Sharing Lessons Learned to Prevent Adverse Events in Anesthesiology Nationwide.

Objectives: The Veterans Health Administration (VHA) lessons learned process for Anesthesia adverse events was developed to alert the field to the occurrences and prevention of actual adverse events. This article details this quality improvement project and perceived impact.

Methods: As part of ongoing quality improvement, root cause analysis related to anesthesiology care are routinely reported to the VHA National Center for Patient Safety.

Anesthesia Adverse Events Voluntarily Reported in the Veterans Health Administration and Lessons Learned.

Background: Anesthesia providers have long been pioneers in patient safety. Despite remarkable efforts, anesthesia errors still occur, resulting in complications, injuries, and even death. The Veterans Health Administration (VHA) National Center of Patient Safety uses root cause analysis (RCA) to examine why system-related adverse events occur and how to prevent future similar events.

Association between Intraoperative Hypotension and Hypertension and 30-day Postoperative Mortality in Noncardiac Surgery.

Background: Although deviations in intraoperative blood pressure are assumed to be associated with postoperative mortality, critical blood pressure thresholds remain undefined. Therefore, the authors estimated the intraoperative thresholds of systolic blood pressure (SBP), mean blood pressure (MAP), and diastolic blood pressure (DBP) associated with increased risk-adjusted 30-day mortality.

Methods: This retrospective cohort study combined intraoperative blood pressure data from six Veterans Affairs medical centers with 30-day outcomes to determine the risk-adjusted associations between intraoperative blood pressure and 30-day mortality.

A randomized, open-label study of the safety and tolerability of fospropofol for patients requiring intubation and mechanical ventilation in the intensive care unit.

Background: Current drugs for induction and maintenance of sedation in mechanically ventilated patients in the intensive care unit have limitations. Fospropofol, a prodrug of propofol, has not been studied as a sedative in the ICU setting.

Methods: In this randomized, open-label pilot study, patients received 1 of 3 regimens with a goal of maintaining a Ramsay Sedation Score of 2 to 5: (1) fospropofol IV infusion with a bolus and increased infusion rate for agitation events (infusion/bolus); (2) fospropofol IV infusion with an increased infusion rate for agitation events (infusion only); or (3) propofol IV infusion with an increased infusion rate for agitation events.

Factors influencing oxygen store during denitrogenation in the healthy patient.

Study Objective: To define the various factors that influence the rate of effective preoxygenation.

Design: Prospective, randomized study.

Setting: Procedure room in a teaching hospital.

Dexmedetomidine pharmacodynamics: Part II: Crossover comparison of the analgesic effect of dexmedetomidine and remifentanil in healthy volunteers.

Background: Dexmedetomidine is a highly selective alpha2-adrenoceptor agonist used for short-term sedation of mechanically ventilated patients. The analgesic profile of dexmedetomidine has not been fully characterized in humans.

Methods: This study was designed to compare the analgesic responses of six healthy male volunteers during stepwise target-controlled infusions of remifentanil and dexmedetomidine.

Dexmedetomidine pharmacodynamics: part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers.

Background: Dexmedetomidine, a highly selective alpha2-adrenoceptor agonist used for short-term sedation of mechanically ventilated patients, has minimal effect on ventilation.

Methods: This study compared the respiratory effect of dexmedetomidine to that of remifentanil. The authors measured and compared respiratory responses of six healthy male volunteers during (1) a stepwise target-controlled infusion of remifentanil, (2) a stepwise target-controlled infusion of dexmedetomidine, and (3) a pseudonatural sleep session.

The role of the alpha2-adrenoceptor agonist dexmedetomidine in postsurgical sedation in the intensive care unit.

Dexmedetomidine was evaluated for sedation of 401 post-surgical patients in this double-blind, randomized, placebo-controlled, multicenter trial. Dexmedetomidine or saline was started on arrival in the intensive care unit (ICU) (1.0 mcg/kg for 10 minutes), then titrated at 0.

ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimens.

Objective: To compare dexmedetomidine-based to propofol-based sedation after coronary artery bypass graft (CABG) surgery in the intensive care unit (ICU).

Design: Randomized, open label.

Setting: Twenty-five centers in the United States and Canada.

Tracheoscopy with the rapiscope to verify endotracheal tube placement.

Study Objective: To determine whether tracheoscopy is an accurate and quick method for verifying correct placement of the tracheal tube after intubation.

Design: Prospective, randomized study.

Setting: Operating rooms of a teaching hospital.

Severe methemoglobinemia on reexposure to benzocaine.

We report a 65-year-old male who developed severe methemoglobinemia only on reexposure to benzocaine. The patient needed two awake fiberoptic intubations for emergency surgeries. On the second exposure, the patient was septic and malnourished, and he was taking acetaminophen.

The effect of hemodialysis on protein metabolism. A leucine kinetic study.

To assess the effect of hemodialysis on protein metabolism, leucine flux was measured in seven patients before, during, and after high efficiency hemodialysis using cuprophane dialyzers and bicarbonate dialysate during a primed-constant infusion of L-[1-13C]leucine. The kinetics [mumol/kg per h, mean +/- SD] are as follows: leucine appearance into the plasma leucine pool was 86 +/- 28, 80 +/- 28, and 85 +/- 25, respectively, before, during, and after dialysis. Leucine appearance into the whole body leucine pool, derived from plasma [1-13C]alpha-ketoisocaproate enrichment, was 118 +/- 31, 118 +/- 31, and 114 +/- 28 before, during, and after dialysis, respectively.

Accuracy of the FEF CO2 detector in the assessment of endotracheal tube placement.

The sensitivity and reliability of the FEF end-tidal CO2 detector were investigated for its suitability in the assessment of correct placement of an endotracheal tube. Sensitivity was determined by having eight blinded volunteers observe the color change in the FEF detector with the administration of different volumes and varying CO2 concentrations of gas mixture. The color change in the FEF detector was also assessed during esophageal ventilations before and after administration of carbonated beverage into the stomach of swine and during cardiopulmonary resuscitation in swine.

Efficacy of therapeutic suggestions for improved postoperative recovery presented during general anesthesia.

There have been claims that the postoperative course of patients may be improved by presentation during general anesthesia of therapeutic suggestions which predict a rapid and comfortable postoperative recovery. This study evaluated the effectiveness of such therapeutic suggestions under double-blind and randomized conditions. A tape recording predicting a smooth recovery during a short postoperative stay without pain, nausea, or vomiting was played during anesthesia to about half the patients (N = 109), while the remaining, control patients were played a blank tape instead (N = 100).

Reliability of capnography in identifying esophageal intubation with carbonated beverage or antacid in the stomach.

To evaluate the reliability of capnography in identifying esophageal intubation in the presence of a carbonated beverage in the stomach, we first investigated the amount of CO2 released from different carbonated beverages and antacids in a simulated stomach; next we measured the end-expired CO2 level during esophageal ventilation with a carbonated beverage in the stomachs of six swine. CO2 levels of approximately 20% were consistently observed in all carbonated beverages. The CO2 levels obtained with sodium bicarbonate, Maalox, and sodium citrate were 19.

Stable and reproducible porcine model of acute lung injury induced by oleic acid.

Background And Methods: Previous studies on acute lung injury induced with oleic acid did not attempt to limit the influence of secondary changes on pulmonary circulation, and cardiopulmonary variable data were only collected and processed intermittently. Our study was designed to continuously monitor the following variables in five swine: systemic and pulmonary pressure; mixed venous oxygen saturation (SVO2) and arterial oxygen saturation (SaO2); minute oxygen consumption and CO2 production before, during, and for 4 hr after the infusion of oleic acid. A personal computer was programmed to produce 20-sec updates of deadspace ratio (VD/VT), venous admixture (Qsp/Qt), pulmonary (PVR) and systemic vascular resistance (SVR), and cardiac output (Qt) from these data.

Human learning during general anaesthesia and surgery.

To determine if learning occurs during general anaesthesia, 72 women undergoing surgery were given postoperative implicit memory tests in which performance could be influenced by auditory information presented during general anaesthesia. Two methods of anaesthesia were used: nitrous oxide and opioids (n = 24) or nitrous oxide and isoflurane (1, 1.3 and 1.

A comparative study of methods of detection of esophageal intubation.

The trachea and esophagus of 21 patients were simultaneously intubated to comparatively evaluate methods for detecting esophageal intubation. In succession, the trachea and esophagus were ventilated with the same inspiratory volume of 621 +/- 45 mL (mean +/- SD). Carbon dioxide (CO2) levels, volumes, and temperatures of expired gas were measured from the tracheal and esophageal tubes.