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.

[Cross-validation of simple questioning methods to determine patient satisfaction with anaesthesia care]. / Kreuzvalidierung einfacher Messverfahren zur Ermittlung der Patientenzufriedenheit mit der anästhesiologischen Versorgung.

INTRODUCTION: Evaluation of patient satisfaction with the perioperative care is an integral part of modern quality management. For this purpose simple questioning techniques are often used in clinical practise or reports of clinical trials. However, little research has been performed to investigate whether these tools and methods are useful and provide valid information. METHODS: Two-hundred patients undergoing elective surgical procedures were interviewed. Five different simple techniques or questions that have been used in the international and in the German literature throughout the last years were applied in random sequence together with the validated German translation of the QoR-9 questionnaire to measure quality of recovery. All analyses were performed descriptively. RESULTS: All investigated techniques could be answered without help by another person in 95 % up to 100 %. All simple dichotomous questions regarding satisfaction were insufficient to discriminate satisfied from less satisfied patients. A rating using grades known from the German school system (1 - 6) and a visual analogue scale (VAS; 0 - 100 mm) obtained ratings lower than the maximum possible values in 10 % and 11 % of the patients respectively. Furthermore, the flexibility that was provided by these tools was not utilized by the patients. The results of the QoR-9 questionnaire as a marker of postoperative recovery showed only a moderate correlation with ratings of patient satisfaction. CONCLUSION: Until now, there is no method or questioning technique in the German language that can be recommended for a quality assurance program. Thus, further research is needed to develop tools that provide valid information with adequate resolution to allow discrimination of patient satisfaction with perioperative care.

[The balanced scorecard. "Tool or toy" in hospitals]. / Balanced Scorecard. "Tool or toy" im Krankenhaus?

The change in hospital funding with diagnosis related groups (DRG), medical advances as well as demographic changes will call for new quantitative and qualitative standards imposed on German hospitals. Increasing costs and competition in the health care sector requires new and innovative strategies for resource management. Today's policy is mainly defined by rationing and intensified workload. The introduction of DRGs will presumably further constrict management perspectives on pure financial aspects. However, to ensure future development, compassionate services and continued existence of hospitals, a balance of seemingly conflicting perspectives, such as finance, customer, process, learning and growth are of utmost importance. Herein doctors and nurses in leading positions should play a key role in changing management practice. For several years the balanced scorecard has been successfully used as a strategic management concept in non-profit organizations, even in the health care sector. This concept complies with the multidimensional purposes of hospitals and focuses on policy deployment. Finally it gives the opportunity to involve all employees in the original development, communication and execution of a balanced scorecard approach.

[Clinical practice improvement--clinical practice quality improvement of local health care processes]. / Clinical Practice Improvement--Qualitätsverbesserung lokaler medizinischer Versorgungsprozesse.

Clinical Practice Improvement (CPI) is a methodological approach to develop analytically-based protocols to achieve desirable outcomes at the lowest essential cost over the continuum of local care processes. Several elements of the CPI approach make it attractive to clinicians: First, it is a scientific bottom-up approach that places accountability for practice improvement and outcomes with local clinicians. Clinicians are not told to blindly follow a guideline or protocol developed by others, but instead collect data on outcomes, on treatments, and on patient signs and symptoms that support practice change. CPI supports caregivers in making their own decisions about optimal care on the basis of objective statistical evidence gathered in the routine, everyday practice of medicine. Second, CPI measurement encompasses a comprehensive view of the care management process: patient characteristics, process steps, and outcomes. All three classes of data are considered simultaneously. This comprehensive measurement framework provides a basis for meaningful analyses of significant associations, as well as relationships between process and outcome. Third, the CPI methodology focuses on deployment and application. There is a continual emphasis on factors that can be implemented to improve outcomes and the process to achieve these results. This focus on implementation guides who is involved in the design, what data are collected, what questions are answered during analyses, and who designs the protocols or improvements in practice.

Droperidol and 5-HT3-receptor antagonists, alone or in combination, for prophylaxis of postoperative nausea and vomiting. A meta-analysis of randomised controlled trials.

BACKGROUND: Droperidol and 5-HT3-receptor antagonists are among the most potent antiemetics to prevent postoperative nausea and vomiting (PONV). Combinations of these drugs have been used to increase the efficacy of antiemetic treatment. However, so far the quantitative effect of this combination has not been evaluated systematically. METHODS: Results from randomised controlled trials investigating the efficacy of 5-HT3-receptor antagonists or droperidol alone versus the combination of both drugs to prevent PONV were included in a meta-analysis. Studies were systematically searched using Medline, EMBASE, the Cochrane-Library, and by manually screening the reference lists of matching review articles and current issues of locally available peer-reviewed anaesthesia journals. Seven papers with data on granisetron published by Fujii and co-workers were not considered. The main end point in each study was defined as occurrence of nausea, retching, or vomiting within 6 h ("early PONV") and within 48 h ("late PONV") after surgery. The relative risks (RR) and the numbers needed to treat (NNT) of the pooled data with their corresponding 95% confidence intervals (given in parentheses) were calculated using a random effects model. RESULTS: Eight studies with 881 patients (adults: n=801; children (mean age: 8 yr): n=80) were included in the analysis. Droperidol was applied to 340 patients, 5-HT3-receptor antagonists to 198, and 343 were treated with a combination of both drugs. Seven out of these eight studies reported increased antiemetic efficacy of the combination group compared with the single drugs (droperidol and 5-HT3-receptor antagonists respectively). However, in none of the trials did this difference reach statistical significance. When a meta-analytic analysis based on these results was performed the combination of droperidol with a 5-HT3-receptor antagonist was not associated with a significantly increased antiemetic efficacy. In 12 to 13 patients a 5-HT3-receptor antagonist has to be added to droperidol prophylaxis to prevent one additional patient from PONV who would have had suffered from PONV when treated with droperidol alone (RR "early PONV": 1.52 (0.95-2.44); RR "late PONV": 1.24 (0.89-1.74)). Similar results were obtained when the antiemetic effect of adding droperidol to a prophylaxis with 5-HT3-receptor antagonists was analysed. In this case 10 to 12 patients have to be treated with the 5-HT3-droperidol combination instead of with a 5-HT3-receptor antagonist alone to prevent one additional patient from PONV (RR "early PONV": 1.55 (0.68-3.52); RR "late PONV": 1.29 (0.77-2.17)). There were no reports of an increased incidence of adverse effects. CONCLUSION: The data on the combination of droperidol with 5-HT3-receptor antagonists suggest that there is a trend towards increased efficacy of the combination therapy compared to the single drugs. However, so far there are insufficient data to recommend this combination treatment for prophylaxis.

Building a large-scale perioperative anaesthesia outcome-tracking database: methodology, implementation, and experiences from one provider within the German quality project.

The German Society of Anaesthesiology and Intensive Care Medicine evaluates voluntary, standardized, everyday, perioperative anaesthesia outcome measures. A standard minimal data set is collected for national benchmarking. This article reviews the implementation of a data acquisition system in one academic centre that has participated in this long-term nationwide project since its initiation in 1992. The population studied comprised 96,107 patients up to 1997. The overall incidence of anaesthesia-related incidents, events and complications (IEC) was 22%. Results are presented and discussed for 63 different IEC, seven functional system categories and five severity grades. The proposed methodology, using computer-readable records, was suitable for comprehensive and detailed outcome documentation. However, an extensive data validation system was necessary. IEC reporting results were largely dependent on the documentation culture. The future of outcome tracking in routine anaesthesia may lie in multicentre comparisons with multivariate-adjusted risk and comorbidity data from each provider's integrated information system.

The performance of electroencephalogram bispectral index and auditory evoked potential index to predict loss of consciousness during propofol infusion.

UNLABELLED: The bispectral index (BIS) of the electroencephalogram and middle latency auditory evoked potentials are likely candidates to measure the level of unconsciousness and, thus, may improve the early recovery profile. We prospectively investigated the predictive performance of both measures to distinguish between the conscious and unconscious state. Twelve patients undergoing lower limb orthopedic surgery during regional anesthesia additionally received propofol by target-controlled infusion for sedation. The electroencephalogram BIS and the auditory evoked potential index (AEPi), a mathematical derivative of the morphology of the auditory evoked potential waveform, were recorded simultaneously in all patients during repeated transitions from consciousness to unconsciousness. Logistic regression procedures, receiver operating characteristic analysis, and sensitivity and specificity were used to compare predictive ability of both indices. In the logistic regression models, both the BIS and AEPi were significant predictors of unconsciousness (P < 0.0001). The area under the receiver operating characteristic curve for discrete descending index threshold values was apparently, but not significantly (P > 0.05), larger for the AEPi (0.968) than for the BIS (0.922), indicating a trend of better discriminatory performance. We conclude that both the BIS and AEPi are reliable means for monitoring the level of unconsciousness during propofol infusion. However, AEPi proved to offer more discriminatory power in the individual patient. IMPLICATIONS: Both the bispectral index of the electroencephalogram and the auditory evoked potentials index are good predictors of the level of sedation and unconsciousness during propofol infusion. However, the auditory evoked potentials index offers better discriminatory power in describing the transition from the conscious to the unconscious state in the individual patient.

[Meta-analysis of controlled randomized studies on droperidol for prevention of postoperative phase vomiting and nausea]. / Metaanalyse kontrollierter randomisierter Studien zum Einsatz von Droperidol zur Prophylaxe von Ubelkeit und Erbrechen in der postoperativen Phase.

OBJECTIVE: Randomised, controlled trials using prophylactic droperidol to prevent postoperative nausea and vomiting (PONV) were included in a meta-analysis to estimate efficiency and dose-response of treatment. MATERIALS AND METHODS: Studies were systematically extracted from Medline, the manufacturer's database, and a supplemental search of references lists and current issues of locally available anaesthesia journals. Complete prevention of PONV defined as absence of nausea, retching, and vomiting within 6 hours (early PONV) and within 48 hours (late PONV) was chosen as the main end point. Additional information such as dose of droperidol, time and way of administration, and biometric data of the patients were extracted from each study. The pooled relative risk and the number-needed-to treat (NNT) were calculated. RESULTS: A total of 72 studies with 107 comparative subgroups were accepted for analysis according to the prospectively defined criteria. Of these sixty-nine trials reported a lower incidence of PONV with droperidol. The incidence of early and late PONV among the 5370 patients receiving droperidol was 23.4% and 38.2%, respectively. The corresponding incidence among the 3954 control patients was 40.7% and 53.9%. The relative risk for patients receiving prophylactic droperidol of suffering from early PONV was 0.58 and 0.71 for late PONV. The NNT for preventing one patient from PONV was 5.8 and 6.4 for early and late PONV, respectively. Treatment with droperidol was more effective when the baseline risk for PONV was higher than 25% for early PONV and 35% for late PONV. Under these circumstances the NNT was between 2.6 and 5.6. There was no dose response relationship for droperidol when the drug was applied in doses ranging from 0.5 to 300 micrograms.kg-1 body weight. It was not possible to derive reliable information about the incidence of side-effects of the droperidol administration. CONCLUSION: Droperidol is an effective antiemetic drug. The drug can be administered to patients with an increased risk of suffering from PONV without antiemetic prophylaxis. Since a positive dose response is lacking, droperidol should only be administered in doses of 1 mg or less.

Interaction modeling of propofol and sufentanil on loss of consciousness.

STUDY OBJECTIVES: To examine the possible pharmacodynamic interaction of propofol and sufentanil with respect to the induction of loss of consciousness. DESIGN: Prospective, randomized, double-blinded study. SETTING: University hospital. PATIENTS: 30 female, ASA physical status I and II patients undergoing elective gynecologic surgery. INTERVENTIONS: Patients were allocated randomly to receive an individual combination of propofol (1, 2, 3, 4, 5, or 6 micrograms/ml) and sufentanil (0.1, 0.2, 0.3, 0.5, or 1.0 ng/ml) target blood concentrations using target-controlled infusions. MEASUREMENTS AND MAIN RESULTS: Study endpoint was loss of consciousness, which was tested by response to verbal commands and classified as responder or nonresponder, as assessed by the anesthetist, who was blinded to the drugs' target blood concentrations. Nonlinear association (interaction) of both drugs was accomplished with logistic regression analysis using the maximum likelihood method, based principally on the hypothesis of interaction: In [p/(1-p)] = beta 0 + beta 1 x Cprop + beta 2 x Csuf + beta 3 x Cprop x Csuf with a p-value < 0.05 for coefficient estimates considered significant. In the logistic regression model, sufentanil and propofol showed no supra-additive interaction regarding loss of consciousness (p = 0.5916). CONCLUSIONS: Our results give no evidence of additional hypnotic properties of sufentanil compared to the other fentanyl congeners, although logistic regression may be of limited value in modeling interaction of hypnotic-analgesic combinations.

The impact of minor perioperative anesthesia-related incidents, events, and complications on postanesthesia care unit utilization.

UNLABELLED: The German Society of Anesthesiology and Intensive Care Medicine evaluates the standardized and routine reporting of perioperative anesthesia-related incidents, events, and complications (IEC). As part of the long-term project's definitions, IECs are graded according to severity and to their clinical consequence on further postanesthesia monitoring and treatment demands. The adult study population of our department comprised 37,079 patients recovering from anesthesia in a tertiary university hospital from July 1992 through June 1997. Cardiac, obstetric, craniotomy, thoracotomy, laparotomy, and emergency operations were excluded. Multivariate regression statistics were used to calibrate the impact of minor graded IECs on necessary postanesthesia care unit (PACU) utilization. Minor and severe IECs appeared in 22.1% and 0.2% of the patients. A minor IEC occurrence was a statistically significant (P < 0.001) predictor of PACU utilization in a multivariate regression model. The mean difference of PACU length of stay for patients with minor IECs was prolonged by a range of 6%-26% when adjusted for coexisting severity features such as age, gender, ASA physical status, and type and duration of anesthesia and surgery. We conclude that the IEC methodology integrates epidemiologic information about perioperative anesthesia outcome. Minor but frequently occurring IECs have an impact on PACU utilization and are thus important to measure and follow. IMPLICATIONS: It is desirable to know how anesthesia-related incidents, events, and complications influence postanesthesia care. Analyses of standardized and routine perioperative outcome data, as proposed by the German anesthesia quality project, can show that even minor events consume relevant resources and are thus important to measure and follow.

Peri-operative tolerance to large-dose 6% HES 200/0.5 in major urological procedures compared with 5% human albumin.

We studied the long-term efficacy and safety of medium-molecular-weight hydroxyethyl starch (HES) administered in doses above 20 ml.kg-1 during major blood replacement therapy. Blood replacement for 50 patients used 6% HES 200/0.5 (HES group) or 5% albumin (ALB group) and additional blood components according to a defined protocol. We compared safety, efficacy and costs in 4 peri-operative days. Colloid administration on the day of surgery was 38.4 ml.kg-1 (HES group) and 35.1 ml.kg-1 (ALB group). Haemodynamic, coagulation and renal function parameters were similar. Although total serum protein was still different on the third postoperative day (53.45 gl-1 (HES group) and 60.6 gl-1 (ALB group) (p < 0.01)) the colloid osmotic pressure always remained above 19.5 (2.5) mmHg (HES group). Blood loss (3810 (1632) ml (HES group) and 3455 (1733) ml (ALB group)) and the requirement for blood components was comparable. Costs were reduced by 35% (p < 0.05) in the HES group. We conclude that using 6% HES 200/0.5 as the only colloid for treatment even of large blood loss is a safe and economic alternative to albumin.

[The incidence of perioperative events with optimized documentation discipline]. / Inzidenz perioperativer Ereignisse bei optimierter Dokumentationsdisziplin.

AIM: The German Society of Anesthesiology and Intensive Care Medicine evaluated the standardized reporting of perioperative anaesthesia-related incidents, events, and complications (IEC). As part of the data validation efforts, the problem of variation in documentation procedure was evaluated. METHODS: A study group of particularly motivated and instructed residents and attendants was scrutinized at a University teaching hospital from April through June 96. IEC assessment was completed according to the Society's definitions. RESULTS: Out of 4242 anaesthetics during the study period 839 (19.8%) were completed by the study group. In the univariate analysis, the incidence of IECs was significantly (P < 0.001) more reported by the physicians studied (36.4%) than by the control group (18.6%). In a multivariate analysis, while adjusting for all covariables, reported incidence of IEC was 2.4-fold significantly increased (P < 0.001). CONCLUSIONS: This study is another step in validating the assessment of IECs. The results gain importance with respect to upcoming nationwide quality comparisons among anaesthesia providers. In addition, they give a better estimate of economic implications from IECs within the institution.

A cross-validated multifactorial index of perioperative risks in adults undergoing anaesthesia for non-cardiac surgery. Analysis of perioperative events in 26907 anaesthetic procedures.

OBJECTIVE: To develop a severity index of anaesthetic risk that predicts relevant perioperative adverse events in adults. DESIGN: Prospective cross-sectional study. SETTING: Department of anaesthesiology at one university hospital. PATIENTS: 26907 consecutive anaesthetic procedures in patients over 15 years of age and a complete preoperative evaluation. Patients undergoing cardiac and obstetric surgery were excluded. MEASUREMENTS AND MAIN RESULTS: Demographic data, preoperative health status, type of anaesthesia, operative procedures, and perioperative incidents (standardised on a national basis) were acquired by means of a computerised anaesthetic record system. Occurrence of at least one perioperative event with impact on postanaesthetic care was computed by a multivariate logistic regression model against 17 variables with different characteristics representing possible risk factors. Fourteen variables proved to be independent risk factors. The weighting of the variables was expressed in scores which added up to form a simple index for each patient. Patients without major risk factors (0-10 points) had a 0.3% risk of suffering from a relevant incident. Patients with more than 60 points had a 28.6% risk. The results were well demonstrated by cross-validation. CONCLUSIONS: The index seems to reflect the risk of relevant perioperative incidents. It can be used for audit purposes. In daily routine, the index could focus our attention on patients with increased perioperative risk. However, it is limited in detecting particular constellations of factors which interact on each other with regard to perioperative risk.

Clinical utility of EEG parameters to predict loss of consciousness and response to skin incision during total intravenous anaesthesia.

We studied 30 female patients undergoing elective surgery, to assess the reliability of electroencephalogram spectral edge frequency and median frequency to predict loss of consciousness and movement in response to skin incision during total intravenous anaesthesia. Each patient received a different combination of propofol (1, 2, 3, 4, 5 or 6 micrograms.ml-1) and sufentanil (0.1, 0.2, 0.3, 0.5 or 1.0 ng.ml-1) target concentrations for induction of anaesthesia using target controlled infusions, assigned randomly. In a logistic regression model, spectral edge frequency was a significant determinant of both loss of consciousness (p = 0.0006) and movement to skin incision (p = 0.0044), whereas for median frequency no significant prediction model could be established. The probabilities of 50% and 95% no response for spectral edge frequency were 13.4 Hz and 6.8 Hz, respectively. The variability of the data limited the predictive value, so that spectral edge frequency was a poor predictor and median frequency was no predictor of response in the individual patient during total intravenous propofol/sufentanil anaesthesia.

Assessment of the safety and tolerance of 6% hydroxyethyl starch (200/0.5) solution: a randomized, controlled epidemiology study.

UNLABELLED: None of the natural and synthetic colloids currently available is free from the risk of side effects. This study was performed to contribute to the epidemiology of adverse reactions of the widely used 200/0.5 hydroxyethyl starch 6% solution (HES). Study end points were anaphylactoid reactions during preanesthesia infusion and perioperative course, and pruritus 5 days postoperatively (clinical examination and inquiry) and 8 wk after application (mailed patient questionnaire). We consecutively randomized 750 patients undergoing minor elective surgery into two parallel groups treated with HES (from two different manufacturers) and one control group treated with lactated Ringer's solution. The study population was well matched among the groups and consisted of patients of both sexes, aged 18-95 yr, ASA physical status I-III. No drug-related anaphylactoid reactions were detected during either of the observation intervals. There was no episode of pruritus after the fifth postoperative day. Incidence of pruritus after 8 wk was quite frequent but not significantly different (chi2 test, P = 0.77): 9.1% and 12.0% in the two HES groups and 11.5% in the lactated Ringer's solution control group. Except for pruritus, we conclude that HES was associated with no more complications than lactated Ringer's solution. IMPLICATIONS: Anaphylactoid reactions and pruritus (itching) after the administration of a 6% hydroxyethyl starch (200/0.5) versus lactated Ringer's solution were assessed in a prospective, randomized, controlled study. There were no differences, although there was a more than 10% incidence of pruritus in both groups.

Validation of routine incidence reporting of one anaesthesia provider institution within a nation-wide quality of process assessment program.

In 1992, a long-term project was launched by the German Society for Anaesthesiology and Intensive Care Medicine to render quality comparisons between anaesthesia providers. As one of the first volunteer centres, we established the standardised reporting of perioperative anaesthesia related incidents, events, and complications (IEC) in any routine anaesthetic procedure performed. This present study is aimed to explore the longitudinal stability of IEC recordings in one institution, which should be a prerequisite for valid external comparisons. Methods. The analyses were completed on an adult population of 49945 consecutive anaesthetic procedures with peripheral surgery from July 1992 until December 1996. Attribute quality control charts with monthly samples of an average of 954 anaesthetics were used to assess statistical variability of specific IEC incidences. Results. Average proportions were 20% for moderate IEC, 2.7% for severe IEC, 13% for moderate cardio-vascular IEC, 1.3% for severe cardio-vascular IEC, and 2.4% for respiratory IEC. Moderate IEC proportions showed considerable variability during the study period. A series of excess proportions was probably due to educational activities on documentation discipline. In contrast, clinically severe IEC proportions were rather stable. Stability of cardio-vascular IEC proportions resembled the picture of the overall IEC assessment. Monthly respiratory IEC proportions showed smallest variability during the study period. Discussion. Use of the quality control statistics is suitable to distinguish random from systematic influence on quality indicators. IEC recordings that are not specific in pathophysiologic type or are of low grade of clinical severity, are heavily dependent on systematic documentation features. We assume that peak values, such as in times of optimised documentation discipline, better reflect reality than average values because missing reporting is much more likely than false positives.

Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia.

BACKGROUND: The prevalence of respiratory diseases in smokers and nonsmokers and the incidence of perioperative respiratory events (PREs) were investigated for patients undergoing general anaesthesia. The aim was to quantify well-known problems and to identify possible new associations between smoking and PREs. METHODS: From July 1992 to December 1994, risk factors, demographic data, and PREs were documented by an automatically readable anaesthetic record (ARAR). PREs were used as defined by the German Society of Anaesthesiology and Intensive Care. RESULTS: Of 26961 subsequent anaesthesias in adults, 7122 (26.4%) were performed in smokers with a prevalence of chronic bronchitis of 23.3% (4.8% in nonsmokers). 1573 PREs occurred in 1397 (5.2%) of all anaesthetics. 459 events concerned intubation problems and problems in technical airway management. 1114 specific respiratory events (SPREs) like re-intubation, laryngospasm, bronchospasm, aspiration, hypoventilation/hypoxaemia and others had a total incidence of 5.5% in smokers and 3.1% in nonsmokers. The relative risk (RR) of SPREs was 1.8 in all smokers, 2.3 in young (16-39 years) smokers, and 6.3 in obese young smokers. The RR of perioperative bronchospasm was 25.7 in young smokers with chronic bronchitis. CONCLUSION: The impact of smoking on perioperative respiratory problems should make anaesthetists take this widespread preoperative condition seriously, particularly in young adults. The presented method of incident reporting (based on a national classification) could contribute to future research in anaesthetic epidemiology.

Epidemiology of acute renal failure and outcome of haemodiafiltration in intensive care.

OBJECTIVE: To examine the epidemiology of acute renal failure (ARF) and to identify predictors of mortality in patients treated by continuous venovenous haemodiafiltration (CVVHDF). DESIGN: Uncontrolled observational study. SETTING: One intensive care unit (ICU) at a surgical and trauma centre. PATIENTS: A consecutive sample of 3591 ICU treatments. MEASUREMENTS AND RESULTS: Demographic data, indications for ICU admission, severity scores and organ system failure at the beginning of CVVHDF were set against the occurrence of ARF and ICU mortality. 154 (4.3% of ICU patients and 0.6% of the hospital population) developed ARF and were treated with CVVHDF. Higher American Society of Anaesthesiologists (ASA) status and higher Apache II score were associated with ICU incidence of ARF. However, these criteria were not able to predict outcome in ARF. A simplified predictive model was derived using multivariate logistic regression modelling. The mortality rates were 12% with one failing organ system (OSF), 38% with two OSF, 72% with three OSF, 90% with four OSF and 100% with five OSF. The adjusted odds ratio (OR) of death was 7.7 for cardiovascular failure, 6.3 for hepatic failure, 3.6 for respiratory failure, 3.0 for neurologic failure, 5.3 for massive transfusion and 3.7 for age of 60 years or more. CONCLUSION: General measures of severity are not useful in predicting the outcome of ARF. Only the nature and number of dysfunctioning organ systems and massive transfusion at the beginning of CVVHDF and the age of the patients gave a reliable prognosis in this group of patients.

[Perioperative monitoring of the course of anesthesia, the postanesthesia visit and inquiry of patient satisfaction. A prospective study of parameters in process and outcome quality in anesthesia]. / Perioperative Anästhesieverlaufsbeobachtungen, postanästhesiologische Visite und Befragung zur Patientenzufriedenheit.Eine prospektive Studie zu Parametern der Prozess und Ergebnisqualität in der Anästhesie.

PURPOSE: This study is an investigation into the results of reporting on incidents during and after anaesthesia, to reveal any possible associations between intra-procedural and final outcome. The study contributes to the quality assurance project of the German Society of Anaesthesiology and Intensive Care (DGAI). We adjusted and tabulated our data for preoperative risk and for different methods of anaesthesia. This nation-wide DGAI project was launched to compare clinical institutions in accordance with German social legislation. METHOD: DGAI recommends standardised documentation of parameters representing quality of process (QP) defined by a 63-items list, during every anaesthesia course. Additionally, quality of outcome parameters (QO) defined by a 64-items list should be assessed by an anaesthetist during a standardised postoperative ward round by means of spot checks. A questionnaire covering subjective complaints (SC) and patient satisfaction, is optional. The combination of these tools was evaluated during a 5-month period in every patient (n = 282) on a traumatological surgery ward. RESULTS: QP and QO showed a significant association (p < 0.0001). The incidence of both parameters increases according to risk factors like age and ASA physical status. This was not significant in respect of the type of anaesthesia (p = 0.20). Whereas perioperative QP parameters were less frequent in regional versus general anaesthesia (p < 0.0001), there was no postoperative difference in QO as seen by the anaesthetist (p = 0.20). However, postoperative SC were less frequent with regional anaesthesia (p < 0.0001). The association of QO and SC was mot significant (p = 0.24). There was comparable preoperative morbidity (p = 0.74) for both anaesthetic procedures. 96.5% of all patients expressed overall satisfaction. Despite this fact, nausea (25%), vomiting (29%), thurst (29%) and particularly wound pain (33%) were frequent. CONCLUSIONS: Quality parameters assessed by anaesthetists and patients are independent in respect to their frequency. For this purpose, anaesthesiological quality assurance must focus on both the anaesthetist and the patient. As clinical consequence, we suggest establishing an interdisciplinary post-anaesthesia service. Acceptance by, and collaboration between, the surgical disciplines are indispensable especially for a successful application of effective pain and antiemetic therapy.

Effects of graded doses of vasopressin on median fibrillation frequency in a porcine model of cardiopulmonary resuscitation: results of a prospective, randomized, controlled trial.

OBJECTIVE: To assess the effects of graded doses of vasopressin vs. saline on median fibrillation frequency and defibrillation success in a porcine model of cardiopulmonary resuscitation. DESIGN: Prospective, randomized, controlled trial. SETTING: Animal laboratory in a university medical center. SUBJECTS: Twenty-eight domestic pigs (body weight between 26 and 31 kg), aged 12 to 14 wks. INTERVENTIONS AND MAIN RESULTS: After 4 mins of ventricular fibrillation and 3 mins of closed-chest cardiopulmonary resuscitation, the animals were allocated to receive either 0.2 U/kg of vasopressin (n = 7), 0.4 U/kg of vasopressin (n = 7), 0.8 U/kg of vasopressin (n = 7), or 10 mL of saline (n = 7, control group). Using radiolabeled microspheres, myocardial blood flow rates during cardiopulmonary resuscitation-before drug administration and 90 secs and 5 mins after drug administration-were as follows in the four groups (mean +/- SEM): 18.8 +/- 0.9, 17.2 +/- 1.1, and 14.6 +/- 1.4 mL/min/100 g in the control group; 17.8 +/- 2.2, 49.6 +/- 6.3 (p < .01 vs. control group), and 29.4 +/- 3.1 mL/min/100 g (p < .05 vs. control group) in the group receiving 0.2 U/kg of vasopressin; 17.1 +/- 1.0, 52.4 +/- 7.5 (p < .01 vs. control group), and 52.2 +/- 5.8 mL/min/100 g (p < .001 vs. control group) in the group receiving 0.4 U/kg of vasopressin; and 18.1 +/- 1.6, 94.9 +/- 9.2 (p < .001 vs. control group), and 57.2 +/- 6.3 mL/min/100 g (p < .001 vs. control group) in the group receiving 0.8 U/kg of vasopressin. Using spectral analysis, median frequencies of ventricular fibrillation-before drug administration and 90 secs and 5 mins after drug administration-were as follows in the four groups: 9.6 +/- 0.4, 8.5 +/- 0.8, and 7.2 +/- 1.0 Hz in the control group; 9.7 +/- 0.5, 12.9 +/- 0.8 (p < .01 vs. control group), and 12.7 +/- 0.8 Hz (p < .001 vs. control group) in the group receiving 0.2 U/kg of vasopressin; 10.3 +/- 0.2, 12.7 +/- 0.9 (p < .01 vs. control group), and 12.8 +/- 0.7 Hz (p < .001 vs. control group) in the group receiving 0.4 U/kg of vasopressin; and 10.0 +/- 0.9, 14.1 +/- 0.9 (p < .001 vs. control group), and 12.5 +/- 0.9 Hz (p < .001 vs. control group) in the group receiving 0.8 U/kg of vasopressin at the same points in time. Median frequency before the first defibrillation attempt was 12.3 +/- 0.4 Hz in the resuscitated animals (n = 19) and 8.2 +/- 1.2 Hz in the nonresuscitated animals (n = 9) (p < .001). CONCLUSIONS: This study contributes to the characterization of the effect of increasing global myocardial blood flow on median fibrillation frequency after administration of graded doses of vasopressin in a porcine model of ventricular fibrillation. Interventions such as vasopressor treatment that increase fibrillation frequency improve the chance of successful defibrillation.