Ten years of the Helsinki Declaration on patient safety in anaesthesiology: An expert opinion on peri-operative safety aspects.

: Patient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the 'Helsinki Declaration on Patient Safety in Anaesthesiology'. In May/June 2020, ESA and EBA are celebrating the 10th anniversary of the Helsinki Declaration on Patient Safety in Anaesthesiology; a good opportunity to look back and forward evaluating what was achieved in the recent 10 years, and what needs to be done in the upcoming years. The Patient Safety and Quality Committee (PSQC) of ESA invited experts in their fields to contribute, and these experts addressed their topic in different ways; there are classical, narrative reviews, more systematic reviews, political statements, personal opinions and also original data presentation. With this publication we hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.

Exhaled nitric oxide measurement before pediatric adenotonsillectomy: A feasibility study.

BACKGROUND: Exhaled nitric oxide (eNO) is a known biomarker for the diagnosis and monitoring of bronchial hyperreactivity in adults and children. AIMS: To investigate the potential role of eNO measurement for predicting perioperative respiratory adverse events in children, we sought to determine its feasibility and acceptability before adenotonsillectomy. METHODS: We attempted eNO testing in children, 4-12 years of age, immediately prior to admission for outpatient adenotonsillectomy. We used correlations between eNO levels and postoperative adverse respiratory events to make sample size predictions for future studies that address the predictability of the device. RESULTS: One hundred and three (53%) of 192 children were able to provide an eNO sample. The success rate increased with age from 23% (9%-38%) at age 4 to over 85% (54%-98%) after age 9. Using the eNO normal value (<20 ppb) as a cutoff, an expected sample size to detect a significant difference between children with and without adverse events is 868, assuming that respiratory adverse events occur in 29% of children. CONCLUSIONS: eNO testing on the day of surgery has limited feasibility in children younger than 7 years of age. The most common reason for failure was inadequate physical performance while interacting with the testing device. The role of this respiratory biomarker in the context of perioperative outcomes for pediatric adenotonsillectomy remains unknown and should be further studied with improved technologies.

High-Dose Desflurane for Tocolysis During Intrapartum Myelomeningocele Repair in a Patient With Post-Adriamycin Cardiomyopathy.

High-dose desflurane is an uncommon need during general anesthesia. At our institution, open fetal surgery cases are managed with high desflurane concentrations to ensure uterine relaxation. We present a case of a 32-year-old parturient with a history of mild cardiomyopathy undergoing open fetal myelomeningocele repair. Phenylephrine and dopamine infusions helped maintain hemodynamic stability at 18% desflurane, while cardiac function was monitored with transthoracic echocardiography. This case is notable for the unknown risk of using high-dose desflurane with a preexisting cardiomyopathy and raises the question of the acceptable maternal risk in the setting of fetal surgery.

Addressing the variation of post-surgical inpatient census with computer simulation.

OBJECTIVE: This study describes the development of a Discrete Event Simulation (DES) of a large pediatric perioperative department, and its use to compare the effectiveness of increasing the number of post-surgical inpatient beds vs. implementing a new discharge strategy on the proportion of patients admitted to the surgical unit to recover. MATERIALS AND METHODS: A DES of the system was developed and simulated data were compared with 1 year of inpatient data to establish baseline validity. Ten years of simulated data generated by the baseline simulation (control) was compared to 10 years of simulated data generated by the simulation for the experimental scenarios. Outcome and validation measures include percentage of patients recovering in post-surgical beds vs. "off floor" in medical beds, and daily census of inpatient volumes. RESULTS: The proportion of patients admitted to the surgical inpatient unit rose from 79.0% (95% CI, 77.9-80.1%) to 89.4% (95% CI, 88.7-90.0%) in the discharge strategy scenario, and to 94.2% (95% CI, 93.5-95.0%) in the additional bed scenario. The daily mean number of patients admitted to medical beds fell from 9.3 ± 5.9 (mean ± SD) to 4.9 ± 4.5 in the discharge scenario, and to 2.4 ± 3.2 in the additional bed scenario. DISCUSSION: Every hospital is tasked with placing the right patient in the right bed at the right time. Appropriately validated DES models can provide important insight into system dynamics. No significant variation was found between the baseline simulation and real-world data. This allows us to draw conclusions about the ramifications of changes to system capacity or discharge policy, thus meeting desired system performance measures.

Managing fresh gas flow to reduce environmental contamination.

Anesthetic drugs have the potential to contribute to global warming. There is some debate about the overall impact of anesthetic drugs relative to carbon dioxide, but there is no question that practice patterns can limit the degree of environmental contamination. In particular, careful attention to managing fresh gas flow can use anesthetic drugs more efficiently--reducing waste while achieving the same effect on the patient. The environmental impact of a single case may be minimal, but when compounded over an entire career, the manner in which fresh gas flow is managed by each individual practitioner can make a significant difference in the volume of anesthetic gases released into the atmosphere. The maintenance phase of anesthesia is the best opportunity to reduce fresh gas flow because circuit gas concentrations are relatively stable and it is often the longest phase of the procedure. There are, however, methods for managing fresh gas flow during induction and emergence that can reduce the amount of wasted anesthetic vapor. This article provides background information and discusses strategies for managing fresh gas flow during each phase of anesthesia with the goal of reducing waste when using a circle anesthesia system. Monitoring oxygen and anesthetic gas concentrations is essential to implementing these strategies safely and effectively. Future technological advances in anesthetic delivery systems are needed to make it less challenging to manage fresh gas flow.

Is the pleth variability index a surrogate for pulse pressure variation in a pediatric population undergoing spine fusion?

OBJECTIVE: To compare simultaneous measurements of pulse pressure variation (PPV) and pleth variability index (PVI) in patients undergoing spinal fusion. AIMS: To determine if PVI can be used as a surrogate for PPV and also the influence of the prone position on these measurements. BACKGROUND: Spine fusion is an involved surgical procedure requiring attention to fluid administration. Dynamic indices for assessing fluid responsiveness like PPV have proven useful to guide fluid administration. Plethysmographic waveform variation like PVI is an appealing surrogate for measurements like PPV that require invasive arterial pressure measurement. Spine fusion patients are unique and the potential of either PPV or PVI to guide fluid therapy has not been studied. METHODS: Patients undergoing spine fusion for scoliosis were studied. In addition to the usual monitors including direct arterial pressure measurement, a multi-wavelength pulse co-oximeter was applied to measure PVI. Paired measurements of PPV and PVI were obtained and limits of agreement determined using the method of Bland and Altman. PPV and PVI in prone and supine positions were compared by paired t-test. RESULTS: The bias between PVI and PPV measurements was -0.56% with 95% limits of agreement of +21.67% to -20.55%. There was no significant difference between the prone and supine measurements at the P = 0.05 level (Table 1). CONCLUSIONS: Our data indicate that PVI is not a surrogate for PPV. PVI measurements were not influenced by changing from the supine to prone position and therefore may prove useful for patients undergoing spine surgery.

Continuous peripheral nerve blockade for inpatient and outpatient postoperative analgesia in children.

BACKGROUND: This is an audit of the continuous peripheral nerve blockade (CPNB) program that was implemented at our institution to provide postoperative analgesia after orthopedic procedures in children. METHODS: We reviewed the departmental regional anesthesia registry and the medical records of consecutive children who received CPNB for postoperative analgesia at The Children's Hospital of Philadelphia between February 2003 and July 2006. Patients were prospectively followed until cessation of the effects of CPNB and/or resolution of any related complications. Data collected contemporaneously included presence of sensory and motor blockade, pain scores in inpatients, opioid administration, and complications related to CPNB. RESULTS: A total of 226 peripheral nerve catheters were placed in 217 patients. One hundred eight patients (112 catheters) were discharged home with CPNB. The ages ranged from 4 to 18 yr (13.7 +/- 3.4). Local anesthetic solution (0.125% bupivacaine [n = 164], 0.1% ropivacaine [n = 12], or 0.15% ropivacaine [n = 27]) was infused at an initial rate of 2-12 mL/h based on patients' weights and locations of catheters. The mean duration of local anesthetic infusion was 48.4 +/- 29.3 h (range 0-160 h). The percentage of patients who did not require any opioids in the first 8, 24, and 48 h after surgery was 56%, 26%, and 21%, respectively. The incidence of nausea and vomiting was 14% (13% in outpatients, 15% in inpatients). Complications were noted in 2.8% of patients. Three patients had prolonged numbness (>24 h) that resolved spontaneously; one developed superficial cellulitis that resolved with a course of antibiotics; one had difficulty removing the catheter at home and one developed tinnitus 24 h after starting CPNB that resolved quickly after clamping of the catheter followed by removal. CONCLUSION: It is feasible to implement a CPNB program to provide an alternative method of inpatient and outpatient postoperative analgesia after orthopedic surgery in children when appropriate expertise is available. Patient and family education along with frequent follow-up are crucial to detect and address adverse events promptly.