Preoperative coagulation screening tests in pediatric patients: Clinical relevance and hemorrhagic outcomes of abnormal results.

PURPOSE: Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes. METHODS: Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. RESULTS: 1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8-538.5, P=.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology. CONCLUSIONS: Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.

Pruebas de coagulación preoperatorias en pacientes pediátricos: relevancia clínica y consecuencias hemorrágicas de los resultados anómalos / Preoperative coagulation screening tests in pediatric patients: Clinical relevance and hemorrhagic outcomes of abnormal results

Objetivo: Las pruebas de evaluación de la coagulación en niños siguen realizándose con frecuencia en muchos países, para evaluar el riesgo de hemorragia. El objetivo de este estudio fue valorar el manejo de la prolongación inesperada del tiempo de tromboplastina parcial activada (APTT) y el tiempo de protrombina (PT) en niños previa a la cirugía electiva, y el riesgo hemorrágico perioperatorio. Métodos: Se incluyó a los niños con APTT y/o PT prolongados que acudieron a consulta de anestesia preoperatoria desde enero del 2013 a diciembre del 2018. Se agrupó a los pacientes en función de si habían sido derivados a Hematología o habían sido programados para cirugía sin pruebas adicionales. El resultado primario fue comparar las complicaciones hemorrágicas perioperatorias. Resultados: Se evaluó para elegibilidad a 1.835 niños. Presentaron resultados anormales 102 de ellos (5,6%) y el 45% fue derivado a Hematología previo a la cirugía. Los trastornos hemorrágicos significativos estuvieron asociados a a una historia hemorrágica (personal y/o familiar) positiva, odds ratio de 51 (IC 95% de 4,8 a 538,5, p = 0,0011). No se encontró diferencia en términos de resultados de hemorragia perioperatoria entre los grupos. Se observó un coste adicional de 181 € por paciente y una mediana de demora preoperatoria de 43 días en los pacientes derivados a Hematología. Conclusiones: Nuestros resultados sugieren que la derivación a Hematología tiene un valor limitado en niños asintomáticos con APTT y/o PT prolongados. Las complicaciones hemorrágicas fueron similares entre los pacientes derivados y los no derivados a Hematología. Una historia familiar positiva de hemorragia puede ayudar a identificar a los pacientes con mayor riesgo de sangrado, por lo que debería guiar la petición de los análisis de coagulación y la derivación a Hematología. Esfuerzos adicionales son necesarios para estandarizar las herramientas preoperatorias de evaluación hemorrágica en niños.(AU)

Purpose: Coagulation screening tests in children are still frequently performed in many countries to evaluate bleeding risk. The aim of this study was to assess the management of unexpected prolongations of the activated partial thromboplastin time (APTT) and prothrombine time (PT) in children prior to elective surgery, and the perioperative hemorrhagic outcomes. Methods: Children with prolonged APTT and/or PT who attended a preoperative anesthesia consultation from January 2013 to December 2018 were included. Patients were grouped according to whether they were referred to a Hematologist or were scheduled to undergo surgery without further investigation. The primary endpoint was to compare perioperative bleeding complications. Results: 1835 children were screened for eligibility. 102 presented abnormal results (5.6%). Of them, 45% were referred to a Hematologist. Significant bleeding disorders were associated with a positive bleeding history, odds ratio of 51 (95% CI 4.8 to 538.5, P = 0.0011). No difference in perioperative hemorrhagic outcomes were found between the groups. An additional cost of 181 euros per patient and a preoperative median delay of 43 days was observed in patients referred to Hematology. Conclusions: Our results suggest that hematology referral has limited value in asymptomatic children with a prolonged APTT and/or PT. Hemorrhagic complications were similar among patients referred and not referred to Hematology. A positive personal or family bleeding history can help identify patients with a higher bleeding risk, thus it should guide the need for coagulation testing and hematology referral. Further efforts should be made to standardize preoperative bleeding assessments tools in children.(AU)

[Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures]. / Directrices de procedimientos de comprobación y validación («chequeo¼) previos a la anestesia de la Sociedad Española de Anestesiología.

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es.

Directrices de procedimientos de comprobación y validación («chequeo») previos a la anestesia de la Sociedad Española de Anestesiología / Spanish Society of Anaesthesia (SEDAR) guidelines for pre-anaesthesia checking procedures

Este documento que presentamos pretende servir de guía para la elaboración por cada centro de una lista de chequeo previo a la anestesia o pre-anestesia, tal y como recomienda la reciente declaración de Helsinki sobre seguridad del paciente en anestesia. Además, la reciente implantación del «check-list quirúrgico de la OMS» (safe surgery check-list) incluye un epígrafe de chequeo de anestesia. El grupo de trabajo se constituyó con este fin según los estatutos de la Sociedad Española de Anestesiología, Reanimación y Tratamiento del Dolor (SEDAR). La nueva cultura de seguridad del paciente que se está implantando en la práctica médica y las recomendaciones de las sociedades europeas de anestesia nos obligan a actualizar y realizar protocolos que mejoren los resultados en este aspecto fundamental de nuestra especialidad. Tomando como ejemplo las actualizaciones de las listas de comprobación de diferentes asociaciones de anestesiólogos como la americana, británica o canadiense, hemos elaborado esta propuesta. Para ello hemos contado con la ayuda de expertos en respiradores y la colaboración y consejos de anestesiólogos expertos de todas las comunidades autónomas. Después de sucesivas correcciones, fue publicada en la página web de la SEDAR para que cualquier anestesiólogo pudiera aportar sus correcciones o su opinión. Finamente el documento ha sido aprobado por la junta directiva de la SEDAR, antes de ser enviado para su publicación en esta revista. Los objetivos de este documento son: proporcionar unas directrices o recomendaciones de comprobación aplicables a todos los sistemas de anestesia, realizar un listado descriptivo de comprobación que incluya todos los elementos necesarios para el procedimiento anestésico y aportar un listado con los elementos del chequeo en forma de esquema para disponer de él en cada equipo de anestesia o de otro similar realizado por cada centro, que incluya respirador, monitores, material auxiliar y fármacos. Por tanto, para cumplir con las recomendaciones de seguridad del paciente del European Board of Anaesthesiology (EBA), European Society of Anaesthesiology (ESA) y de la OMS, cada centro debe elaborar una lista de comprobación y verificación (en adelante «chequeo») previo a la anestesia. Este documento proporciona unas directrices aplicables a todos los sistemas de anestesia de tal manera que cada departamento pueda desarrollar sus propios protocolos de comprobación, adaptados a sus equipos de anestesia y a sus procedimientos de trabajo. De acuerdo con la directiva de la SEDAR, este grupo de trabajo colaborará con los fabricantes de equipos de anestesia para desarrollar listas de comprobación específicas de cada uno de sus modelos para que estén disponibles en www.sedar.es(AU)

We present this document as a guide to preparing a specific institutional pre-anaesthesia checklist, as recommended in the Helsinki declaration on patient safety in anaesthesiology. Also, the recently recommended WHO "safe surgery check-list" includes a check-list for anaesthesia. A working group was established in accordance with the charter of the Spanish Society of Anaesthesiology and Resuscitation (Sociedad Española de Anestesiología y Reanimación [SEDAR]). The new patient safety culture introduced into medicine, and the recommendations of European anaesthesia societies has led us to design and update protocols in order to improve results in this important part of our speciality. We have prepared these recommendations or guidelines using, as examples, updates of pre-anaesthesia check-lists by other American (ASA), British, or Canadian societies of anaesthesia. With that aim, we enlisted the help of anaesthesia ventilator experts and the participation and advice of experienced anaesthesiologists from all parts of Spain. After various corrections and modifications, the document was available at www.sedar.es, so that any anaesthesiologist could propose any correction, or give their opinion. Finally, these guidelines have been approved by the SEDAR Board of Directors, before it was sent for publication in this journal. The aims of this document are to provide: a guideline applicable to all anaesthesia machines, a descriptive pre-anaesthesia check-list that include everything necessary for the anaesthesia procedure, and a resumed check-list to be available in all the anaesthesia machines or other equivalent, but prepared for each institution, which should include anaesthetic equipment and drugs. So, in order to ensure the aims and requirements of the European Board of Anaesthesiology, the European Society of Anaesthesiology, and the WHO are met, each institution should have a protocol for checking equipment and drugs. These guidelines are applicable to any anaesthesia equipment, enabling every institution to develop their own checking protocols, adapted to their anaesthesia machines and their procedures. With the consent of the SEDAR, this group will collaborate with anaesthesia machines providers in order to develop specific checklists for each of their models that will be available at www.sedar.es(AU)

[Application of a critical incident reporting and analysis system in an anesthesiology department]. / Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia.

OBJECTIVES: To ascertain the changes in anesthesia-related morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; chi2 test, P < 0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; chi2, P < 0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors.

[Incident reporting systems and patient safety in anesthesia]. / Sistemas de comunicación de incidentes y seguridad del paciente en anestesia.

Incident reporting schemes collect information on adverse events, errors, complications, or problems with the aim of analyzing their causes and suggesting changes to prevent recurrence. Such schemes are currently part of clinical safety programs in various countries. Although the ideal form for a reporting system is debated, an essential part of its success will be the establishment of a culture of safety within an organization. The underlying assumption is that even though errors are an inherent part of a process that relies on human beings, they are nearly always favored by a chain of system failures. Therefore, reporting is intended to stimulate a culture of learning rather than assigning blame. The main limitations of such schemes are under reporting, the use of different terms and concepts, the lack of resources for research and development, and the scarcity or lack of legislation to guarantee the proper use of information without legal consequences.

Sistemas de comunicación de incidentes y seguridad del paciente en anestesia / Incident reporting systems and patient safety in anesthesia

Los sistemas de comunicación de incidentes recogeninformación sobre sucesos adversos, errores, complicacioneso problemas con el objetivo de analizar sus causasy sugerir cambios para evitar su repetición. Actualmenteson parte de los programas de seguridad clínica en diversospaíses. Aunque existe controversia acerca de cuálesserían las características del sistema de comunicaciónideal, para que éste tenga éxito se necesita una cultura deseguridad asentada en la organización. El planteamientode base asume que aunque los errores son inherentes alproceso humano casi siempre los propicia una cadena defallos en el sistema, por lo que los sistemas de comunicaciónse diseñan para estimular una cultura de aprendizajey no de culpabilización. Sus principales limitacionesson la posibilidad de infracomunicación, las diferentesterminologías y conceptos utilizados, la falta de recursospara su investigación y desarrollo, y la escasa o nulalegislación que permita su buen uso sin implicacioneslegales

Incident reporting schemes collect information onadverse events, errors, complications, or problems withthe aim of analyzing their causes and suggesting changesto prevent recurrence. Such schemes are currently partof clinical safety programs in various countries. Althoughthe ideal form for a reporting system is debated,an essential part of its success will be the establishmentof a culture of safety within an organization. The underlyingassumption is that even though errors are aninherent part of a process that relies on human beings, theyare nearly always favored by a chain of system failures.Therefore, reporting is intended to stimulate a culture oflearning rather than assigning blame. The main limitationsof such schemes are under reporting, the use of differentterms and concepts, the lack of resources for researchand development, and the scarcity or lack oflegislation to guarantee the proper use of informationwithout legal consequences

Utilización de un sistema de comunicación y análisis de incidentes críticos en un servicio de anestesia / Application of a critical incident reporting and analysis system in an anesthesiology department

OBJETIVOS: Conocer los cambios en la morbi-mortalidad anestésica con la utilización de un sistema de comunicación de incidentes críticos y valorar los efectos de la resolución de los factores de error detectados. PACIENTES Y MÉTODOS: Consideramos incidente crítico toda situación en la que se redujo o pudo haberse reducido el margen de seguridad del paciente. Analizamos el periodo entre enero de 1999 y diciembre de 2004. RESULTADOS: Se realizaron 68.627 procedimientos anestésicos y se comunicaron 547 incidentes críticos (0,79%). En 279 incidentes (51%) se identificó un error activo. Los factores latentes asociados con mayor frecuencia fueron el error de diagnóstico de la situación, los problemas de comunicación y la falta de comprobación del equipamiento y de los fármacos. El 81,8% de los incidentes no tuvieron ningún efecto sobre el paciente. En el 78,9% el incidente se consideró evitable. La introducción de una lista de comprobación del equipamiento antes de la anestesia redujo los incidentes de 90 por 21809 casos en 31 meses a 34 por 22.064 casos en 29 meses; χ, p<0,05; odds ratio [OR]= 2,68; intervalo de confianza [IC] del 95%= 1,80-3,9811. El etiquetado de jeringas redujo los errores en la administración de medicación de 45 por 21.809 casos en 31 meses a 27 por 22.064 casos en 29 meses; χ, p<0,05; OR= 1,68; IC del 95%= 1,04-2,72. CONCLUSIONES: Como consecuencia del análisis sistemático de los incidentes se adoptaron distintas medidas correctoras, algunas de las cuales demostraron una reducción estadísticamente significativa en los incidentes de equipamiento y los incidentes farmacológicos

OBJECTIVES: To ascertain the changes in anesthesiarelated morbidity and mortality after application of a scheme for reporting critical incidents and to assess the effect of implementing preventive measures against the detected errors. PATIENTS AND METHODS: We defined a critical incident to be any situation in which the margin of safety for the patient was reduced or might have been reduced. We analyzed data from the period between January 1999 and December 2004. RESULTS: The number of critical incidents was 547 (0.79% of 68627 anesthetic procedures). Human error was identified in 279 incidents (51%). The most frequent factors underlying errors were wrong diagnosis of the situation, communication problems, and failure to check equipment and drugs. The patient suffered no adverse effect in 81.8% of the incidents; 78.9% were considered preventable. Introducing an equipment checklist before anesthesia reduced the number of incidents from 90 events in 21809 cases in 31 months to 34 events out of 22064 cases in 29 months; χ2 test, P<0.05; odds ratio (OR), 2.68; 95% confidence interval (CI), 1.80-3.98). Labeling syringes reduced errors in the administration of medications from 45 errors in 21 809 cases in 31 months to 27 in 22064 cases in 29 months; χ2, P<0.05; OR, 1.68; 95% CI, 1.04-2.72. CONCLUSIONS: Corrective measures were adopted as a result of the incident reporting scheme. Some of the measures led to a statistically significant reduction in equipment and drug administration errors