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

Intraoperative awareness - a three year prospective study using bispectral index monitor [BIS]

Patients who experience awareness under surgery may suffer from the post-traumatic stress disorder [PTSD] with its long-lasting psychological damage. In addition, there are also media attention and legal consequences. In spite of understanding its causes, it is still occurring worldwide. This prospective study was conducted to determine the incidence of awareness using the bispectral index monitor [BIS] when its causes are eliminated. There were 2328 patients admitted to the study. Their ages ranged from 14-104 yr [mean 38.6 yr]. All patients were interviewed in the postoperative period. There was no report of awareness during the course of surgery. Pre-and intraoperative anesthetic attention to patients presented for surgery, together with the use of modern anesthetic delivery units possessing facilities for monitoring BIS, and anesthetic gases, and the provision of good analgesia, are the most important combination in eliminating awareness during surgery

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

Postintubation tracheal damage: a four year prospective study

A 4-year prospective study was undertaken to estimate the incidence and identify the pathogenesis of cuff-induced major tracheal damage. All tracheal tubes were implantation tested and the cuffs were of the high- volume low-pressure type. The cuff pressure was continuously monitored and maintained below 3kPa. During the period of the study, 684 patients were intubated. Their average age was 33.6 years [range 14-96].The average intubation period was 9.3 days [range 1-256]. At first, the damage was diagnosed clinically, radiologically and then confirmed by computed tomography. Three patients [0.4%] developed lesions that were not related to excessive [CP]. In this study CP control seems to have eliminated a known major cause of intubation-associated tracheal injury. To date, there is no alternative to tracheal intubation. However the laryngeal mask seems ideal if invasion of the trachea is to be avoided altogether

Incidence of pulmonary embolism in total knee arthroplasty

The end-tidal carbon dioxide concentration [ETCO2] of 47 patients undergoing prosthetic knee operations was monitored to detect pulmonary embolism during the arthroplasties. The ETCO2 of one patient dropped suddenly following the release of the tourniquet and insertion of the bone cement. Intracardiac aspiration did not reveal any air. At autopsy there was massive pulmonary thromboembolism and the deep veins of the right leg contained old formed thrombi. Patients undergoing such procedures should be investigated to exclude the presence of deep vein thrombosis so that measures to prevent pulmonary thromboembolism must be taken well in advance. As regards the occurence of air embolism it is believed that insertion of the bone cement is the most important single factor in the prevention of air embolism during knee arthroplasty

Disseminated intravascular coagulopathy diagnosed by computed tomography

A 24-year-old man was brought to casualty after a fall. He suffered from head injury and multiple fractures. On arrival he was apneic and the heart was at a standstill. Resuscitation was successful and the patient was taken to the CT room to assess the extent of his head trauma. At the end of the procedure, maintaining adequate ventilation proved to be very difficult; the blood pressure was rapidly falling and the ECG showed severe bradycardia. Asystole followed and resuscitation was unsuccessful. Postmortem CT scanning of the chest revealed that the tracheobronchial tree was flooded with blood and coagulation profile showed the picture of disseminated intravascular coagulopathy. CT may be useful in the diagnosis of some pathological conditions when autopsy is difficult to perform

Mortality in the surgical intensive care unit

Study of admissions to the surgical intensive care unit [SICU] at King Khalid University Hospital in Riyadh was carried out from 1982 to 1987. There were 1149 surgical admissions, of whom 96 patients died [mortality rate 8.3%]. Eighty-six patients died of multi system and organ failure [MSOF]. Sepsis appeared to be the ultimate cause of death in 54 patients of the organ failure group [62.8%]. Twenty four% of this group had positive blood cultures, and 57% had more than one positive culture site. Gram-negative bacilli and gram-positive cocci were the predominant organisms with only two positive anaerobic cultures. In this study the risk for developing sepsis starts at the age of 50, otherwise our data confirm previous studies on the influence of sepsis and MSOF on mortality in SICU. Recommendations for future improvement in patient's care and investment in antibiotic research are made