Ellison C. Pierce, Jr., M.D., and a small number of specialty leaders and scientists formed a remarkable, diverse team in the mid-1980s to address a dual crisis: a safety crisis for anesthetized ...patients and a medical malpractice insurance crisis for anesthesiologists. This cohesive team's efforts led to the formation of the Anesthesia Patient Safety Foundation, the American Society of Anesthesiologists's Committees on Standards of Care and on Patient Safety and Risk Management, and the society's Closed Claims Project. The commonality of leaders and members of the Anesthesia Patient Safety Foundation and American Society of Anesthesiologists initiatives provided the strong coordination needed for their efforts to effect change, introduce standards of care and practice parameters, obtain financial support needed to grow patient safety-oriented new knowledge, integrate industry and other relevant leaders outside of anesthesiology, and involve all anesthesia professions. By implementing successful patient safety initiatives, they promoted the recognition that anesthesiology and patient safety are inextricably linked.
Perioperative pulmonary aspiration of gastric contents has been associated with severe morbidity and death. The primary aim of this study was to identify outcomes and patient and process of care risk ...factors associated with gastric aspiration claims in the Anesthesia Closed Claims Project. The secondary aim was to assess these claims for appropriateness of care. The hypothesis was that these data could suggest opportunities to reduce either the risk or severity of perioperative pulmonary aspiration.
Inclusion criteria were anesthesia malpractice claims in the American Society of Anesthesiologists Closed Claims Project that were associated with surgical, procedural, or obstetric anesthesia care with the year of the aspiration event 2000 to 2014. Claims involving pulmonary aspiration were identified and assessed for patient and process factors that may have contributed to the aspiration event and outcome. The standard of care was assessed for each claim.
Aspiration of gastric contents accounted for 115 of the 2,496 (5%) claims in the American Society of Anesthesiologists Closed Claims Project that met inclusion criteria. Death directly related to pulmonary aspiration occurred in 66 of the 115 (57%) aspiration claims. Another 16 of the 115 (14%) claims documented permanent severe injury. Seventy of the 115 (61%) patients who aspirated had either gastrointestinal obstruction or another acute intraabdominal process. Anesthetic management was judged to be substandard in 62 of the 115 (59%) claims.
Death and permanent severe injury were common outcomes of perioperative pulmonary aspiration of gastric contents in this series of closed anesthesia malpractice claims. The majority of the patients who aspirated had either gastrointestinal obstruction or acute intraabdominal processes. Anesthesia care was frequently judged to be substandard. These findings suggest that clinical practice modifications to preoperative assessment and anesthetic management of patients at risk for pulmonary aspiration may lead to improvement of their perioperative outcomes.
Most clinically available thermometers accurately report the temperature of whatever tissue is being measured. The difficulty is that no reliably core-temperature-measuring sites are completely ...noninvasive and easy to use-especially in patients not undergoing general anesthesia. Nonetheless, temperature can be reliably measured in most patients. Body temperature should be measured in patients undergoing general anesthesia exceeding 30 min in duration and in patients undergoing major operations during neuraxial anesthesia. Core body temperature is normally tightly regulated. All general anesthetics produce a profound dose-dependent reduction in the core temperature, triggering cold defenses, including arteriovenous shunt vasoconstriction and shivering. Anesthetic-induced impairment of normal thermoregulatory control, with the resulting core-to-peripheral redistribution of body heat, is the primary cause of hypothermia in most patients. Neuraxial anesthesia also impairs thermoregulatory control, although to a lesser extent than does general anesthesia. Prolonged epidural analgesia is associated with hyperthermia whose cause remains unknown.
Methane emissions from tree stems Barba, Josep; Bradford, Mark A.; Brewer, Paul E. ...
The New phytologist,
April 2019, Letnik:
222, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Tree stems from wetland, floodplain and upland forests can produce and emit methane (CH₄). Tree CH₄ stem emissions have high spatial and temporal variability, but there is no consensus on the ...biophysical mechanisms that drive stem CH₄ production and emissions. Here, we summarize up to 30 opportunities and challenges for stem CH₄ emissions research, which, when addressed, will improve estimates of the magnitudes, patterns and drivers of CH₄ emissions and trace their potential origin.We identified the need: (1) for both long-term, high-frequency measurements of stem CH₄ emissions to understand the fine-scale processes, alongside rapid large-scale measurements designed to understand the variability across individuals, species and ecosystems; (2) to identify microorganisms and biogeochemical pathways associated with CH₄ production; and (3) to develop a mechanistic model including passive and active transport of CH₄ from the soil–tree–atmosphere continuum. Addressing these challenges will help to constrain the magnitudes and patterns of CH₄ emissions, and allow for the integration of pathways and mechanisms of CH₄ production and emissions into process-based models. These advances will facilitate the upscaling of stem CH₄ emissions to the ecosystem level and quantify the role of stem CH₄ emissions for the local to global CH₄ budget.
Abstract
Objectives
To elucidate pathologic markers of acute and chronic stress found but rarely reported in chronic child abuse.
Methods
Autopsies of 3 cases of fatal child abuse with ...well-documented chronic maltreatment are reported, with an emphasis on the nontraumatic findings of acute and chronic stress.
Results
Besides the overwhelming physical injuries, all 3 children and 1 additional case obtained for consultation had telogen effluvium, a form of alopecia well known to be associated with stress in adults and some children but never reported in chronic abuse. All 3 had the microscopic findings of markedly involuted thymus, a well-known marker of physiologic stress in children but only occasionally referred to in child abuse. All 3 also had microscopic findings of myocardial necrosis associated with supraphysiologic levels of catecholamine, a well-documented finding associated with stress but rarely reported in fatalities associated with child abuse. Two of the 3 children also had Anitschkow-like nuclear changes in cardiac tissue, markers associated with prior, nonischemic myocardial pathologies that may be associated with prior episodes of acute stress.
Conclusions
Pathologists are urged to explore these markers as supportive evidence in their own investigations of possible child abuse fatalities, especially when associated with stress.
Over decades, anesthesiologists have used intravenous adenosine as mainstay therapy for diagnosing or treating supraventricular tachycardia in the perioperative setting. More recently, specific ...adenosine receptor therapeutics or gene-targeted mice deficient in extracellular adenosine production or individual adenosine receptors became available. These models enabled physicians and scientists to learn more about the biologic functions of extracellular nucleotide metabolism and adenosine signaling. Such functions include specific signaling effects through adenosine receptors expressed by many mammalian tissues; for example, vascular endothelia, myocytes, hepatocytes, intestinal epithelia, or immune cells. At present, pharmacological approaches to modulate extracellular adenosine signaling are evaluated for their potential use in perioperative medicine, including attenuation of acute lung injury; renal, intestinal, hepatic and myocardial ischemia; or vascular leakage. If these laboratory studies can be translated into clinical practice, adenosine receptor-based therapeutics may become an integral pharmacological component of daily anesthesiology practice.
Post-surgical inflammatory neuropathy Staff, Nathan P.; Engelstad, JaNean; Klein, Christopher J. ...
Brain (London, England : 1878),
10/2010, Letnik:
133, Številka:
10
Journal Article
Recenzirano
Odprti dostop
Post-surgical neuropathies are usually attributed to mechanical factors, such as compression, stretch, contusion or transection. The role of inflammatory mechanisms in neuropathies occurring after ...surgeries is poorly appreciated and not well characterized, and may provide a rationale for immunotherapy. A total of 23 selected patients with post-surgical neuropathies received nerve biopsies, of which 21 demonstrated increased inflammation. Here we report the clinical features in these 21 cases of biopsy-confirmed and 12 cases of clinically suspected post-surgical inflammatory neuropathies, in whom no trauma to the nerves was documented. All neuropathies developed within 30 days of a surgical procedure. Of 33 patients, 20 were male and the median age was 65 years (range 24–83). Surgical procedures were orthopaedic (n = 14), abdominal/pelvic (n = 12), thoracic (n = 5) and dental (n = 2). Patients developed focal (n = 12), multifocal (n = 14) or diffuse (n = 7) neuropathies. Focal and multifocal neuropathies typically presented with acute pain and weakness, and focal neuropathies often mimicked mechanical aetiologies. Detailed analyses, including clinical characteristics, electrophysiology, imaging and peripheral nerve pathology, were performed. Electrophysiology showed axonal damage. Magnetic resonance imaging of roots, plexuses and peripheral nerves was performed in 22 patients, and all patients had abnormally increased T2 nerve signal, with 20 exhibiting mild (n = 7), moderate (n = 12) or severe (n = 1) enlargement. A total of 21 patients had abnormal nerve biopsies that showed increased epineurial perivascular lymphocytic inflammation (nine small, five moderate and seven large), with 15 diagnostic or suggestive of microvasculitis. Evidence of ischaemic nerve injury was seen in 19 biopsies. Seventeen biopsies had increased axonal degeneration suggesting active neuropathy. Seventeen biopsied patients were treated with immunotherapy. In 13 cases with longitudinal follow-up (median 9 months, range 3–71 months), the median neuropathy impairment score improved from 30 to 24 at the time of last evaluation (P = 0.001). In conclusion: (i) not all post-surgical neuropathies are mechanical, and inflammatory mechanisms can be causative, presenting as pain and weakness in a focal, multifocal or diffuse pattern; (ii) these inflammatory neuropathies may be recognized by their spatio-temporal separation from the site and time of surgery and by the characteristic magnetic resonance imaging features; (iii) occasionally post-surgical inflammatory and mechanical neuropathies are difficult to distinguish and nerve biopsy may be required to demonstrate an inflammatory mechanism, which in our cohort often, but not exclusively, exhibited pathological features of microvasculitis and ischaemia; and (iv) recognizing the role of inflammation in these patients’ neuropathy led to rational immunotherapy, which may have resulted in the subsequent improvement of neurological symptoms and impairments.
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