Accuracy of surgical complication rate estimation using ICD-10 codes.

BACKGROUND: The ICD-10 codes are used globally for comparison of diagnoses and complications, and are an important tool for the development of patient safety, healthcare policies and the health economy. The aim of this study was to investigate the accuracy of verified complication rates in surgical admissions identified by ICD-10 codes and to validate these estimates against complications identified using the established Global Trigger Tool (GTT) methodology. METHODS: This was a prospective observational study of a sample of surgical admissions in two Norwegian hospitals. Complications were identified and classified by two expert GTT teams who reviewed patients' medical records. Three trained reviewers verified ICD-10 codes indicating a complication present on admission or emerging in hospital. RESULTS: A total of 700 admissions were drawn randomly from 12 966 procedures. Some 519 possible complications were identified in 332 of 700 admissions (47·4 per cent) from ICD-10 codes. Verification of the ICD-10 codes against information from patients' medical records confirmed 298 as in-hospital complications in 141 of 700 admissions (20·1 per cent). Using GTT methodology, 331 complications were found in 212 of 700 admissions (30·3 per cent). Agreement between the two methods reached 83·3 per cent after verification of ICD-10 codes. The odds ratio for identifying complications using the GTT increased from 5·85 (95 per cent c.i. 4·06 to 8·44) to 25·38 (15·41 to 41·79) when ICD-10 complication codes were verified against patients' medical records. CONCLUSION: Verified ICD-10 codes strengthen the accuracy of complication rates. Use of non-verified complication codes from administrative systems significantly overestimates in-hospital surgical complication rates.

Continuous ventilation during intubation through a supraglottic airway device guided by fiberoptic bronchoscopy: a observational assessment.

INTRODUCTION: supraglottic airway devices remain, despite advances in video laryngoscopy, important tools in the management of unexpected difficult airways. Intubation through a functioning supraglottic airway device with the aid of a fiberoptic bronchoscope is a well-known technique usually performed in apnoea. With a simple modification, the patient can be ventilated during this procedure. METHODS: In this observational study, Tracheal intubation Assisted by Bronchoscopy And Sad during Continuous Oxygenation (TABASCO) was performed as part of department training routine in 26 elective, fasted patients. A supraglottic airway device was used as a conduit for an endotracheal tube. RESULTS: All patients were easily intubated and ventilation was maintained during the procedure. The gap between the outer diameter of the fiberoptic bronchoscope and the inner diameter of the endotracheal tube was more than 2 mm in 25 of 26 patients. Effective ventilation was confirmed by clinical signs, capnography and pressure-volume curves. No signs of airtrapping occurred. DISCUSSION: No adverse events were observed during this form of airway management in this small series of elective and fasted patient when performed by an anaesthesiologist experienced in fiberoptic intubation. A gap between fiberoptic bronchoscope and endotracheal tube inner lumen seems to be prerequisite for easy ventilation through the supraglottic airway. In trained hands, this technique can be a means to secure an airway with an intubating bronchoscope without pausing ventilations. A prerequisite for this is a well-functioning supraglottic airway device.

The effects of safety checklists in medicine: a systematic review.

BACKGROUND: Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes. METHODS: The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included. RESULTS: The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists. CONCLUSION: Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

The brain networks encoding visceral sensation in patients with gastrointestinal symptoms due to diabetic neuropathy.

BACKGROUND: Increasing evidence points to association between long-term diabetes mellitus and abnormal brain processing. The aim of this study was to investigate central changes due to electrical stimulation in esophagus in patients with upper gastrointestinal (GI) symptoms due to diabetic neuropathy. METHODS: Twenty-three diabetes patients with upper GI symptoms and 27 healthy controls were included. A standard ambulatory 24-h electrocardiography was carried out. 122-channel esophageal evoked brain potentials to electrical stimulation were acquired. Brain source/network analysis was performed. Gastroparesis Cardinal Symptom Index was used to evaluate upper GI symptoms and SF-36 questionnaire was utilized to assess patients' quality of life (QOL). KEY RESULTS: Diabetes patients with GI symptoms showed modifications in three brain networks: (i) brainstem/operculum/frontal cortex, (ii) operculum/cingulate, and (iii) mid-cingulate/anterior-cingulate/operculum/deep limbic structures. Operculum brain source in patients was localized deeper and more anterior in all three networks. The shift of operculum source was correlated with the severity of upper GI symptoms, decreased heart beat-to-beat interval, and decreased SD of the intervals. The activation of the first network was delayed in patients. Operculum source had higher activity than cingulate in the second network in patients, and this was correlated with decreased physical QOL. Deep limbic source was localized deeper in patients, which also correlated with decreased physical QOL. CONCLUSIONS & INFERENCES: This study indicates involvement of central nervous system in diabetes. Reorganization within opercular cortex was correlated with GI symptoms suggesting that operculo-cingulate cortex could contribute to development and maintenance of GI symptoms in diabetes patients.

Macrostructural brain changes in patients with longstanding type 1 diabetes mellitus - a cortical thickness analysis study.

Longstanding diabetes mellitus (DM) is associated with the risk of complications affecting the central nervous system. The aims were to study brain volume and cortical thickness in regional brain areas in DM patients and to correlate the findings with relevant clinical data.15 patients with longstanding (average 24.6 years) type 1 DM and 20 healthy controls were studied in a 3T magnetic resonance scanner. Using an automated surface based cortical segmentation method, cortical thickness was assessed in anatomical regions including total and lobe-wise grey and white matter volumes. Also morphological changes were evaluated.No differences between patients and controls were found in regard to number of white matter lesions (P=0.50), grey and white matter volumes (P=0.25) and overall cortical thickness (P=0.64). Subanalysis revealed exclusively reduced cortical thickness of the postcentral (P=0.03) and superior parietal gyrus (P=0.008) in patients. The cortical thickness of these regions was not associated with diabetes duration, age at diabetes onset or to HbA1c (all P>0.08). Patients with peripheral neuropathy showed reduced right postcentral gyrus cortical thickness compared to patients without peripheral neuropathy (P=0.02).Patients with longstanding type 1 diabetes showed cortical thinning involving sensory related areas, even though no overall macrostructural brain alterations were detected. This could possibly have underlying functional significance since cortical thinning was associated to presence of peripheral neuropathy. The absence of universal macrostructural changes might illustrate that more pronounced brain pathology is likely to be preceded by more subtle microstructural changes as reported in other studies.

Brain networks encoding rectal sensation in type 1 diabetes.

INTRODUCTION: It has been shown that patients with type 1 diabetes mellitus and gastrointestinal (GI) symptoms have abnormal processing of sensory information following stimulation in the oesophagus. In order to find less invasive stimuli to study visceral afferent processing and to further elaborate the gut-brain network in diabetes, we studied brain networks following rectal electrical stimulations. METHODS: Twelve type 1 diabetes patients with GI symptoms and twelve healthy controls were included. A standard ambulatory 24-h electrocardiography was performed. 122-channel-evoked brain potentials to electrical stimulation in the rectum were recorded. Brain source-connectivity analysis was done. GI symptoms were assessed with the gastroparesis cardinal symptom index and quality of life (QOL) with SF-36. Any changes in brain source connectivity were correlated to duration of the disease, heart beat-to-beat intervals (RRs), clinical symptoms, and QOL of the patients. RESULTS: Diabetic patients with GI symptoms showed changes relative to controls in the operculum-cingulate network with the operculum source localized deeper and more anterior (P≤0.001) and the cingulate source localized more anterior (P=0.03). The shift of operculum source was correlated with the duration of the disease, severity of GI symptoms, and decreased RR (P<0.05). The shift of the cingulate source was correlated with the mental QOL (P=0.04). In healthy controls, the contribution of the cingulate source to the network was higher than the contribution of the operculum source (P≤0.001), whereas in patients the contribution of the two sources was comparable. CONCLUSION: This study gives further evidence for CNS involvement in diabetes. Since network reorganizations were correlated to GI symptoms, irregularities of rectal-evoked potentials can be viewed as a proxy for abnormal bottom-up visceral afferent processing. The network changes might serve as a biomarker for disturbed sensory visceral processing of GI symptoms in diabetes patients.

Impact of the World Health Organization's Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study.

BACKGROUND: Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital. METHODS: We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture. RESULTS: The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors 'frequency of events reported' and 'adequate staffing' with regression coefficients at -0.25 [95% confidence interval (CI), -0.47 to -0.07] and 0.21 (95% CI, 0.07-0.35), respectively. Overall, the intervention group reported significantly more positive culture scores-including at baseline. CONCLUSIONS: Implementation of the SSC had rather limited impact on the safety culture within this hospital.

Peripheral and central nervous contribution to gastrointestinal symptoms in diabetic patients with autonomic neuropathy.

BACKGROUND & AIMS: Long-term diabetes mellitus (DM) has been associated with neuronal changes in the enteric, peripheral and/or central nervous system. Moreover, abnormal visceral sensation and gastrointestinal (GI) symptoms are seen in up to 75% of patients. To explore the role of diabetic autonomic neuropathy (DAN) in patients with long-standing DM, we investigated psychophysical responses and neuronal activity recorded as evoked brain potentials and dipolar source modelling. METHODS: Fifteen healthy volunteers and 14 type-1 DM patients with DAN were assessed with a symptom score index characterizing upper GI abnormalities. Multichannel (62) electroencephalography was recorded during painful electrical stimulation of the lower oesophagus. Brain activity to painful stimulations was modelled using Brain Electrical Source Analysis (besa). RESULTS: Diabetic patients had higher stimulus intensities to evoke painful sensation (p ≤ 0.001), longer latencies of N2 and P2 components (both p ≤ 0.001), and lower amplitudes of P1-N2 and N2-P2 complexes (p ≤ 0.001; p = 0.02). Inverse modelling of brain sources showed deeper bilateral insular dipolar source localization (p = 0.002). Symptom score index was negatively correlated with the depth of insular activity (p = 0.004) and positively correlated with insular dipole strength (p = 0.03). CONCLUSION: DM patients show peripheral and central neuroplastic changes. Moreover, the role of abnormal insular processing may explain the appearance and persistence of GI symptoms related to DAN. This enhanced understanding of DAN may have future clinical and therapeutical implications.

Effects of isolated hyperinsulinaemia on sensory function in healthy adults.

AIMS: Gastrointestinal symptoms such as pain, bloating, nausea and vomiting are more frequent in pre-diabetic states as well as established diabetes, compared to healthy individuals. The mechanisms behind these symptoms are multi-factorial and complex. Furthermore, the effect of isolated hyperinsulinaemia on visceral and peripheral sensory function is poorly understood. Thus, the current study aimed to evaluate effects of acute hyperinsulinaemia on sensory function in healthy adults. METHODS: The sensitivity to electrical oesophageal and median nerve stimulation was assessed in 15 healthy volunteers together with recording of evoked brain potentials. All subjects were studied both fasting and using a euglycaemic hyperinsulinaemic clamp. RESULTS: There was on average a 15% increased sensitivity to oesophageal electrical stimulation during hyperinsulinaemia compared to fasting state (P<0.05), but the sensation after median nerve stimulation remained stable (P=0.58). No significant changes in latencies and amplitudes of evoked brain potentials were observed after oesophageal or median nerve stimulation (all P>0.05). CONCLUSIONS: This study suggests that acute isolated hyperinsulinaemia increases visceral sensitivity, but does not influence the somatic sensory function. The lack of changes in the evoked brain potentials may indicate that hyperinsulinaemia affects the visceral sensory system at a peripheral level. Our result suggests distinct functions of insulin in the various parts of the nervous system, and yields further clues to the significance of insulin as a satiety signal.

The effect of a simple checklist on frequent pre-induction deficiencies.

BACKGROUND: A substantial proportion of anaesthesia-related adverse events are preventable by identification and correction of errors in planning, communication, fatigue, stress, and equipment. The aim of this study was to develop and implement a pre-induction checklist in order to identify and solve problems before induction of anaesthesia. METHODS: The checklist was developed in a stepwise manner using a modified Delphi technique, literature search, expert's opinion, and a pilot version, and then implemented in a clinical environment during a 13-week study period. Each list was registered and analysed using statistical process control. The checklist was mandatory, but emergency cases were excluded. RESULTS: The checklist, containing 26 items, was used in 502 (61%) of a total of 829 inductions. Eighty-five checklists (17%) identified one or more missing items. The number of missing items decreased significantly throughout the study period. The most important missing items were lack of a second laryngoscope available, introducer not having been fitted to the endotracheal tube, the endotracheal tube cuff not having been tested, and no separate ventilation bag being available. It took a median of 88.5 s (range 52-118) to perform the checklist when no items were missing. The pre-induction time was the same before and after the checklist was introduced (25.1 vs. 24.3 min, P50.25). CONCLUSIONS: It is possible to develop, introduce, and use a pre-induction checklist even in a hectic and stressful clinical environment. The checklist identified and reduced a surprisingly large number of missing items required in a standard induction protocol.

Safety and efficacy of ghrelin agonist TZP-101 in relieving symptoms in patients with diabetic gastroparesis: a randomized, placebo-controlled study.

BACKGROUND: Gastroparesis, a chronic disorder of abnormal gastric motility, is common in patients with diabetes mellitus. A synthetic, selective ghrelin receptor agonist, TZP-101, is in clinical development for treatment of gastroparesis. This double-blind, randomized, placebo-controlled study evaluated the safety and efficacy of multiple TZP-101 doses in patients with moderate to severe symptomatic diabetic gastroparesis. METHODS: Patients were admitted to the hospital and adaptively randomized to receive a single 30-min intravenous infusion of 20, 40, 80, 160, 320, or 600 µg kg(-1) TZP-101, (n = 57) or placebo, (n = 19) for four consecutive days. Symptoms were evaluated daily with the patient-rated Gastroparesis Cardinal Symptom Index (GCSI) and Gastroparesis Symptom Assessment (GSA). Clinicians rated gastroparesis symptoms on treatment day 4. KEY RESULTS: The 80 µg kg(-1) dose was identified as the most effective dose. On day 4, there was statistically significant improvement compared with placebo in the severity of GCSI Loss of Appetite and Vomiting scores for that dose group (P = 0.034 and P = 0.006). In addition, at the 80 µg kg(-1) dose, the proportion of patients with at least 50% improvement in vomiting score was significantly different (P = 0.019) compared with placebo. Meal-related GSA scores for Postprandial fullness were significantly improved in the 80 µg kg(-1) TZP-101 group compared with placebo (P = 0.012). Clinicians rated the 80 µg kg(-1) group better improved than placebo for overall symptom assessment (P = 0.047). Safety profiles were similar in the placebo and TZP-101 groups and all doses were well-tolerated. CONCLUSIONS & INFERENCES: TZP-101 appears to be safe, well-tolerated, and effective at acutely addressing several gastroparesis symptoms.

Dysglycaemia in vascular surgery patients.

UNLABELLED: Oral glucose tolerance tests (OGTTs) have detected a pathologic glucose metabolism in up to 60% of patients with acute coronary syndromes. Only one-third of these were previously diagnosed. The purpose of this study was to determine the prevalence of abnormal glucose metabolism among vascular surgery patients. METHODS: Between October 2006 and September 2007, 465 consecutive patients admitted to the vascular surgery unit were asked to participate in the study; however, 121 declined. Among the patients included, 68 had previously known diabetes. A total of 276 patients performed an oral glucose tolerance test (OGTT). We categorised the findings based on fasting and 2-h plasma glucose levels into four groups: diabetes mellitus, impaired glucose tolerance (IGT), impaired fasting glucose (IFG) and normal glucose metabolism. Information regarding the affected vascular bed and relevant medical history was also registered. RESULTS: Of the 276 patients who underwent OGTT, 66 (24%) had IGT, 23 (8%) had IFG and 33 (12%) had diabetes. As many as 17 of the 33 patients with newly diagnosed diabetes would have fulfilled the criteria for diagnosis based only on their fasting glucose levels. Including the patients with previously known diabetes, the prevalence of dysglycaemia was 55% and that of diabetes 29%. CONCLUSIONS: Total prevalence of dysglycaemia in vascular surgery patients corresponds well to that of acute coronary syndromes. The prevalence of unknown pathological glucose metabolism was 44% in our OGTT material. The use of fasting glucose as the sole diagnostic tool for diabetes would have resulted in the correct diagnosis in only half of the patients tested. OGTT should be considered as a routine investigation in non-diabetic vascular surgery patients. It remains to be seen whether early diagnosis and treatment of dysglycaemia in this patient group will influence the surgical treatment and outcome.

A case of unexpected difficult airway due to lingual tonsil hypertrophy.

Clinical value of preoperative bedside screening tests for predicting difficult airway remains limited. Asymptomatic lingual tonsil hypertrophy is a known cause of unexpected difficult airway. We report a case as a reminder of this.

Intrauterine growth restriction.

This study reviewed the screening, diagnosis, prophylaxis, and treatment of intrauterine growth restriction using the PubMed database for key words and the Cochrane database for systematic reviews. Identification of risk factors and measurement of symphysis-fundus height are currently the screening standards. Diagnosis is verified by ultrasonography. Accuracy of diagnosis may be improved by using customized fetal growth curves, symphysis-fundus height charts, and 3-dimensional ultrasonographic evaluation and measuring umbilical artery Doppler dimensional ultrasonographic evaluation measuring umbilical artery Doppler impedance. Prophylaxis with acetylsalicylic acid, started in the first or second trimester or combined with heparin before conception, may reduce the incidence of growth restriction in specific groups at high risk. Active management may reduce incidence in patients with mild to moderate asthma, and targeted treatment of infections may also be beneficial. Antenatal corticosteroid treatment also reduces the perinatal morbidity and mortality associated with IUGR. Bed rest has no demonstrated beneficial effects.

Cardiopulmonary distress during obstetrical anaesthesia: attempts to diagnose amniotic fluid embolism in a case series of suspected allergic anaphylaxis.

BACKGROUND: Cardiopulmonary distress during obstetrical anaesthesia may result from a drug-induced allergic reaction, but, in the obstetrical setting, allergic anaphylaxis may be inseparable from amniotic fluid embolism in terms of the clinical presentation. Further investigations, using allergy tests and other laboratory analyses, are then needed to pursue a diagnostic clarification. METHODS: Twelve women suspected of having developed anaphylaxis during obstetrical anaesthesia underwent allergy follow-up investigations and further serological tests with the amniotic fluid embolism marker sialyl Tn and complement factors (C3 and C4) in an attempt to differentiate amniotic fluid embolism from drug-induced allergic anaphylaxis. RESULTS: The diagnostic programme revealed one case of probable amniotic fluid embolism and four cases of probable drug-induced allergic anaphylaxis. Of the remaining seven cases, there were two cases that, by diagnostic exclusion, could be classified as possible cases of amniotic fluid embolism. The cause of the reactions remained unresolved in five cases. CONCLUSIONS: It can be difficult to differentiate between anaphylaxis and amniotic fluid embolism, especially amongst survivors. Diagnostic markers that can be applied on peripheral blood samples are promising, but larger studies are needed to validate their use in the diagnosis of causes of cardiopulmonary distress during obstetrical anaesthesia.

Pneumomediastinum in labour -- probably not caused by a lumbar epidural anaesthesia.

We describe a case of pneumomediastinum and subcutaneous emphysema during labour. The patient had previously received an epidural anaesthesia to alleviate labour pain. We found several reports of subcutaneous emphysema and pneumomediastinum (or pneumothorax) possibly caused by or related to epidural anaesthesia use, but conclude that the epidural anaesthesia was probably not a cause in our case.

Anaesthetic complications associated with myotonia congenita: case study and comparison with other myotonic disorders.

Myotonia congenita (MC) is caused by a defect in the skeletal muscle chloride channel function, which may cause sustained membrane depolarisation. We describe a previously healthy 32-year-old woman who developed a life-threatening muscle spasm and secondary ventilation difficulties following a preoperative injection of suxamethonium. The muscle spasms disappeared spontaneously and the surgery proceeded without further problems. When subsequently questioned, she reported minor symptoms suggesting a myotonic condition. Myotonia was found on clinical examination and EMG. The diagnosis MC was confirmed genetically. Neither the patient nor the anaesthetist were aware of the diagnosis before this potentially lethal complication occurred. We give a brief overview of ion channel disorders including malignant hyperthermia and their anaesthetic considerations.

Evaluation of thiopentone-midazolam-fentanyl anaesthesia in pigs.

Induction of anaesthesia in swine by thiopentone (27.1-35.7 mg/kg, mean 29.9 mg/kg) was followed by bolus doses and continuous infusion of midazolam and fentanyl (0.90 mg/kg followed by 0.90 mg/kg/h and 0.025 mg/kg followed by 0.025 mg/kg/h, respectively). This produced good anaesthesia and analgesia for up to 2 h in 6 Norwegian Landrace pigs (wt: 17-42 kg), based on responses to painful stimuli elicited by pinching the nasal septum, the mouth, the forefoot and the perineal skin area. The first responses occurred after 110 min of anaesthesia. No significant drop in rectal temperature due to the regimen was noted during monitoring periods (140-180 min). This combined intravenous anaesthetic regimen gave good anaesthesia and analgesia to pigs for up to 2 h as monitored by clinical signs. The regimen may not be sufficient for longer time periods. We cannot advocate the incorporation of neuromuscular blocking agents in this regimen.

A transport and monitoring unit for piglets under general anaesthesia.

A transport and monitoring unit for fully anaesthetized piglets (weight 20-30 kg) was made. The unit provided easy transport for short or longer distances while at the same time making continuous monitoring of invasive blood pressure (IBP), temperature and HR possible. The animals stayed in the unit for the duration of the experiments which required that the anaesthetized animal be kept in exactly the same position for several hours. This, as well as the experimental animal's welfare, was ensured by the unit. Such a unit can be used for any lengthy transportation of experimental animals to research facilities located separately from animal laboratories.