Patient-reported safety incidents as a new source of patient safety data: an exploratory comparative study in an acute hospital in England.

Objectives To compare a new co-designed, patient incident reporting tool with three established methods of detecting patient safety incidents and identify if the same incidents are recorded across methods. Method Trained research staff collected data from inpatients in nine wards in one university teaching hospital during their stay. Those classified as patient safety incidents were retained. We then searched for patient safety incidents in the corresponding patient case notes, staff incident reports and reports to the Patient Advice and Liaison Service specific to the study wards. Results In the nine wards, 329 patients were recruited to the study, of which 77 provided 155 patient reports. From these, 68 patient safety incidents were identified. Eight of these were also identified from case note review, five were also identified in incident reports, and two were also found in the records of a local Patient Advice and Liaison Service. Reports of patients covered a range of events from their immediate environment, involving different health professionals and spanning the entire spectrum of care. Conclusion Patient safety incidents reported by patients are unlikely to be found through other established methods of incident detection. When hospitalized patients are asked about their care, they can provide a unique perspective on patient safety. Co-designed, real-time reporting could be a helpful addition to existing methods of gathering patient safety intelligence.

Ultrasound-guided Transversus Abdominis plane block versus continuous wound infusion for post-caesarean analgesia: a randomized trial.

OBJECTIVE: To compare the analgesic effect of ultrasound-guided Transversus Abdominis Plane (TAP) block versus Continuous Wound Infusion (CWI) with levobupivacaine after caesarean delivery. METHODS: We recruited parturients undergoing elective caesareans for this multicenter study. Following written informed consent, they received a spinal anaesthetic without intrathecal morphine for their caesarean section. The postoperative analgesia was randomized to either a bilateral ultrasound guided TAP block (levobupivicaine = 150 mg) or a CWI through an elastomeric pump for 48 hours (levobupivacaine = 150 mg the first day and 12.5 mg/h thereafter). Every woman received regular analgesics along with oral morphine if required. The primary outcome was comparison of the 48-hour area under the curve (AUC) pain scores. Secondary outcomes included morphine consumption, adverse events, and persistent pain one month postoperatively. RESULTS: Recruitment of 120 women was planned but the study was prematurely terminated due to the occurrence of generalized seizures in one patient of the TAP group. By then, 36 patients with TAP and 29 with CWI had completed the study. AUC of pain at rest and during mobilization were not significantly different: 50 [22.5-80] in TAP versus 50 [27.5-130] in CWI (P = 0.4) and 190 [130-240] versus 160 [112.5-247.5] (P = 0.5), respectively. Morphine consumption (0 [0-20] mg in the TAP group and 10 [0-32.5] mg in the CWI group (P = 0.09)) and persistent pain at one month were similar in both groups (respectively 29.6% and 26.6% (P = 0.73)). CONCLUSION: In cases of morphine-free spinal anesthesia for cesarean delivery, no difference between TAP block and CWI for postoperative analgesia was suggested. TAP block may induce seizures in this specific context. Consequently, such a technique after a caesarean section cannot be recommended. TRIAL REGISTRATION: ClinicalTrials.gov NCT01151943.

Mentorship for newly appointed consultants: what makes it work?

BACKGROUND: Mentorship has been identified as a beneficial practice for doctors and may be particularly valuable for newly appointed consultants. It is associated with a number of potential clinical and non-clinical gains, such as enhanced job satisfaction and well-being. Despite strong support, many formalised schemes fail to launch or gain momentum. Research to date has largely focused on the gains associated with mentorship but has lacked study of the factors that facilitate uptake and maintenance of mentoring relationships by physicians. OBJECTIVES: To explore perceptions of mentorship, the extent to which UK doctors appear to value mentorship and factors that may contribute to its successful use. DESIGN: Qualitative, descriptive, multi-centre study. SAMPLE: 30 doctors including registrars, those newly appointed to consultant grade, senior doctors and medical leaders from nine hospitals in the north of England. METHOD: Semistructured individual interviews were undertaken between August and December 2013. RESULTS: Findings revealed a demand for mentorship for new consultants, with widely recognised benefits associated with its use. Several factors were identified as critical to successful mentorship relationships, including consistent understanding and expectations of mentorship between mentee and mentor, positive prior experiences, a suitable match between mentee and mentor, making time for people to act as mentors and the ensuring that mentors can meet a diverse and changing set of needs. CONCLUSIONS: Mentorship for newly appointed consultants is valued, but current models of mentorship may suffer from rigid structures, mismatched expectations of participants and the absence of a culture of mentorship from training into practice. A social network approach, in which doctors have the opportunity to engage with a range of mentors through informal and naturally occurring relationships, may be one way to encourage successful and sustained mentoring relationships among doctors. An organisational culture in which mentorship is permitted and is the norm may enable such approaches to be widely adopted.

Convulsions in 2 patients after bilateral ultrasound-guided transversus abdominis plane blocks for cesarean analgesia.

OBJECTIVE: Transversus abdominis plane (TAP) block is commonly used for postcesarean section analgesia and compares favorably with other systemic and regional analgesia techniques. No major complications of ultrasound-guided TAP block have previously been reported in this indication. We report 2 cases of systemic local anesthetic toxicity in this context leading to seizures and treated with lipid emulsion. CASE REPORT: The first event occurred 10 minutes after ultrasound-guided bilateral injections, each consisting of 20 mL of levobupivacaine 3.75 mg/mL. Two episodes of tonic-clonic seizure required resuscitation measures and 200 mL of lipid emulsion. The second case 25 minutes after a 20-mL bilateral injection of ropivacaine 7.5 mg/mL. One generalized tonic-clonic seizure required bag-mask ventilation and 250 mL of lipid emulsion. In both cases, patients were successfully treated and fully recovered. CONCLUSIONS: These cases cast a cautionary note for the use of TAP blocks after cesarean delivery. The risk of systemic local anesthetic toxicity after this procedure remains unknown in this population and plasma concentration of local anesthetics should be measured in case of suspected toxicity. To limit this risk, a low concentration of local anesthetic solution should be chosen when a "20 mL bilaterally" regimen is necessary to achieve the required spread for a successful block.

Dexmedetomidine reduces propofol and remifentanil requirements during bispectral index-guided closed-loop anesthesia: a double-blind, placebo-controlled trial.

BACKGROUND: The α2-adrenergic agonist dexmedetomidine is a sedative and can be used as an adjunct to anesthetics. Our primary goal was thus to determine the extent to which dexmedetomidine reduces the requirement for propofol and remifentanil. METHODS: This double-blinded, randomized study (NCT00921284) used an automated dual closed-loop administration to maintain the Bispectral Index between 40 and 60. Sixty-6 ASA physical status I and II patients were given either dexmedetomidine (1 µg/kg over 10 minutes followed by a continuous infusion of 0.5 µg/kg/h throughout surgery) or comparable volumes of saline as a placebo. Propofol and remifentanil requirements were compared using nonparametric tests and expressed as medians (interquartile ranges). RESULTS: Twenty-eight patients in each group completed the study. Patients given dexmedetomidine required less propofol (1.0 [0.7-1.3] vs 1.3 [1.0-1.7] mg/kg, P = 0.002) and remifentanil (1.2 [1.0-1.4] vs 1.6 [1.1-2.8] µg/kg, P = 0.02) for anesthetic induction. The propofol dosage required for anesthetic maintenance was 29% (with a 95% confidence interval, 18-40) lower in patients given dexmedetomidine (2.2 [1.5-3.0] vs 3.1 [2.4-4.5] mg/kg/h, P = 0.005), whereas the remifentanil dosage was not significantly different (0.16 [0.09-0.17] vs 0.14 [0.13-0.21] µg/kg/h with P = 0.3). The incidence of adverse events, including hemodynamic instability and delayed recovery, was comparable with and without dexmedetomidine. The first postoperative request for morphine analgesia was delayed in patients given dexmedetomidine (median fourth hour vs first hour, P = 0.008). CONCLUSIONS: Dexmedetomidine administration significantly reduced the requirement for both propofol and remifentanil during anesthetic induction and reduced propofol use during maintenance of anesthesia. Dexmedetomidine also delayed postoperative analgesic use. Dexmedetomidine is a useful adjuvant that reduces anesthetic requirement and provides postoperative analgesia.

Ultrasound and neurostimulation-guided axillary brachial plexus block for resection of a hemodialysis fistula aneurysm.

An ASA III patient presenting with a voluminous hemodialysis fistula aneurysm at the elbow was scheduled for its resection. Axillary brachial plexus block was performed under ultrasound and neurostimulation guidance. Despite unexpected nerve positions in relation to pathological vascular anatomy, this combined approach resulted in an adequate block with a low volume of local anesthetic, without obvious vascular puncture or intraneural injection.

A comparison of the deflecting-tip bronchial blocker with a wire-guided blocker or left-sided double-lumen tube.

OBJECTIVE: To compare a new bronchial blocker, the Cohen blocker, with the Arndt blocker and a left double-lumen tube (DLT). DESIGN: A prospective, randomized, controlled trial. SETTING: University hospital. PARTICIPANTS: Forty-eight patients undergoing lung surgery. INTERVENTION: Intubation with 1 of the 3 devices. Comparisons among groups included (1) time for initial positioning, (2) degree of lung collapse at pleura opening, and (3) number of intraoperative fiberoptic examinations. MEASUREMENTS AND MAIN RESULTS: Positioning of the Cohen blocker (256 [166-341] seconds; median [interquartile range]) took no longer compared with the Arndt blocker (253 [184-305] seconds), and there was a trend toward difference between the 2 blockers and the DLT (137 [102-199] seconds) (p = 0.07). The time to place the Cohen blocker was longer in cases of left bronchus occlusion compared with a right one (340 [300-450] v 170 [124-259] seconds, p = 0.02); they were similar in the Arndt group. The degree of lung collapse was different among groups (p = 0.05), but the difference between any pair did not reach statistical significance. The number of patients who required at least 1 additional FOB examination was not statistically different (50% of patients in each blocker group v 19% in the DLT group). CONCLUSIONS: There was a trend toward a difference between times to place a bronchial blocker and the DLT. The Cohen blocker is more difficult to position in the left main bronchus than in the right one.

Combined ultrasound and neurostimulation guidance for popliteal sciatic nerve block: a prospective, randomized comparison with neurostimulation alone.

BACKGROUND: Ultrasound imaging, an effective tool to localize peripheral nerves, may facilitate block performance. However, its usefulness during popliteal sciatic nerve block has not been assessed. METHODS: In this prospective, randomized, patient-blinded study, we compared the block time (as the primary end-point) of a popliteal sciatic nerve block with double-injection performed using anatomical landmarks and neurostimulation (NS group; n = 30) versus combined ultrasound and neurostimulation guidance (US-NS group; n = 30). Each block procedure was performed by a single operator. Correct needle placement was defined by a minimal stimulating current < or = 0.5 mA, or, in the US-NS group, by mobilization of the nerve by the needle shaft even if the minimal stimulating current > 0.5 mA. Ten milliliter levobupivacaine 0.5% was administered separately on the tibial and common peroneal nerves without needle adjustment to improve the spread of anesthetic in the US-NS group. All procedures were video-recorded, and a maximum of 7 min was allowed to perform the block. Successful block was defined as complete loss of cold sensation in the sciatic distribution and an inability to perform a plantar and dorsal flexion of the foot at 30 min. RESULTS: Five patients in the NS group and three in US-NS group were excluded from the study for prolonged procedure. Block time was not significantly different between groups. The number of needle passes was lower only for the detection of the first nerve in the US-NS group (1 [1-2] vs 2 [1-6]; P < 0.01). A greater success rate was observed at 30 min in the US-NS group (65% vs 16%; P < 0.001). CONCLUSIONS: Combined ultrasound and neurostimulation guidance does not decrease block time but increases the success rate of popliteal sciatic nerve block observed at 30 min.

The comparability of bispectral index and state entropy index during maintenance of sufentanil-sevoflurane-nitrous oxide anesthesia.

BACKGROUND: Manufacturers recommend maintaining Bispectral (BIS) or Spectral Entropy (State Entropy, SE) indexes between 40 and 60 during the maintenance of anesthesia. We compared these indexes during this period. METHODS: Data were obtained from 58 patients receiving sufentanil-sevoflurane-nitrous oxide anesthesia. The anesthesiologist was blinded to BIS and SE. Artifact-free concurrent BIS and SE values (7792 pairs), automatically recorded at 1-min intervals, were compared using Bland-Altman analysis, Kappa coefficient for agreement and crude proportion of agreement. The occurrence of errors of judgment (Type 1 defined as one parameter <40 and the other >60, or Type 2 defined as BIS and SE values on different sides of a threshold [40 or 60]) was also counted. RESULTS: Bias was -2 with limits of agreement of -18 and 9. Kappa BIS/SE obtained from all patients was 0.537 +/- 0.147; crude agreement >0.80 was observed in 45% of patients. Type 1 number of errors of judgment corresponded to two instances. Median and interquartile values of Type 2 number of errors of judgment were 4.5 [3.0-6.0] when considering a difference between BIS and SE more than 5. CONCLUSION: Although limits of agreement between BIS and SE were large, Kappa value moderate, and crude agreement <0.80 in more than half of the patients, making completely contradictory decisions (e.g., deepening the anesthetic based on one parameter and lightening it based upon the other) would have been exceptional. More common would have been a risk of error between no change versus increasing or decreasing anesthetic depth.

Neurologic dysfunction after major thoracic surgery in a patient with severe arteriosclerotic disease receiving epidural analgesia.

We present a patient who underwent pulmonary lobectomy with thoracic epidural analgesia and developed postoperative sensory-motor symptoms of the lower limbs. Radiological investigation indicated ischemia of the conus medullaris as the likely cause. The motor deficit disappeared gradually and the patient was mobilizing independently when discharged on postoperative day 21.

Does monitoring bispectral index or spectral entropy reduce sevoflurane use?

A decrease in volatile anesthetic consumption has been demonstrated using bispectral index (BIS), whereas data concerning spectral entropy are lacking. One hundred and forty adult patients scheduled for surgical procedures lasting more than 1 h were prospectively randomized to receive an anesthetic controlled either by BIS or by spectral entropy or solely by clinical variables. Anesthesia was induced with propofol and sufentanil. Sufentanil was infused continuously thereafter. Sevoflurane was administered in 1 L/min O2/N2O. The sevoflurane concentration was adjusted according to conventional clinical variables in the standard practice group, whereas the 40-60 interval was applied for the BIS and spectral entropy-guided groups. The sevoflurane vaporizer was weighed before and after anesthesia, and consumption was calculated. Groups were comparable for demographic data except for weight (heavier in the spectral entropy-guided group, P < 0.05). Compared with standard practice, patients with BIS or spectral entropy monitoring required 29% less sevoflurane (normalized sevoflurane consumption to the weights of the patients and to the durations of anesthesia; both P < 0.03) and a similar sufentanil dose. An unintended improvement in the standard practice group (positive bias) was observed. In conclusion, BIS and spectral entropy monitoring have the same sparing effect of sevoflurane.

Measurement of left mainstem bronchus using multiplane CT reconstructions and relationship between patient characteristics or tracheal diameters and left bronchial diameters.

STUDY OBJECTIVES: To measure the tracheal diameters (TDs) [transverse (Tr) TD, and anteroposterior (AP) TD] and left main bronchus diameters (LBDs) [Tr and AP] using multiplane CT scan reconstructions with a tridimensional correction of the declination. To evaluate the relationship between clinical variables and CT scan diameters of the tracheobronchial tree. To aid in the selection of a double-lumen tube of appropriate size. DESIGN: Prospective observational study. SETTING: Private and university hospitals. PATIENTS: A total of 206 patients (105 women and 101 men) undergoing a CT scan for medical investigations or preoperative evaluation. INTERVENTION: No intervention. MEASUREMENTS AND RESULTS: TDs and LBDs are greater in men (p < 0.001). The Tr-TD is smaller than AP-TD for men (p < 0.001). The Tr-LBD is greater than AP-LBD in both sexes (p < 0.001). In men, height, Tr-TD, and AP-TD are predictive factors for Tr-LBD, while Tr-TD and AP-TD are the only predictive factors for AP-LBD. In women, Tr-TD and AP-TD are the only predictive factors for Tr-LBD and AP-LBD. The smallest LBD (ie, the lesser of the Tr-LBD or the AP-LBD [called the smallest LBD]) is the Tr-LBD in 25.2% of the cases. The mean (+/- SD) ratio of the smallest LBD/Tr-TD is 0.70 +/- 0.14 for men and 0.65 +/- 0.12 for women. The estimated (Est) LBD is calculated using this ratio. The mean value for Est-LBD minus the smallest LBD is 1.6 +/- 1.3 mm, and this difference is < 1 mm in 40% of male patients and 39% of female patients. CONCLUSIONS: In conclusion, the left main bronchus is most often elliptic, and the smallest LBD cannot be accurately evaluated using patient characteristics or a ratio from TD.

Titration of propofol for anesthetic induction and maintenance guided by the bispectral index: closed-loop versus manual control: a prospective, randomized, multicenter study.

BACKGROUND: This report describes a closed-loop titration of propofol target control infusion based on a proportional-differential algorithm guided by the Bispectral Index (BIS) allowing induction and maintenance of general anesthesia and compares this to manual propofol target control infusion. METHODS: One hundred sixty-four patients scheduled to undergo elective minor or major surgery were prospectively randomized in a multicenter study into the closed-loop (n = 83) or manual target control infusion group (n = 81). The goal was to reach a BIS target of 50 during induction and to maintain it between 40 and 60 during maintenance. For both groups, remifentanil target control infusion was adjusted manually, and ventilation was without nitrous oxide. RESULTS: Closed-loop control was able to provide anesthesia induction and maintenance for all patients. During induction, propofol consumption was lower in the closed-loop group (1.4 +/- 0.5 vs. 1.8 +/- 0.6 mg/kg; P < 0.0001), but the duration was longer (320 +/- 125 vs. 271 +/- 120 s; P < 0.0002). Adequate anesthesia maintenance, defined as the BIS in the range of 40-60, was significantly higher in the closed-loop group (89 +/- 9 vs. 70 +/- 21%; P < 0.0001), with a decrease of the occurrence of BIS less than 40 (8 +/- 8 vs. 26 +/- 22%; P < 0.0001). Time from discontinuation of propofol infusion to tracheal extubation was shorter in the closed-loop group (7 +/- 4 vs. 10 +/- 7 min; P < 0.017). Unwanted somatic events and hemodynamic instability were similar. CONCLUSION: Automatic control of consciousness using the BIS is clinically feasible and outperforms manual control.