Incidence, causes, and management of failed awake fibreoptic intubation-A retrospective study of 833 procedures.

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.

Why babies die in unplanned out-of-institution births: an enquiry into perinatal deaths in Norway 1999-2013.

INTRODUCTION: The aims were to describe causes of death associated with unplanned out-of-institution births, and to study whether they could be prevented. MATERIAL AND METHODS: Retrospective population-based observational study based on data from the Medical Birth Registry of Norway and medical records. Between 1 January 1999 and 31 December 2013, 69 perinatal deaths among 6027 unplanned out-of-institution births, whether unplanned at home, during transportation, or unspecified, were selected for enquiry. Hospital records were investigated and cases classified according to Causes of Death and Associated Conditions. RESULTS: 63 cases were reviewed. There were 25 (40%) antepartum deaths, 10 (16%) intrapartum deaths, and 24 neonatal (38%) deaths. Four cases were in the unknown death category (6%). Both gestational age and birthweight followed a bimodal distribution with modes at 24 and 38 weeks and 750 and 3400 g, respectively. The most common main cause of death was infection (n = 14, 22%), neonatal (n = 14, 22%, nine due to extreme prematurity) and placental (n = 12, 19%, seven placental abruptions). There were 86 associated conditions, most commonly perinatal (n = 32), placental (n = 15) and maternal (n = 14). Further classification revealed that the largest subgroup was associated perinatal conditions/sub-optimal care, involving 25 cases (40%), most commonly due to sub-optimal maternal use of available care (n = 14, 22%). CONCLUSIONS: Infections, neonatal, and placental causes accounted for almost two-thirds of perinatal mortality associated with unplanned out-of-institution births in Norway. Sub-optimal maternal use of available care was found in more than one-fifth of cases.

Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient.

BACKGROUND: Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs. METHODS: All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients' records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs. RESULTS: A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4-66.4) minutes and in the OR 98.2 (94.6-101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844). CONCLUSIONS: VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.

Characteristics and outcome of unplanned out-of-institution births in Norway from 1999 to 2013: a cross-sectional study.

OBJECTIVE: To study the incidence, maternal characteristics and outcome of unplanned out-of-institution births (= unplanned births) in Norway. DESIGN: Register-based cross-sectional study. POPULATION: All births in Norway (n = 892 137) from 1999 to 2013 with gestational age ≥22 weeks. METHODS: Analysis of data from the Medical Birth Registry of Norway from 1999 to 2013. Unplanned births (n = 6062) were compared with all other births (reference group). RESULTS: The annual incidence rate of unplanned births was 6.8/1000 births and remained stable during the period of study. Young multiparous women residing in remote municipalities were at the highest risk of experiencing unplanned births. The unplanned birth group had higher perinatal mortality rate for the period, 11.4/1000 compared with 4.9/1000 for the reference group (incidence rate ratio 2.31, 95% confidence interval 1.82-2.93, p < 0.001). Annual perinatal mortality rate for unplanned births did not change significantly (p = 0.80) but declined on average by 3% per year in the reference group (p < 0.001). The unplanned birth group had a lower proportion of live births in all birthweight categories. Live born neonates with a birthweight of 750-999 g in the unplanned birth group had a more than five times higher mortality rate during the first week of life, compared with reference births in the same birthweight category. CONCLUSIONS: Unplanned births are associated with adverse outcome. Excessive mortality is possibly caused by reduced availability of necessary medical interventions for vulnerable newborns out-of-hospital.

Impact of changed management policies on operating room efficiency.

BACKGROUND: To increase operating room (OR) efficiency, a new resource allocation strategy, a new policy for patient urgency classification, and a new system for OR booking was implemented at a tertiary referral hospital. We investigated the impact of these interventions. METHODS: We carried out a before-and-after study using OR data. A total of 23,515 elective (planned) and non-elective (unplanned) orthopaedic and general surgeries were conducted during calendar year 2007 (period 1) and July 2008 to July 2009 (period 2). The Wilcoxon-Mann-Whitney test was used to calculate statistical significance. RESULTS: An increased amount of case time (7.1%, p < 0.05) was conducted without any increase in out-of-hours case time. Despite having three fewer ORs for electives, slightly more elective case time was handled with 26% less use of overtime (p < 0.05). Mean OR utilization was 56% for the 17 mixed ORs, 60% for the 14 elective ORs, and 62% for the 3 dedicated ORs. A 20% growth (p < 0.05) of non-elective case time was primarily absorbed through enhanced daytime surgery, which increased over 48% (p < 0.05). As a result, the proportions of case time on evenings and nights decreased. Specifically, case time at night decreased by 26% (p < 0.05), and the number of nights without surgery increased from 55 to 112 (out of 315 and 316, respectively). Median waiting time for the middle urgencies increased with 1.2 hours, but over 90% received treatment within maximum acceptable waiting time (MAWT) in both periods. Median waiting time for the lowest urgencies was reduced with 12 hours, and the proportion of cases treated within MAWT increased from 70% to 89%. The proportion of high urgency patients (as a proportion of the total) was reduced from 20% to 12%. Consequently, almost 90% of the operations could be planned at least 24 hours in advance. CONCLUSIONS: The redesign facilitated effective daytime surgery and a more selective use of the ORs for high urgency patients out of hours. The synergistic effect probably exceeded the sum of the individual effects of the changes, because the effects of each intervention facilitated the successful implementation of others.

How do we know that we are doing a good job - can we measure the quality of our work?

There is an increasing demand for systems for measuring the quality of our medical work. In this article, we present a suggestion for how one can attempt to do this in a department of anaesthesia. It would be desirable to measure real clinical outcomes such as morbidity and mortality. However, such events are rare and not suitable for routine recording of work quality. Instead, we propose a system based on indicators of process quality and surrogate clinical outcomes. Surrogates may provide useful information if chosen carefully and checked for validity. We further suggest that such indicators be recorded routinely on every anaesthesia chart. The rate of the indicator can then be followed over time with the use of statistical process control methods. The foundation for such a system for measuring quality is the presence of a good quality culture in the department, with a good team spirit, communication and cooperation.

[Risk in anaesthesia]. / Risiko ved anestesi.

BACKGROUND: Modern anaesthesia is still associated with a risk of serious complications. This article focuses on frequency, causes, and prevention of the most important anaesthetic complications. MATERIAL AND METHODS: The article is based on literature identified through a non-systematic search in Pub-Med, and the author's research and experience in this field. RESULTS: The risk of death associated with anaesthesia is closely related to patient age and physical status. In otherwise healthy patients (ASA 1), the risk of such deaths is approximately 1:250 000. Medication errors occur in approximately 1:1 000 anaesthetic procedures. The risk of awareness during general anaesthesia is approximately 1:650. Neural injury from epidural and spinal anaesthesia is rare, even more so in obstetrics. Anaphylaxis caused by muscle relaxant drugs is more common in Norway than in many other industrialized countries. Pulmonary aspiration occurs in approximately 1:7 000 anaesthetic procedures, but with low morbidity in healthy patients. The incidence of anaesthetic accidents is higher in infants than older children, and requires special competence. Serious anaesthetic complications are most often related to the cardiovascular and respiratory system. The complications are often multicausal, and human errors and organizational factors contribute in 50-70 % of the cases. INTERPRETATION: Optimization of the patient's preoperative health is important to improve safety. The focus of the anaesthesiology department should be education and guidelines. Systems and routines for improved safety must also take into account that human and organizational factors may cause anaesthetic accidents.

[Paediatric intensive care]. / Intensivmedisinsk behandling av barn.

BACKGROUND: Child physiology and disease is not the same as in adults, which implies different challenges within intensive care. The aim of this review article is to shed light on special diagnostic and therapeutic problems in paediatric intensive care. MATERIAL AND METHODS: The review is based on literature identified through a non-systematic search in PubMed, and on the authors' own clinical experience. RESULTS: Common causes for admitting children to intensive care units are head injuries; septic shock and respiratory failure. Perfusion-directed therapy of severe traumatic head injuries is well recognized, but optimal age-appropriate cut-off values have yet to be defined for cerebral perfusion pressure and intracranial pressure. Therapeutic hypothermia is still controversial and the latest study concludes against this option. Paediatric septic shock is usually caused by low cardiac output, and dopamine or adrenaline are the most suitable agents for pharmacological circulation support, in contradiction to treatment in adults for whom noradrenaline is the preferred vasopressor because of dominating vasoplegia. Activated protein C is not recommended in children. Non-invasive pressure ventilation is used increasingly in children with respiratory failure. The authors have experienced that this reduces the need for intubation, but it has not been documented in studies. Development of tolerance, withdrawal symptoms and physical dependency are substantial clinical problems in long-term sedation and analgesic treatment of children, and are associated with high doses and long duration of infusions. INTERPRETATION: Paediatric intensive care is different from that in adults. Therapy is more based on experience than evidence from well-designed clinical studies.

Statistical process control methods allow the analysis and improvement of anesthesia care.

PURPOSE: Quality aspects of the anesthetic process are reflected in the rate of intraoperative adverse events. The purpose of this report is to illustrate how the quality of the anesthesia process can be analyzed using statistical process control methods, and exemplify how this analysis can be used for quality improvement. METHODS: We prospectively recorded anesthesia-related data from all anesthetics for five years. The data included intraoperative adverse events, which were graded into four levels, according to severity. We selected four adverse events, representing important quality and safety aspects, for statistical process control analysis. These were: inadequate regional anesthesia, difficult emergence from general anesthesia, intubation difficulties and drug errors. We analyzed the underlying process using 'p-charts' for statistical process control. RESULTS: In 65,170 anesthetics we recorded adverse events in 18.3%; mostly of lesser severity. Control charts were used to define statistically the predictable normal variation in problem rate, and then used as a basis for analysis of the selected problems with the following results: Inadequate plexus anesthesia: stable process, but unacceptably high failure rate; Difficult emergence: unstable process, because of quality improvement efforts; Intubation difficulties: stable process, rate acceptable; Medication errors: methodology not suited because of low rate of errors. CONCLUSION: By applying statistical process control methods to the analysis of adverse events, we have exemplified how this allows us to determine if a process is stable, whether an intervention is required, and if quality improvement efforts have the desired effect.

The reliability of endtidal CO2 in spontaneously breathing children during anaesthesia with laryngeal mask airway, low flow, sevoflurane and caudal epidural.

BACKGROUND: Noninvasive devices for monitoring endtidal CO2 (PECO2) are in common use in paediatric anaesthesia. Questions have been raised concerning the reliability of these devices in spontaneous breathing children during surgery. Our anaesthetic technique for elective infraumbilical surgery consists of spontaneous breathing through a Laryngeal Mask Airway (LMA), low fresh gas flow, sevoflurane and a caudal epidural. We wanted to compare PECO2 and arterial CO2 (PaCO2) during surgery. METHODS: Twenty children, aged 1-6 years, scheduled for infraumbilical surgery, were studied and one arterial sample was taken 45 min after induction of anaesthesia. PECO2, inspiratory PCO2, oxygen saturation, heart rate, respiratory rate, mean arterial blood pressure and expiratory sevoflurane concentration were measured every 5 min. The respiratory and circulatory parameters were stable during surgery. RESULTS: The mean PaCO2 - PECO2 difference was 0.15 (0.16) kPa [1.1 (1.2 mmHg)]. CONCLUSIONS: PECO2 is a good indicator of PaCO2 in our anaesthetic setting.

[Serious intraoperative problems--a five-year review of 83,844 anesthetics].

PURPOSE: The low incidence of mortality and major morbidity in anesthesia makes it difficult to study the pattern of potential accidents and to develop preventive strategies. Anesthetic 'near-misses', however, occur more frequently. Using data from a simple routine-based system of problem reporting, we have analyzed the pattern and causes of serious non-fatal problems, in order to improve preventive strategies. METHODS: We prospectively recorded anesthesia-related information from all anesthetics for five years. The data included intraoperative problems, which were graded into four levels, according to severity. We analyzed only the serious nonfatal problems, which were sorted according to clinical presentation, and also according to which factor was most important in the development of the problem. We assessed any untoward consequences for the patient, and whether the problems could have been prevented. RESULTS: Serious problems were recorded in 315 cases out of 83,844 (0.4%). Anesthesia was considered the major contributing factor in 111 cases. Difficult intubation, difficult emergence from general anesthesia, allergic reactions, arrhythmia and hypotension were the dominating problems. Twenty-six anesthesia related problems resulted in changes in level of postoperative care, and one patient later died in the intensive care unit after anaphylactic shock. Eighty-two problems could have been prevented by simple strategies. CONCLUSION: Analysis of serious nonfatal problems during anesthesia may contribute to improved preventive strategies. Data from a routine-based system are suitable for this type of analysis. Intubation, emergence, arrhythmia, hypotension and anaphylaxis cause most serious problems, and should be the object of preventive strategies.