Utstein registration used as a tool in organisational development.

OBJECTIVE: To evaluate the results of out-of-hospital CPR in a county after seven independent local EMS organisations were merged into one, and to evaluate the use of Utstein registration as a tool in the reorganisation process. MATERIALS AND METHODS: All out-of-hospital cardiac arrests in Ostfold county in which the EMS system was responded to in 1997 were registered according to the Utstein template. The results were reported back to the EMS personnel and presented to the media. RESULTS: Of 163 cardiac arrests of cardiac origin where CPR was attempted, 59% received bystander CPR. 13% were discharged from hospital alive (9.1/100 000 inhabitants), 32% of those with VF/VT. At discharge 18 of 22 patients functioned normally with cerebral performance category 1 and Overall performance category 1. The media had previously been very critical of the decision to centralise the emergency services. There was large media coverage when the results were presented, and criticism virtually disappeared. The registration and presentation appeared to create a feeling of unity among the EMS personnel. CONCLUSIONS: The Utstein registration functioned well as a tool both internally and externally in an EMS reorganisation process.

[Causes and risk factors of intraoperative anesthesia complications. A prospective study of 14,735 anesthesias]. / Arsaker og risikofaktorer ved peroperative anestesiproblemer. En prospektiv studie av 14,735 anestesier.

Identification of risk factors is an essential part of our efforts to minimize problems during anesthesia. 14,735 patients were included in a prospective study in order to assess the magnitude of risk and identify risk factors. The rate of complications increased substantially after the age of 40, due mainly to a large number of patients with poor preoperative physical condition. High age in itself was not associated with increased risk of complications. Contrary to former belief, the maintenance period of anesthesia does represent a considerable risk of complications requiring emergency intervention by an anesthesiologist. The complications were related to the conduct of anaesthesia in 70% of the total number of cases and to poor physical status and the surgery in 30%. However, poor physical condition and the surgery were responsible for 50% of the very serious complications and for all the four deaths on the table. The results of the survey confirm that thorough preoperative preparation of the patient is extremely important in order to reduce intraoperative risk, especially in emergency surgery.

[Registration of problems during anesthesia. Analysis of risk factors and quality control]. / Registrering av problemer under anestesi. Risikoanalyse og kvalitetskontroll.

Society continues to increase its demands on the medical profession in regard to quality. We believe this situation should be met by a more systematic approach to risk evaluation and quality assessment of our work. We report an attempt to establish a routine system for recording complications during anesthesia. We included all 14,735 patients who were anesthetized during one year. Data on preoperative disease, type of anesthesia and operation, and problems encountered during anesthesia were recorded on the routine anesthesia chart. An arbitrary scale from 1-3 indicated the severity of the problem. Postoperatively, data from each patient were fed into a personal computer. The system is feasible in a busy clinical setting. Key problems are work discipline, exact criteria for complications, and quality control of anesthesia charts. 655 problems were recorded in 599 patients. 80 problems were very serious. Problems such as drop in blood pressure, intubation, laryngeal spasm and cardiac arrhythmias dominated. Such registration increases awareness for the safety of the patients, and enables us to assess the risk and evaluate the quality of our work. The system is now an integral part of the department's routine.

A study of risk evaluation and quality control in anaesthesia.

Because the community expects increasingly high standards of medical performance, there is every reason for meticulous recording of the problems which can arise during one's work. The aim must be to quantify risks, identify problem areas and create an instrument to facilitate quality control and the analysis of critical events. In the course of one calendar year, problems occurring in all 14,735 patients who underwent anaesthesia in a regional hospital were recorded systematically, classified as to their degree of severity, and entered alongside relevant patient data into individual anaesthesia records; following operation, the information was fed into a data base. The system proved to work well in a heavily committed anaesthesia unit. The main methodological difficulties lay in acquiring the necessary discipline, applying consistently the definitions of complications and controlling data. In all 655 problems were registered in 599 patients, 80 of these being severe; among the most prominent were hypotension, difficulties with intubation, cardiac arrhythmias and laryngeal spasm. Such a system of registration promotes increased alertness to questions of patient safety. Registration of problems is now integrated into the unit's permanent routines.

Total intravenous anaesthesia with midazolam and flumazenil in outpatient clinics. A comparison with isoflurane or thiopentone.

Total intravenous anaesthesia with midazolam and alfentanil, reversed with the benzodiazepine antagonist flumazenil, was studied in patients admitted for outpatient gynaecological dilatation and curettage. One hundred patients were randomly allocated to four groups with different anaesthetic techniques: I: alfentanil and thiopentone induction, 66% N2O maintenance; II: alfentanil and midazolam sedation prior to isoflurane and N2O induction and maintenance; III: midazolam and alfentanil induction; oxygen/air, placebo reversal; IV: midazolam and alfentanil induction, oxygen/air, flumazenil reversal. All methods of anaesthesia proved satisfactory with no serious side-effects or complications. Induction was faster in Group I (26 s) compared with Group III and IV (37-38 s) and Group I (62 s). Respiration was less depressed in Group II compared with the other groups. Recovery function was better in Group IV during the first 30 postoperative min and worse in Group III during the first 120 postoperative min compared with the other groups. Reduced performances in P-deletion and 4-choice reaction-time tests in the midazolam patients were not reversed by 0.5 mg flumazenil, suggesting that flumazenil did not antagonize all benzodiazepine effects in our patients. Postoperative amnesia was most pronounced in Group III. There was no significant difference in patient function 7 h postoperatively, at home in the evening or during the next days. We conclude that total intravenous anaesthesia with alfentanil and midazolam with flumazenil reversal is a promising technique for short outpatient anaesthetic procedures.

The extent of stress-protection after plate osteosynthesis in the human tibia.

The extent of stress-protection was investigated in 12 patients with previous tibial fractures treated by steel plate fixation. They were examined by computed tomography (CT) scanning one or two days after plate removal. The cortical density and thickness were determined by the CT scans. In the previously plated segment, a significant reduction in cortical density was found, and the reduction was most pronounced in the quadrant directly beneath the plate. The osteopenia did not increase with increasing duration of plate application in excess of one year. No significant differences in cortical thickness between plated and control tibiae occurred. The results indicate that stress-shielding after rigid plating in the human tibia is less pronounced than that previously reported from experimental studies in animals.

Bone atrophy after plate fixation. Computed tomography of femoral shaft fractures.

Twelve patients with previous femoral shaft fracture treated by rigid plate fixation were examined by computed tomography (CT) scanning 1 or 2 days after plate removal. In the previously plated segment an average reduction in cortical density of 11 per cent was found, and the reduction was most pronounced in the cortex directly beneath the plate. No reduction in cortical thickness of the plated bone occurred. Proximal and distal to the site of the plate, and in the ipsilateral tibial shaft, a slight reduction in cortical density and thickness averaging 2-3 per cent was found.

Long-term therapy with sustained-release theophylline.

Twenty patients with partially reversible bronchial obstruction due to chronic obstructive lung disease participated in a study comparing serum levels, clinical and side-effects of a sustained-release formulation of theophylline with placebo. Prior to the study, theophylline dosages were individually adjusted to give serum levels of 55 to 75 mumol/l 4 hours after tablet intake. Theophylline or placebo was then administered every 12 hours with crossover after 6 weeks. During the study, patients were examined in the morning every second week and lung function tests carried out before and after salbutamol inhalation. Doses required to achieve the desired serum concentration showed great inter-individual variations, but the obtained levels were stable during the whole study. Lung function tests were significantly better in the theophylline period. After inhalation of salbutamol, values were also better in the theophylline period but the differences were less marked and of no statistical significance. Subjective improvement from theophylline was not observed. Side-effects reported were mild and caused no withdrawals.