Crisis management during anaesthesia: water intoxication

BACKGROUND

Irrigation of closed body spaces may lead to substantial perioperative fluid and electrolyte shifts. A syndrome occurring during transurethral resection of prostate (TURP), and a similar syndrome described in women undergoing transcervical endometrial ablation (TCEA) are both characterised by a spectrum of symptoms which may range from asymptomatic hyponatraemia to convulsions, coma, and death. Such potentially serious consequences require prompt recognition and appropriate management of this "water intoxication" syndrome.

OBJECTIVES

To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for water intoxication, in the management of this syndrome occurring in association with anaesthesia.

METHODS

The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved.

RESULTS

From the first 4000 incidents reported to AIMS, 10 reports of water intoxication were identified, two from endometrial ablations under general anaesthesia and eight from male urological procedures under spinal anaesthesia. The "core" crisis management algorithm detected a problem in seven cases; however, it was deficient in dealing with neurological presentations. Diagnosis of the cause of the incident would have required a specific water intoxication sub-algorithm in eight cases and a hypotension algorithm in a further two cases. Corrective strategies also required a specific sub-algorithm in eight cases, while the hypotension and cardiac arrest sub-algorithms were required in conjunction with the water intoxication sub-algorithm in the remaining two.

CONCLUSION

This relatively uncommon problem is managed poorly using the "core" crisis management sub-algorithm and requires a simple specific sub-algorithm for water intoxication.

Crisis management during anaesthesia: vascular access problems

BACKGROUND

In confronting an evolving crisis, the anaesthetist should consider the vascular catheter as a potential cause, abandoning assumptions that the device has been satisfactorily placed and is functioning correctly.

OBJECTIVES

To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for vascular access problems, in the management of crises occurring in association with anaesthesia.

METHODS

The potential performance of a structured approach was evaluated for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS).

RESULTS

There were 128 incidents involving problems related to vascular access. The structured approach begins distally, checking the infusion device or fluid (12 incidents), moving proximally by way of the fluid giving line (10), the line deadspace (8), then the catheter/skin interface (65), and on to the peripheral vascular tree (3) and central venous space (23), and finally, the interface of the vascular access system and the attending staff (7). The approach was able to accommodate all the vascular access problems among the first 4000 incidents reported to AIMS.

CONCLUSION

The approach has potential as an easily remembered and applied clinical tool to lead to early resolution of vascular access problems occurring during anaesthesia.

Pneumococcal vaccines for children and adults with bronchiectasis

BACKGROUND

Bronchiectasis is increasingly recognized as a major cause of respiratory morbidity especially in developing countries. Even in affluent countries, bronchiectasis is increasingly seen in some community subsections (e.g. Aboriginal communities) and occurs as a comorbidity and disease modifier in respiratory diseases such as chronic obstructive pulmonary disease (COPD). Respiratory exacerbations in people with bronchiectasis is associated with reduced quality of life, accelerated pulmonary decline, hospitalisation and even death. Conjugate pneumococcal vaccine is part of the routine infant immunisation schedule in many countries. Current recommendations for additional pneumococcal vaccination include children and adults with chronic suppurative disease.

OBJECTIVES

To evaluate the effectiveness of pneumococcal vaccine as routine management in children and adults with bronchiectasis in (a) reducing the severity and frequency of respiratory exacerbations and (b) pulmonary decline.

SEARCH STRATEGY

The Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases were searched by the Cochrane Airways Group. Pharmaceutical manufacturers of pneumococcal vaccines were also contacted. The latest searches were performed in October 2006.

SELECTION CRITERIA

All randomised controlled trials that utilised pneumococcal vaccine on children and adults with bronchiectasis. All types of pneumococcal vaccines were included.

DATA COLLECTION AND ANALYSIS

Results of searches were reviewed against pre-determined criteria for inclusion. No eligible trials were identified and thus no data was available for analysis. One small non-randomised controlled trial in children was reported.

MAIN RESULTS

No randomised controlled trials pertaining effectiveness of pneumococcal vaccine as routine management in children and adults with bronchiectasis were found. A benefit in elimination of Strep. pneumoniae in the sputum was found in a non-randomised trial in children but no clinical effect was described.

AUTHORS' CONCLUSIONS

At present, there is a lack of reliable evidence to support or refute the routine use of pneumococcal vaccine as routine management in children and adults with bronchiectasis. Randomised controlled trials examining the efficacy of this intervention using various vaccine types in different age groups are needed. Until further evidence is available, it is recommended that health providers adhere to national guidelines.

Invasive Haemophilus influenzae disease in Alaskan residents aged 10 years and older before and after infant vaccination programs

CONTEXT

The introduction of Haemophilus influenzae type b (Hib) vaccination of children has led to a decline in incidence of Hib disease in young Alaskan children. However, the impact of vaccination on unimmunized Alaskan adolescents and adults has not been studied.

OBJECTIVE

To characterize trends in incidence of and mortality due to invasive H influenzae disease in Alaskan residents aged 10 years and older prior to and after the introduction of a statewide Hib infant vaccination program.

DESIGN AND SETTING

Population-based, descriptive correlational study conducted 1980-1996 in Alaska.

SUBJECTS

One hundred twenty-nine individuals (31 Alaska Natives and 98 nonnative Alaska residents) aged 10 years and older in whom H influenzae was cultured from a normally sterile site.

MAIN OUTCOME MEASURES

Incidence of H influenzae infection before (1980-1990) vs after (1991-1996) vaccination program initiation; serotype, biotype, and beta-lactamase production of isolates.

RESULTS

The overall annual incidence of invasive H influenzae in those aged 10 years and older declined 33%, from 2.1 per 100,000 persons per year to 1.4 per 100,000 persons per year (P=. 03) after initiation of statewide infant Hib vaccination programs in 1991. This reduction appeared to be the result of a decrease in serotype b disease (82%; P<.001). Infection with other H influenzae serotypes and nontypeable strains increased from 0.5 per 100,000 persons per year to 1.1 per 100,000 persons per year (P=.01). Incidence declined from 4.2 per 100,000 persons per year to 1.2 per 100,000 persons per year in Alaska Natives (P=.005) and from 1.7 per 100,000 persons per year to 1.4 per 100,000 persons per year in nonnative Alaska residents (P=.37). Pneumonia (43%), sepsis (26%), and meningitis (16%) were the most common clinical presentations. Alcohol/drug abuse was comorbid in 15% of patients, while 13% of patients were pregnant women. beta-Lactamase production occurred in 35% of isolates and was stable throughout the surveillance. The overall case-fatality rate was 15%.

CONCLUSION

The overall statewide incidence of invasive H influenzae infections in unimmunized persons aged 10 years and older decreased after the initiation of an infant Hib vaccine program, perhaps by decreasing Hib carriage in child reservoirs. An increase in non-serotype b strains was observed. This trend justifies the need for continued surveillance of invasive disease caused by H influenzae. JAMA. 2000.

Severe respiratory syncytial virus disease in Alaska native children. RSV Alaska Study Group

Hospitalization rates for respiratory syncytial virus (RSV) infection range from 1 to 20/1000 infants. To determine the rate and severity of RSV infections requiring hospitalization for infants in the Yukon-Kuskokwim (YK) Delta of Alaska, a 3-year prospective surveillance study was conducted. The annual rate of RSV hospitalization for YK Delta infants <1 year of age was 53-249/1000. RSV infection was the most frequent cause of infant hospitalization. RSV disease severity did not differ among non-high-risk infants in the YK Delta and at Johns Hopkins Hospital (JHH). On average, 1/125 infants born in the YK Delta required mechanical ventilation for RSV infection. During the peak season, approximately $1034/child <3 years of age was spent on RSV hospitalization in the YK Delta. In YK Delta infants </=6 months old, RSV microneutralizing antibody titers <1200 were associated with severe disease (odds ratio=6.2, P=.03). In the YK Delta and at JHH, newborns may be at greater risk for severe RSV illness than previously thought.

Laparoscopic cholecystectomy as a day surgery procedure

Outcome is presented for 40 consecutive laparoscopic cholecystectomies performed in a public teaching hospital day surgery unit. The unanticipated hospital admission rate on the day of surgery was 17.5% (seven patients) and the majority of these (12.5%; five patients) were due to surgery-related considerations. Two other admissions were due to nausea and vomiting. One patient was admitted to hospital on the second postoperative day with nausea and vomiting. Procedure duration for the day cases averaged 98 minutes (SD25; range 60-167). Recovery room times before discharge averaged 272 minutes (SD 58; range 125-365). Each day surgery patient averaged 3.3 postoperative home visits from community nurses. Most patients (94%) mobilized at home by the second postoperative day and 85% resumed normal activities of daily living by two weeks. At follow-up, 25 patients (76%) stated they were happy to spend the first night at home, but seven (21%) would have preferred to remain in hospital for the first postoperative night. Laparoscopic cholecystectomy can be performed successfully as a day-case procedure, but long operating and recovery room times and potentially high admission rates suggest that these factors should be considered in cost equations for day-case management of this procedure.

Hospitalizations for respiratory syncytial virus infection in Alaska Native children

To characterize the epidemiology of Alaska Native children hospitalized for respiratory syncytial virus infections, we reviewed records of hospitalizations during the winter seasons of 1991 to 1992 and 1992 to 1993 at a hospital in Anchorage and a rural hospital in the Yukon Kuskokwim Delta (YKD) region of southwestern Alaska. The median age of hospitalization for respiratory syncytial virus infection was 2 months of age for YKD residents and 4.5 months for Anchorage residents. Sixteen percent of the hospitalized YKD children were less than 1 month of age, whereas the same was true for only 3% of the Anchorage children. Eight percent of the YKD patients required mechanical ventilation, whereas none of the Anchorage patients required ventilation. The median hospital stay was 4.8 days for YKD patients and 3.2 days for Anchorage patients. Hospitalization rates for infants less than 1 year of age were 33/1000 for Alaska Natives in Anchorage and 100/1000 for those in the YKD region. The extremely high hospitalization rate, especially among very young infants in the rural YKD region, points to a need for early preventive efforts.

Decline of Haemophilus influenzae type b disease in a region of high risk: impact of passive and active immunization

Haemophilus influenzae type b (Hib) is a major cause of serious childhood bacterial infections. Before 1989 Alaska Native infants in the Yukon Kuskokwim Delta (YKD) had the highest recorded Hib disease rate, 2960:100,000 in children less than 1 year of age with 6 to 35 (mean, 13) cases/year between 1980 and 1988. In July, 1989, Alaska Area Native Health Service initiated a passive immunization project in the YKD using bacterial polysaccharide immunoglobulin (BPIG) administered at 3-month intervals to prevent Hib infections in infants less than 13 months of age. On January 1, 1991, after licensure of Hib conjugate vaccines for infants, the program was modified to a passive-active strategy using BPIG at birth and PedvaxHIB at 2, 4 and 12 months of age. Between July 1, 1989, and December 31, 1990, 80% of YKD children less than 1 year of age received at least 1 dose of BPIG. During this period there were 7 Hib cases in this age group, but only 1 of the cases had received any BPIG. Between January 1, 1991, and December 31, 1992, 4 Hib cases occurred in 2 YKD children. During the combined period, July 1, 1989, to December 31, 1992, the incidence of Hib disease for infants less than 1 year of age was 302:100,000. A dramatic decrease in Hib disease was observed in this high incidence region concurrent with implementation of passive and passive-active immunization strategies.

The Australian Incident Monitoring Study. Problems before induction of anaesthesia: an analysis of 2000 incident reports

The first 2000 incidents reported to the Australian Incident Monitoring study (AIMS) were examined to identify those incidents which occurred preoperatively (defined as occurring prior to the commencement of general or regional anaesthesia). The 35 incidents, representing 1.7% of the total, which occurred in this time period were analysed with a view to identifying areas in which current practice could be improved. Almost all incidents led to significant delays in operating lists, and 9 resulted in cancellation of surgery. A number of areas of concern specific to the preoperative period were identified. Inadequate coordination between surgical and anaesthetic staff in patient preparation was a frequent cause of preoperative incidents. Improvement in this area may reduce surgical delays and patient morbidity. Problems with premedication drugs resulted in 8 of the 35 incidents, and care must be taken in the prescription and administration of these drugs to minimise adverse effects on patients. Only 2 cases of incorrect patient identification were reported. However, in view of its disastrous consequences, vigilance in patient identification by all members of the operating team, including the anaesthetist, is essential.

The Australian Incident Monitoring Study. Physical injuries and environmental safety in anaesthesia: an analysis of 2000 incident reports

Of the first 2000 incidents reported to the Australian Incident Monitoring Study, 56 (3%) involved environmental hazards or injuries to patients or staff. There were 17 cases of oral trauma (14 of tooth loss or damage, in 7 of which poor dentition played a role), 10 incidents involving problems with the operating table, 6 cases of skin or eye damage and 6 cases in which an electrical hazard was identified. Five incidents occurred during transport, and there were 4 cases of monitor induced trauma, 4 "needlestick" injuries and 4 miscellaneous incidents. Recommendations are made for trying to avoid or reduce the incidence of some of these problems.

The Australian Incident Monitoring Study. Problems associated with vascular access: an analysis of 2000 incident reports

There were 65 incidents involving access to the vascular system amongst the first 2000 reported to the Australian Incident Monitoring Study. Thirty-three involved peripheral venous access (14 cases of extravascular extravasation, 8 of unintended arterial cannulation, 6 of disruptions to intravenous lines, and 5 of problems with infusion lines, taps, pumps and connectors). Eighteen cases involved central venous access (9 cases of arterial puncture with haematomas, 5 with morbidity and/or prolonged admission), 5 of catheter misplacement and pneumo- or hydro-thorax and 4 of problems arising from operator inexperience. Thirteen cases involved peripheral arterial access (5 involved equipment problems (3 with possible air embolism), 3 of mistaking an arterial for a venous line (drugs were injected in 2), 3 of losing arterial lines or signals, and 2 in which the presence of an arterial line placed the patient at risk). The anaesthetist should always question the continued integrity of any vascular access system, even when it has recently been shown to be functioning, and the possibility of later "migration" and misplacement should always be borne in mind. Whenever possible, correct placement of the tip should be checked (e.g. by visual inspection of the site, use of test doses, aspiration of blood, pressure measurement, X-rays). When there is more than one line, all lines and sites of access (e.g. 3-way taps) should be clearly labelled and checked before anything is injected or infused.