Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.

BACKGROUND: The incidence and prevalence of obesity are increasing world wide. In the UK, obesity governmental strategy has primarily focused on prevention measures, with less focus on the demands of treating obese patients in hospital. Increasing service demand by obese patients coupled with a lack of adequate provision for care of these patients may lead to an increase in patient safety incidents. By classifying patient safety incidents associated with obesity reported to the National Patient Safety Agency, this report aims to identify areas for improvement in the quality and safety of care of the obese patient. METHODS: A search of the National Reporting and Learning System database was conducted for all incidents caused by or relating to obesity for the period 1 January 2005 to 31 August 2008. The keywords 'obesity', 'overweight', 'BMI' (body mass index), and 'bariatric' were used. The relevant free text fields of the resulting set of incidents were then searched for the terms designed to isolate incidents occurring in anaesthesia, critical care, and surgery. Reported incidents were analysed and subsequently categorised to identify incident themes. Levels of harm were also established. RESULTS: 555 patient safety incidents were identified; 388 met inclusion criteria for analysis. 148 incidents were related to assessment, diagnosis or treatment, 213 related to infrastructure and 27 related to staffing. The majority of incidents were classified as no or low harm. Three deaths were reported, all within the domain of anaesthesia. CONCLUSIONS: This report identifies that the majority of safety incidents associated with obesity were related to infrastructure, suggesting that there is inadequate provision in place for the care of obese patients. While levels of harm were mostly low, the occurrence of incidents resulting in severe harm or death highlights the specific dangers associated with the care of the obese patient. A global approach to improving the safety of care delivery for obese patients is recommended, including obesity specific training, management structures, care pathways, and equipment provisioning.Further planning and development of operation policies is needed to ensure the safe delivery of healthcare to obese patients in the future.

Military assistance to the civil authority: medical liaison with the Manchester clinicians after the Arena bombing.

UK Defence Medical Services' personnel have experienced an intense exposure to patients injured during war over the last decade and a half. As some bitter lessons of war surgery were relearned and innovative practices introduced, outcomes for patients impr oved consistently as experience accumulated. The repository of many of the enduring lessons learnt at the Role 4 echelon of care remain at the Queen Elizabeth Hospital Birmingham (QEHB), with the National Health Service and Defence Medical Services personnel who treated the returning casualties. On 22 May 2017, a terrorist detonated an improvised explosive device at the Manchester Arena, killing 22 and wounding 159 people. In the aftermath of the event, QEHB was requested to provide support to the Manchester clinicians and teleconferencing and then two clinical visits were arranged. This short report describes the nature of the visits, outlines the principles of Military Aid to the Civil Authority and looks to the future role of the Defence Medical Services in planning and response to UK terrorism events.

Double-stranded RNA increases kinin B1 receptor expression and function in human airway epithelial cells.

Increased levels of kinins have been detected within the airways during upper respiratory viral infections (URIs). Rhinovirus, the major URI associated with acute exacerbations of asthma, is an ssRNA virus that primarily infects the airway epithelium and produces dsRNA during replication. We asked whether dsRNA could increase the expression of kinin receptors in airway epithelial cells, thereby potentiating the inflammatory consequences of kinin generation. Human airway epithelial cell line BEAS-2B was stimulated with the dsRNA analog Poly I:C and kinin receptor expression detected by quantitative RT-PCR as well as radioligand binding. Poly I:C induced an increase in B1 and B2 receptor mRNA levels in BEAS-2B and primary human normal bronchial epithelial cells. At the cell surface, only B1 receptor expression was increased by Poly I:C. Furthermore, pretreatment of BEAS-2B cells with Poly I:C enhanced the induction of phospho-ERK following B1 receptor ligand stimulation. To investigate whether these finding had potential in vivo relevance, we assessed B1 receptor expression in nasal tissue obtained from 8 normal human subjects with URIs and 3 control subjects. Five of the URI subjects demonstrated increased B1 receptor mRNA compared to the 3 control subjects. We suggest that increased expression of B1 receptor in the human airway following a URI could increase the risk of an exacerbation of asthma by contributing to increased inflammation in the airway.

Improving rehabilitation after critical illness through outpatient physiotherapy classes and essential amino acid supplement: A randomized controlled trial.

PURPOSE: Patients recovering from critical illness may be left with significant muscle mass loss. This study aimed to evaluate whether a 6-week program of enhanced physiotherapy and structured exercise (PEPSE) and an essential amino acid supplement drink (glutamine and essential amino acid mixture [GEAA]) improves physical and psychological recovery. MATERIALS AND METHODS: Intensive care patients aged 45 years or older, with a combined intensive care unit stay/pre-intensive care unit stay of 5 days or more were recruited to a randomized controlled trial examining the effect of PEPSE and GEAA on recovery. The 2 factors were tested in a 2 × 2 factorial design: (1) GEAA drink twice daily for 3 months and (2) 6-week PEPSE in first 3 months. Primary efficacy outcome was an improvement in the 6-minute walking test at 3 months. RESULTS: A total of 93 patients were randomized to the study. Patients receiving the PEPSE and GEA had the biggest gains in distance walked in 6-minute walking test (P < .0001). There were also significant reductions in rates of anxiety in study groups control supplement/PEPSE (P = .047) and GEAA supplement/PEPSE (P = .036) and for GEAA supplement/PEPSE in depression (P = .0009). CONCLUSION: Enhanced rehabilitation combined with GEAA supplement may enhance physical recovery and reduce anxiety and depression.

Vascular surgical society of great britain and ireland: randomized double-blind study of dopexamine versus placebo in aortic surgery

BACKGROUND: Mechanisms involved in the development of colon- ic ischaemia are not fully understood and there are conflicting reports regarding predisposing factors. The aim of this study was to evaluate the effect of dopexamine hydrochloride on the incidence of colonic ischaemia following aortic surgery and to correlate immunohistochemical markers of inflammatory activation in its pathogenesis. METHODS: Thirty patients, of mean age 65 (range 46-84) years, undergoing elective infrarenal aortic surgery were randomized to receive a perioperative infusion of either dopexamine 2 &mgr;g kg-1 min-1 (n = 12) or 0.9 per cent saline placebo (n = 18). All patients underwent colonoscopy and biopsy following induction of anaesthesia and at 1 week after operation. Sections were stained with haematoxylin and eosin, and for mast cell tryptase (MCT), myeloperoxidase (MPO) and both the inducible (iNOS) and endothelial (eNOS) isoforms of nitric oxide synthase. Sections were analysed blindly and independently by two histopathologists. Patient and operative data were collected and stored separately. RESULTS: Colonic ischaemia was noted in nine patients based on microscopic findings. Endoscopy alone had a sensitivity of 56 per cent. There was a significantly lower incidence of colonic ischaemia in patients receiving dopexamine compared with placebo (P < 0.05). One death resulted from colonic infarction in the placebo group 11 days after operation. There was increased MPO and MCT expression in patients with histological evidence of ischaemia (P < 0.05); iNOS staining within the vascular (P = 0.001) and lamina propria (P < 0.05) components of the mucosa was also significantly greater. No association was found with eNOS. CONCLUSION: Perioperative dopexamine infusion confers a degree of protection to colonic mucosa following aortic surgery, possibly through an anti-inflammatory effect.

The effect on serum lipid concentrations of a prolonged infusion of propofol--hypertriglyceridaemia associated with propofol administration.

Serum concentrations of triglyceride, cholesterol and high density lipoprotein-cholesterol (HDL-cholesterol) were measured in an ICU patient after he had received a 10-day continuous infusion of propofol. No additional parenteral lipid was given in the 72 h prior to initial sampling, but a total of 71 of 10% intralipid had been administered over the remaining 7 days. The total cumulative dose of propofol was 66.1 g (range 0.7-6.4 mg kg-1 h-1). There was no visual appearance of lipaemia. Both the serum triglyceride and cholesterol concentrations increased (triglyceride level increased to 4 times normal whereas the cholesterol elevation was minimal). The HDL-cholesterol concentration decreased. At 72 h after discontinuing the infusion of propofol the triglyceride level remained elevated, the cholesterol concentration had returned to normal and the HDL-cholesterol concentration remained unchanged. The implications of hypertriglyceridaemia are discussed.

Inorganic fluoride concentration after long-term sedation with isoflurane.

We report on five patients in whom long-term sedation with isoflurane for up to 7 days was used successfully. Serum inorganic fluoride concentrations were measured daily. The concentrations ranged from 12 mmol l-1 to 29 mmol l-1. These were well below the described renal toxic level of 50 mmol l-1. There was no deterioration in renal function attributable to the use of isoflurane.

The use of propofol for sedation of critically ill patients undergoing haemodiafiltration.

OBJECTIVE: To assess the requirement for propofol to provide sedation in critically ill patients in established renal failure during the commencement of haemodiafiltration. DESIGN: Prospective clinical study. SETTING: ICU, University Hospital. PATIENTS: 10 adult patients. All were mechanically ventilated, had acute oliguric renal failure which necessitated continuous veno-venous haemodiafiltration and were receiving a continuous intravenous infusion of propofol for sedation. Sedation was assessed using a scoring system. INTERVENTION: Veno-venous haemodiafiltration. MEASUREMENTS AND RESULTS: Connection of the extracorporeal circuit produced a reduction in plasma propofol concentration in 7 out of 9 patients (one sample misplaced) with subsequent awakening in 3 of these 7 patients. The commencement of haemodiafiltration itself did not significantly influence the requirement for propofol (8 out of 10 patients). CONCLUSION: Haemodiafiltration does not substantially influence the requirement for propofol but the initial introduction of the extracorporeal circuit will reduce plasma concentrations in the majority of patients. This may be due to haemodilution alone or absorption of plasma albumin (with propofol) onto the membrane.

Haemodynamic effects of the position chosen for the insertion of an epidural catheter.

An epidural catheter may be inserted with the patient either in the flexed left lateral or the sitting position. We have studied, non-invasively, the haemodynamic changes associated with these positions, using the thoracic bio-impedance method (BOMED NCCOM3 Monitor). Maternal arterial pressure and fetal heart rate were monitored simultaneously. Twenty healthy pregnant patients at term and 20 non-pregnant healthy controls, matched for age and height, were studied. The pregnant patients were scheduled for elective caesarean section and had singleton healthy fetuses. A significant reduction in stroke index (SI) occurred when the pregnant patients were repositioned from supine 15degrees wedged position to either flexed left lateral (P < 0.01) or sitting positions (P < 0.05). Similar reductions in SI with positioning were observed in the non-pregnant patients: flexed left lateral (P < 0.01); and sitting (P < 0.01). These changes in SI produced significant reductions in cardiac index (CI) in both groups. In the pregnant patients the CI was significantly lower in the flexed left lateral than in the sitting position (P < 0.01). Consequently maternal systolic blood pressure was lower in the flexed left lateral position (P < 0.01).

Corticosteroid-induced gene expression in allergen-challenged asthmatic subjects taking inhaled budesonide.

BACKGROUND AND PURPOSE: Inhaled corticosteroids (ICS) are the cornerstone of asthma pharmacotherapy and, acting via the glucocorticoid receptor (GR), reduce inflammatory gene expression. While this is often attributed to a direct inhibitory effect of the GR on inflammatory gene transcription, corticosteroids also induce the expression of anti-inflammatory genes in vitro. As there are no data to support this effect in asthmatic subjects taking ICS, we have assessed whether ICS induce anti-inflammatory gene expression in subjects with atopic asthma. EXPERIMENTAL APPROACH: Bronchial biopsies from allergen-challenged atopic asthmatic subjects taking inhaled budesonide or placebo were subjected to gene expression analysis using real-time reverse transcriptase-PCR for the corticosteroid-inducible genes (official gene symbols with aliases in parentheses): TSC22D3 [glucocorticoid-induced leucine zipper (GILZ)], dual-specificity phosphatase-1 (MAPK phosphatase-1), both anti-inflammatory effectors, and FKBP5 [FK506-binding protein 51 (FKBP51)], a regulator of GR function. Cultured pulmonary epithelial and smooth muscle cells were also treated with corticosteroids before gene expression analysis. KEY RESULTS: Compared with placebo, GILZ and FKBP51 mRNA expression was significantly elevated in budesonide-treated subjects. Budesonide also increased GILZ expression in human epithelial and smooth muscle cells in culture. Immunostaining of bronchial biopsies revealed GILZ expression in the airways epithelium and smooth muscle of asthmatic subjects. CONCLUSIONS AND IMPLICATIONS: Expression of the corticosteroid-induced genes, GILZ and FKBP51, is up-regulated in the airways of allergen-challenged asthmatic subjects taking inhaled budesonide. Consequently, the biological effects of corticosteroid-induced genes should be considered when assessing the actions of ICS. Treatment modalities that increase or decrease GR-dependent transcription may correspondingly affect corticosteroid efficacy.

Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the Task Force on Safety and Quality of the European Society of Intensive Care Medicine (ESICM).

OBJECTIVES: To define a set of indicators that could be used to improve quality in intensive care medicine. METHODOLOGY: An European Society of Intensive Care Medicine Task Force on Quality and Safety identified all commonly used key quality indicators. This international Task Force consisted of 18 experts, all with a self-proclaimed interest in the area. Through a modified Delphi process seeking greater than 90% consensual agreement from this nominal group, the indicators were then refined through a series of iterative processes. RESULTS: A total of 111 indicators of quality were initially found, and these were consolidated into 102 separate items. After five discrete rounds of debate, these indicators were reduced to a subset of nine that all had greater than 90% agreement from the nominal group. These indicators can be used to describe the structures (3), processes (2) and outcomes (4) of intensive care. Across this international group, it was much more difficult to obtain consensual agreement on the indicators describing processes of care than on the structures and outcomes. CONCLUSION: This document contains nine indicators, all of which have a high level of consensual agreement from an international Task Force, which could be used to improve quality in routine intensive care practice.

Use of ranitidine in children undergoing cardiopulmonary bypass.

Sixty children aged 6 wk to 10 yr were studied. The children were undergoing cardiopulmonary bypass (CPB) for correction of congenital heart defects. The aim of the study was to provide prophylaxis for stress-induced gastric ulceration by elevating the gastric pH to at least 3.5. Two infusion regimes of ranitidine were compared: 0.1 and 0.2 mg/kg.h. The period of study was from induction of anesthesia until the end of the first 24 h after surgery. Both regimes were effective. The 0.2-mg/kg.h infusion produced a significantly higher plasma concentration of ranitidine throughout the study period without any additional clinical benefit. Both regimes produced, within 3 h of cessation of CPB, a significant elevation in mean gastric pH to at least 5.3. This paper concludes that 0.1-mg/kg.h infusion of ranitidine is a safe and efficacious regime for the critically ill pediatric patient.

Survival, morbidity, and quality of life after discharge from intensive care.

OBJECTIVE: To assess survival, morbidity (physical and psychological), quality of life (QOL), and employment status of intensive care survivors up to 12 months after discharge from the intensive care unit (ICU). DESIGN: Prospective study. SETTING: University hospital adult ICU. PATIENTS: Between August 1, 1995, and July 31, 1996, 370 patients were admitted. Of these patients, 29% died in the ICU. Three months after discharge from the ICU, 227 patients were alive, and 143 agreed to participate. Cumulative mortality was calculated using the original complete cohort. MEASUREMENTS AND MAIN RESULTS: Demographic data, severity of acute illness (Acute Physiology and Chronic Health Evaluation [APACHE] II), admitting specialty, primary diagnosis, and length of stay were recorded. Physical and ICU-related psychological morbidity (Hospital Anxiety and Depression scale score) were recorded. Health-related QOL was assessed using the Short-Form 36. All the questionnaires were completed in the clinic at 3 months. Assessment of physical morbidity and employment status at 6 and 12 months were conducted by telephone. The cumulative mortality was 39% at 3 months, 41% at 6 months, and 43% at 12 months. Deaths after 3 months occurred in the group who refused follow-up. The median age for the follow-up group was 51 yrs; the gender split was 68 women and 75 men; the mean admission APACHE II score was 18.79 (SD 6.15); and the median length of ICU stay was 3.8 days. At 3 months, approximately 80% of all patients interviewed were satisfied with their QOL. Older men (>65 yrs) and younger women (<65 yrs) demonstrated significantly better health with respect to some subdomains of the Short-Form 36 compared with their counterparts. The prevalence of psychological distress (Hospital Anxiety and Depression scale score, > or =8) was low: 11.9% had heightened anxiety, and 9.8% were depressed. There were high levels of fatigue, poor concentration, and sleep disturbance; the latter was more marked in women (p = .022). Improvement in all three symptoms occurred during the next 9 months. Significantly more women reported loss of hair (p < .0001). Men were slower to return to employment; 75% of women had returned by 6 months compared with only 65% of men at 1 yr. CONCLUSION: Assessment of outcome after ICU stay must include QOL measurements. Three months after discharge, there is a low incidence of ICU-related psychological or psychiatric illness and the majority of patients are satisfied. Differences in the incidence and nature of morbidity exist between the genders.

An evaluation of intercostal nerve blockade for analgesia following renal transplantation.

In a double-blinded study we examined the effect of supplementing patient-controlled morphine analgesia with intercostal nerve blockade to identify if this improved analgesia and reduced morphine requirements following renal transplantation. Fifty patients were randomized to receive unilateral intercostal nerve block with either 0.5% bupivacaine or saline to the lower five intercostal nerves. Each block was performed on the side of surgical incision following the completion of surgery. Patients receiving bupivacaine blockade reported reduced pain scores and used less morphine in the initial 4 h following renal transplantation, but did not demonstrate a significant reduction in overall pain scores, total 24 h morphine requirements, or sedation scores. Two patients developed a pneumothorax, neither of which were clinically apparent at the time of diagnosis, and only detected by chest radiography. A chest radiograph should therefore be considered mandatory after intercostal nerve blockade.

Concentrations of atracurium and laudanosine in cerebrospinal fluid and plasma in three intensive care patients.

We have measured concentrations of atracurium and laudanosine in cerebrospinal fluid (CSF) and plasma in three intensive care patients receiving atracurium infusions of 22.5-106 h duration to maintain neuromuscular block. Two patients had suffered severe closed head injuries and the third patient had developed respiratory failure following the clipping of two intracranial aneurysms. The total dose of atracurium given was 14.3-136.6 mg kg-1; rate of infusion was 0.6-1.38 mg kg-1 h-1. Plasma concentrations of atracurium and laudanosine were 0.73-3.11 micrograms ml-1 and 0.48-8.65 micrograms ml-1, respectively; CSF concentration of laudanosine was 70-440 ng ml-1. No adverse effects attributable to these concentrations of laudanosine were observed.

Comparison of the maternal and fetal effects associated with intermittent or continuous infusion of extradural analgesia.

Eighty normal primigravidae received an extradural dose of 0.25% bupivacaine and were then allocated randomly to receive "top-ups" of 0.25% bupivacaine (group A) or an infusion of 0.125% bupivacaine (group B). Group B received supplementary top-ups if required. Group A required more top-ups (147 vs 80) (P < 0.01). No maternal advantage was demonstrated from each regimen. Fetal state was assessed by analysis of the cardiotocograph during labour and the condition of the fetus at delivery. Three different patterns of late deceleratory episodes were identified (grades 1-3). Total numbers of episodes per group were similar (group A, 71; group B, 69). More episodes in group A were related to top-ups (42/71 vs 18/69; P < 0.01) but the incidence of episodes after a top-up was similar (group A, 42/147 (28.6%); group B, 18/80 (22.5%)). In group A, 31/42 events (73.8%) were transient compared with 11/18 persistent episodes (61.1%) (> 10 min duration) in group B. However, the difference in the deceleratory patterns did not influence the condition of the fetuses at delivery.

Concentrations of atracurium and laudanosine in cerebrospinal fluid and plasma during intracranial surgery.

Concentrations of atracurium and laudanosine in cerebrospinal fluid (CSF) and plasma were assayed in nine patients receiving atracurium infusions of 111-251 min duration to maintain neuromuscular block during intracranial surgery. The total dose of atracurium was 1.57-2.60 mg kg-1 and the plasma concentration of atracurium was 1.27-5.44 micrograms ml-1. Concentrations of laudanosine in CSF and plasma increased during the infusion period, and after 125-140 min reached means of 202.5 ng ml-1 and 1448.7 ng ml-1, respectively. The highest recorded concentration of laudanosine in CSF was 570 ng ml-1, in one of two CSF samples found to contain atracurium. After operation, two patients had fits, but these were not thought to be related to laudanosine. It is concluded that during infusion of atracurium, laudanosine accumulates in both plasma and CSF.

Effect of dopexamine on outcome after major abdominal surgery: a prospective, randomized, controlled multicenter study. European Multicenter Study Group on Dopexamine in Major Abdominal Surgery.

OBJECTIVE: To test the hypothesis that dopexamine reduces postoperative mortality and morbidity in high-risk, major abdominal surgery patients, when given to fluid-resuscitated patients starting before the operation and continued for 24 hrs after surgery. DESIGN: Prospective, randomized, controlled, double-blind multicenter trial. SETTING: Intensive care units in 13 hospitals from six European countries. PATIENTS: A total of 412 patients with predefined high-risk criteria, undergoing major abdominal surgery with an expected duration of at least 1.5 hrs. INTERVENTIONS: The patients received placebo (n = 140), dopexamine at 0.5 microg/kg/min (n = 135), or dopexamine at 2.0 microg/kg/ min (n = 137) starting after preoperative hemodynamic stabilization and continued for 24 hrs after surgery. MEASUREMENTS AND MAIN RESULTS: The primary outcome variable was mortality at 28 days. Analysis was by intention to treat. Dopexamine had no effect on mortality (at 28 days, 13%, 7%, and 15%, for the groups receiving placebo, dopexamine at 0.5 microg/kg/ min, and dopexamine at 2.0 microg/kg/min, respectively), despite the expected dose-dependent hemodynamic responses. No effect was observed on the occurrence of organ dysfunction, duration of intensive care unit stay, or length of hospital stay. CONCLUSION: We conclude that dopexamine in doses that result in increased cardiac output and oxygen delivery after preoperative stabilization with fluids does not improve outcome after major abdominal surgery compared with fluids alone. Based on post hoc subgroup analysis and stratification according to the number of risk factors, we suggest that the concept should be further tested in patients at higher risk of complications or undergoing emergency surgery.