Flying blind in anesthesia: a safety concern

We describe two cases of sudden loss of display of all the monitors of Zeus anesthesia work station during operation, which is a major safety concern. Flying blind in anesthesia could be devastating. These cases attempt to highlight the need for greater vigilance by anesthesiologists and have implications for improvement in technology

Anesthetic deaths in a developing country

It is important to ascertain the contribution of anesthesia to perioperative mortality in order to enable improvement in the safety and quality of care. Scanty literature regarding anesthetic mortality from developing countries is available. We present data regarding anesthesia related mortality in a university hospital in a developing country. We reviewed all patient deaths occurring between 1992-2003 occurring within 24 hours of anesthesia, as part of departmental quality assurance activity. The aim of study was to identify any contributing factors associated with mortality, and to compare our data with similar studies from developed and developing countries. 111, 289 cases were h and led in this period. Within 24 hours the crude mortality was 35 [3.14: 10,000]. 3 patients died at induction, 13 intraoperatively and one at emergence. In the postoperative period 18 [51%] cases of mortality occurred. In 4 [11%] cases anesthesia was found to be solely responsible [0.35 per 10,000], in 8 [23%] cases anesthesia was found to be partially responsible [0.7 per 10,000]. In 23 patient disease and surgical factors played a primary role. In 10 [28.5%] cases deaths were considered to be avoidable. Two time periods were also compared. Between 1992-1998 anesthesia mortality was 0.68: 10,000 anesthetics, and from 1999-2003 it was 0.18: 10,000 Higher mortality was observed with advancing age, higher ASA status, emergency and complex surgical procedures. Human factor, human error, inadequate preoperative preparation, inappropriate postoperative care and lack of supervision were identified as preventable factors

Estimation of blood loss during caesarean section: an audit

To evaluate the blood ordering practice and blood transfusion for Caesarean sections at our institution and to compare the estimated blood loss between anaesthetists and obstetricians. A review of 126 patients undergoing both elective and emergency Caesarean section was undertaken in 2002. Information collected included the number of blood units cross-matched preoperatively, type of surgery [emergency or elective], type of anaesthesia, parity of the patient, estimated blood loss by both anaesthetists and obstetricians, intraoperative and postoperative transfusion within 48 hours and pre and post operative haemoglobin [Hb] and haemocrit [Hct]. A total of 215 units were cross-matched for 126 patients undergoing Caesarean section delivery. A small amount [9.5%] were transfused intraoperatively and 5.5% postoperatively. The average blood loss estimated by anaesthetists was 498 +/- 176 ml and that by obstetricians was 592 ± 222 ml. The calculated blood loss based on patients blood volume and drop in Hct was 787 +/- 519 ml. The cross-match transfusion ratio was 9.7. Conclusion: Only 13% of our patients needed blood transfusion. The mean blood loss was estimated to be more by the obstetricians as compared to the anaesthetists. We recommend that the practice of routine cross-match practice prior to Caesarean section should be re-looked by institutions practicing obstetric anaesthesia

Diagnostic value of chest X-ray and echocardiography for cardiac tamponade in post cardiac surgery patients

To investigate the effectiveness of X-ray and echocardiography [ECHO] as a diagnostic tool for cardiac tamponade in adult cardiac surgery patients. Thirty five coronary artery bypass and graft surgery patients who developed cardiac tamponade at Cleveland clinic foundation, were included in this study. Their diagnosis was confirmed at the time of re-exploration in the operating room. These patients were followed retrospectively for demographics, X-ray and echocardiography findings. Abnormal and enlarged cardiac silhouette which was different from first postoperative X-ray was used as radiological criteria for tamponade while echocardiographic diagnosis was left to the discretion of cardiologist. Twenty four males [69%] and 11 [31%] females with an average age of 60.7 +/- 15.2 years were included in this study. Only 7 [20%] patients met our criteria for radiological diagnosis of tamponade. All 35 patients showed pericardial effusion on ECHO while cardiac tamponade was present in 30 [86%] patients. Tamponade developed on an average on 4th postoperative day. Radiological diagnosis of cardiac tamponade based on changes in cardiac silhouette provide limited information while ECHO is a reliable diagnostic tool when combined with clinical findings

Unplanned prolonged postanaesthesia care unit length of stay and factors affecting it

To identify the factors that prolong the length of stay in the post anaesthesia care unit [PACU]. This audit was conducted in the PACU of a university hospital. A special form was designed and filled for those patients who stayed unplanned in the PACU for more than two hours. All patients who were admitted to the PACU after surgery were included. Patients undergoing cardiothoracic surgery, those directly shifted to ICU and cases done under local anaesthesia were excluded. Data was collected for 20 months by a designated recovery nurse for all included patients including those admitted outside the scheduled surgery hours. The total number of patients who were admitted to the PACU during the audit period were 13644, out of these 1114 [8.1%] stayed in the PACU for more than 2 hours. The percentage of overstay patients on monthly basis ranged from 6.4% to 10%. The commonest reason was the need for postoperative monitoring 578 [51.8%], unavailability of beds in the special care areas 264 [23.7%], pain management 68 [6.1%] and 61 [5.4%] for postoperative ventilation. Our results show that majority of patients stayed in the PACU for more than two hours either because they needed postoperative monitoring or because of unavailability of bed in the special care areas

Standardization of anaesthesia ready time and reasons of delay in induction of anaesthesia

Anaesthesia-Ready Time [ART] is the time taken by the anaesthetist to provide sufficient anaesthetic depth for start of surgery. Our aim was to set benchmark timings for ART and compare it with our current practice. Benchmark ART time of 15 minutes was set for American Society of Anesthesiologists [ASA] class I and II patients, 30 minutes for ASA III and IV patients, 20 minutes for spinal and 30 minutes for epidural anaesthesia. An additional 15 minutes was added for each invasive procedure. Three hundred elective cases were audited. Seventy eight percent of the cases were within benchmark timings. The main causes of delay included undergraduate students performing procedures [24.6%], teaching invasive lines to postgraduates [21.3%] and paediatric patients [16.4%]. The introduction of benchmark timings and its regular auditing can help standardize operating room booking time and reducing patient cost

Unanticipated hospital admission after andbulatory surgery

The unplanned admission rate is considered to be an important measure of the quality of ambulatory surgical units. The objective of our study was to evaluate the unanticipated hospital admission rate from the Surgical Day Care [SDC] unit of our university affiliated teaching hospital and to analyze the reasons for admission. A review of all unanticipated admissions over a one-year period was done. The admission rate was calculated and the reasons for admission were analysed. The overall admission rate was 4.93%. Most of the admissions were ordered by the surgeons [97%]. The main reasons for admission were patient observation indicated for various reasons [72%] and patient request [18%]. Eighty percent of the admitted patients had received general anaesthesia. Admissions were also related to the male gender [69%], age over 65 years [27%] and surgeries ending in the afternoon [69%]. On analyzing the reasons for admission, a large number of admissions were found to be due to preventable causes. We conclude that proper selection of patients, careful scheduling of lists and education of patients and clinical professionals can help to avoid many unanticipated admissions after day care surgical procedures