Unrestricted drinking before surgery: an iterative quality improvement study.

Average pre-operative fasting times for clear liquids are many times longer than those specified in national and international guidelines. We sought to decrease fasting times by applying a quality management tool aimed at continuous improvement. Through the application of iterative 'plan-do-study-act' cycles, tools to reduce pre-operative liquid fasting times were developed and applied, the effects measured, analysed and interpreted and the conclusions used to inform the next plan-do-study-act cycle. The first step was the introduction of unrestricted drinking until the patient was called to the operating theatre, with training of anaesthetic staff, adaption of local standard procedures and verbal information for patients. This did not result in short liquid fasting times, median (IQR [range]) 12.0 (9.5-14.0 [0.8-23.5]) h. In the second cycle, fasting cards were introduced as a subliminal written training tool for staff, patients and their relatives. This enabled short liquid fasting times to be achieved for outpatients (2.6 (0.8-5.1 [0.3-16]) h) and pre-admission patients (3.4 (1.8-9.4 [0.2-17.2]) h), but not for inpatients (6.5 (2.0-11.7 [0.2-16.2]) h). The third cycle included lectures for ward staff, putting up information posters throughout the hospital, revision of all written materials and provision of screencasts on the homepage for staff and patients. This decreased median liquid fasting time to 2.1 (1.2-3.8 [0.4-18.8]; p < 0.0001) h, with inpatients having the shortest fasting time of 1.4 (1.1-3.8 [0.4-18.8]) h. Repeated quality improvement cycles, adapted to local context, can support sustained reductions in pre-operative liquid fasting times.

[Live-threatening bronchospasm during anesthesia induction : when pure routine becomes a nightmare]. / Lebensbedrohlicher Bronchospasmus bei Narkoseeinleitung : Wenn reine Routine zum Albtraum wird.

This article reports a case of live-threatening respiratory failure during induction of anesthesia. An 18-year-old female was admitted to hospital for an axillary abscess incision on a public holiday. The patient had a history of asthmatic episodes and an allergy to milk protein and 2 years previously an asthmatic attack had possibly been treated by mechanical ventilation. Retrospectively, this event turned out to be a cardiac arrest with mechanical ventilation for 24 h. During induction of anesthesia the patient suddenly developed massive bronchospasms and ventilation was impossible for minutes. Oxygen saturation fell below 80% over a period of 12 min with a lowest measurement of 13%. The patient was treated with epinephrine, prednisolone, antihistamine drugs, ß(2)-agonists, s-ketamine and methylxanthines and 15 min later the oxygen saturation returned to normal values. After mild therapeutic hypothermia for 24 h mechanical ventilation was still required for another 4 days. The patient recovered completely and was discharged home on day 19. Initially propofol was suspected of having caused an anaphylactic shock but in retrospect, the diagnosis of near fatal asthma was more likely. The onset of the event was facilitated by the patient playing down the history of asthmatic episodes due to a strong wish for independency and negation of the severity of the disease.

[Multiorgan failure due to chronic granulomatous disease]. / Multiorganversagen bei septischer Granulomatose.

A 21-year-old male patient developed an acute septic clinical picture with intra-abdominal abscesses and multiorgan failure. The underlying disease was chronic granulomatous disease, an inherited disorder of granulocyte function caused by failure of intracellular superoxide production. In spite of surgical procedures and a calculated antibiotic and antimycotic therapy, the patient died within a few days from septic shock. This case report describes the typical problems of patients with a congenital immunodeficiency who grow out of the care of highly specialised pediatric-immunological departments.

[Guide dogs--a partnership between man and beast. A German tragedy, that needs friends of animals and human beings]. / Blindenführhunde--Partnerschaft zwischen Mensch und Tier. Eine deutsche Tragödie, die Tier- und Menschenfreunde braucht.

The method and special problems in the training of guide-dogs in Germany compared to other European countries are described. Though the guide-dog was introduced in Germany after the First World War, the training of guide-dogs is now in a bad way, because the lack of demands for qualifications of the instructors.