Point prevalence of surgical checklist use in Europe: relationship with hospital mortality.

BACKGROUND: The prevalence of use of the World Health Organization surgical checklist is unknown. The clinical effectiveness of this intervention in improving postoperative outcomes is debated. METHODS: We undertook a retrospective analysis of data describing surgical checklist use from a 7 day cohort study of surgical outcomes in 28 European nations (European Surgical Outcomes Study, EuSOS). The analysis included hospitals recruiting >10 patients and excluding outlier hospitals above the 95th centile for mortality. Multivariate logistic regression and three-level hierarchical generalized mixed models were constructed to explore the relationship between surgical checklist use and hospital mortality. Findings are presented as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). RESULTS: A total of 45 591 patients from 426 hospitals were included in the analysis. A surgical checklist was used in 67.5% patients, with marked variation across countries (0-99.6% of patients). Surgical checklist exposure was associated with lower crude hospital mortality (OR 0.84, CI 0.75-0.94; P=0.002). This effect remained after adjustment for baseline risk factors in a multivariate model (adjusted OR 0.81, CI 0.70-0.94; P<0.005) and strengthened after adjusting for variations within countries and hospitals in a three-level generalized mixed model (adjusted OR 0.71, CI 0.58-0.85; P<0.001). CONCLUSIONS: The use of surgical checklists varies across European nations. Reported use of a checklist was associated with lower mortality. This observation may represent a protective effect of the surgical checklist itself, or alternatively, may be an indirect indicator of the quality of perioperative care. CLINICAL TRIAL REGISTRATION: The European Surgical Outcomes Study is registered with ClinicalTrials.gov, number NCT01203605.

No association between ultrasound-guided insertion of central venous catheters and bloodstream infection: a prospective observational study.

BACKGROUND: Ultrasound guidance for the insertion of central venous catheters (CVCs) reduces mechanical complications and shortens insertion time, but its effect on CVC-associated bloodstream infection (CABSI) remains controversial. AIM: To test the effect of ultrasound-guided CVC insertion on CABSI in a hospital-wide setting. METHODS: A four-year prospective cohort study was conducted at a university-affiliated, tertiary care centre. All patients receiving a non-tunnelled CVC, inserted by an anaesthetist, were enrolled. Catheter surveillance was performed by trained infection control nurses and checked by an infection control doctor. The primary outcome was CABSI as defined by the US Centers for Disease Control and Prevention. The secondary outcome was all-cause mortality up to 28 days after CVC removal. FINDINGS: In total, 2312 patients with 2483 CVCs were included and analysed. Ultrasound guidance was used for 844 CVC insertions (34.0%), with a significant increasing trend over the study period [incidence rate ratio 1.13, 95% confidence interval (CI) 01.11-1.15; P < 0.001]. Forty-seven CABSIs were identified, representing an overall incidence of 2.1 episodes per 1000 catheter-days. No association was detected between ultrasound guidance and CABSI (hazard ratio 0.69, 95% CI 0.36-1.30; P = 0.252). All-cause mortality was 11.0% (253/2312), with no significant trend and no association with ultrasound guidance. CONCLUSION: Ultrasound guidance had no effect on CABSI or mortality. In a hospital-wide setting with baseline CABSI rates at the standard level currently found in high-income countries, the use of ultrasound has no additional benefit for the prevention of CABSI.

Geneva cocktail for cytochrome p450 and P-glycoprotein activity assessment using dried blood spots.

The suitability of the capillary dried blood spot (DBS) sampling method was assessed for simultaneous phenotyping of cytochrome P450 (CYP) enzymes and P-glycoprotein (P-gp) using a cocktail approach. Ten volunteers received an oral cocktail capsule containing low doses of the probes bupropion (CYP2B6), flurbiprofen (CYP2C9), omeprazole (CYP2C19), dextromethorphan (CYP2D6), midazolam (CYP3A), and fexofenadine (P-gp) with coffee/Coke (CYP1A2) on four occasions. They received the cocktail alone (session 1), and with the CYP inhibitors fluvoxamine and voriconazole (session 2) and quinidine (session 3). In session 4, subjects received the cocktail after a 7-day pretreatment with the inducer rifampicin. The concentrations of probes/metabolites were determined in DBS and plasma using a single liquid chromatography-tandem mass spectrometry method. The pharmacokinetic profiles of the drugs were comparable in DBS and plasma. Important modulation of CYP and P-gp activities was observed in the presence of inhibitors and the inducer. Minimally invasive one- and three-point (at 2, 3, and 6 h) DBS-sampling methods were found to reliably reflect CYP and P-gp activities at each session.

Hospital-wide survey of the use of central venous catheters.

There are few data on indications for central venous catheter (CVC) use. We conducted an observational, hospital-wide prospective cohort study to quantify the indications for catheter placement over dwell time and to investigate agreement between healthcare workers (HCWs) on CVC use. Catheter use was observed by on-site visits, HCW interviews, and screening of patient charts. A total of 378 CVCs were inserted in 292 patients, accounting for 2704 catheter-days. Of these, 93% CVCs were multilumen catheters and 70% were placed in the intensive care unit (ICU). Median dwell time (interquartile range) was 5 (2-9) days overall, and 4 (2-7) and 8 (3-15) in the ICU and non-ICU settings, respectively. The mean number of specified indications for CVC use per day was 1.7 (1.9 for ICU and 1.5 for non-ICU; P<0.001). The most frequent reason (49%) for catheter use was prolonged (>7 days) antibiotic therapy followed by parenteral nutrition (22.3%). A total of 130 catheter-days (4.8%) were unnecessary with a higher proportion in non-ICU settings (6.6%). In 94% of cases, there was agreement among HCWs on indications for CVC use. However, 35 on-site visits (8.3%) in non-ICU settings revealed that neither the nurse nor the treating physician knew why the catheter was in place. ICU catheters have a short dwell time but are utilised more often, whereas catheters in non-ICU settings show a reverse characteristic. Prevention measures targeting catheter care are more likely to be successful in non-ICU settings.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy.

Propofol sedation by non-anaesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anaesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.

Bilateral pneumothoraces following central venous cannulation.

We report the occurrence of a bilateral pneumothoraces after unilateral central venous catheterization of the right subclavian vein in a 70-year-old patient. The patient had no history of pulmonary or pleural disease and no history of cardiothoracic surgery. Two days earlier, she had a median laparotomy under general and epidural anaesthesia. Prior to the procedure, the patient was hemodynamically stable and her transcutaneous oxygen saturation was 97% in room air. We punctured the right pleural space before cannulation of the right subclavian vein. After the procedure, the patient slowly became hemodynamically instable with respiratory distress. A chest radiograph revealed a complete left-side pneumothorax and a mild right-side pneumothorax. The right-side pneumothorax became under tension after left chest tube insertion. The symptoms finally resolved after insertion of a right chest tube. After a diagnostic work-up, we suspect a congenital "Buffalo chests" explaining bilateral pneumothoraces and a secondary tension pneumothorax.

Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected.

Catheter-related bloodstream infections (CRBSIs) are among the most frequent healthcare-associated infections and cause considerable morbidity, mortality, and resource use. CRBSI surveillance serves quality improvement, but is often restricted to intensive care units (ICUs). We conducted a four-month prospective cohort study of all non-cuffed central venous catheters (CVCs) to design an efficient CRBSI surveillance and prevention programme. CVCs were assessed on a daily basis for ward exposure time, care parameters, and the occurrence of laboratory-confirmed CRBSI. Overall, 248 patients with 426 CVCs accounted for 3567 CVC-days (median: 5) and 15 CRBSI episodes. CVCs were inserted by anaesthetists, ICU physicians and internists in 45%, 47%, and 8% of cases, respectively. CVC utilisation rates for intensive care, internal medicine, non-abdominal surgery and abdominal surgery were 29.8, 3.8, 1.7 and 4.9 per 100 patient-days, respectively. Fourteen percent of patients changed wards while having a CVC in place, so spending CVC-days at risk within multiple departments. CRBSI incidence densities for ICU, internal medicine, surgery and abdominal surgery were 5.6, 1.9, 2.4 and 7.7 per 1000 CVC-days at risk, respectively. In a univariate Cox proportional hazards model, the high CRBSI rate in abdominal surgery was associated with longer CVC duration, frequent use of parenteral nutrition and CVC insertion by anaesthetists. CRBSI numbers were insufficient to perform a multivariate analysis. Our surveillance revealed similar CRBSI rates in both ICU and non-ICU departments, and when frequent ward transfers occurred. Hospital-wide CRBSI surveillance is advisable when a large proportion of CVC-days occur outside the ICU.

Pre-hospital tracheal intubation in patients with traumatic brain injury: systematic review of current evidence.

BACKGROUND: We reviewed the current evidence on the benefit and harm of pre-hospital tracheal intubation and mechanical ventilation after traumatic brain injury (TBI). METHODS: We conducted a systematic literature search up to December 2007 without language restriction to identify interventional and observational studies comparing pre-hospital intubation with other airway management (e.g. bag-valve-mask or oxygen administration) in patients with TBI. Information on study design, population, interventions, and outcomes was abstracted by two investigators and cross-checked by two others. Seventeen studies were included with data for 15,335 patients collected from 1985 to 2004. There were 12 retrospective analyses of trauma registries or hospital databases, three cohort studies, one case-control study, and one controlled trial. Using Brain Trauma Foundation classification of evidence, there were 14 class 3 studies, three class 2 studies, and no class 1 study. Six studies were of adults, five of children, and three of both; age groups were unclear in three studies. Maximum follow-up was up to 6 months or hospital discharge. RESULTS: In 13 studies, the unadjusted odds ratios (ORs) for an effect of pre-hospital intubation on in-hospital mortality ranged from 0.17 (favouring control interventions) to 2.43 (favouring pre-hospital intubation); adjusted ORs ranged from 0.24 to 1.42. Estimates for functional outcomes after TBI were equivocal. Three studies indicated higher risk of pneumonia associated with pre-hospital (when compared with in-hospital) intubation. CONCLUSIONS: Overall, the available evidence did not support any benefit from pre-hospital intubation and mechanical ventilation after TBI. Additional arguments need to be taken into account, including medical and procedural aspects.

[Sleep disturbances in critically ill patients]. / Schlafstörungen bei kritisch kranken Patienten.

Sleep is an essential part of life with many important roles which include immunologic, cognitive and muscular functions. Of the working population 20% report sleep disturbances and in critically ill patients an incidence of more than 50% has been shown. However, sleep disturbances in the intensive care unit (ICU) population have not been investigated in detail. Sleep disturbances in ICU patients have a variety of reasons: e.g. patient-related pathologies like sepsis, acute or chronic pulmonary diseases, cardiac insufficiency, stroke or epilepsy, surgery, therapeutical interventions like mechanical ventilation, noise of monitors, pain or medication. Numerous scales and questionnaires are used to quantify sleep and the polysomnogramm is used to objectify sleep architecture. To improve sleep in ICU patients concepts are needed which include in addition to pharmacological treatment (pain reduction and sedation) synchronization of ICU activities with daylight, noise reduction and music for relaxation. In order to establish evidence-based guidelines, research activities about sleep and critical illness should be intensified. Questions to be answered are: 1) Which part of sleep disturbances in critically ill patients is directly related to the illness or trauma? 2) Is the grade of sleep disturbance correlated with the severity of the illness or trauma? 3) Which part is related to the medical treatment and can be modified or controlled? In order to define non-pharmacological and pharmacological concepts to improve sleep quality, studies need to be randomized and to include different ICU populations. The rate of nosocomial infections, cognitive function and respiratory muscle function should be considered in these studies as well. This will help to answer the question, whether it is useful to monitor sleep in ICU patients as a parameter to indicate therapeutical success and short-term quality of life. Follow-up needs to be long enough to detect adverse effects of withdrawal symptoms after termination of analgesia and sedation or delirium.

Klippel-Trenaunay syndrome with small vessel pulmonary arterial hypertension.

A patient with Klippel-Trenaunay syndrome and pulmonary arterial hypertension not associated with chronic thrombo-embolic pulmonary hypertension is described. It is hypothesised that pulmonary arterial hypertension is another complication associated with the Klippel-Trenaunay syndrome, possibly due to haemodynamic changes of small vessel abnormalities.

Time and tidal volume-dependent ventilator-induced lung injury in healthy rats.

BACKGROUND AND OBJECTIVE: We evaluated the effect of duration of mechanical ventilation with different tidal volumes (VT) on ventilator-induced lung injury in healthy rats. METHODS: Anaesthetized rats were ventilated with VT between 9 and 45 mL kg[-1] for 1 or 7 h with a positive end-expiratory pressure of 2.5 cmH2O. RESULTS: After 1 h, rats ventilated even with the highest applied VT (36 and 45 mL kg[minus sign]1, resulting in average peak airway pressures of 30 +/-3 and 37 +/- 4 cmH2O), had no detectable alterations in dynamic or static lung mechanics, gas exchange or pulmonary permeability, but a moderate degree of lung inflammation (neutrophil accumulation in broncho-alveolar lavage) observed in all groups. In contrast, after 3 h of ventilation, rats ventilated with the highest VT (36 and 45 mL kg[minus sign]1) died from progressive circulatory failure and high-permeability pulmonary oedema, manifested by hypoxaemia, an increased alveolar-arterial protein concentration ratio and a reduced static lung compliance (mortality rate at 7 h, 62.5% and 100%). Animals with lower VT all survived and presented no changes in the measured variables. CONCLUSION: These results in normal rats demonstrate the preponderant effect of the duration (>3 h) of 'aggressive' ventilation and the cut-off value of the level of VT applied (>27 mL kg[minus sign]1).

[Effects of equiosmolar load of 20% mannitol, 7.5% saline and 0.9% saline on plasma osmolarity, haemodynamics and plasma concentrations of electrolytes]. / Effets de charges équiosmolaires de mannitol 20%, de NaCl 7,5% et de NaCl 0,9% sur l'osmolarité, l'hémodynamique et les électrolytes plasmatiques.

OBJECTIVES: Mannitol 20% (M) and NaCl 7.5% (H) are hypertonic solutions used in-patient in hypovolaemic shock and in case of increased ICP. To our knowledge no study in humans compared them in an equiosmolar load. The objectives of this study were to compare the pharmacokinetics of both solutions in an equiosmolar load with an isotonic solution (NaCl 0.9% (C)) in terms of osmolarity, electrolytes and haemodynamic parameters over time. STUDY DESIGN: Prospective, randomized, controlled study. PATIENTS: Thirty ASA I and II patients undergoing non haemorrhagic surgery under general anesthesia. METHODS: Three groups were studied (groups M, H and C), each receiving an equiosmolar load (4.95 mOsm kg(-1)) of solutions of mannitol 20%, saline 7.5% and saline 0.9% over ten minutes. Vital parameters (non invasive blood pressure, heart rate, oesophageal temperature) were monitored and blood samples (hemoglobin, hematocrit, K(+), Na(+), Cl(-), urea, creatinine, glucose, mannitolemia, osmolarity) were assessed preoperatively and intraoperatively at times 0, 3, 5, 10, 15, 30, 45, 60, 90, 120, 150 min of perfusion. RESULTS: In both hypertonic groups, osmolarity was maximal at the end of infusion (group M: 329 +/- 7 mOsm l(-1); group H: 321 +/- 11 mOsm l(-1)); at the same time, Na(+) value was lowest in group M: 129 +/- 3 mmol l(-1) and highest in group H: 151 +/- 5 mmol l(-1), P < 0.001) with normalisation at 60 min. These results were also statistically significant when compared to the isotonic group (group C: osmolarity: 296 +/- 3 mOsm l(-1), P < 0.001; Na(+): 140 +/- 2 mmol l(-1), P < 0.001). Plasma volume expansion was statistically significantly larger in-group C between 10 and 15 min compared to both hypertonic groups (haematocrit: group C: 35 +/- 4%, group M: 39 +/- 5%; group H: 41 +/- 3%, P < 0.004). Haemodynamic parameters were similar in the 3 groups with however a trend towards lowers HR in the mannitol group, particularly at T10. Temperature was lower in the control group because of the volume infused. Cl(-) was higher in the H group. CONCLUSION: A single infusion of 4.95 mOsm kg(-1) of mannitol 20% or NaCl 7.5% induces a similar osmolar variation over time with a maximal effect after 10 min.

Propofol and midazolam versus propofol alone for sedation following coronary artery bypass grafting: a randomized, placebo-controlled trial.

The aim was to compare the efficacy and side-effects of propofol combined with a constant, low dose of midazolam versus propofol alone for sedation. In a prospective, randomized and double-blinded study, 60 male patients scheduled for elective coronary bypass grafting were enrolled. Postoperatively, patients were stratified to receive either a continuous intravenous infusion of midazolam 1 mg/h or placebo. Target Ramsay sedation score was 3 to 5 corresponding to conscious sedation. An intention-to-treat design for propofol was performed to reach target sedation. Efficacy of sedation was statistically significantly higher in the group midazolam + intention-to-treat with propofol compared with the group placebo + intention-to-treat with propofol (91% vs 79%; P=0.0005). Nine of 27 patients in the midazolam group (33.4%) and nine of 26 patients in the placebo group (34.6%) needed no supplementary propofol. Weaning time from mechanical ventilation was longer in the midazolam group whether or not they required supplemental propofol when compared with placebo group (all: 432 +/- 218 min vs 319 +/- 223 min; P=0.04; supplementary propofol: 424 +/- 234 min vs 265 +/- 175 min; P=0.03). The cumulative number of patients remaining intubated was significantly higher in the group midazolam + propofol compared with the group placebo + propofol (P=0.03). In conclusion, target sedation is reached slightly more often by the co-administration of propofol and a low dose of midazolam, but weaning time from mechanical ventilation is prolonged by the co-administration of propofol and a low dose of midazolam.

[Evidence-based medicine and the systematic review in perioperative medicine]. / Evidence-based Medicine und systematische Reviews in der perioperativen Medizin. Modeerscheinung oder Notwendigkeit?

The aim of Evidence-based medicine (EBM) is the unbiased and systematic identification and synthesis of valid scientific data. These best-evidence data may then be used for clinical decision-making. The systematic review is the most important tool of EBM and gives a specific answer to a specific question. More than 200 systematic reviews have been published in perioperative medicine. They treat complications and risks related to anaesthesia, postoperative and labour analgesia, nausea and vomiting, regional anaesthesia, blood transfusion and fluids replacement, and resuscitation. The majority of these systematic reviews are of good quality. In the specific settings of perioperative medicine the number of systematic reviews has become so important that recommendations for evidenced-based strategies of prevention and therapy can be formulated.

Transcranial Doppler versus angiography in patients with vasospasm due to a ruptured cerebral aneurysm: A systematic review.

BACKGROUND AND PURPOSE: Transcranial Doppler (TCD) is used for diagnosis of vasospasm in patients with subarachnoid hemorrhage due to a ruptured aneurysm. Our aim was to evaluate both the accuracy of TCD compared with angiography and its usefulness as a screening method in this setting. METHODS: A search (MEDLINE, EMBASE, Cochrane Library, bibliographies, hand searching, any language, through January 31, 2001) was performed for studies comparing TCD with angiography. Data were critically appraised using a modified published 10-point score and were combined using a random-effects model. RESULTS: Twenty-six reports compared TCD with angiography. Median validity score was 4.5 (range 1 to 8). Meta-analyses could be performed with data from 7 trials. For the middle cerebral artery (5 trials, 317 tests), sensitivity was 67% (95% CI 48% to 87%), specificity was 99% (98% to 100%), positive predictive value (PPV) was 97% (95% to 98%), and negative predictive value (NPV) was 78% (65% to 91%). For the anterior cerebral artery (3 trials, 171 tests), sensitivity was 42% (11% to 72%), specificity was 76% (53% to 100%), PPV was 56% (27% to 84%), and NPV was 69% (43% to 95%). Three of these 7 studies reported on the same patients, each on another artery, and for 4, data recycling could not be disproved. Other arteries were tested in only 1 trial each. CONCLUSIONS: For the middle cerebral artery, TCD is not likely to indicate a spasm when angiography does not show one (high specificity), and TCD may be used to identify patients with a spasm (high PPV). For all other situations and arteries, there is either lack of evidence of accuracy or of any usefulness of TCD. Most of these data are of low methodological quality, bias cannot not be ruled out, and data reporting is often uncritical.

Efficacy and safety of patient-controlled opioid analgesia for acute postoperative pain. A quantitative systematic review.

BACKGROUND: The usefulness of intravenous patient-controlled analgesia (PCA) with opioids for postoperative analgesia is not well defined. METHODS: We systematically searched (MEDLINE, EMBASE, Cochrane Library, bibliographies, any language, to January 2000) for randomised trials comparing opioid-based PCA with the same opioid given intramuscularly, intravenously, or subcutaneously. Weighted mean differences (WMD) for continuous data, relative risks (RR) and numbers-needed-to-treat (NNT) for dichotomous data were calculated with 95% confidence intervals (CI) using fixed and random effects models. RESULTS: Data from 32 trials were analysed: 22 (1139 patients) were with morphine, five (682) with pethidine, three (184) with piritramide, one (47) with nalbuphine and one (20) with tramadol. In three morphine and one pethidine trial (352 patients), more patients preferred PCA (89.7% vs. 65.8%, RR 1.41 (95%CI 1.11 to 1.80), NNT 4.2). Combined dichotomous data on pain intensity and relief, and the need for rescue analgesics from eight morphine, one pethidine, one piritramide, and one nalbuphine trial (691 patients), were in favour of PCA (RR 1.22 (1.00 to 1.50), NNT 8). In two morphine trials (152), pulmonary complications were more frequently prevented with PCA (100% vs. 93.3%, RR 1.07 (1.01 to 1.14), NNT 15). There was equivalence for cumulative opioid consumption, pain scores, duration of hospital stay, and opioid-related adverse effects. CONCLUSION: These trials provide some evidence that in the postoperative pain setting, PCA with opioids, compared with conventional opioid treatment, improve analgesia and decrease the risk of pulmonary complications, and that patients prefer them.

Propofol [correction of propfol] versus methohexital for electroconvulsive therapy: a meta-analysis.

A systematic search (Medline, Cochrane library, Embase, bibliographies, to 5.2000, no language restriction) was performed for published reports of randomized comparisons of propofol and methohexital for anesthesia during electroconvulsive therapy. We analyzed 15 trials with data on 706 patients. The duration of motor seizure was shorter with propofol (range, 18-39 seconds) than with methohexital (range, 26-48 seconds, weighted mean difference 8.4 seconds [95% CI, 6.6-10.0]). With both propofol and methohexital, there was little evidence of an association between dose and duration of motor seizure (for propofol: r2 = 0.25, P = .08; for methohexital: r2 = 0.11, P = .27). Two small trials investigated clinical outcome; results were inconclusive. Data on adverse effects were sparse. Duration of seizure was not proven to be a useful measure of treatment success in the study of electroconvulsive therapy with propofol or methohexital. The impact of the technique of anesthesia on the underlying disease needs to be established.