Quality and outcomes in anaesthesia: lessons from litigation.

Healthcare litigation in the UK continues to grow at an alarming rate, with claims against anaesthetists and critical care physicians increasing each year. This has led to a huge financial burden for the taxpayer and a sharp increase in professional indemnity fees for individual doctors. Although such litigation should provide valuable information to educate practitioners and reduce future similar claims, there appear to be significant barriers preventing important lessons from being learned. Detailed learning opportunities are available only to the healthcare providers being sued or the expert witnesses employed to analyse the claims. Most practitioners have to rely on indemnifiers' case reports, closed-claim analyses, and ad hoc publications for information. In this review, we suggest ways in which important lessons from litigation could be brought to the attention of all clinicians. Currently, most clinicians are unable to determine whether key components of their practice such as consent, clinical decision-making, and documentation are of an acceptable standard for legal scrutiny. By reporting outcomes of Coroners' inquests, clinical and criminal negligence cases, and referrals to the General Medical Council, it would be hoped that more explicit standards of performance could be derived. Ultimately, this may not only improve patient safety, but protect practitioners from unjustifiable claims. Finally, given the critical importance of experts in the above process, we believe that a system for professional registration and regulation should be explored to ensure that they offer accurate, representative, and unbiased opinions and have the appropriate expertise in the subject matter to be analysed.

Ultrasound-guided infraclavicular axillary vein cannulation: a useful alternative to the internal jugular vein.

BACKGROUND: Ultrasound (US) guidance reduces complications and increases accuracy during internal jugular vein (IJV) cannulation. The subclavian vein (SCV) is popular but is less amenable to US guidance. The axillary vein (AxV), a direct continuation of the SCV, is an alternative, but to date, experience with US is limited to small case series. METHODS: Retrospective procedural data were collected on 2586 sequential patients referred for insertion of tunnelled central venous access at a UK tertiary centre from 2004 to 2011. RESULTS: A total of 99.8% of patients tolerated the procedure with local anaesthesia ± sedation; six patients had general anaesthesia. Twenty-six (1%) patients had uncorrected coagulopathy or thrombocytopenia. A total of 2572 (99.5%) of patients were cannulated successfully: right AxV 1644 cases, left AxV 279, right IJV 547, left IJV 89, other techniques 13, and 14 (0.5%) cases failed. The initial site chosen was successful in 96%. In patients who previously underwent long-term cannulation, 93.3% of lines were sited easily. Forty-eight (1.9%) procedural complications occurred. CONCLUSIONS: In this large analysis of US-guided central venous access in a complex patient group, the majority of patients were cannulated successfully and safely. The subset of patients undergoing AxV cannulation demonstrated a low rate of complications. The AxV route of access appears to be a safe and effective alternative to the IJV.

Influenza A-induced rhabdomyolysis and acute kidney injury complicated by posterior reversible encephalopathy syndrome.

We report a case of Influenza A-induced rhabdomyolysis causing acute kidney injury in a young adult female who required invasive ventilation and renal replacement therapy. This case was further complicated by posterior reversible encephalopathy syndrome. Although this represents an extremely rare neurological complication of Influenza A infection, an appreciation of the condition and its management is important, given the high numbers of critically ill patients recently affected by H1N1 Influenza A in intensive care units in the UK.

Cost-effectiveness analysis of general anaesthesia versus local anaesthesia for carotid surgery (GALA Trial).

BACKGROUND: Health outcomes and costs are both important when deciding whether general (GA) or local (LA) anaesthesia should be used during carotid endarterectomy. The aim of this study was to assess the cost-effectiveness of carotid endarterectomy under LA or GA in patients with symptomatic or asymptomatic carotid stenosis for whom surgery was advised. METHODS: Using patient-level data from a large, multinational, randomized controlled trial (GALA Trial) time free from stroke, myocardial infarction or death, and costs incurred were evaluated. The cost-effectiveness outcome was incremental cost per day free from an event, within a time horizon of 30 days. RESULTS: A patient undergoing carotid endarterectomy under LA incurred fewer costs (mean difference pound178) and had a slightly longer event-free survival (difference 0.16 days, but the 95 per cent confidence limits around this estimate were wide) compared with a patient who had GA. Existing uncertainty did not have a significant impact on the decision to adopt LA, over a wide range of willingness-to-pay values. CONCLUSION: If cost-effectiveness was considered in the decision to adopt GA or LA for carotid endarterectomy, given the evidence provided by this study, LA is likely to be the favoured treatment for patients for whom either anaesthetic approach is clinically appropriate.

General anaesthesia versus local anaesthesia for carotid surgery (GALA): a multicentre, randomised controlled trial.

BACKGROUND: The effect of carotid endarterectomy in lowering the risk of stroke ipsilateral to severe atherosclerotic carotid-artery stenosis is offset by complications during or soon after surgery. We compared surgery under general anaesthesia with that under local anaesthesia because prediction and avoidance of perioperative strokes might be easier under local anaesthesia than under general anaesthesia. METHODS: We undertook a parallel group, multicentre, randomised controlled trial of 3526 patients with symptomatic or asymptomatic carotid stenosis from 95 centres in 24 countries. Participants were randomly assigned to surgery under general (n=1753) or local (n=1773) anaesthesia between June, 1999 and October, 2007. The primary outcome was the proportion of patients with stroke (including retinal infarction), myocardial infarction, or death between randomisation and 30 days after surgery. Analysis was by intention to treat. The trial is registered with Current Control Trials number ISRCTN00525237. FINDINGS: A primary outcome occurred in 84 (4.8%) patients assigned to surgery under general anaesthesia and 80 (4.5%) of those assigned to surgery under local anaesthesia; three events per 1000 treated were prevented with local anaesthesia (95% CI -11 to 17; risk ratio [RR] 0.94 [95% CI 0.70 to 1.27]). The two groups did not significantly differ for quality of life, length of hospital stay, or the primary outcome in the prespecified subgroups of age, contralateral carotid occlusion, and baseline surgical risk. INTERPRETATION: We have not shown a definite difference in outcomes between general and local anaesthesia for carotid surgery. The anaesthetist and surgeon, in consultation with the patient, should decide which anaesthetic technique to use on an individual basis. FUNDING: The Health Foundation (UK) and European Society of Vascular Surgery.

Dopexamine hydrochloride, a novel drug with renal vasodilator properties: two case studies.

Two patients who received an infusion of dopexamine hydrochloride are presented. The dopexamine infusion was associated with a useful increase in urine output. The mechanisms for these effects are discussed and the renovascular dilatation associated with dopexamine highlighted.

Carotid endarterectomy under local anaesthesia.

Carotid endarterectomy has been widely used for the surgical treatment of carotid stenosis, and may be performed under either general or local anaesthesia. This article examines the relative merits of both techniques for carotid endarterectomy, and describes the local anaesthetic technique used by the authors for this procedure.

The carina as a radiological landmark for central venous catheter tip position.

BACKGROUND: Many publications, including the instructions accompanying central venous catheters, state that it is negligent to site the catheter tip in the right atrium. If the catheter tip is above the carina on a post-procedure radiograph then it is generally accepted that the catheter lies outside the right atrium. It is also recommended that the catheter tip should lie in the long axis of the superior vena cava without acute abutment to the vein wall. We performed a retrospective audit of the position of central venous catheter tips on routine post-procedure chest radiographs in intensive care unit patients, to see if these potentially conflicting requirements had been met. METHODS: We identified 213 central venous catheters suitable for analysis, within a study population of 200 consecutive cases. We measured the distance of the central venous catheter tip above or below the carina and the angle of the central venous catheter tip to the vertical (a surrogate marker for the angle of abutment of the tip to the approximately vertical superior vena cava wall). RESULTS: For right-sided catheters there was a high (74/163) number placed with their tips below the carina, but a very low number (4/163) with their tips at a steep (>40 degrees ) angle to the vertical. For left-sided catheters very few (7/50) were placed with their tips below the carina, but for those 43 sited above the carina most could be considered to be in suboptimal positions. This was because they were either too high and had not even crossed the midline (9), or had an acute angle (>40 degrees ) between the tip and the vertical (27). CONCLUSIONS: We suggest that for left-sided catheters placement of the tip below the carina is more likely to result in a satisfactory placement.

Visualisation of needle position using ultrasonography.

Anaesthetists and intensivists spend a considerable proportion of their working time inserting needles and catheters into patients. In order to access deeper structures like central veins and nerves, they have traditionally relied on surface markings to guide the needle into the correct position. However, patients may present challenges due to anatomical abnormalities and size. Irrespective of the skill of the operator, there is the ever-present risk of needle misplacement with the potential of damage to structures like arteries, nerve bundles and pleura. Repeated attempts, even if ultimately successful, cause patient suffering and probably increase the risk of infection and other long term complications. Portable and affordable, high-resolution ultrasound scanners, has accelerated the interest in the use of ultrasound guidance for interventional procedures. Ultrasound guidance offers several advantages including a greater likelihood of success, fewer complications and less time spent on the procedure. Even if the target structure is identified correctly there is still the challenge to place the needle or other devices in the optimum site. The smaller and deeper the target, the greater the challenge and potential usefulness of ultrasound guidance. As a result of limited training in the use of ultrasound we believe that many clinicians fail to use it to its full potential. A lack of understanding, with regard to imaging the location of the needle tip remains a major obstacle. Needle visualisation and related topics form the basis for this review.

Percutaneous cervical pharyngostomy: a traditional technique revisited.

Enteral tube feeding is widely used in intensive care units, high dependency units and general wards. In some patients, an adequate intake is not maintained because patients cannot tolerate the tube. Insertion of an enteral feeding tube via a pharyngostomy is simple and potentially more easily tolerated. We describe our experience with three critically ill patients, using disposable vascular access equipment and a dilational technique. All three patients received markedly increased nutrition, but one patient suffered haemorrhagic complications.

A review of an anaesthetic led vascular access list.

The demand for insertion of long-term central venous (Hickman type) catheters is thought to be increasing. Organisation is required to meet this demand in a safe and efficient manner. This report reviews the results from a dedicated, anaesthetic led vascular access list over the initial 61-month period. One thousand procedures were performed. Nine hundred and twenty catheters were inserted under local anaesthesia, with or without intravenous sedation and analgesia. Eighty catheters were removed. All procedures were performed during a dedicated once weekly, morning list. A total of 53% of all procedures were performed on a day-case basis, 43% on in-patients. Only 1.5% of patients required an unexpected overnight stay (usually medically unfit patients). There were 81 (9%) cancellations on the day of procedure due to neutropaenia, pneumonia or urinary tract infections. Ultrasound guidance was used initially selectively in 14%, latterly in 100% of procedures and fluoroscopy in all insertions to confirm or adjust catheter position. This service has been well received by patients and oncology services. In addition it provides an interesting area of practice for anaesthetists and an ideal environment for teaching more advanced aspects of central venous access. It may provide a template of service for other centres.

Removal of obstructing blood clot from the lower airway: an alternative suction technique.

Clotted blood or organised thrombus in the lower airway may present clinicians with life-threatening airway obstruction or pulmonary collapse. An alternative suction technique is described, which applies suction directly to a tracheal tube.

MDMA induced hyperthermia: a survivor with an initial body temperature of 42.9 degrees C.

A young male survived hyperpyrexia (42.9 degrees C) following MDMA ("Ecstasy") ingestion. He developed convulsions, rhabdomyolysis, metabolic acidosis, and respiratory failure. This was successfully managed by assisted ventilation, aggressive fluid therapy, and the early administration of dantrolene, in addition to cooling measures. This is the first report of a survivor with such a severe hyperpyrexia.