Anaesthesiologists' views on the need for point-of-care information system in the operating room: a survey of the European Society of Anaesthesiologists.

BACKGROUND AND OBJECTIVE: In this preliminary study we wanted to explore the attitudes of anaesthesiologists to a point-of-care information system in the operating room. The study was conducted as a preliminary step in the process of developing such a system by the European Society of Anaesthesiologists (ESA). METHODS: A questionnaire was distributed to all 2240 attendees of the ESA's annual meeting in Gothenburg, Sweden, which took place in April 2001. RESULTS: Of the 329 responders (response rate of 14.6%), 79% were qualified specialists with more than 10 yr of experience (68%), mostly from Western Europe. Most responders admitted to regularly experiencing lack of medical knowledge relating to real-time patient care at least once a month (74%) or at least once a week (46%), and 39% admitted to having made errors during anaesthesia due to lack of medical information that can be otherwise found in a handbook. The choice ofa less optimal but more familiar approach to patient management due to lack of knowledge was reported by 37%. Eighty-eight percent of responders believe that having a point-of-care information system for the anaesthesiologists in the operating room is either important or very important. CONCLUSIONS: This preliminary survey demonstrates that lack of knowledge of anaesthesiologists may be a significant source of medical errors in the operating room, and suggests that a point-of-care information system for the anaesthesiologist may be of value.

Dental mirror for difficult nasotracheal intubation.

A patient with a previous surgical history of a cleft lip and palate repair and a pharyngeal flap pharyngoplasty was admitted for repair of mandibular prognathism. Following induction of anaesthesia, it was impossible to advance the nasotracheal tube into the oropharynx. Using a dental mirror and retrograde tracheal intubation equipment, under direct vision, the nasotracheal tube was finally advanced into the oropharynx.

Patient data management systems in anaesthesia: an emerging technology.

The purpose of this review is to define the expectations of an on-line automatic patient data management system (PDMS) into anaesthesia work-stations in and around the operating room suite. These expectations are based on review of available information in the medical literature, and trials of several systems that are available commercially, three of them in a more detailed fashion (i.e. Informatics, Datex and North American Drager). The ideal PDMS should: -- communicate with and capture the information from different monitors, anaesthesia machines and electronic gadgets (e.g., infusion pumps) used in the operating room (OR), while presenting selected relevant values and trends on a screen. -- inform the anaesthetist of deviations from preselected limits of physiological and technical values. In the future, the system will hopefully be upgraded to include an algorithm-based decision support system. -- communicate with the hospital mainframe computer, and automatically transfer demographic data, laboratory and imaging results, and records obtained during preoperative consultations. -- at the end of each anaesthetic procedure, create an anaesthetic record with relevant data automatically collected by the system, as well as that which was entered manually by the physician during the procedure. A copy of this anaesthesia file must be kept on a computerized archive system. None of the systems so far evaluated fulfilled all our expectations. We have therefore adopted approach for the gradual introduction of such a system into our OR environment over the next two to five years, during which expected improvements may be incorporated to upgrade the system.

[Fentanyl vs alfentanil anesthesia for in vitro fertilization].

In a prospective double-blind study, 36 women undergoing ultrasonically guided oocyte retrieval for in vitro fertilization (IVF) were examined. Anesthesia in 19 was based on alfentanil, up to 0.025 mg/kg and in 17, fentanyl, 0.0025 mg/kg. There were no significant differences between groups with regard to age, weight, duration of procedure and pregnancy rate. There were no complications aside from nausea and vomiting. Amnesia for the puncture and analgesia were always perfect. Induction was significantly shorter for alfentanil, 1.3 +/- 0.7 min, than for fentanyl, 3.4 +/- 2.2 (p less than 0.01). All who received fentanyl were drowsy at the end of the procedure, while those in the alfentanil group were fully awake and able to move from operating table to stretcher with minimal help. We therefore recommend alfentanil as the base for anesthesia for IVF.

Ventriculosubgaleal shunt: an effective CSF drainage in shunt disconnection.

A 4-year-old girl with a right ventriculoperitoneal shunt presented with a huge subcutaneous fluid collection in the scalp on the right side. There were no neurological symptoms or signs. On CT, a normal-sized ventricular system was seen. The shunt was disconnected distal to the antisiphon device and transmitted fluid into a subgaleal collection, which functioned as a reservoir for excess fluid. The ability of the subgaleal space to serve as a reservoir for cerebrospinal fluid is discussed.

Aspiration in caesarean section successfully treated with high continuous positive airway pressure (CPAP).

A case of aspiration pneumonitis during Caesarean section is described. The patient was treated with high-level continuous positive airway pressure (CPAP) resulting in marked improvement and discharge from the Intensive Care Unit 44 hours after the aspiration had occurred.

Observations on extradural morphine analgesia in various pain conditions.

We report the extradural administration of low-dose morphine in 10 ml of 10% dextrose (2-3 mg) to 98 adult patients with various types of acute and chronic pain. Extradural morphine injections were given either via a Tuohy needle (single or repeat injection) or via an extradural catheter. Pain relief was evaluated by subjective scoring and by the subsequent need for systemic analgesics. In 56% of patients, pain relief was considered good or excellent, in 24% it was fair, and in 20%, poor. The best results were after surgery and trauma and in patients with advanced peripheral vascular disease. The analgesia of each dose of extradural morphine lasted for 8 h (mean range 4-36 h). There was no motor, sensory or sympathetic blockade and no respiratory or haemodynamic complications. Dizziness and vomiting occurred in two patients, and urinary retention for about 12 h in three.

Intermittent mandatory ventilation during anaesthesia using the Manley Servovent ventilator.

The lungs of 25 patients were ventilated with intermittent mandatory ventilation (IMV) during anaesthesia using the Manley Servovent Model MS. This ventilatory mode is especially suitable for prolonged operations in which there is no need for muscle relaxation. While incorporating the advantages of spontaneous and mechanical ventilation, it is superior to both in selected cases. The Manley Servovent Model MS ventilator is capable of delivering IMV without modification, using a single source of gas.

The variable effect of PEEP in acute respiratory failure associated with multiple trauma.

Both short and longterm effects of positive end-expiratory pressure (PEEP) on oxygenating capacity (OC) were investigated in three groups of patients with acute respiratory failure following multiple trauma (MT). Group A consisted of six patients with "uncomplicated" MT; Group B, eight patients with MT and generalized sepsis; Group C, nine patients with MT and lung contusion. OC was evaluated in terms of PaO2/FIO2 and P(A-a)DO2 on FIO 2 = 1.0. OC was markedly and equally reduced in the three patient groups before use of PEEP. The use of a mean PEEP of 6-7 cm H2O resulted in an initial improvement in mean PaO2/FIO2 of 152.5, 36.1, and 59.2 mm Hg, and an overall improvement of 196.8, 57.5, and 107.0 mm Hg in Groups A, B, and C, respectively. There was a similar improvement in both the initial and the overall effect of PEEP on P(A-a)DO2 in the three groups. The difference in the improvement in OC due to PEEP was statistically significant between Groups A and B. It is concluded that acute respiratory failure following MT includes a wide spectrum of clinical syndromes, and that the improvement in OCT due to PEEP depends on the clinical sydrome that is responsible for the respiratory failure associated with MT.

Collapse of endotracheal tubes due to overinflation of high-compliance cuffs.

Overinflation of endotraceal-tube cuffs may seriously compromise the patient's airway, due to collapse of the wall of the endotracheal tube. Two case reports describe this complication, with x-ray demonstration of the hyperinflated cuffs.

The effect of PEEP on oxygenating capacity in acute respiratory failure with sepsis.

We report an evaluation of the effect of postive-end-expiratory-pressure (PEEP) on improving pulmonary oxygenating capacity in the adult respiratory distress syndrome (ARDS), when the latter is associated with generalized gram-negative sepsis. Fifty-seven cases treated in our RICU with PEEP ventilation (April 1972 to January 1975) were retrospectively reviewed. Oxygenating capacity improvement was evaluated in terms of the changes in PaO2/FIO2 and AaDO2 (FIO2 = 1.0). Both the short term (2-3 hours from the initiation of PEEP) and the overall effects of PEEP were evaluated. A mean PEEP of 5.6 cm H2O initially increased PaO2/FIO2 by a mean of 94 torr and decreased AaDO2 (FIO2 = 1.0) by 105 torr in the 28 nonseptic patients. In the 29 septic patients, 5.1 cm H2O PEEP initially increased PaO2/FIO2 by 32 torr and decreased AsDO2 (FIO2 = 1.0) by 38 torr. The differences between the septic and nonseptic patients were statistically significant (P less than 0.001). Likewise, the long-term effect of similar levels of PEEP was in increasing PaO2/FIO2 by 142 torr and by 75 torr in the nonseptic and septic patients, respectively. The final reduction in AaDO2 (FIO2 = 1.0) was 163 torr and 87 torr in the nonseptic and septic patients, respectively. These differences between patient groups were also statistically significant (P less than 0.02). Mortality during PEEP was 15/29 and 3/28 in the septic and nonseptic patients, respectively. Overall mortality in the septic and nonseptic groups was 18/29 and 5/28, respectively. We conclude that ARDS with sepsis constitutes a more severe pulmonary insult than ARDS without sepsis, and/or that generalized sepsis creates a more prolonged pulmonary insult that makes it less amenable to PEEP. Thus, high levels of PEEP may be needed to treat ARDS associated with sepsis.