Antipsychotic-Induced Neuroleptic Malignant Syndrome After Cardiac Surgery.

We report a case of neuroleptic malignant syndrome (NMS) in a postoperative cardiac surgery patient after the administration of typical and atypical antipsychotics for the treatment of delirium. On postoperative day 8, the patient's temperature peaked at 40.6°C. Agitation, rigidity, elevation in creatine kinase, and leukocytosis were associated findings. NMS was suspected on postoperative day 10. All antipsychotics were discontinued; dantrolene infusions and fluid therapy were initiated. After 2 days of NMS treatment, the patient's symptoms resolved. The temporal relationship between discontinuation of all antipsychotics, initiation of dantrolene, and clinical improvement supports the diagnosis of antipsychotic-induced NMS.

An Ethogram to Quantify Operating Room Behavior.

BACKGROUND: The operating room (OR) is a highly social and hierarchical setting where interprofessional team members must work interdependently under pressure. Due primarily to methodological challenges, the social and behavioral sciences have had trouble offering insight into OR dynamics. PURPOSE: We adopted a method from the field of ethology for observing and quantifying the interpersonal interactions of OR team members. METHODS: We created and refined an ethogram, a catalog of all our subjects' observable social behaviors. The ethogram was then assessed for its feasibility and interobserver reliability. RESULTS: It was feasible to use an ethogram to gather data in the OR. The high interobserver reliability (Cohen's Kappa coefficients of 81 % and higher) indicates its utility for yielding largely objective, descriptive, quantitative data on OR behavior. CONCLUSIONS: The method we propose has potential for social research conducted in healthcare settings as complex as the OR.

In-hospital mortality after cardiac surgery: patient characteristics, timing, and association with postoperative length of intensive care unit and hospital stay.

BACKGROUND: It is important to characterize in-hospital mortality after cardiac surgery and understand the relationships between postoperative length of intensive care unit stay, postoperative length of hospital stay, and the likelihood of in-hospital mortality. METHODS: We retrospectively identified all cardiac surgery cases that resulted in in-hospital mortality over an 8-year period at a single center. For these subjects we collected demographic data, preoperative comorbidities, and postoperative complications. We performed stepwise multivariate linear regression to determine which postoperative complications were associated with mortality timing. We also analyzed the relationships between postoperative length of intensive care unit stay, postoperative length of hospital stay, and in-hospital mortality in all patients (including survivors) who had cardiac surgery during the same time period. Finally, we calculated the daily incremental observed mortality rate for patients in the hospital up to postoperative day 50. RESULTS: Six hundred twenty-one in-hospital mortalities occurred among 18,348 patients during the study period (3.4%). Four postoperative complications were associated with mortality timing. Cardiac arrest had a negative association with the number of days until mortality, while deep sternal wound infection, stroke, and pneumonia had a positive association (all p<0.05). Postoperative complications explained 15% of the variability in mortality timing (R2 model=0.15). The odds ratio for in-hospital mortality was 1.033 for each postoperative day in the hospital and 1.071 for each postoperative day in the intensive care unit (both p<0.05). CONCLUSIONS: Most in-hospital mortality occurs during the first week after cardiac surgery with few mortalities occurring after a protracted hospital course. Postoperative complications have a limited ability to explain the variability in mortality timing. Increased length of postoperative intensive care unit stay and hospital stay after cardiac surgery are associated with an increased likelihood of in-hospital mortality.

The absence of cruelty is not the presence of humanness: physicians and the death penalty in the United States.

The death penalty by lethal injection is a legal punishment in the United States. Sodium Thiopental, once used in the death penalty cocktail, is no longer available for use in the United States as a consequence of this association. Anesthesiologists possess knowledge of Sodium Thiopental and possible chemical alternatives. Further, lethal injection has the look and feel of a medical act thereby encouraging physician participation and comment. Concern has been raised that the death penalty by lethal injection, is cruel. Physicians are ethically directed to prevent cruelty within the doctor-patient relationship and ethically prohibited from participation in any component of the death penalty. The US Supreme Court ruled that the death penalty is not cruel per se and is not in conflict with the 8th amendment of the US constitution. If the death penalty is not cruel, it requires no further refinement. If, on the other hand, the death penalty is in fact cruel, physicians have no mandate outside of the doctor patient relationship to reduce cruelty. Any intervention in the name of cruelty reduction, in the setting of lethal injection, does not lead to a more humane form of punishment. If physicians contend that the death penalty can be botched, they wrongly direct that it can be improved. The death penalty cocktail, as a method to reduce suffering during execution, is an unverifiable claim. At best, anesthetics produce an outward appearance of calmness only and do not address suffering as a consequence of the anticipation of death on the part of the condemned.

Neuroleptic malignant syndrome versus serotonin syndrome: the search for a diagnostic tool.

OBJECTIVE: To evaluate the use of urine dopamine and catecholamine concentrations as diagnostic aids in a patient with neuroleptic malignant syndrome (NMS) in the emergency department setting. CASE SUMMARY: A 61-year-old female on multiple medications, including several antipsychotics, rapidly deteriorated, with fever, lead-pipe rigidity, and decreased level of consciousness. The patient died 20 days after initial presentation to an emergency department. The Naranjo probability scale indicated probable causality for NMS due to quetiapine, haloperidol, and risperidone in this patient, whereas the Naranjo scale assigned only possible causality for serotonin syndrome developing with serotonergic agents. Laboratory investigations of blood and urine revealed elevations in dopamine, metanephrines, and epinephrines, as well as trazodone and risperidone. Serotonin metabolites were not elevated. DISCUSSION: NMS is a rare and potentially severe adverse effect associated with the use of antipsychotic medications. It is mainly characterized by hyperthermia, altered mental state, hemodynamic dysregulation, elevated serum creatine kinase, and rigors. It has been associated with multisystem organ failure potentially leading to rhabdomyolysis, acute respiratory distress syndrome, and disseminated intravascular coagulation. The prevalence of this syndrome is associated with the use of neuroleptics. Serotonin syndrome is another adverse drug reaction leading to NMS associated with elevated serotonin. It occurs when multiple serotonergic medications are ingested and is associated with rapid onset of altered mental status, myoclonus, and autonomic instability. Differentiating between NMS and serotonin syndrome can be challenging because of their similar clinical presentation. This case highlights the importance of a diagnostic aid being available to help distinguish between the 2 syndromes. CONCLUSIONS: We propose that laboratory findings that include dopamine and serotonin metabolites can be used as adjuncts to clinical and prescription histories in the diagnosis of NMS. The use of urinary catecholamine as a diagnostic aid in NMS needs further evaluation.

Impact of 24-hour in-house intensivists on a dedicated cardiac surgery intensive care unit.

BACKGROUND: Intensive care unit (ICU) physician staffing models for cardiac surgery patients vary widely and correlate poorly with outcomes. Clinical outcomes associated with 24-hour, in-house intensivists working in a dedicated post-cardiac surgical unit has not been previously investigated. We sought to examine the safety and efficacy of such a model. METHODS: A retrospective, propensity-matched, cohort study of all patients undergoing a cardiac surgical procedure at a single tertiary center was performed. The control cohort (n = 1,467) consisted of patients admitted to the traditional, mixed surgical intensive care unit (SICU) from January 2005 to January 2007. The intervention cohort (n = 1,089) consisted of patients admitted to a newly created "hybrid" cardiac surgery ICU (CICU) from January 2007 to January 2008, which was staffed by 24-hour in-house consultant intensivists and a daytime, fast track cardiac anesthesiologist. The primary outcomes were blood product utilization, requirement for ventilation, and ICU recidivism. RESULTS: The proportion of patients in the CICU cohort who received transfused red blood cells was decreased compared with the SICU cohort (30.2% versus 42.3%, p < 0.001). Similar reductions in platelets and fresh frozen plasma were also observed. The CICU patients were less likely to arrive to the ICU intubated (43.7% versus 66.5%, p < 0.001). There were no differences in postoperative complications. Overall hospital length of stay was reduced in the CICU cohort by a median of 1 day (6 days [interquartile range, 5 to 8] versus 7 days [5 to 9], p < 0.001). Significant reductions in mortality and ICU recidivism were not observed. CONCLUSIONS: The current Manitoba CICU model of 24-hour intensive care physician/cardiac anesthesiologist staffing in postoperative cardiac surgery care is associated with reduced transfusion of blood components, decreased requirement for mechanical ventilation, and shorter hospital length of stay.