Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.37 million anaesthetic procedures.

BACKGROUND: Improved anaesthesia safety has made severe anaesthesia-related incidents, complications, and deaths rare events, but concern about morbidity and mortality in anaesthesia continues. This study examines possible severe adverse outcomes or death recorded in a large national surveillance system based on a core data set (CDS). METHODS: Cases from 1999 to 2010 were filtered from the CDS database. Cases were defined as elective patients classified as ASA physical status grades I and II (without relevant risk factors) resulting in death or serious complication. Four experts reviewed the cases to determine anaesthetic involvement. RESULTS: Of 1 374 678 otherwise healthy, ASA I and II patients in the CDS database, 36 met the study inclusion criteria resulting in a death or serious complication rate of 26.2 per million [95% confidence interval (CI), 19.4-34.6] procedures, and for those with possible direct anaesthetic involvement, 7.3 per million cases (95% CI, 3.9-12.3). CONCLUSIONS: This is the first study assessing severe incidents and complications from a national outcome-tracking database. Annual identification and review of cases, perhaps with standardized database queries in the respective departments, might provide more detailed information about the cascades that lead to unfortunate outcomes.

[Anesthesiological considerations for patients with trisomy 21 (Down syndrome)]. / Anästhesiologische Besonderheiten der Trisomie 21 (Down-Syndrom).

The most common chromosomal abnormality is trisomy 21 which is also known as Down syndrome and occurs in approximately 1 in 800 births. The majority of the resulting disabling conditions cannot be cured and affect people of all ages, ethnicity and economic levels. Life expectancy has increased with advances in medical care in the same way as in the rest of the population. One of the major tasks for health care professionals is to help these differently abled children and their families function in the most effective way possible as they learn to accept the limitations imposed by a persistent disability. Signs and symptoms of trisomy 21 are very variable based on the trias of mental retardation to a variable degree, hand anomalies and cardiac complications. Other abnormalities are atlantoaxial instability (AAI), tracheal stenosis, a predisposition to respiratory complications, chronic hypothyroidism, microgenia and macroglossia. These conditions are relevant to anesthetic procedures and patients with Down syndrome and their families have specific expectations and attitudes towards medical and anesthetic treatment.

Veno-venous extracorporeal membrane oxygenation (ECMO) support during anaesthesia for oesophagectomy.

The use of extracorporeal membrane oxygenation in adults has increased in popularity and importance for the support of patients with cardiac or pulmonary failure. Although it is now quite commonly used in the intensive care unit, its use has rarely been described as a means of support during anaesthesia and surgery. We report the case of a patient who required curative resection of the oesophagus following previous left pneumonectomy where veno-venous extracorporeal membrane oxygenation was required both during surgery and for the first three days postoperatively. We describe the anaesthetic management of this patient who only had a single lung, review other alternatives and discuss why extracorporeal membrane oxygenation was particularly suited to this case. To the best of our knowledge, the anaesthetic literature to date does not contain a case report of this type.

Paediatric Perianesthesia questionnaire: development and data from eight hospitals across Germany.

BACKGROUND: Opinions about satisfaction with care are rarely obtained from children and few studies of this type exist in the area of paediatric anaesthesia. In this study, we developed a comprehensive self-administered questionnaire to measure the level of paediatric and, as a substitute in younger children, parental satisfaction with anaesthesia. In addition, we aimed to identify factors influencing satisfaction and compare results between hospitals. METHODS: We followed a rigorous protocol including construction of a pilot questionnaire and qualitative and quantitative analysis. The questionnaire was adapted for confounding variables. We analysed satisfied and dissatisfied groups and compared satisfaction scores between participating hospitals. RESULTS: A questionnaire was developed which comprised 37 questions assessed on a five-point Likert scale. With a response rate of 71%, a total of 1052 patients completed the questionnaire. In the final analysis, 760 questionnaires (72%) were included. Most questionnaires were answered by the parents [705 (92.8%)]. The mean age of children was 6.7 (4.97) yr. Multivariate analysis found a history of previous anaesthetic problems and the identity of the person answering the questionnaire as influencing factors on the sum score. The most important differences between satisfied and dissatisfied children were found for the dimensions 'privacy and waiting', 'information giving', and 'discomfort'. Scores differed between hospitals. CONCLUSIONS: Our psychometric questionnaire provides a novel approach to paediatric patient satisfaction with anaesthesia care and covers areas deemed important by children, parents, and carers. Significant differences between satisfied and dissatisfied groups and between participating hospitals were found.

The Anesthesia Preoperative Evaluation Clinic (APEC): a prospective randomized controlled trial assessing impact on consultation time, direct costs, patient education and satisfaction with anesthesia care.

AIM: Anesthetic preoperative evaluation clinics (APECs) are relatively new institutions. Although cost effective, APECs have not been universally adopted in Europe. The aim of this study was to compare preoperative anesthetic assessment in wards with an APEC, assessing time, information gain, patient satisfaction and secondary costs. METHODS: Two hundred and seven inpatients were randomized to be assessed at the APEC or on the ward by the same two senior anesthetists. The outcomes measured were the length of time for each consultation, the amount of information passed on to patients and the level of patient satisfaction. The consultation time was used to calculate impact on direct costs. A multivariate analysis was conducted to detect confounding variables. RESULTS: Ninety-four patients were seen in the APEC, and 78 were seen on the ward. The total time for the consultation was shorter for the APEC (mean 8.4 minutes [P<0.01]), and we calculated savings of 6.4 Euro per patient. More information was passed on to the patients seen in the APEC (P<0.01). The general satisfaction scores were comparable between groups. A multivariate analysis found that the consultation time was significantly influenced by the type of anesthesia, the magnitude of the operation and the location of the consultation. Gain in information was significantly influenced by age, education and the location of the visit. CONCLUSION: The APEC reduced consultation times and costs and had a positive impact on patient education. The cost savings are related to personnel costs and, therefore, are independent of other potential savings of an APEC, whereas global patient satisfaction remains unaltered.

The Heidelberg Peri-anaesthetic Questionnaire--development of a new refined psychometric questionnaire.

We have developed a questionnaire to assess patients' peri-anaesthetic satisfaction. We recruited 1398 patients and 59 health care professionals for construction and validation. Relevant items were rated for preferences. The resulting questions underwent a cognitive and a standard pretest. The resultant Heidelberg Peri-anaesthetic Questionnaire consists of 38 questions about five identified themes: trust and atmosphere; fear; discomfort; treatment by personnel; and information and waiting. Internal consistency was demonstrated for the sum score (Cronbach's alpha = 0.79) and the five factors (Cronbach's alpha = 0.42-0.79). Multivariate analysis found significant influences of age, school education, marital status and duration of anaesthesia. Dissatisfied patients had a median (IQR [range]) of 73% (66-76% [35-83]), and satisfied patients 92% (90-94% [88-100]) of the sum score. The Heidelberg Peri-anaesthetic Questionnaire offers a valid and reliable way to identify dissatisfied patients and generate quality improvement and also has use as a benchmark tool.

A pregnant woman with acute myocardial infarction due to coronary artery dissection: pre-hospital and in-hospital management.

A young pregnant woman (32nd week of gestation) presented with acute chest pain due to right coronary artery dissection (CAD) in a pre-hospital setting. The pre-hospital diagnosis by the ambulance staff of an acute myocardial infarction in the antenatal period based on a 12-lead ECG combined with successful treatment by percutaneous coronary intervention with stenting is novel.

[Acute coronary syndrome in the prehospital phase]. / Das akute Koronarsyndrom in der Prähospitalphase.

Cardiovascular diseases are the number one cause of death in Germany. In 2002 about 70,000 people died of acute myocardial infarction (AMI) and of these 37% died before arrival at hospital which underlines the relevance of adequate prehospital care. The generic term acute coronary syndrome (ACS) was introduced because a single pathomechanism accounts for the different forms and comprises unstable angina pectoris (iAP), non-ST-elevation myocardial infarction (NSTEMI), ST-elevation myocardial infarction (STEMI) and sudden cardiac death (SCD). Characteristic features are retrosternal pain, vegetative symptoms and radiation of pain into the adjoining regions. Further differentiation can only be achieved by the 12-lead ECG, as cardiac-specific enzymes do not play a role in prehospital decisions. Prehospital delays should be avoided, history and physical examination should be brief but focused, vital parameters should be assessed and monitored. Basic treatment for ACS should comprise inhalative oxygen, nitrates, morphine, aspirin and beta-blockers. If STEMI is diagnosed, patients with symptoms <12 h should undergo fibrinolytic therapy unless there is primary percutaneous coronary intervention (PCI) available within 90 min or if contraindicated. Heparin should be given to patients with STEMI depending on the choice of fibrinolytic agent, it otherwise results in a higher risk of bleeding, but in patients with iAP or NSTEMI it reduces mortality. All patients must be accompanied by the emergency physician during transportation and should be brought to a hospital with primary PCI, especially those with complicated ACS. Treatment of complications depends largely on the type, persistence and severity.

Loss of CD95 expression is linked to most but not all p53 mutants in European hepatocellular carcinoma.

Experimental data have shown p53-dependent CD95 induction to be associated with increased levels of apoptosis after cytostatic treatment in hepatoma cells. A study of Japanese hepatocellular carcinoma (HCC) has reported an inverse correlation between CD95 and p53 expression. To examine the interaction of p53 and CD95 in tumors we investigated which alterations in p53 can be linked to loss of CD95 expression in European HCC. In 39 tumors we analyzed CD95 by immunohistochemistry and assessed the correlation between the findings of the p53 status as determined by immunohistochemistry and single-strand conformation polymorphism with polymerase chain reaction sequencing. In 10 of 14 tumors with evidence of p53 aberration there was also loss of CD95 expression, compared to 6 of 25 samples with apparent wild-type p53 (P<0.01). Three tumors with p53 mutations but sustained CD95 expression showed single base substitutions mapping to a narrow region of 20 codons in p53. A significant correlation with differentiation status of the tumor was found for the p53 aberration but not for CD95 expression. This is the first study to link loss of CD95 expression to specific p53 alterations in HCC. Functional p53 appears to be a major factor for CD95 expression in hepatocytes, the loss of which could contribute to chemoresistance and possibly immune evasion in hepatocellular carcinoma. Sustained CD95 expression in tumors with certain p53 aberrations may indicate functional heterogeneity of p53 mutants.

CDKN2 mutation is infrequent in german hepatocellular carcinoma.

For hepatocellular carcinoma, only scarce and controversial data on CDKN2 alterations are available. A high rate of mutations in a Chinese study contrasts with a low rate found in Japanese tumors and a CDKN2 germline mutation in 4/26 Swiss tumors examined. We analyzed 23 hepatocellular carcinomas from German patients for homozygous deletions of CDKN2 by coamplification with the human tyrosine hydroxylase (TH) gene and for CDKN2 mutations by PCR-single strand conformation polymorphism analysis and direct DNA sequencing. Our results indicate the lack of homozygous deletions. In one tumor, DNA sequencing showed a GCG-ACG (alanine-threonine) substitution at codon 148, a polymorphism in exon 2 of CDKN2. We conclude that the alteration of CDKN2 by deletion or mutation appears not to be a frequent event in hepatocarcinogenesis in German patients.