[Critical incidents in acute pain management-A risk analysis of CIRS reports]. / Kritische Ereignisse in der Akutschmerztherapie ­ eine Risikoanalyse von CIRS-Meldungen.

BACKGROUND: Areas of activity with many intersections pose an increased risk for errors and critical incidents. Therefore, procedures for acute pain therapy are potentially associated with an increased risk for adverse patient outcomes. OBJECTIVE: The aim was to identify and grade the risk of critical incidents in the context of acute pain management. MATERIAL AND METHODS: The register of the nationwide reporting system critical incident reporting system of the Professional Association of German Anesthesiologists, the German Society for Anesthesiology and Intensive Care Medicine and the Medical Center for Quality in Medicine (CIRSmedical Anesthesiology) was screened for incidents concerning pain management. Out of 5365 cases reported nationwide up to 24 March 2020, 508 reports with the selection criterion "pain" could be identified and reviewed and 281 reports (55%) were included in a systematic analysis. RESULTS: Of the 281 reports most came from anesthesiology departments (94%; 3% from surgery departments and 3% from other departments). The reported cases occurred most frequently on normal wards but a relevant proportion of the reports concerned intermediate and intensive care units or areas covered by a pain service (PS). Based on the description of the incident in the report, an involvement of the PS could be assumed for 42% of the cases. In terms of time, most of the events could be assigned to normal working hours (90%) and working days (84%; weekends 16%). The analyzed reports related to parenteral administration of analgesics (40%) and central (40%) or peripheral regional anesthesia procedures (23%) and 13% of the reports related to patient-controlled intravenous analgesia (PCIA; multiple answers possible). Most of the events were caused by technical errors, communication deficits and deviations from routine protocols. A relevant number of the cases were based on mix-ups in the administration route, the dosage, or the active agent. About one third of the sources of error were of an organizational nature, 59% of the cases posed a possible vital risk and in 16% of cases patients had vital complications. The risk grading by risk matrix resulted in an extremely high risk in 7%, a high risk in 62%, a moderate risk in 25% and a low risk in 6% of the cases. Comparing risk assessment of events with involvement of different analgesic methods, multiple medication, combination of analgesic methods or involvement of PS showed no significant differences. Likewise, no differences could be identified between the risk assessments of events at different superordinate cause levels. If more than one overriding cause of error had an impact, initially no higher risk profile was found. CONCLUSION: Incidents in the context of acute pain management can pose high risks for patients. Incidents or near-incidents are mostly related to mistakes and lack of skills of the staff, often due to time pressure and workload as well as to inadequate organization.

Using the STOP-BANG questionnaire to predict hypoxaemia in patients recovering from noncardiac surgery: a prospective cohort analysis.

BACKGROUND: The STOP-BANG questionnaire is a validated, eight-point dichotomized scale used to screen preoperative patients for obstructive sleep apnoea. Sleep apnoea causes hypoxaemia, and nocturnal oxygen desaturation is diagnostic in these patients. We tested the hypothesis that STOP-BANG score is associated with hypoxaemia after noncardiac surgery. METHODS: This analysis was a sub-study of VISION, a prospective cohort study of perioperative cardiovascular events. With institutional review board approval, we included 630 patients in the final analysis. We assessed the association between the STOP-BANG score and postoperative hypoxaemia, defined as integrated area under the curve of [Formula: see text] saturation of 90% per h using median quantile regression. Secondarily, we selected a subset of STOP-BANG questions that best predicts postoperative hypoxaemia using 'Least Absolute Shrinkage and Selection Operator' method, and then assessed the association between the new score based on the selected questions and the primary outcome using quantile regression. RESULTS: The median [q1, q3] area under [Formula: see text] of 90% per h was 0.09 [0.02, 0.39] %-h. The STOP-BANG score was not associated with hypoxaemia, with a multivariable slope coefficient of 0.002 (95% CI: -0.01, 0.01) %-h for a unit increase in the score (P=0.76). Secondarily, no association was found between the new score based on the two retained STOP-BANG questions, treatment for hypertension and neck circumference >40 cm, and the primary outcome with a multivariable slope coefficient of 0.03 (98.3% CI: -0.01, 0.06) %-h/score (P=0.07). CONCLUSIONS: The STOP-BANG score does not predict hypoxaemia in adults recovering from noncardiac surgery. CLINICAL TRIAL REGISTRATION: NCT00512109.

Association between fibromyalgia and adverse perioperative outcomes.

BACKGROUND: Fibromyalgia, the classic non-inflammatory pain syndrome, has been associated with chronic inflammatory makers which are linked with increased morbidity and mortality. We tested the primary hypothesis that patients with fibromyalgia undergoing hospital procedures have a high risk of cardiovascular complications. Our secondary goals were to evaluate the association of fibromyalgia with: (i) in-hospital thromboembolic events, (ii) in-hospital mortality, and (iii) in-hospital microvascular complications. METHODS: We obtained 21.78 million discharge records from 2009 to 2010 from the US Agency for Healthcare Research and Quality censuses across the seven states. We matched fibromyalgia records and compared records with controls based on age, gender, state of discharge, principal procedure, and a propensity score developed from the set of diagnosis-related predictors. A multivariable logistic regression was used to compare matched fibromyalgia patients and controls on the primary and secondary outcomes. RESULTS: We matched 89 589 pairs for a total sample size of 179 178 discharge records. The adjusted odds ratio for in-hospital cardiovascular complications was 1.04 [99% confidence interval (CI): 0.90-1.19, P=0.51], for thromboembolic events was 1.03 (99% CI: 0.93-1.15, P=0.46), for in-hospital mortality was 0.81 (99% CI: 0.73-0.89, P<0.001), and for microvascular complications was 0.96 (99% CI: 0.88, 1.04, P=0.18). Two separate sensitivity analyses produced results similar to that of the primary analysis for all three complication outcomes. CONCLUSIONS: We found no evidence that the diagnosis of fibromyalgia increased the risk of in-hospital complications. Fibromyalgia seems to be associated with a reduction in in-hospital mortality, but this requires confirmation with a large prospective controlled study.

Postoperative analgesia after preincisional administration of remifentanil.

AIM: The aim of this study was to assess postoperative analgesia after preincisional and postincisional administration of remifentanil. METHODS: Randomized trial, 24 hours. SETTING: University hospital, hospitalized care. PATIENTS: 48 adult patients scheduled for lumbar vertebral surgery. INTERVENTIONS: in group R5, patients received an infusion of 0.2 microg kg(-1) min(-1) remifentanil over 5 minutes, followed by a break of 15 minutes before anesthesia was started. Anesthesia was induced by infusion of 0.25 microg kg(-1) min(-1) remifentanil and a bolus of 1.5 microg kg(-1) propofol, followed by a continuous infusion of 2 to 3 microg kg(-1) h-1 propofol and 0.25 microg kg(-1) min(-1) remifentanil until end of anesthesia. In group R20, patients received 0.05 microg kg(-1) min(-1) remifentanil over 20 minutes before the induction of anesthesia. In group RL, anesthesia was induced and maintained with propofol. After surgery began, a remifentanil infusion of 0.5 microg kg(-1) min(-1) was given for 50 minutes, then reduced to 0.25 microg kg(-1) min(-1). The total remifentanil doses were similar in the 3 groups. MEASURES: patients used patient-controlled analgesia (piritramide) for postoperative pain management. They recorded pain on a numeric rating scale every half hour. STATISTICS: Kruskal-Wallis test, pairwise Mann-Withney U-test, orthogonal polynomials (pain scores). RESULTS: PATIENTS given postincisional remifentanil (RL) had the slowest decrease in postoperative pain scores (p<0.01) and the highest cumulative piritramide consumption (p<0.08). CONCLUSION: The preincisional administration of remifentanil followed by a continuous infusion of 0.25 microg kg(-1) min(-1) appears to reduce pain scores and piritramid consumption when compared with a postincisional regimen.

Remifentanil-propofol versus sufentanil-propofol anaesthesia for supratentorial craniotomy: a randomized trial.

BACKGROUND AND OBJECTIVE: Remifentanil has unique pharmacokinetics that might allow faster recovery after neurosurgery. We investigated the effects of a propofol/sufentanil versus a remifentanil/propofol regimen on the primary end-point tracheal extubation time. METHODS: In the Neurosurgery Department of a University Hospital, 36 patients awaiting craniotomy for supratentorial tumour resection were randomly assigned to one of two study groups. In the sufentanil/propofol group, anaesthesia was induced with 0.5 microg kg(-1) sufentanil and 1-2 mg kg(-1) propofol. Propofol infusion and boluses of sufentanil were administered for maintenance. In the remifentanil/propofol group, anaesthesia was started with an infusion of remifentanil (0.2-0.35 microg kg(-1) min(-1)) and a bolus of propofol (1.5-2 mg kg(-1)). Patients received a propofol infusion and a remifentanil infusion for maintenance of anaesthesia. Recovery times were taken from cessation of the propofol infusion. In addition, data about self-reported nausea and vomiting, pain and analgesic requirements were collected. RESULTS: Patients in the remifentanil/propofol group were extubated earlier (mean times 6.4 (+/- SD 4.7) versus 14.3 (+/- 9.2) min; P = 0.003). The two groups were similar with respect to postoperative nausea and vomiting, and patient-reported pain scores. Fifty per cent of the remifentanil/propofol patients and 88% of the sufentanil/propofol patients required no analgesics within 1 h after operation (P = 0.03). CONCLUSIONS: The remifentanil/propofol regimen provided quicker recovery. The two regimens were similar in terms of postoperative nausea and vomiting and patient-reported pain scores, but patients in the remifentanil/ propofol group required more analgesics within 1 h postoperatively.

Remifentanil-clonidine-propofol versus sufentanil-propofol anesthesia for coronary artery bypass surgery.

OBJECTIVE: To compare a remifentanil-clonidine-propofol regimen with conventional sufentanil-propofol anesthesia. DESIGN: Randomized, nonblinded trial. SETTING: A single university hospital. PARTICIPANTS: Male patients scheduled for coronary artery bypass graft (CABG) surgery. INTERVENTIONS: In the control group, anesthesia was induced with 0.5 microg/kg of sufentanil and 0.2 to 0.3 mg/kg of etomidate after preoxygenation. Propofol (50 to 100 microg/kg/min) and sufentanil (0.5 to 1.0 microg/kg/h) were started after endotracheal intubation. Sufentanil was stopped after aortic decannulation. In the remifentanil-clonidine group, anesthesia was started with remifentanil (0.15 to 0.3 microg/kg/min), followed by etomidate (0.2 to 0.3 mg/kg). Propofol was started at 50 to 100 microg/kg/min, and after endotracheal intubation, clonidine infusion was started (6 to 20 microg/h). Patients received piritramide (0.15 mg/kg) and metamizole (20 mg/kg) for transitional analgesia. In both groups, propofol infusion was reduced to 30 to 60 microg/kg/min at skin closure and stopped when assisted spontaneous breathing led to adequate gas exchange. MEASUREMENTS AND MAIN RESULTS: The main outcomes were recovery times; somatic variables; plasma catecholamine levels; and self-recorded pain, nausea, and vomiting. Patients in the remifentanil-clonidine group were extubated earlier and had lower plasma epinephrine and norepinephrine levels. After transitional analgesia, the remifentanil-clonidine patients had similar postoperative analgesic use and self-reported pain and side-effect scores. CONCLUSION: Compared with a sufentanil-propofol regimen, an anesthetic regimen for CABG surgery that combines remifentanil, clonidine, and propofol provides similar hemodynamics. The remifentanil-clonidine regimen reduces catecholamine levels and hastens recovery from anesthesia.