Retrospective analysis of cases of intraoperative awareness in a large multi-hospital health system reported in the early postoperative period.

BACKGROUND: Awareness with recall under general anesthesia remains a rare but important issue that warrants further study. METHODS: We present a series of seven cases of awareness that were identified from provider-reported adverse event data from the electronic anesthesia records of 647,000 general anesthetics. RESULTS: The low number of identified cases suggests an under-reporting bias. Themes that emerge from this small series can serve as important reminders to anesthesia providers to ensure delivery of an adequate anesthetic for each patient. Commonalities between a majority of our identified anesthetic awareness cases include: obesity, use of total intravenous anesthesia, use of neuromuscular blockade, and either a lack of processed electroencephalogram (EEG) monitoring or documented high depth of consciousness index values. An interesting phenomenon was observed in one case, where adequately-dosed anesthesia was delivered without technical issue, processed EEG monitoring was employed, and the index value suggested an adequate depth of consciousness throughout the case. CONCLUSIONS: Provider-reported adverse event data in the immediate post-operative period are likely insensitive for detecting cases of intraoperative awareness. Though causation cannot firmly be established from our data, themes identified in this series of cases of awareness with recall under general anesthesia provide important reminders for anesthesia providers to maintain vigilance in monitoring depth and dose of anesthesia, particularly with total intravenous anesthesia.

Refractory Sexual Arousal Subsequent to Sacral Neuromodulation.

BACKGROUND: Sacral neuromodulation has become a widely used treatment for lower urinary tract symptom and dysfunction. It has been observed to benefit sexual function in the domains of arousal and desire. Studies have yet to report markedly increased arousal symptoms as an adverse effect. CASE: We present the case of a 57-year-old woman who developed symptomatic persistent genital arousal following implantation of a neuromodulator. Despite device reprogramming, a trial of the device being shut off, and eventual device removal, she continued to have residual new-onset undesired genital hyper-arousal symptoms. CONCLUSION: Our patient demonstrated markedly increased and persistent arousal symptoms that may be the result of upregulated or alternative activation of sacral nerve pathways. While other case reports describe improvement in persistent genital arousal disorder symptoms through neuromodulation, no studies mention hyperarousal symptoms as an adverse side effect after sacral neuromodulator placement nor persistence despite removal of the implant.

Three-Hour Bundle Compliance and Outcomes in Patients With Undiagnosed Severe Sepsis.

BACKGROUND: The aim of this study was to compare completion of the Surviving Sepsis Campaign 3-hour treatment recommendations and patient-centered outcomes between patients with severe sepsis who received a sepsis-specific diagnosis code with those who did not. METHODS: This was a retrospective cohort analysis of adult patients admitted through an academic medical center ED who received an antibiotic and met criteria for severe sepsis. We measured and compared the Surviving Sepsis Campaign 3-hour treatment recommendations along with patient-centered outcomes in patients who were diagnosed with severe sepsis and those who were not. RESULTS: A total of 5,631 patients were identified (60.6 ± 17.2 years of age; 48.9% women). Less than half (32.8%) received an International Classification of Diseases, ninth revision, diagnosis code of 995.92. Completion of all four bundle components in < 3 hours was low for all patients (8.72%). Therapeutic components (a broad-spectrum antibiotic and IV fluids) were completed more often (31.3%). Those with a diagnosis code received all four bundle components (10.2% vs 7.9%; P < .005), as well as therapeutic components at a higher frequency (36.0% vs 29.0%; P < .001). Patients with a diagnosis code had higher mortality (6.3% vs 2.3%), more frequent ICU admissions (44.7% vs 22.5%), and longer hospitalizations (9.2 ± 6.9 days vs 6.9 ± 6.7 days) than did patients with severe sepsis with no diagnosis code (all P < .001). CONCLUSIONS: Severe sepsis continues to be an underdiagnosed and undertreated condition. Patients who were diagnosed had higher treatment rates yet experienced worse outcomes. Continued investigation is needed to identify factors contributing to diagnosis, treatment, and outcomes in patients with severe sepsis.

Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients.

OBJECTIVES: To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock. DESIGN: Retrospective cohort. SETTING: Six hundred fifty-six bed urban academic medical center. PATIENTS: Emergency department patients greater than or equal to 18 years old with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded. INTERVENTIONS: Not available. MEASUREMENTS AND MAIN RESULTS: We identified 3,929 severe sepsis patients, with overall mortality 12.8%. Nine hundred eighty-four patients (25.0%) progressed to septic shock. The median time to antimicrobial was 3.77 hours (interquartile range = 1.96-6.42) in those who progressed versus 2.76 hours (interquartile range = 1.60-4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (odds ratio = 1.18; 95% CI, 1.01-1.36), Charlson Comorbidity Index (odds ratio = 1.18; 95% CI, 1.11-1.27), number of infections (odds ratio = 1.05; 95% CI, 1.02-1.08), and time to first antimicrobial (odds ratio = 1.08; 95% CI, 1.06-1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad-spectrum antimicrobial was associated with progression (odds ratio = 1.06; 95% CI, 1.05-1.08). Time to initial antimicrobial was also associated with in-hospital mortality (odds ratio = 1.05; 95% CI, 1.03-1.07). CONCLUSIONS: This study emphasizes the importance of early, broad-spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.