Drug safety in paediatric anaesthesia Kaufmann, J.; Wolf, A.R.; Becke, K. ...
British journal of anaesthesia,
20/May , Letnik:
118, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Life-threatening drug errors are more common in children than in adults. This is likely to be because of their variations in age and weight, combined with the occasional exposure of most ...anaesthetists to paediatric patients. Drug administration in anaesthesia is mostly undertaken by a single operator and thus represents a potentially greater risk compared with other areas of medicine. This increased risk is believed to be offset by anaesthetists working with only a limited number of drugs on a very frequent and repetitive basis. However, high rates of errors continue to be reported. Paediatric anaesthesia practice requires individual age- and weight-specific drug dose calculations and is therefore without a ‘familiar’ or ‘usual’ dose. The aim of this narrative systematic review of existing recommendations and current evidence of preventive strategies is to identify measures to enhance the safety and quality of drug administration in paediatric anaesthesia. This review collates and grades the evidence of such interventions and recommendations and assesses their feasibility. Most highly effective available measures require low or limited costs and labour. The presented solutions should, therefore, achieve a high level of acceptance and contribute significantly to safety and quality of care in paediatric anaesthesia.
Survival from a malignant hyperthermia (MH) crisis is highly dependent on early recognition and prompt action. MH crises are very rare and an increasing use of total i.v. anaesthesia is likely to ...make it even rarer, leading to the potential risk of reduced awareness of MH. In addition, dantrolene, the cornerstone of successful MH treatment, is unavailable in large areas around the world thereby increasing the risk of MH fatalities in these areas. The European Malignant Hyperthermia Group collected and reviewed all guidelines available from the various MH centres in order to provide a consensus document. The guidelines consist of two textboxes: Box 1 on recognizing MH and Box 2 on the treatment of an MH crisis.
Summary
Human malignant hyperthermia is a life‐threatening genetic sensitivity of skeletal muscles to volatile anaesthetics and depolarizing neuromuscular blocking drugs occurring during or after ...anaesthesia. The skeletal muscle relaxant dantrolene is the only currently available drug for specific and effective therapy of this syndrome in man. After its introduction, the mortality of malignant hyperthermia decreased from 80% in the 1960s to < 10% today. It was soon discovered that dantrolene depresses the intrinsic mechanisms of excitation–contraction coupling in skeletal muscle. However, its precise mechanism of action and its molecular targets are still incompletely known. Recent studies have identified the ryanodine receptor as a dantrolene‐binding site. A direct or indirect inhibition of the ryanodine receptor, the major calcium release channel of the skeletal muscle sarcoplasmic reticulum, is thought to be fundamental in the molecular action of dantrolene in decreasing intracellular calcium concentration. Dantrolene is not only used for the treatment of malignant hyperthermia, but also in the management of neuroleptic malignant syndrome, spasticity and Ecstasy intoxication. The main disadvantage of dantrolene is its poor water solubility, and hence difficulties are experienced in rapidly preparing intravenous solutions in emergency situations. Due to economic considerations, no other similar drugs have been introduced into routine clinical practice.
Malignant hyperthermia Wappler, F
European journal of anaesthesiology,
October 2001, Letnik:
18, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Malignant hyperthermia is an autosomal-dominant inherited disorder of the skeletal muscle cell characterized by a hypermetabolic response to all commonly used inhalational anaesthetics and ...depolarizing muscle relaxants. The clinical syndrome includes muscle rigidity, hypercapnia, tachycardia and myoglobinuria as result of increased carbon dioxide production, oxygen consumption and muscle membrane breakdown. In human beings and animals susceptible to malignant hyperthermia, it is generally accepted that an increase in the level of myoplasmic free calcium is the cause of the syndrome. Various hypotheses have been proposed to account for the increase of intracellular calcium levels, e.g. a defect in the calcium release channel of the sarcoplasmic reticulum (ryanodine receptor), an abnormality of the excitation-contraction coupling mechanisms, or alterations in second messenger systems of skeletal muscles. This review gives an overview of the main features of this disease and recent advances in research including pathophysiology, treatment, diagnosis and genetics as well as association with other disorders.
Vancomycin-resistant Enterococcus faecium (VRE) is emerging in German intensive care units (ICUs). On a 32-bed surgical ICU at a university hospital, increasing numbers of nosocomial cases occurred ...despite enforcement of hand hygiene and environmental disinfection.
To introduce universal octenidine-based bathing in order to reduce the burden of VRE.
Between January 2012 and March 2014, patients were screened for VRE on admission and twice weekly. Active surveillance was undertaken for VRE infections and colonizations, and for bloodstream infections (BSI) with any pathogen. Intervention in this before–after study comprised of standardized octenidine-based bathing. Distinct subgroups of VRE colonizations or infections were defined and used for statistical analysis of frequency, prevalence and incidence density.
In the pre-intervention period (January 2012 to April 2013), the admission prevalence of VRE was 4/100 patients and the mean incidence density of nosocomial cases was 7.55/1000 patient-days (PD). Pulsed-field gel electrophoresis analysis revealed prevalence of three vanA and two vanB clusters. In the post-intervention period (August 2013 to March 2014), the admission prevalence of VRE was 2.41/100 patients and the mean incidence density of nosocomial cases was 2.61/1000 PD P = 0.001 (pre- vs post-intervention). Thirteen nosocomial VRE infections were identified in the pre-intervention period, compared with one nosocomial VRE infection in the post-intervention period. Incidence densities of BSI pre- and post-intervention were 2.98 and 2.06/1000 PD (P = 0.15), respectively.
The epidemiology of emerging VRE appeared as a complex mix of admitted cases and transmissions in small clusters, challenging infection control measures. The implementation of universal octenidine-based bathing combined with a standardized washing regime led to a significant reduction in nosocomial VRE.
Background
Anaesthesiology plays a key role in promoting safe perioperative care. This includes the perioperative phase in the post‐anaesthesia care unit (PACU) where problems with incomplete ...information transfer may have a negative impact on patient safety and can lead to patient harm. The objective of this study was to analyse information transfer during post‐operative handovers in the PACU.
Methods
With a self‐developed checklist including 59 items the information transfer during post‐operative handovers was documented and subsequently compared with patient information in anaesthesia records during a 2‐month period.
Results
A total number of 790 handovers with duration of 73 ± 49 s was analysed. Few items were transferred in most of the cases such as type of surgery (97% of the cases), regional anaesthesia (94% of the cases) and cardiac instability (93% of the cases). However, some items were rarely transferred, such as American Society of Anesthesiologists physical status (7% of the cases), initiation of post‐operative pain management (12% of the cases), antibiotic therapy (14% of the cases) and fluid management (15% of the cases). There was a slight correlation between amount of information transferred and duration of post‐operative handovers (r = 0.5).
Conclusion
The study shows that post‐operative handovers in the PACU are in most cases incomplete. It appears useful to optimise the post‐operative handover process, for example by implementing a standardised handover checklist.
In this study, we tested the reliability of a non-invasive finger-cuff-based continuous arterial blood pressure monitoring device (Nexfin®, BMEYE, Amsterdam, NL) in critically ill surgical patients.
...Invasive intra-arterial and non-invasive arterial pressure measurements from 25 patients during a 4-h period were compared at five time points. Correlation and linear regression analysis were used and mean bias, precision sd of bias and limits of agreement (LOA) bias (2.0 sd) were calculated using the Bland–Altman method.
Eight data pairs were excluded because of error message from the non-invasive technique, and thus a total of 117 data pairs were analysed. Overall, correlation between mean arterial pressure (MAP) was r2=0.50. Bias, precision, and LOA between invasive and non-invasive MAP were 6 (12) and −18 to +30 mm Hg. In patients requiring norepinephrine (83 data pairs), correlation was r2=0.28 and bias, precision, and LOA were 6 (13) and −20 to +32 mm Hg, whereas in patients not receiving norepinephrine (34 data pairs) r2 was 0.80 and mean bias, precision, and LOA were 6 (11) and −16 to +28 mm Hg. In patients with peripheral oedema (49 data pairs), r2 was 0.40 and mean bias, precision and LOA were 7 (15) and −23 to +37 mm Hg. In patients without oedema (64 data pairs), r2 was 0.66 and mean bias, precision, and LOA were 5 (9) and −13 to +23 mm Hg.
Non-invasive blood pressure monitoring with Nexfin® does not seem to be sufficiently accurate to replace intra-arterial invasive blood pressure measurements in critically ill patients.
Sepsis is one of the leading causes of death. Treatment attempts targeting the immune response regularly fail in clinical trials. As HCMV latency can modulate the immune response and changes the ...immune cell composition, we hypothesized that HCMV serostatus affects mortality in sepsis patients.
We determined the HCMV serostatus (i.e., latency) of 410 prospectively enrolled patients of the multicenter SepsisDataNet.NRW study. Patients were recruited according to the SEPSIS-3 criteria and clinical data were recorded in an observational approach. We quantified 13 cytokines at Days 1, 4, and 8 after enrollment. Proteomics data were analyzed from the plasma samples of 171 patients.
The 30-day mortality was higher in HCMV-seropositive patients than in seronegative sepsis patients (38% vs. 25%, respectively; p = 0.008; HR, 1.656; 95% CI 1.135-2.417). This effect was observed independent of age (p = 0.010; HR, 1.673; 95% CI 1.131-2.477). The predictive value on the outcome of the increased concentrations of IL-6 was present only in the seropositive cohort (30-day mortality, 63% vs. 24%; HR 3.250; 95% CI 2.075-5.090; p < 0.001) with no significant differences in serum concentrations of IL-6 between the two groups. Procalcitonin and IL-10 exhibited the same behavior and were predictive of the outcome only in HCMV-seropositive patients.
We suggest that the predictive value of inflammation-associated biomarkers should be re-evaluated with regard to the HCMV serostatus. Targeting HCMV latency might open a new approach to selecting suitable patients for individualized treatment in sepsis.
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