Clinical information systems and quality of care in the intensive care unit.

The introduction of new medical technology needs to be associated with the assessment of the value of this technology in patient care. Traditional outcome measures of quality in health care (such as survival, cost, and "quality of life") may be of little value in assessing quality of patient care at the bedside. A model of quality in bedside patient care is presented and used in the assessment of the impact of introducing a bedside information system on patient care quality.

Intraoperative patient-controlled analgesia: an alternative to physician administration during outpatient monitored anesthesia care.

Outpatients undergoing minor diagnostic and therapeutic procedures associated with intermittent discomfort are frequently given bolus injections of intravenous opioid analgesics. In a group of 80 healthy women undergoing vaginal ovum pickup procedures, we evaluated patient-controlled administration of alfentanil using a patient-controlled analgesia device (with a lockout interval of 3 min) as an alternative to conventional physician-controlled administration. The two alfentanil administration techniques were equally effective in providing intraoperative analgesia. The average alfentanil dosage requirements were 1.49 +/- 0.50 and 1.46 +/- 0.55 micrograms.kg-1.min-1 (mean +/- SD) in the physician- and patient-controlled groups, respectively. The incidence of postoperative nausea was the same in both treatment groups (8%). Even with the mandatory lockout interval, intraoperative patient-controlled administration of alfentanil was comparable to physician-controlled administration with respect to patient comfort and satisfaction during vaginal ovum pickup procedures.

A controlled oximetric evaluation of inhalational, opioid and epidural analgesia in labour.

The effects on patient oxygenation of nitrous oxide, narcotic and epidural analgesia in labour were evaluated using pulse oximetry. Five groups of ten patients received either no analgesia (Control, Group 1), an epidural block alone (Group 2), nitrous oxide in oxygen alone (Group 3), intramuscular pethidine (Group 4), or nitrous oxide in oxygen combined with intramuscular pethidine (Group 5). Derived parameters included the maximum (MAX), minimum (MIN), average maximum (AV MAX), and average minimum (AV MIN) arterial haemoglobin oxygen saturation (SaO2), and differences between maxima and minima (MAX-MIN). There was a statistically significant difference between Group 1 and Group 5 for MIN, AV MIN and MAX-MIN SaO2 (P less than 0.05). All other groups showed no significant difference in any parameter when compared with the control group. The results are discussed with reference to normal and disordered maternal physiological changes in pregnancy. It is suggested that nitrous oxide should not be used for analgesia in labour where there is concern about maternal, placental or foetal reserve.

A theoretical mechanism for massive supraglottic swelling following carotid endarterectomy.

Potentially life-threatening massive supraglottic swelling is occasionally seen in patients presenting with neck swelling following carotid endarterectomy. This is considered to be a distinct clinical entity, and a theoretical mechanism based on a review of the relevant anatomy and physiology is postulated.

Coronary vasospasm during percutaneous trigeminal rhizotomy.

A case of myocardial infarction as a result of coronary vasospasm during percutaneous trigeminal rhizotomy is presented. Potential consequences of the profound sympathetic response during this procedure are discussed. Invasive haemodynamic monitoring as well as prophylaxis with nitrates and calcium antagonists may be useful in patients prone to coronary vasospasm who undergo this procedure.

Diffusion hypoxia: a reappraisal using pulse oximetry.

Sixty healthy surgical patients were monitored during surgery with a pulse oximeter. At the completion of the operation, nitrous oxide and oxygen were discontinued abruptly in 50 of these patients. During air breathing, a small drop in arterial hemoglobin oxygen saturation (SaO2), to about 4% below preoperative values, was observed in all patients. In 10 patients, only oxygen was given before removal of the mask. There was no sudden drop in SaO2 in these patients, but by 5 minutes after discontinuation there was no difference between the two groups of patients--SaO2 was reduced 2 to 3% below preoperative values in both groups. For patients without cardiopulmonary disease, the phenomenon of "diffusion hypoxia" is a mild and transient event. Clinically significant hypoxemia (SaO2 less than 90%) after removal of nitrous oxide/oxygen at the completion of the anesthetic occurred in 3 patients (6%) and was associated with airway obstruction in each case.

Anaesthetic-related recovery room complications.

A prospective survey was conducted over a one-month period in all surgical patients admitted to the recovery room of a university-affiliated teaching hospital. Complications arising in the recovery room were documented by the nursing staff according to predefined criteria and were critically evaluated. A total of 443 patients were admitted to the recovery room and in 133 (30%) of these, some form of complication was noted. There were 86 patients with complications referable to the central nervous system, 68 with abnormal cardiovascular parameters, 24 with nausea and/or vomiting and 10 with abnormalities referable to the respiratory system. Many patients had more than one complication. The results are discussed, with emphasis on their relevance to current anaesthetic practice. It is concluded that many patients exhibit recovery room complications when they are specifically sought. The recovery period remains a time of great potential danger to patients.

The Australian skier: his environment, injuries, and some aspects of casualty transport.

Skiing in Australia is not a new phenomenon. Since the early 1890s, when miners in the snowfield regions discovered snowshoeing using wooden palings, the craze has steadily grown in Australia, as in other countries. The Australian winter occurs six months out of phase with the northern winter, but we also have other unique problems in regard to skiing conditions, and therefore possibly ski trauma. This presentation discusses first our local skiing conditions and then presents some statistics from one of our major resorts. Two aids used by our emergency services may also be of interest.