Post-tonsillectomy hemorrhage. Monopolar microdissection needle versus cold dissection

To compare the rate, severity, need for intervention, and blood transfusion requirement in post-tonsillectomy bleeding following the use of either cold dissection or the monopolar microdissection needle method. A prospective randomized study conducted at Abha Private Hospital, Abha, Kingdom of Saudi Arabia, on patients undergoing tonsillectomy between June 2006 and December 2010. Patients were allocated randomly by using cold dissection or monopolar microdissection techniques. Collected information included demographic data, method, duration of surgery, and estimated blood loss. Timing of bleeding and management were recorded. A total of 1419 patients underwent tonsillectomy, 634 male and 785 female with mean age of 14.8 years [range 2-48 years]. Cold dissection was used in 674 patients and monopolar microdissection needle in 745 patients. Mean surgical time in the cold dissection group was 7 minutes [range 3.5-15 minutes], while in the monopolar microdissection group was 3.2 minutes [range 2.2-9.5 minutes]. Twenty-seven patients developed post-tonsillectomy bleeding [rate of 1.9%]; 21 [3.1%] from the cold dissection and 6 [0.8%] from the monopolar microdissection group, [p<0.001]. All patients were hospitalized. Eleven patients; 9 from the cold dissection group and 2 following monopolar microdissection, underwent surgical intervention to stop bleeding. No patient received blood transfusion. Patients underwent tonsillectomy using the monopolar microdissection [Colorado needle] had statistically significant less post-tonsillectomy bleeding rate and severity compared with those using the cold dissection method

Inadvertent endobronchial intubation: a sentinel event

Unintentional bronchial intubation may result in serious complications such as lung collapse or pneumothorax. These complications amount to sentinel events should be reported, and a hospital sentinel event policy should be implemented, including corrective actions to prevent recurrence. A 12-month prospective observational study in a multidisciplinary adult intensive care unit [ICU] to estimate the frequency of inadvertent bronchial intubation and its major sequels in intubated patients admitted to the unit. Complications will be reported as sentinel events attracting investigation by root cause analysis method, action plan, and follow-up. There were 36 [12.9%] cases of inadvertent bronchial intubations in 279 orally-intubated patients admitted to the ICU during the study period [1.5.2010 - 30.4.2011], 2 [0.7%] of them already developed total left lung collapse. The hospital sentinel event policy was activated followed by action plan, which included raising the awareness of the problem, presentations, and regular checking on the position of the tube following tracheal intubation at different location in the hospital. Early detection and correction of endobronchial intubation will prevent complications developing. Applying sentinel event policy on complications of inadvertent bronchial intubation will encourage finding permanent solution to an old and preventable problem. Anesthetic and resuscitative regulatory bodies should incorporate methods of checking on correct position of tracheal tubes in their training programs. Knowing that the tube may advance into a bronchus, they should insist on regular checking of the tube in a manner similar to monitoring patient's vital signs

Benchmarking inadvertent perioperative hypothermia guidelines with the National Institute for Health and Clinical Excellence

To improve standards of patients' care and safety, we benchmarked our practice guidelines of prevention of inadvertent perioperative hypothermia with those of the National Institute for Health and Clinical Excellence [NICE] of the United Kingdom. The study started in November 2008 and lasted for 18 months and was conducted at the Armed Forces Hospital, Wadi Al-Dawasir, Kingdom of Saudi Arabia. The NICE clinical guidelines [CG65] published in April 2008 were downloaded from its website. Each practiced item in our guidelines was compared with its equivalent of NICE guidelines, absent equivalent NICE guidelines on our list were immediately added and implemented. To ensure compliance, follow-up audits took place every 3 months for an 18-month period. Benchmarking demonstrated that most steps taken in our hospital match those of NICE guidelines, except for guidelines governing the preoperative phase. This phase was added to our policy and procedures guidelines and immediately implemented. The follow-up audits carried out every 3 months showed that the incidence of hypothermia fell from a previous 1.5 to 0.3%. Benchmarking is an evaluation of the current position of own practice compared to best practice to identify areas and means of performance improvement. Benchmarking must be part of quality improvement programs in healthcare. In this study, improvement in the service delivered to patients resulted in a drop in the incidence of inadvertent perioperative hypothermia

Incidence of perioperative cardiac arrest: analysis of anesthetics over 18-year period

Several studies have surveyed perioperative cardiac arrests and their outcomes, regardless of whether patients were successfully resuscitated or died. No such studies have originated from the Kingdom of Saudi Arabia. This is a study of perioperative cardiac arrests and their outcome in a Saudi General Hospital, over an 18-year period. Armed Forces Hospital, Wadi Al-Dawasir, Kingdom of Saudi Arabia, serves military personnel and their families, in addition to eligible civilian members of the community. Operating theaters' records were examined to collect details of patients who underwent some form of surgical procedure since the commission of the Hospital on 12.07.1992 up until 30.09.2010. Those surgical cases were traced in the Medical Records Department and the outcome of each case was reviewed. The numbers and causes of cardiac arrests and death occurring during the intraoperative and within the first postoperative 24 hours, were noted. There were 15,832 patients received anesthesia during the 18-year period. Five patients died during this period [an incidence of 0.03%], all were emergency cases and were due to non-anesthetic causes; four of them died intraoperatively and the fifth died within the first 24 hour postoperatively. There were 5 non-anesthetic deaths in the perioperative period during the 18-year period. The absence of anesthesia-related cardiac arrests in such patient population has demonstrated that adopting quality improvement measures, teamwork approach and applying strict, but updated and evidence-based, guidelines are essential in the prevention of such catastrophes. A multicentre similar survey is needed to include all types of surgical operations

Benchmarking of World Health Organization surgical safety checklist

To compare the quality of our services with the World Health Organization [WHO] surgical safety recommendations as a reference, to improve our services if they fall short of that of the WHO, and to publish our additional standards, so that they may be included in future revision of WHO checklist. We conducted this study on 15th July 2008 at the Armed Forces Hospital, Wadi Al-Dawasir, Kingdom of Saudi Arabia. We compared each WHO safety standard item with its corresponding standard in our checklist. There were 4 possibilities for the comparison: that our performance meet, was less than or exceeded the quality-of-care measures in the WHO checklist, or that there are additional safety measures in either checklist that need to be considered by each party. Since its introduction in 1997, our checklist was applied to 11828 patients and resulted in error-free outcomes. Benchmarking proved that our surgical safety performance does not only match the standards of the WHO surgical safety checklist, but also exceeds it in other safety areas [for example measures to prevent perioperative hypothermia and venous thromboembolism]. Benchmarking is a continuous quality improvement process aimed at providing the best available at the time in healthcare, and we recommend its adoption by healthcare providers. The WHO surgical safety checklist is a bold step in the right direction towards safer surgical outcomes. Feedback from other medical establishments should be encouraged

Intubation-induced tracheal stenosis - the urgent need for permanent solution

The most common site for the occurrence of intubation-induced tracheal damage is at the area in contact with the inflatable cuff. After the change from high-pressure to low-pressure cuffs, major tracheal lesions still continue to occur. This is a case of tracheal stenosis that occurred after 7 days of intubation with standard cuffed tube whose cuff pressure was assessed by subjective means. Three weeks later, patient was in need of reintubation, the trachea was found to be stenotic at the site of the previous tube cuff. Emergency tracheostomy had to be performed and computed axial tomography [CT] confirmed the tracheal stenosis. A month later, the patient had another cardiac arrest from which he did not recover. Our message in this report is to throw light and alert clinicians involved in tracheal intubation, of the presence of the Lanz endotracheal tube whose pilot balloon is designed to automatically regulate the intra-cuff pressure and thus prevent the occurrence of tracheal stenosis due to high pressure. We strongly recommend the presence of Lanz tracheal tubes as standard emergency equipment in intensive care settings and in any situation in which cuff pressure is likely to increase

Incidence of intraoperative hypothermia: adopting protocol for its prevention

To determine the incidence of hypothermia during surgical procedures when adequate methods of preserving normothermia are applied. A prospective study in which patients ASA I-IV presented for surgery at the Armed Forces Hospital, Wadi Al-Dawasir, Kingdom of Saudi Arabia during the period from July 2000 until February 2003, in whom body core temperature was between 35-37 degree, were included. Ambient temperature of the operating room was thermostatically adjusted to record 26 degree and 24 degree if patients were less than 10 year-old or above. Depending on type of surgery; the patients were provided with space blankets and were lying on warm mattresses. Fluid or blood warmers and forced-air surface warming were used when needed. There were 3886 surgical patients operated upon during the period of the study. Their average age was 34.5 years [range 15 days to 104 years]. Sixty patients [1.54%] developed intraoperative hypothermia [core temperature <35oC] and were admitted to the intensive care unit for monitoring and gradual rewarming. There was no mortality amongst them. Out of those 60 patients, 17 [28.3%] expressed dissatisfaction on this part of the service, but the overall patient's satisfaction scored 99.6%. Aggressive measures must be adopted to preserve normothermia as prevention of intraoperative hypothermia improves patient's outcome. All patients should have their core body temperature monitored during surgery. However, application of available methods of keeping normothermia reduces the incidence of intraoperative hypothermia but does not abolish it completely. Hypothermic patients should be closely monitored during gradual rewarming, preferably in the intensive care setting. A protocol for prevention of intraoperative hypothermia must be adopted by all operating theaters

Awareness during surgery

Patients who experience awareness under surgery may suffer from the post-traumatic stress disorder with its long-lasting psychological damage. Furthermore, there are also media attention and legal consequences. In spite of understanding its causes, it is still occurring worldwide and there are no reports of awareness in the Saudi medical literature. This prospective study was conducted to determine the incidence of awareness when its causes are eliminated and to record patient satisfaction. Surgical patients >4 years old [ASA I-III] admitted to the Armed Forces Hospital, Wadi Al-Dawasir, Kingdom of Saudi Arabia, between October 1998 and November 2002 were included in the study. Patients were given a premedicant with an amnesic effect. Anesthetic equipment with a built-in end-tidal anesthetic gas monitor was checked preoperatively. Minimal anesthetic concentrations of vapors were delivered and monitored. Intraoperative analgesia was provided whenever appropriate. Patients were closely observed for signs of intraoperative awareness under general anesthesia. All patients were interviewed within 24 hours postoperatively on the occurrence of awareness and service satisfaction. There were 4368 patients admitted to the study. Their ages ranged from 14-104 years [mean 40.2 years]. All patients were interviewed in the postoperative period. There was no report of awareness during surgery and patient satisfaction score was 100%. Preoperative and intraoperative anesthetic attention to patients presented for surgery, together with the use of modern anesthetic delivery units possessing facilities for monitoring anesthetic gases, and the provision of good analgesia are the most important combination in eliminating awareness during surgery