despite guidelines allowing clear liquids up to 2 hours before anesthesia, preoperative fasting for pediatric inpatients is often unnecessarily prolonged. This delay can lead to prolonged recovery time and increased postoperative pain. Efforts to reduce fasting duration in pediatric surgical patients is an evolving standard in pediatric anesthesiology. The primary aim of this quality improvement project was to reduce the average inpatient fasting duration undergoing anesthesia by 25% within a year of our pilot intervention. Secondary aims included measuring the adoption rate of the intervention and comparing aspiration rates as a balancing measure.Methods: At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates.Results: Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates.Conclusion: This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.

  View details for DOI 10.1097/pq9.0000000000000246

  View details for PubMedID 32010870

• Near Miss in Intraoperative Magnetic Resonance Imaging: A Case for In Situ Simulation. Pediatric quality & safety Rama, A., Knight, L. J., Berg, M., Chen, M., Gonzales, R., Delhagen, T., Copperman, L., Caruso, T. J. 2019; 4 (6): e222

  Abstract

  Pediatric patients in intraoperative magnetic resonance imaging (iMRI) settings are at high risk for morbidity should an adverse event occur. We describe an experience in the iMRI scanner where no harm occurred, yet revealed an opportunity to improve the safety of patients utilizing the iMRI. The perioperative quality improvement team, resuscitation team, and radiology nurse leadership collaborated to understand the process better through in situ simulation.Methods: After a problem analysis, the team planned an in situ, high-fidelity simulation with predefined learning objectives to identify previously overlooked opportunities for improvement. The iMRI simulation had unique considerations, including the use of a magnetic resonance imaging (MRI)-compatible mannequin and ensuring participants' safety. Audiovisual equipment was placed in strategic locations to record the MRI and operating room (OR) segments of the simulation, and trained health-care simulation experts provided debriefing.Results: After completion of the iMRI simulation, the quality improvement team solicited feedback from participants and reviewed the video-recorded simulation. Several opportunities for improvement surrounding staff responsibilities and unique aspects of the iMRI environment were identified.Conclusions: iMRI in situ simulation has not been previously described. It presents unique challenges given the integration of personnel from OR and radiology environments, anesthetized patients, and risks from the high-powered MRI magnet. Other institutions utilizing hybrid ORs with iMRI may consider conducting in situ simulations using the described methods.

  View details for DOI 10.1097/pq9.0000000000000222

  View details for PubMedID 32010849

• Virtual reality successfully provides anxiolysis to laboring women undergoing epidural placement. Journal of clinical anesthesia Kist, M., Bekemeyer, Z., Ralls, L., Carvalho, B., Rodriguez, S. T., Caruso, T. J. 2019: 109635

  View details for DOI 10.1016/j.jclinane.2019.109635

  View details for PubMedID 31662229

• Regional anesthesia for cardiac surgery. Current opinion in anaesthesiology Caruso, T. J., Lawrence, K., Tsui, B. C. 2019

  Abstract

  PURPOSE OF REVIEW: Anesthesia for cardiac surgery has traditionally utilized high-dose opioids to blunt the sympathetic response to surgery. However, recent data suggest that opioids prolong postoperative intubation, leading to increased morbidity. Given the increased risk of opioid dependency after in-hospital exposure to opioids, coupled with an increase in morbidity, regional techniques offer an adjunct for perioperative analgesia. The aim of this review is to describe conventional and emerging regional techniques for cardiac surgery.RECENT FINDINGS: Well-studied techniques such as thoracic epidurals and paravertebral blocks are relatively low risk despite lack of widespread adoption. Benefits include reduced opioid exposure after paravertebral blocks and reduced risk of perioperative myocardial infarction after epidurals. To further lower the risk of epidural hematoma and pneumothorax, new regional techniques have been studied, including parasternal, pectoral, and erector spinae plane blocks. Because these are superficial compared with paravertebral and epidural blocks, they may have even lower risks of hematoma formation, whereas patients are anticoagulated on cardiopulmonary bypass. Efficacy data have been promising, although large and generalizable studies are lacking.SUMMARY: New regional techniques for cardiac surgery may be potent perioperative analgesic adjuncts, but well-designed studies are needed to quantify the effectiveness and safety of these blocks.

  View details for DOI 10.1097/ACO.0000000000000769

  View details for PubMedID 31356362

• Varying Screen Size for Passive Video Distraction During Induction of Anesthesia in Low Risk Children: A Pilot Randomized Controlled Trial. Paediatric anaesthesia Rodriguez, S., Jang, O., Hernandez, J. M., George, A. J., Caruso, T. J., Simons, L. 2019

  Abstract

  BACKGROUND: Preoperative anxiety affects up to 65% of children who undergo anesthesia induction and often results in uncooperative behaviour. Electronic devices have been used to distract children to reduce anxiety and create a more enjoyable preoperative experience. Few studies have compared the effects of different video delivery systems on preoperative anxiety.AIM: The primary aim was to determine if a large projection based video screen mounted to a patient's bed decreased anxiety when compared to a tablet during mask induction of anesthesia in children from 4-10 years of age.METHODS: We performed a prospective, randomized trial to determine differences in our primary outcome, preoperative anxiety, between the large Bedside Entertainment and Relaxation Theater (BERT) and a smaller tablet screen. Secondary outcomes included 1) induction compliance, 2) child fear, 3) frequency of emergence delirium, and 4) satisfaction.RESULTS: In examining the primary outcome for 52 patients, there was a main effect for time on mYPAS scores, f(2, 51)=13.18, p<0.01. mYPAS scores significantly increased across time for both groups. The interaction for time (T0, T1 or T2) x group (BERT vs. Tablet) was not significant, f(2, 51)=1.96, p=0.15; thus changes in mYPAS scores across time did not differ by group status. There was no significant difference in induction compliance, child fear, emergence delirium, or satisfaction between the two groups.CONCLUSION: In a low risk population, preoperative anxiety was low and induction compliance was high when pairing screen based distraction interventions, regardless of size, with parental presence at induction of anesthesia. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30916447

• Toward Opioid-Free Fast Track for Pediatric Congenital Cardiac Surgery. Journal of cardiothoracic and vascular anesthesia Esfahanian, M., Caruso, T. J., Lin, C., Kuan, C., Purkey, N. J., Maeda, K., Tsui, B. C. 2019

  View details for DOI 10.1053/j.jvca.2019.02.003

  View details for PubMedID 30852093

• Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) augments oxygenation in children with cyanotic heart disease during microdirect laryngoscopy and bronchoscopy. Journal of clinical anesthesia Caruso, T. J., Sidell, D. R., Lennig, M., Menendez, M., Fonseca, A., Rodriguez, S. T., Tsui, B. 2019; 56: 53–54

  View details for PubMedID 30690312

• Speeding the Detection of Vessel Cannulation: An In-Vitro Stimulation Study. Anesthesia and analgesia Muffly, M. K., Ku, A., Drover, D. R., Rodriguez, S., Caruso, T. J., Ku, A., Tsui, B. C. 2019

  Abstract

  BACKGROUND: Some practitioners "prime" small IV angiocatheter needles with 0.9% sodium chloride-claiming this modification speeds visual detection of blood in the angiocatheter flash chamber on vessel cannulation.METHODS: We compared the time required for human blood to travel the length of saline-primed and saline-unprimed 24- and 22-gauge angiocatheter needles (Introcan Safety IV Catheter; B. Braun, Bethlehem, PA). A syringe pump (Medfusion 4000, Cary, NC) advanced each angiocatheter needle through the silicone membrane of an IV tubing "t-piece" (Microbore Extension Set, 5 Inch; Hospira, Lake Forest, IL) filled with freshly donated human blood. When the angiocatheter needle contacted the blood, an electrical circuit was completed, illuminating a light-emitting diode. We determined the time from light-emitting diode illumination to visual detection of blood in the flash chamber by video review. We tested 105 saline-primed angiocatheters and 105 unprimed angiocatheters in the 24- and 22-gauge angiocatheter sizes (420 catheters total). We analyzed the median time to visualize the flash using the nonparametric Wilcoxon rank sum test in R (http://www.R-project.org/). The Stanford University Administrative Panel on Human Subjects in Medical Research determined that this project did not meet the definition of human subjects research and did not require institutional review board oversight.RESULTS: In the 24-gauge angiocatheter group, the median (and interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.14 (0.61-1.47) seconds compared with 0.76 (0.41-1.20) seconds in the saline-primed group (P = 0.006). In the 22-gauge catheter group, the median (interquartile range) time for blood to travel the length of the unprimed angiocatheter needle was 1.80 (1.23-2.95) seconds compared with 1.46 (1.03-2.54) seconds in the saline-primed group (P = .046).CONCLUSIONS: These results support the notion that priming small angiocatheter needles, in particular 24-gauge catheters, with 0.9% sodium chloride may provide earlier detection of vessel cannulation than with the unprimed angiocatheter.

  View details for PubMedID 30633054

• A multifaceted quality improvement project improves intraoperative redosing of surgical antimicrobial prophylaxis during pediatric surgery. Paediatric anaesthesia Colletti, A. A., Wang, E., Marquez, J. L., Schwenk, H. T., Yeverino, C., Sharek, P. J., Caruso, T. J. 2019

  Abstract

  Accurate intraoperative antibiotic redosing contributes to prevention of surgical site infections in pediatric patients. Ensuring compliance with evolving national guidelines of weight-based, intraoperative redosing of antibiotics is challenging to pediatric anesthesiologists.Our primary aim was to increase compliance of antibiotic redoses at the appropriate time and appropriate weight-based dose to 70%. Secondary aims included a subset analysis of time compliance and dose compliance individually, and compliance based on order entry method of the first dose (verbal or electronic).At a freestanding, academic pediatric hospital, we reviewed surgical cases between May 1, 2014 and October 31, 2017 requiring antibiotic redoses. After an institutional change in cefazolin dosing in May 2015, phased interventions to improve compliance included electronic countermeasures to display previous and next dose timing, an alert five minutes prior to next dose, and weight-based dose recommendation (September 2015). Physical countermeasures include badge cards, posting of guidelines, and updates to housestaff manual (September 2015). Statistical process control charts were used to assess overall antibiotic redose compliance, time compliance, and dose compliance. The chi-square test was used to analyze group differences.3,015 antibiotic redoses were administered during 2,341 operative cases between May 1, 2014 and October 31, 2017. Mean monthly compliance with redosing was 4.3% (May 2014-April 2015) and 73% (November 2015-October 2017) (p < 0.001). Dose-only compliance increased from 76% to 89% (p < 0.001) and time-only compliance increased from 4.9 to 82% (p < 0.001). After implementation of countermeasures, electronic order entry compared with verbal order was associated with higher dose compliance, 90% vs. 86% (p = 0.015).This quality improvement project, utilizing electronic and physical interventions, was effective in improving overall prophylactic antibiotic redosing compliance in accordance with institutional redosing guidelines. This article is protected by copyright. All rights reserved.

  View details for PubMedID 31034725

• Intraoperative Methadone Is Associated with Decreased Perioperative Opioid Use Without Adverse Events: A Case-Matched Cohort Study. Journal of cardiothoracic and vascular anesthesia Robinson, J. D., Caruso, T. J., Wu, M., Kleiman, Z. I., Kwiatkowski, D. M. 2019

  Abstract

  To determine if there is an association of intraoperative methadone use and total perioperative opioid exposure in patients undergoing congenital heart surgeries.Retrospective, case-match cohort study.Single center quaternary care teaching hospital.Seventy-four patients with congenital heart disease (CHD) undergoing surgical repair or palliative surgery.Thirty-seven patients undergoing CHD surgeries receiving intraoperative methadone were matched to 37 patients based upon age and procedure who did not receive intraoperative methadone. The primary study outcome was to evaluate total opioid use in intravenous milligrams of morphine equivalents per kilogram (mg ME/kg) within the first 36-hours postoperatively. Mann-Whitney U test was used to compare total opioid exposure.The total opioid use was compared between groups. The methadone cohort required less opioids intraoperatively, in the first 12 hours postoperatively, and during the first 36 hours postoperatively (2.51 v 4.39 mg ME/kg, p < 0.001; 0.43 v 1.28 mg ME/kg, p = 0.001; and 0.83 v 1.91 mg ME/kg, p < 0.001) compared with the matched control cohort. There were no differences in clinical outcomes or adverse events. A dose-dependent reduction in opioid consumption in high- versus low-dose groups also was not observed.Intraoperative methadone use was associated with a decrease in perioperative opioid exposure in patients undergoing congenital heart surgery and was not associated with adverse events or prolonged durations of mechanical ventilation or ICU stay.

  View details for DOI 10.1053/j.jvca.2019.09.033

  View details for PubMedID 31699597

• A Sustainable and Effective Mentorship Model for Graduate Medical Education Programs. Journal of graduate medical education Caruso, T. J., Kung, T., Piro, N., Li, J., Katznelson, L., Dohn, A. 2019; 11 (2): 221–25

  Abstract

  Mentorship models rarely seek generalizability across training programs at the graduate medical education (GME) level.We examined the sustainability and effectiveness of an intervention to increase the number and usefulness of trainee mentorship.A 0.20 full-time equivalent GME faculty adviser position (MD, MEd) implemented mentorship programs in residencies and fellowships. In group 1, 6 GME programs implemented the mentorship strategies prior to 2014, which were used to measure whether the number of mentor relationships were longitudinally sustained. In group 2, 10 different GME programs implemented the mentorship strategies in 2016, which were used to measure whether the intervention immediately increased the number of mentor relationships. To measure mentorship usefulness, trainees rated mentors' ability to promote clinical skills and personal and professional development. The remaining programs were the comparison. Responses from the 2014 and 2016 annual institutional trainee survey were analyzed.The incidence of group 1 reporting mentor relationships in 2014 compared to the incidence of group 1 in 2016 were 89% (41 of 46) and 95% (42 of 44), respectively, suggesting that the intervention was sustained for 2 years (P = .26). Group 2 showed a higher proportion of trainees reporting mentors in 2016 (88%, 149 of 170) compared to preintervention (66%, 71 of 108; P = .00001). Groups 1 and 2 reported significant increases in mentorship usefulness.A GME initiative to enhance mentoring across specialties in 16 GME training programs was self-sustaining and effective.

  View details for DOI 10.4300/JGME-D-18-00650.2

  View details for PubMedID 31024657

  View details for PubMedCentralID PMC6476078

• Virtual Reality during Pediatric Vascular Access: A Pragmatic, Prospective Randomized, Controlled Trial. Paediatric anaesthesia Caruso, T. J., George, A., Menendez, M., De Souza, E., Khoury, M., Kist, M. N., Rodriguez, S. T. 2019

  Abstract

  Vascular access is a minor procedure that is associated with reported pain and fear in pediatric patients, often resulting in procedural incompliance. Virtual reality has been shown to be effective in adult populations for reducing pain and anxiety in various medical settings, although large studies are lacking in pediatrics.The primary aim was to determine if pain would be reduced in pediatric patients using virtual reality undergoing vascular access. The four secondary aims measured patient fear, procedural compliance, satisfaction, and adverse events.A prospective, randomized, controlled trial was completed at a pediatric hospital, enrolling children 7-18 years old undergoing vascular access in a variety of clinical settings, randomized to virtual reality or standard of care. Pain scores were measured using a numeric pain faces scale. The secondary outcomes of patient fear, procedural compliance, satisfaction, and adverse events were measured with the Child Fear Scale, modified induction compliance checklist, and satisfaction surveys, respectively. Chi-squared, t-tests, and regression models were used to analyze the results.The analysis included 106 patients in the virtual reality group and 114 in the control. There were no significant differences in post-procedure pain (VR group estimated 0.11 points lower, 95% confidence interval: 0.50 points lower to 0.28 points greater, p=0.59), post-procedure fear (VR group estimated 0.05 points lower, 95% confidence interval: 0.23 points lower to 0.13 points greater) or compliance (adjusted odds ratio 2.31, 95% confidence interval: 0.96 to 5.56). Children in the virtual reality group were satisfied with the intervention. There were no adverse events.This study demonstrates no reduction in pain while using VR across a heterogeneous pediatric inpatient population undergoing vascular access.

  View details for DOI 10.1111/pan.13778

  View details for PubMedID 31785015

• Accreditation Improves Quality of Oncology Education in Low- and Middle-Income Countries: Perspectives of African Oncologists. Journal of cancer education : the official journal of the American Association for Cancer Education Hammad, N., Stockley, D., Hastings-Truelove, A., Vanderpuye, V., Rubagumya, F., Caruso, T. 2019

  Abstract

  The purpose of this study is to understand the perspectives of African Oncologists on the role of accreditation and on global standards. We developed a survey that addressed African oncologists' opinions on the role of accreditation. The survey also included 187 standards from World Federation of Medical Education Postgraduate medical education (PGME) standards, American Council of Graduate Medical Education (ACGME)-I standards for hematology/oncology, and the Royal College of Physician and Surgeons of Canada Medical Oncology standards. A 3-point scale was employed for each standard: 1 = not important, 2 = important but not essential, 3 = essential. The survey was sent to 79 physicians, 38 responded. Eighty-seven percent agreed that accreditation ensures quality. Forty-five percent agreed it will not increase migration of qualified doctors. Twenty-two individuals who completed the entire survey were analyzed for the standards. Five standards received the highest ratings of 3 (essential) from all respondents. One standard received a rating of < 2.0. The majority of standards had ratings between 2.6 and 2.94 indicating African oncologists found most standards to be useful. Ratings < 2.6 were mostly related to resource constraints. Most African Oncologists believed that accreditation ensures quality of education, and most standards were considered important. This data is useful for developing and adapting accreditation standards in resource-constrained settings.

  View details for DOI 10.1007/s13187-019-01497-3

  View details for PubMedID 30806905

• Operating Room Codes Redefined: A Highly Reliable Model Integrating the Core Hospital Code Team. Pediatric quality & safety Caruso, T. J., Rama, A., Knight, L. J., Gonzales, R., Munshey, F., Darling, C., Chen, M., Sharek, P. J. 2019; 4 (3): e172

  Abstract

  Typically, multidisciplinary teams manage cardiac arrests occurring outside of the operating room (OR). This approach results in reduced morbidity. However, arrests that occur in the OR are usually managed by OR personnel alone, missing the benefits of out-of-OR hospital code teams. At our institution, there were multiple pathways to activate codes, each having different respondents, depending on time and day of the week. This improvement initiative aimed to create a reliable intraoperative emergency response system with standardized respondents and predefined roles.A multidisciplinary improvement team led this project at an academic pediatric hospital in California. After simulations performed in the OR (in situ), the team identified a valuable key driver-a consistent activation process that initiated standard respondents, 24 hours a day, 7 days a week. By utilizing core hospital code members routinely available outside of the OR during days, nights, and weekends, respondents were identified to augment OR personnel. Code roles were preassigned. After education, we conducted in situ simulations that included the perioperative and out-of-OR code team members. We administered a knowledge assessment to perioperative staff.The knowledge assessment for perioperative staff (n = 52) had an average score of 96%. Review of subsequent OR codes reflects an improved initiation process and management.The process for activating the emergency response system and roles for intraoperative code respondents were standardized to ensure a predictable code response, regardless of time or day of the week. Ongoing simulations with perioperative personnel continue to optimize the process.

  View details for DOI 10.1097/pq9.0000000000000172

  View details for PubMedID 31579871

  View details for PubMedCentralID PMC6594783

• Crowd Sourced Assessment of Ureteroscopy with Laser Lithotripsy video feed does not correlate with Trainee Experience. Journal of endourology Conti, S. L., Brubaker, W., Chung, B. I., Sofer, M., Hsi, R. S., Shinghal, R., Elliott, C. S., Caruso, T., Leppert, J. T. 2018

  Abstract

  OBJECTIVES: We sought to validate the use of crowd sourced surgical video evaluation in the evaluation of flexible ureteroscopic laser lithotripsy videos using a modified global assessment scale previously validated for ureteroscopic skills.METHODS: We collected video feeds from 30 intra-renal ureteroscopic laser lithotripsy cases where residents post graduate year(PGY) 2 through 6 handled the ureteroscope. The video feeds were annotated to represent the overall performance and to contain the parts of the procedure being scored. The videos were submitted to a commercially available surgical video evaluation platform. We used a validated ureteroscopic laser lithotripsy global assessment tool that was modified to account for the fact that this scoring system looked at the video feed only. Videos were evaluated by crowd workers recruited using Amazon's Mechanical Turk as well as 5 Endourology trained experts. Mean scores were calculated and intraclass correlation coefficients(ICCs) were computed for the expert domain and total scores. The ICCs were estimated using a linear mixed-effects model. Spearman rank correlation coefficients were calculated as a measure of the strength of the relationships between the crowd mean and the expert average scores.RESULTS: 30 videos were reviewed 2,488 times by 487 crowd workers and five expert endourologists. ICCs between expert raters were all below accepted levels of correlation(0.30) with the overall score having an ICC of .000. Overall the crowd scores did not correlate with expert scores except for the stone retrieval domain (0.60 p = 0.015). Crowd sourced scores had a negative correlation with PGY level(-0.44 p=0.019).CONCLUSIONS: Given the poor agreement between experts and poor correlation between expert and crowd scores when evaluating video feeds of ureteroscopic laser lithotripsy, assessment of skills using intraoperative video feeds may not be reliable. This is further supported by the inverse correlation between crowd scores and PGY level.

  View details for PubMedID 30450963

• The erector spinae plane (ESP) block: A pooled review of 242 cases. Journal of clinical anesthesia Tsui, B. C., Fonseca, A., Munshey, F., McFadyen, G., Caruso, T. J. 2018; 53: 29–34

  Abstract

  STUDY OBJECTIVE: The erector spinae plane block (ESPB) was first described in 2016 as a regional block for thoracic neuropathic pain. Given its short history, there are a paucity of controlled clinical trials, yet an abundance of case reports. The primary aim of this review is to examine pooled clinical data from published literature to gain an understanding of ESPB characteristics.DESIGN: A PubMed search was conducted to identify all ESPB related publications. Inclusion criteria included reports of ESP single shot, continuous infusion, intermittent bolus, human and cadaveric studies. Only publications obtained in English were included. Measures included type of publication, year and country of publication, journal of publication, block technique, anatomic location, age, opioid and adjunct pain medication use, sensory and motor changes, side effects and adverse events. Qualitative statistics were used.MAIN RESULTS: The initial search yielded 201 publications. After application of inclusion and exclusion criteria, 85 publications from 21 journals were included in the pooled review which yielded 242 reported cases between 2016 and 2018. The majority of publications reported single shot techniques (80.2%), followed by intermittent boluses (12.0%) and continuous infusions (7.9%). 90.9% reported use of multimodal analgesia in addition to the ESPB and 34.7% reported sensory changes from ESPB. A reduction in opioid use was reported in 34.7% of cases. One adverse event involving a pneumothorax was reported.CONCLUSIONS: To our knowledge, this is the first review providing a pooled review of ESPB characteristics. The ESPB appears to be a safe and effective option for multiple types thoracic, abdominal, and extremity surgeries.

  View details for PubMedID 30292068

• Programmed Intermittent Bolus Regimen for Erector Spinae Plane Blocks in Children: A Retrospective Review of a Single-Institution Experience. Anesthesia and analgesia Munshey, F., Caruso, T. J., Wang, E. Y., Tsui, B. C. 2018

  Abstract

  With few published reports on erector spinae plane block use in children, limited guidance on perioperative local anesthetic dosing exists. We present a series of 22 patients who received erector spinae plane catheters with programmed intermittent bolus for various surgeries. Median loading dose of 0.4 mL/kg (interquartile range [IQR], 0.1 mL/kg) ropivacaine 0.5%, intraoperative bolus of 0.3 mL/kg/h (IQR, 0.1 mL/kg) ropivacaine 0.2%, and a postoperative programmed intermittent bolus regimen of maximum 0.6 mg/kg/h resulted in highest pain scores on postoperative day 1 with a median score of 1.7 of 10 (IQR, 1.8) and highest morphine equivalents consumed on postoperative day 2 with a median score of 0.16 mg/kg up to 120 hours after surgery.

  View details for DOI 10.1213/ANE.0000000000003817

  View details for PubMedID 30252704

• Safety Stop: A Valuable Addition to the Pediatric Universal Protocol JOINT COMMISSION JOURNAL ON QUALITY AND PATIENT SAFETY Caruso, T. J., Munshey, F., Aldorfer, B., Sharek, P. J. 2018; 44 (9): 552–56

  Abstract

  The World Health Organization (WHO) guidelines and Joint Commission requirements state that the time-out component of the Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery™ must be performed just prior to incision. A mock Joint Commission survey at one institution revealed that the time-out was performed prior to preparation and draping (P&D) of the patient, not afterward, representing both a patient and regulatory risk.The multidisciplinary perioperative quality improvement team at a freestanding, quaternary care, academic pediatric hospital led the development of a new time-out process. An enhanced pediatric Universal Protocol, which included a new component, the safety stop, was created. The safety stop occurred just prior to P&D of the patient, and the time-out was performed just prior to incision, aligning with WHO recommendations. After electronic correspondence and several perioperative leadership meetings, the enhanced pediatric Universal Protocol was initiated. Compliance audits were performed to demonstrate comprehensive adoption.In seven operating room locations, 60 audits were completed in four weeks, with 96.7% (58/60) demonstrating compliance with the new policy. During a subsequent Joint Commission accreditation survey, the enhanced pediatric Universal Protocol with inclusion of the safety stop was highlighted as a leading practice.Although initially it was believed that moving the time-out from prior to P&D to just prior to incision would be a simple solution, flow mapping the complete time-out process identified significant risk of wrong-site or wrong-patient surgery with this solution. This risk was exacerbated by the small body size of pediatric patients being obscured by draping on a typical operating room table.

  View details for PubMedID 30166039

• The successful application of high flow nasal oxygen during microdirect laryngoscopy and bronchoscopy in patients under 7 kg. Journal of clinical anesthesia Caruso, T. J., Gupta, A., Sidell, D. R., Darling, C., Rodriguez, S., Fonseca, A., Tsui, B. 2018; 52: 27–28

  View details for PubMedID 30153541

• A Retrospective Review of a Bed-mounted Projection System for Managing Pediatric Preoperative Anxiety. Pediatric quality & safety Caruso, T. J., Tsui, J. H., Wang, E., Scheinker, D., Sharek, P. J., Cunningham, C., Rodriguez, S. T. 2018; 3 (4): e087

  Abstract

  Introduction: Most children undergoing anesthesia experience significant preoperative anxiety. We developed a bedside entertainment and relaxation theater (BERT) as an alternative to midazolam for appropriate patients undergoing anesthesia. The primary aim of this study was to determine if BERT was as effective as midazolam in producing cooperative patients at anesthesia induction. Secondary aims reviewed patient emotion and timeliness of BERT utilization.Methods: We conducted a retrospective cohort study of pediatric patients undergoing anesthesia at Lucile Packard Children's Hospital Stanford between February 1, 2016, and October 1, 2016. Logistic regression compared induction cooperation between groups. Multinomial logistic regression compared patients' emotion at induction. Ordinary least squares regression compared preoperative time.Results: Of the 686 eligible patients, 163 were in the BERT group and 150 in the midazolam. Ninety-three percentage of study patients (290/313) were cooperative at induction, and the BERT group were less likely to be cooperative (P = 0.04). The BERT group was more likely to be "playful" compared with "sedated" (P < 0.001). There was a reduction of 14.7 minutes in preoperative patient readiness associated with BERT (P = 0.001).Conclusions: Although most patients were cooperative for induction in both groups, the midazolam group was more cooperative. The BERT reduced the preinduction time and was associated with an increase in patients feeling "playful."

  View details for PubMedID 30229198

• Intraoperative antibiotic redosing compliance and the extended postoperative recovery period: often overlooked areas that may reduce surgical site infections. Paediatric anaesthesia Caruso, T. J., Wang, E., Colletti, A. A., Sharek, P. J. 2018

  Abstract

  It was with great interest that we read Compliance with perioperative prophylaxis guidelines and the use of novel outcome measures by Morse, et al.1 The authors should be applauded for presenting a well-balanced review of the rationale behind the use of prophylactic antibiotics, data supporting dosing intervals, and potential outcome measures. This article is protected by copyright. All rights reserved.

  View details for PubMedID 30592343

• Lumbar erector spinae plane catheter via a thoracic approach for iliac crest autograft in a pediatric patient. Journal of clinical anesthesia Darling, C. E., Lin, C., Caruso, T. J., Tsui, B. C. 2018; 54: 164–65

  View details for DOI 10.1016/j.jclinane.2018.12.008

  View details for PubMedID 30554043

• Augmented reality for intravenous access in an autistic child with difficult access. Paediatric anaesthesia Rodriguez, S., Munshey, F., Caruso, T. J. 2018; 28 (6): 569–70

  View details for DOI 10.1111/pan.13395

  View details for PubMedID 29878540

• Cervical erector spinae plane block catheter using a thoracic approach: an alternative to brachial plexus blockade for forequarter amputation. Canadian journal of anaesthesia = Journal canadien d'anesthesie Tsui, B. C., Mohler, D., Caruso, T. J., Horn, J. L. 2018

  View details for PubMedID 29868941

• Bilateral automatized intermittent bolus erector spinae plane analgesic blocks for sternotomy in a cardiac patient who underwent cardiopulmonary bypass: A new era of Cardiac Regional Anesthesia. Journal of clinical anesthesia Tsui, B. C., Navaratnam, M., Boltz, G., Maeda, K., Caruso, T. J. 2018; 48: 9–10

  View details for DOI 10.1016/j.jclinane.2018.04.005

  View details for PubMedID 29684728

• Successful directional thoracic erector spinae plane block after failed lumbar plexus block in hip joint and proximal femur surgery. Journal of clinical anesthesia Darling, C. E., Pun, S. Y., Caruso, T. J., Tsui, B. C. 2018; 49: 1–2

  View details for PubMedID 29775780

• Improving Satisfaction with Pediatric Pain Management by Inviting the Conversation. Joint Commission journal on quality and patient safety Caruso, T. J., Kung, T. H., Good, J., Taylor, K., Ashland, M., Cunningham, C., Gonzalez, E., Wood, M., Sharek, P. 2018; 44 (4): 227–32

  Abstract

  Patient satisfaction with pain management is associated with improved patient adherence to medical management and efficient service utilization. Pediatric pain control is challenging, given the inability to elicit reliable histories, particularly in younger patients. Several studies have suggested that communication surrounding pain management can improve satisfaction, although there are limited data describing structured interventions with measurable outcomes. A quality improvement project was conducted to determine if reliably asking families about pain management was associated with improved patient satisfaction with pain management.In an academic pediatric hospital, nurse manager rounds were used to invite a conversation about pain management. The question, "Pain management is very important to us. Has your child's pain been well controlled?" was added to the established standard questions asked during nurse manager rounds. Effectiveness was measured using the preexisting Press Ganey survey question, "How well was your child's pain controlled?" Responses were compared between those patients who were and were not exposed to the rounding question.Data for 1,032 patients were used to establish baseline satisfaction with pain management scores. In the intervention period, 328 patients received nurse manager rounds and 121 did not. The median of the weighted mean patient survey satisfaction scores were baseline, 91.5%; receiving intervention, 94.2%; and not receiving intervention, 90.0%. Patients who received the intervention reported higher satisfaction with pain management than those who did not (p <0.0001).Hospitals seeking to improve satisfaction with pain management should encourage health care providers to reliably discuss pain control with pediatric patients.

  View details for DOI 10.1016/j.jcjq.2017.10.003

  View details for PubMedID 29579448

• A Postoperative Care Bundle Reduces Surgical Site Infections in Pediatric Patients Undergoing Cardiac Surgeries. Joint Commission journal on quality and patient safety Caruso, T. J., Wang, E. Y., Schwenk, H., Marquez, J. L., Cahn, J., Loh, L., Schaffer, J., Chen, K., Wood, M., Sharek, P. J. 2018

  Abstract

  Pediatric patients undergoing cardiac surgeries are at an increased surgical site infection (SSI) risk, given prolonged cardiopulmonary bypasses and delayed sternal closures. At one institution, the majority of cardiac patients developed SSIs during prolonged recoveries in the cardiovascular intensive care unit (CVICU). Although guidelines have been published to reduce SSIs in the perioperative period, there have been few guidelines to reduce the risk during prolonged hospital recoveries. The aim of this project was to study a postoperative SSI reduction care bundle, with a goal of reducing cardiac SSIs by 50%, from 3.4 to 1.7 per 100 procedures.This project was conducted at a quaternary, pediatric academic center with a 20-bed CVICU. Historical control data were recorded from January 2013 through May 2015 and intervention/sustainment data from June 2015 through March 2017. A multidisciplinary SSI reduction team developed five key drivers that led to implementation of 11 postoperative SSI reduction care elements. Statistical process control charts were used to measure process compliance, and Pearson's chi-square test was used to determine differences in SSI rates.Prior to implementation, there were 27 SSIs in 799 pediatric cardiac surgeries (3.4 SSIs per 100 surgeries). After the intervention, SSIs significantly decreased to 5 in 570 procedures (0.9 SSIs per 100 surgeries; p = 0.0045).This project describes five key drivers and 11 elements that were dedicated to reducing the risk of SSI during prolonged CVICU recoveries from pediatric cardiac surgery, with demonstrated sustainability.

  View details for DOI 10.1016/j.jcjq.2018.05.009

  View details for PubMedID 30170753

• A quality improvement initiative to optimize dosing of surgical antimicrobial prophylaxis. Paediatric anaesthesia Caruso, T. J., Wang, E., Schwenk, H. T., Scheinker, D., Yeverino, C., Tweedy, M., Maheru, M., Sharek, P. J. 2017; 27 (7): 702-710

  Abstract

  The risk of surgical site infections is reduced with appropriate timing and dosing of preoperative antimicrobials. Based on evolving national guidelines, we increased the preoperative dose of cefazolin from 25 to 30 mg·kg(-1) . This quality improvement project describes an improvement initiative to develop standard work processes to ensure appropriate dosing.The primary aim was to deliver cefazolin 30 mg·kg(-1) to at least 90% of indicated patients. The secondary aim was to determine differences between accuracy of cefazolin doses when given as an electronic order compared to a verbal order.Data were collected from January 1, 2012 to May 31, 2016. A quality improvement team of perioperative physicians, nurses, and pharmacists implemented a series of interventions including new electronic medical record order sets, personal provider antibiotic dose badges, and utilization of pharmacists to prepare antibiotics to increase compliance with the recommended dose. Process compliance was measured using a statistical process control chart, and dose compliance was measured through electronic analysis of the electronic medical record. Secondary aim data were displayed as percentage of dose compliance. An unpaired t-test was used to determine differences between groups.Between January 1, 2012 and May 31, 2016, cefazolin was administered to 9086 patients. The mean compliance of cefazolin at 30 mg·kg(-1) from May 2013 to March 2014 was 40%, which prompted initiation of this project. From April 2014 to May 2016, a series of interventions were deployed. The mean compliance from September 2015 to May 2016 was 93% with significantly reduced variation and no special cause variation, indicating that the process was in control at the target primary aim. There were 649 cefazolin administrations given verbally and 1929 given with an electronic order between October 1, 2014 and May 31, 2016. During this time period, the rate of compliance of administering cefazolin at 30 mg·kg(-1) was significantly higher when given after an electronic order than when given verbally, 94% vs 76%.This comprehensive quality improvement project improved practitioner compliance with evidence-based preoperative antimicrobial dosing recommendations to reduce the risk of surgical site infections.

  View details for DOI 10.1111/pan.13137

  View details for PubMedID 28321988

• Standardized ICU to OR handoff increases communication without delaying surgery. International journal of health care quality assurance Caruso, T. J., Marquez, J. L., Gipp, M. S., Kelleher, S. P., Sharek, P. J. 2017; 30 (4): 304-311

  Abstract

  Purpose No studies have examined preoperative handoffs from the intensive care unit (ICU) to OR. Given the risk of patient harm, the authors developed a standardized ICU to OR handoff using a previously published handoff model. The purpose of this paper is to determine whether a standardized ICU to OR handoff process would increase the number of team handoffs and improve patient transport readiness. Design/methodology/approach The intervention consisted of designing a multidisciplinary, face-to-face handoff between sending ICU providers and receiving anesthesiologist and OR nurse, verbally presented in the I-PASS format. Anticipatory calls from the OR nurse to the ICU nurse were made to prepare the patient for transport. Data collected included frequency of handoff, patient transport readiness, turnover time between OR cases, and anesthesia provider satisfaction. Findings In total, 57 audits were completed. The frequency of handoffs increased from 25 to 86 percent ( p<0.0001) and the frequency of patient readiness increased from 61 to 97 percent ( p=0.001). There were no changes in timeliness of first start cases and no significant change in turnover times between cases. Anesthesia provider satisfaction scores increased significantly. Practical implications A standardized, team based ICU to OR handoff increased the frequency of face-to-face handoffs, patient readiness and anesthesia provider satisfaction within increasing turnover between cases. Originality/value Although studies have identified the transition of patients from the ICU to the OR as a period of increased harm, the development of a preoperative ICU to OR handoff had not been described. This intervention may be used in other institutions to design ICU to OR transitions of care.

  View details for DOI 10.1108/IJHCQA-02-2016-0015

  View details for PubMedID 28470134

• Pediatric Postoperative Pulse Oximetry Monitoring During Transport to the Postanesthesia Care Unit Reduces Frequency of Hypoxemia. Joint Commission journal on quality and patient safety Caruso, T. J., Mokhtari, T. E., Coughlan, M. J., Wu, D. S., Marquez, J. L., Duan, M., Freeman, H., Giustini, A., Tweedy, M., Sharek, P. J. 2017; 43 (3): 146–50

  Abstract

  The standard use of pulse oximetry during the transport of postoperative patients from the operating room (OR) to the postanesthesia care unit (PACU) is not routinely practiced. A study was conducted to determine if the frequency of hypoxemia on admission to the PACU decreased after implementation of routine use of transport pulse oximeters for postoperative patients being transferred to the PACU.In this prospective cohort study, which was conducted at an academic pediatric hospital, the primary outcome measure was the frequency of hypoxemic events on arrival to the PACU.A total of 506 patients in the preintervention phase and 597 in the postintervention phase met the inclusion criteria. Six hypoxemic events on arrival to the PACU were identified in preintervention phase versus zero in the postintervention period, p = 0.009. Use of oxygen monitors during transport from the OR to the PACU increased from 0% to 100%, p < 0.0001, in the postintervention phase. The median duration of unmonitored time during transport decreased from 272 seconds to 13 seconds, p < 0.0001. Of the 605 patients who met the inclusion criteria for sustainment audits-conducted 18 months after the postimplementation evaluation-99.8% were transported to the PACU with a pulse oximeter, and there were zero reported hypoxemic patients on PACU admission.The routine use of portable oxygen monitoring when transferring patients from the OR to the PACU is a low-cost, noninvasive safety measure that should be considered at any institution performing pediatric general anesthesia.

  View details for DOI 10.1016/j.jcjq.2016.12.001

  View details for PubMedID 28334593

• Provider-controlled virtual reality experience may adjust for cognitive load during vascular access in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Yuan, J. C., Rodriguez, S., Caruso, T. J., Tsui, J. H. 2017

  View details for PubMedID 28861855

• Caution with the Posey(®) Cufflator™ cuff pressure manometers. Paediatric anaesthesia Kiberd, M. B., Swenson-Schalkwyk, A. K., Caruso, T. J. 2017; 27 (12): 1279–80

  View details for PubMedID 29110434

• Interactive video game built for mask induction in pediatric patients. Canadian journal of anaesthesia = Journal canadien d'anesthesie Rodriguez, S., Tsui, J. H., Jiang, S. Y., Caruso, T. J. 2017

  View details for PubMedID 28646461

• Bedside Entertainment and Relaxation Theater: size and novelty does matter when using video distraction for perioperative pediatric anxiety. Paediatric anaesthesia Rodriguez, S., Caruso, T., Tsui, B. 2017; 27 (6): 668–69

  View details for DOI 10.1111/pan.13133

  View details for PubMedID 28474813

• A Strategic Approach to Implementation of Medical Mentorship Programs. Journal of graduate medical education Caruso, T. J., Steinberg, D. H., Piro, N., Walker, K., Blankenburg, R., Rassbach, C., Marquez, J. L., Katznelson, L., Dohn, A. 2016; 8 (1): 68-73

  Abstract

  Mentors influence medical trainees' experiences through career enhancement and psychosocial support, yet some trainees never receive benefits from involved mentors.Our goals were to examine the effectiveness of 2 interventions aimed at increasing the number of mentors in training programs, and to assess group differences in mentor effectiveness, the relationship between trainees' satisfaction with their programs given the presence of mentors, and the relationship between the number of trainees with mentors and postgraduate year (PGY).In group 1, a physician adviser funded by the graduate medical education department implemented mentorships in 6 residency programs, while group 2 involved a training program with funded physician mentoring time. The remaining 89 training programs served as controls. Chi-square tests were used to determine differences.Survey responses from group 1, group 2, and controls were 47 of 84 (56%), 34 of 78 (44%), and 471 of 981 (48%, P = .38), respectively. The percentages of trainees reporting a mentor in group 1, group 2, and the control group were 89%, 97%, and 79%, respectively (P = .01). There were no differences in mentor effectiveness between groups. Mentored trainees were more likely to be satisfied with their programs (P = .01) and to report that faculty supported their professional aspirations (P = .001). Across all programs, fewer first-year trainees (59%) identified a mentor compared to PGY-2 through PGY-8 trainees (84%, P < .001).A supported mentorship program is an effective way to create an educational environment that maximizes trainees' perceptions of mentorship and satisfaction with their training programs.

  View details for DOI 10.4300/JGME-D-15-00335.1

  View details for PubMedID 26913106

  View details for PubMedCentralID PMC4763391

• Implementation of a standardized postanesthesia care handoff increases information transfer without increasing handoff duration. Joint Commission journal on quality and patient safety / Joint Commission Resources Caruso, T. J., Marquez, J. L., Wu, D. S., Shaffer, J. A., Balise, R. R., Groom, M., Leong, K., Mariano, K., Honkanen, A., Sharek, P. J. 2015; 41 (1): 35-42

  Abstract

  In the transition of a patient from the operating room (OR) to the postanesthesia care unit (PACU), it was hypothesized that (1) standardizing the members of sending and receiving teams and (2) requiring a structured handoff process would increase the overall amount of patient information transferred in the OR-to-PACU handoff process.A prospective cohort study was conducted at a 311-bed freestanding academic pediatric hospital in Northern California. The intervention, which was conducted in February-March 2013, consisted of (1) requiring the sending team to include a surgeon, an anesthesiologist, and a circulating nurse, and the receiving team to include the PACU nurse; (2) standardizing the content of the handoff on the basis of literature-guided recommendations; and (3) presenting the handoff verbally in the I-PASS format. Data included amount of patient information transferred, duration of handoff, provider presence, and nurse satisfaction.Forty-one audits during the preimplementation phase and 45 audits during the postimplementation phase were analyzed. Overall information transfer scores increased significantly from a mean score of 49% to 83% (p < .0001). Twenty-two PACU nurse satisfaction surveys were completed after the preimplementation phase and 14 surveys were completed in the postimplementation phase. Paired mean total satisfaction scores increased from 36 to 44 (p =. 004). The duration of the handoffs trended downward from 4.1 min to 3.5 min (p = 0.10).A standardized, team-based approach to OR-to-PACU handoffs increased the quantity of patient information transferred, increased PACU nurse satisfaction, and did not increase the handoff duration.

  View details for PubMedID 25976722

• Images in clinical medicine. Severe vitamin D deficiency--rickets. New England journal of medicine Caruso, T. J., Fuzaylov, G. 2013; 369 (9)

  View details for DOI 10.1056/NEJMicm1205540

  View details for PubMedID 23984751

• Airway management of recovered pediatric patients with severe head and neck burns: a review PEDIATRIC ANESTHESIA Caruso, T. J., Janik, L. S., Fuzaylov, G. 2012; 22 (5): 462-468

  Abstract

  There are approximately 10,000 pediatric burn survivors in the United States each year, many of whom will present for reconstructive surgery after severe burns in the head and neck (1). These recovered burn victims, who are beyond the acute phase of injury, often have significant scarring and contractures in the face, mouth, nares, neck, and chest, which can make airway management challenging and potentially lead to a 'cannot intubate, cannot ventilate' scenario (2). Although numerous cases have been presented in the literature on this topic (3-17), there are no comprehensive review articles on the unique challenges of airway management in the recovered pediatric burn patient with distorted airway anatomy. This article aims to provide a comprehensive review of airway management in such patients, focusing on challenges encountered during mask ventilation and tracheal intubation, as well as the role of surgical release of neck contractures to facilitate tracheal intubation. Lessons learned from all reported cases identified in a thorough literature search are incorporated into this review.

  View details for DOI 10.1111/j.1460-9592.2012.03795.x

  View details for Web of Science ID 000302540900009

  View details for PubMedID 22260458

• Complementary and Alternative Medicine for Pain: An Evidence-based Review CURRENT PAIN AND HEADACHE REPORTS Dhanani, N. M., Caruso, T. J., Carinci, A. J. 2011; 15 (1): 39-46

  Abstract

  Pain is one of the most prevalent conditions for which patients seek medical attention. Additionally, the number of patients who utilize complementary and alternative medicine as a treatment of pain either in lieu of, or concurrent with, standard conventional treatments continues to grow. While research into the mechanisms, side effect profiles, and efficacies of these alternative therapies has increased in recent years, much more remains unknown and untested. Herein, we review the literature on complementary and alternative medicine for pain, with particular emphasis on evidence-based assessments pertinent to the most common alternative therapies, including acupuncture, herbal therapy, massage therapy, hypnosis, tai chi, and biofeedback.

  View details for DOI 10.1007/s11916-010-0158-y

  View details for Web of Science ID 000286230400007

  View details for PubMedID 21063917

• Magnetic resonance Imaging detected renal volume reduction in refluxing and nonrefluxing kidneys JOURNAL OF UROLOGY Chang, S. L., Caruso, T. J., Shortliffe, L. D. 2007; 178 (6): 2550-2554

  Abstract

  Renal parenchymal damage is a well recognized sequela of urinary tract infection in the setting of vesicoureteral reflux. We investigated renal magnetic resonance imaging as a quantitative modality to detect renal parenchymal damage in children with primary vesicoureteral reflux and urinary tract infection.We retrospectively reviewed the medical records of children with primary vesicoureteral reflux and urinary tract infection who underwent renal magnetic resonance imaging evaluation. Those with other genitourinary pathology were excluded. Controls underwent magnetic resonance imaging for nongenitourinary pathologies. Kidneys were segregated among control, nonrefluxing, and low grade (I to III) and high grade (IV to V) reflux. Size plots (magnetic resonance imaging volume vs age) were drawn for comparison. Gross imaging abnormalities observed were renal scarring and small size.Magnetic resonance imaging was performed in 114 patients with vesicoureteral reflux (228 kidneys, patient age 0.5 to 17.8 years) and 21 controls (42, 0.5 to 12). Higher grades of reflux were associated with smaller volume, and smaller volume was noted in the refluxing and nonrefluxing kidneys of children with vesicoureteral reflux. Kidneys from patients with unilateral or bilateral reflux had significantly decreased renal volume compared to controls (p <0.0001). Kidneys in which vesicoureteral reflux spontaneously resolved had renal volumes similar to control kidneys (p = 0.23).Use of magnetic resonance imaging derived renal volume allows renal comparison and is helpful in evaluating patients with vesicoureteral reflux. In patients with a history of a febrile urinary tract infection and reflux the finding of measurably smaller kidneys appears to be more common than scarring. Whether these findings represent renal atrophy or hypoplasia needs further investigation.

  View details for Web of Science ID 000250847900082

  View details for PubMedID 17937957

• Treatment of naturally acquired common colds with zinc: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Prober, C. G., Gwaltney, J. M. 2007; 45 (5): 569-574

  Abstract

  Over the past 20 years, the use of zinc as an over-the-counter alternative therapy for the common cold has vastly grown in popularity. Recent reports of potentially permanent anosmia caused by intranasal zinc therapy warrant careful analysis of the therapeutic effects of zinc.A search of the Medline database (including articles published during 1966-2006) for studies of zinc and the common cold produced 105 published reports. Fourteen were randomized, placebo-controlled studies that examined the effect of zinc lozenges, nasal sprays, or nasal gels on naturally acquired common colds. Eleven features of experimental design affecting signal quality, chance, bias, and blinding were used to evaluate the 14 placebo-controlled studies. These criteria were validated case definition, quantifiable hypothesis, sample size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of dropout rate, analysis by intent to treat, description of methods of analysis, and measurements of probability. Equal weight was given to each criterion, because failure to meet any one could potentially invalidate the findings of a clinical trial.Four studies met all 11 criteria. Three of these studies reported no therapeutic effect from zinc lozenge or nasal spray. One study reported positive results from zinc nasal gel. Of the remaining 10 studies, 6 reported a positive effect and 4 reported no effect. Intent-to-treat analysis was the most common criterion not met.This structured review suggests that the therapeutic effectiveness of zinc lozenges has yet to be established. One well-designed study did report a positive effect of zinc nasal gel.

  View details for DOI 10.1086/520031

  View details for Web of Science ID 000248557000016

  View details for PubMedID 17682990

• Efficacy of echinilin for the common cold - Echinacea, vitamin C, the common cold, and blinding - Reply CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 41 (5): 763–64

  View details for DOI 10.1086/432628

  View details for Web of Science ID 000230995600032

• Treatment of the common cold with echinacea: A structured review CLINICAL INFECTIOUS DISEASES Caruso, T. J., Gwaltney, J. M. 2005; 40 (6): 807-810

  Abstract

  Echinacea is a herbal preparation that is frequently used to treat the common cold. Spending on echinacea in the United States has risen to >300 million dollars annually.A total of 322 articles related to echinacea and colds, including 9 placebo-controlled clinical trials, were identified using the Medline and PubMed databases. Eleven features of experimental design that affect the accuracy of the measurement of features of interest, the probability of a chance relationship, bias, and blinding were used to evaluate the 9 placebo-controlled studies. The criteria were validated case definition, quantifiable hypothesis, sample-size calculation, randomized assignment, double blinding, proof of blinding, measurement of compliance, measurement of drop-out rate, analysis by intention to treat, description of the methods of analysis, and measurement of probability. Equal weight was given to each criterion, since failure to meet any one of them could potentially invalidate the findings of a clinical trial.Of the 9 studies, 2 met all 11 criteria. The results of both studies were judged to be negative by the people who performed the studies. Of the remaining 7 studies, 6 were judged to have positive results, and 1 was judged to have negative results. The criterion most commonly not met was proof of blinding.This structured review suggests that the possible therapeutic effectiveness of echinacea in the treatment of colds has not been established.

  View details for Web of Science ID 000227492800005

  View details for PubMedID 15736012

• Evaluating Studies of Echinacea of Treating the Common Cold Contagion Caruso, T. J. 2005; 9: 378-381