Severe head injury: control of physiological variables, organ failure and complications in the intensive care unit.

BACKGROUND: In patients with severe head injury, control of physiological variables is important to avoid intracranial hypertension and secondary injury to the brain. The aims of this retrospective study were to evaluate deviations of physiological variables and the incidence of extracranial complications in patients with severe head injury. We also studied if these deviations could be related to outcome. PATIENTS AND METHODS: One hundred and thirty-three patients were included during a 5-year period (1998-2002). Deviations from treatment goals for the following physiological variables were studied: blood pressure, haemoglobin, blood sugar, serum sodium, serum albumin and temperature. Extra cerebral organ complications were also recorded as well as outcome at 6 months. RESULTS: The median age was 32 years (range; 1-88 years). Median Glasgow Coma Scale (GCS) before intubation was 6 (range; 3-14). The frequencies of severe deviations from the desired values of the physiological variables for at least one treatment day were: hypotensive episodes (systolic BP < 90 mmHg) - 20%, anaemia (hgb < 8 g/dL) - 22%, blood glucose > 10 mmol/l - 26%, serum sodium concentration < 130 mmol/l - 10%, serum albumin < 25 g/l(-1)- 31% and hyperthermia > 39 degrees C - 24%. Pneumonia was diagnosed in 71% and Acute Lung Injury (ALI)/Adult Respiratory Distress Syndrome (ARDS) in 26% of the patients. Other complications such as severe sepsis (6%), renal failure (1.5%), a coagulation disorder (6%) and liver failure (one patient) were infrequent. Age, GCS, hypotension during the first day of treatment, elevated blood sugar and low albumin predicted an unfavourable outcome. CONCLUSIONS: Deviations of key physiological variables and pulmonary complications were frequent in patients suffering from severe head injury. During intensive care treatment, hypotension, elevated blood sugar and hypoalbuminemia are possible independent predictors of an unfavourable outcome.

Equipment problems during anaesthesia--are they a quality problem?

BACKGROUND: Anaesthesia equipment problems may contribute to anaesthetic morbidity and mortality. The magnitude and pattern of these problems are not established. We wanted to analyse the frequency, type and severity of equipment-related problems in our department, and if additional efforts to improve safety were needed. METHODS: The study is based on a system in which anaesthesia-related data are recorded from all anaesthetic cases on a routine basis. The data include intraoperative problems and their severity. When a problem occurs, the anaesthetist responsible for the case writes a short description of the event on the anaesthetic chart. From all recorded cases of general and regional anaesthesia, we selected cases recorded with anaesthetic 'equipment/technical problems'. These charts were retrieved from departmental archives for analysis. RESULTS: From 83 154 anaesthetics, we found the frequency of anaesthetic equipment problems to be 0.05% during regional anaesthesia, and 0.23% during general anaesthesia. One-third of problems involved the anaesthesia machine, and in a quarter, human error was involved. No patient died and none suffered any lasting morbidity. CONCLUSION: The rate of equipment problems was low, and most often of low severity. Aside from improvements in routines for preoperative equipment checks, no specific strategies for problem reduction could be suggested. The incidence of equipment problems is not a good quality indicator because of the low rate of occurrence. However, recorded equipment problems may be useful for improving quality, by analysing causative factors, and suggesting preventative strategies.

Guidelines for the practice of anesthesia in Norway.

Since the first version saw the light of day in 1991 the Guidelines have occupied a central position in the Norwegian practice of anesthesia. This document comprises part of the quality management documents held in the departments of anesthesia in Norwegian hospitals. If departments of anesthesia are unable to adhere to certain specific points in the Guidelines, it is recommended that this should be documented in writing. It has been stated by central governmental bodies and patients' insurance organizations that the Guidelines will be an important factor in medico legal cases, although it is not an obligatory legal document for hospital owners. It is our objective that the document will form the foundation for quality assurance work in the departments of anesthesia in Norway. The purpose of this document is to ensure a satisfactory standard for the practice of anesthesia in Norway. 'The Guidelines for the Practice of Anesthesia in Norway' (the Guidelines) is a series of recommended guidelines. The practice of anesthesia in this context includes general anesthesia, regional anesthesia, controlled sedation, postoperative monitoring, and other observations where anesthesia personnel are required. The Guidelines apply to all doctors, nurses, and other personnel undertaking the delegated practice of anesthesia. Deviations from the Guidelines should be explained and documented in every case. The Guidelines should be adhered to in medical emergencies as far as possible. The Guidelines must not be allowed to prevent the execution of immediate and lifesaving measures. The Guidelines should be revised at regular intervals so that it is up-to-date with current legislation and medical and technological developments and practice.

Adverse drug errors in anesthesia, and the impact of coloured syringe labels.

PURPOSE: To describe the frequency and pattern of drug errors in clinical anesthesia, and to evaluate whether a change to colour coded syringe labels, along with education, could reduce the problem of drug errors. METHODS: We prospectively recorded anesthesia-related information from all anesthetic cases for 36 mo, totally 55,426 procedures. Intraoperative problems, including drug errors, were recorded. After eighteen months we changed to colour coded syringe labels, and the effect of this change and education on drug errors was assessed. Errors were divided into four groups: syringe swap, ampoule swap, other 'wrong drug' errors, and wrong dose errors. The problems were graded into four levels, according to severity. RESULTS: A drug error was recorded in 63 cases (0.11%). There were 28 syringe swaps, and muscle relaxants were erroneously given in 15. There were nine ampoule swaps. There were eight 'other wrong drug' cases, and 18 cases where a wrong dose of the correct drug was given. Three of the drug errors were classified as serious, and 27 were of moderate severity. We found no differences between the two periods except for decreased number of ampoule swaps (P = 0.04). CONCLUSION: Drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps occurred most often between syringes of equal size, and were not eliminated by colour coding of labels. As muscle relaxant drugs are most commonly involved, and can cause lasting morbidity, special preventive measures should be taken for this group of drugs.

Decreased glutamate metabolism in cultured astrocytes in the presence of thiopental.

The effect of thiopental on glutamate metabolism was studied by 13C magnetic resonance spectroscopy. Cerebral cortical astrocytes were incubated with 0.5 mM [U-13C]glutamate for 2 hr in the presence of 0.5 or 1 mM thiopental. Labeled glutamate, glutamine, aspartate, and glutathione were observed in cell extracts, and glutamine, aspartate, and lactate in the medium. Not only present in the medium was uniformly labeled glutamate, but also glutamate derived from the tricarboxylic acid (TCA) cycle, and thus glutamate release could be detected. The amounts of [U-13C]glutamate and unlabeled glucose taken up by astrocytes were unchanged in the presence of 0.5 mM thiopental and decreased to about 50% and 80%, respectively when the concentration was increased to 1 mM. The amounts of most metabolites synthesized from [U-13C]glutamate were unchanged in the presence of 0.5 mM thiopental, but decreased [U-13C]glutamine, [U-13C]aspartate, and [U-13C]lactate were observed in the 1 mM group. Surprisingly, the amounts of [1,2,3-13C]glutamate, [2,3-13C]aspartate, and [3,4-13C]aspartate (2nd turn via the TCA cycle) were unchanged. However, this was not the case for [1,2-13C]lactate and [2,3-13C]lactate. Such variations indicate cellular compartmentation, possibly caused by a heterogeneous glutamate concentration within the cells affecting TCA cycle turnover rates differently.

Ventricular fibrillation related to reversal of the neuromuscular blockade in a patient with long QT syndrome.

The long QT syndrome (LQTS) is associated with syncopal attacks or even sudden death at a young age due to ventricular fibrillation. We report a patient with an undiagnosed LQTS who had an episode of cardiac arrest during the final part of general anesthesia, immediately after the drugs for reversal of the neuromuscular blockade were given. We suggest that the administration of glycopyrronium might have been the provoking factor in this patient.

In-hospital cardiopulmonary resuscitation. 5 years' incidence and survival according to the Utstein template.

BACKGROUND: Direct comparison of survival rates from in-hospital cardiopulmonary resuscitation (CPR) remains difficult. The objective of this study was to report outcome according to the Utstein template for in-hospital cardiac arrest and to evaluate the Utstein template itself as applied to a retrospective material. METHODS: The hospital (900 beds, 37,000 annual admissions) has no established do-not-resuscitate (DNR) order policy. CPR outside the Intensive- or Coronary Care Units (ICU/CCU) is performed by an emergency medical team consisting of an anaesthesiologist, a medical resident and a nurse anaesthetist. CPR attempts during 5 years (1990-1994) were analysed retrospectively. Patient survival, cerebral and overall performance category (CPC/OPC) score of the survivors was determined. The Utstein template was evaluated in terms of clinical relevance and data availability. RESULTS: During 5 years, 4927 patients died as in-patients. CPR outside the CCU/ICU was attempted 244 times. CPR was primarily successful on 83 occasions (34%), and 42 patients (17%) were finally discharged with CPC 1 or 2. Survival from primary ventricular fibrillation (VF) or ventricular tachycardia was 40%, pulseless electrical activity 3%, asystole 11% and of rhythm undetermined 6%. Age or sex effects were not observed. CONCLUSION: More than 90% of in-hospital deaths in this hospital are handled without CPR being initiated. Overall survival was 17%, and almost all survivors made a favourable outcome. The Utstein template for in-hospital cardiac arrest performed acceptably as a framework for reporting outcome in this retrospective study.

Out-of-hospital cardiopulmonary resuscitation: a population-based Norwegian study of incidence and survival.

The Trondheim region's (315 km2, population 154,000) emergency medical service (EMS) provides advanced cardiac life support (ACLS) with combined paramedic and physician response. This EMS system is commonly employed in Norway, yet no population based study of outcome in cardiac arrest has been published to date. This retrospective study reports incidence and outcome from every attempted out-of-hospital cardiopulmonary resuscitation (CPR) during 1990 through 1994 according to the Utstein template. Information on the patient's pre-morbid conditions and final outcome was obtained from hospital records. The incidence of cardiac arrest and CPR from all causes was 68 per 100,000 per year, with 83% primary cardiac aetiology. The median alarm to patient arrival interval for ambulance and emergency physician was 8 minutes and 11 minutes, respectively. The presenting rhythm was ventricular fibrillation or tachycardia in 51%, asystole in 34%, pulseless electrical activity in 8% and undetermined in 8%. Definite return of spontaneous circulation occurred in 211 patients (40%, 27 per 100,000 per year) and 57 patients (11%, 7.4 per 100,000 per year) survived to discharge. Most patients made a favourable cerebral outcome, although nine were severely disabled. This is the first population-based Norwegian study of outcome from out-of-hospital cardiac arrest in this combined paramedic/physician staffed EMS. Incidence, survival and neurological outcome are comparable with results obtained in other EMS systems.