Aliaksei Pustavoitau

National study on the distribution, causes, and consequences of voluntarily reported medication errors between the ICU and non-ICU settings.

Objective:To compare the distribution, causes, and consequences of medication errors in the ICU with those in non-ICU settings. Design:A cross-sectional study of all hospital ICU and non-ICU medication errors reported to the MEDMARX system between 1999 and 2005. Adjusted odds ratios are presented. Setting:Hospitals participating in the MEDMARX reporting system. Interventions:None. Measurements and Main Results:MEDMARX is an anonymous, self-reported, confidential, deidentified, internet-accessible medication error reporting program that allows hospitals to report, track, and share medication error data. There were 839,553 errors reported from 537 hospitals. ICUs accounted for 55,767 (6.6%) errors, of which 2,045 (3.7%) were considered harmful. Non-ICUs accounted for 783,800 (93.4%) errors, of which 14,471 (1.9%) were harmful. Errors most often originated in the administration phase (ICU 44% vs. non-ICU 33%; odds ratio 1.63 [1.43–1.86]). The most common error type was omission (ICU 26% vs. non-ICU 28%; odds ratio 1.00 [0.91–1.10]). Among harmful errors, dispensing devices (ICU 14% vs. non-ICU 7.1%; odds ratio 2.09 [1.69–2.59]) and calculation mistakes (ICU 9.8% vs. non-ICU 5.3%; odds ratio 1.82 [1.48–2.24]) were more commonly identified to be the cause in the ICU compared to the non-ICU setting. ICU errors were more likely to be associated with any harm (odds ratio 1.89 [1.62–2.17]), permanent harm (odds ratio 2.45 [1.17–5.13]), harm requiring life-sustaining intervention (odds ratio 2.91 [1.86–4.56]), or death (odds ratio 2.48 [1.18–5.19]). When an error did occur, patients and their caregivers were rarely informed (ICU 1.5% vs. non-ICU 2.1%; odds ratio 0.63 [0.48–0.84]) by the time of reporting. Conclusions:More harmful errors are reported in ICU than non-ICU settings. Medication errors occur frequently in the administration phase in the ICU. When errors occur, patients and their caregivers are rarely informed. Consideration should be given to developing additional safeguards against ICU errors, particularly during drug administration, and eliminating barriers to error disclosures.

Continuous Cerebral Blood Flow Autoregulation Monitoring in Patients Undergoing Liver Transplantation

BackgroundClinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively.MethodsWe performed a prospective observational study in 9 consecutive patients undergoing orthotopic liver transplantation. Patients were monitored with TCD and NIRS. A continuous Pearson’s correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and NIRS data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Both Mx and COx were averaged and compared during the dissection phase, anhepatic phase, first 30xa0min of reperfusion, and remaining reperfusion phase. Impaired autoregulation was defined as Mxxa0≥xa00.4.ResultsAutoregulation was impaired in one patient during all phases of surgery, in two patients during the anhepatic phase, and in one patient during reperfusion. Impaired autoregulation was associated with a MELD scorexa0>15 (pxa0=xa00.015) and postoperative seizures or stroke (pxa0<xa00.0001). Analysis of Mx categorized in 5xa0mmHg bins revealed that MAP at the lower limit of autoregulation (MAP when Mx increased toxa0≥xa00.4) ranged between 40 and 85xa0mmHg. Average Mx and average COx were significantly correlated (pxa0=xa00.0029). The relationship between COx and Mx remained when only patients with bilirubinxa0>1.2xa0mg/dL were evaluated (pxa0=xa00.0419). There was no correlation between COx and baseline bilirubin (pxa0=xa00.2562) but MELD score and COx were correlated (pxa0=xa00.0458). Average COx was higher for patients with a MELD scorexa0>15 (pxa0=xa00.073) and for patients with a neurologic complication than for patients without neurologic complications (pxa0=xa00.0245).ConclusionsThese results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.

Establishing intensivist-driven ultrasound at the PICU bedside--it's about time*.

Objective: To discuss pediatric intensivist–driven ultrasound and the exigent need for research and practice definitions pertaining to its implementation within pediatric critical care, specifically addressing issues in ultrasound-guided vascular access and intensivist-driven echocardiography. Conclusions: Intensivist-driven ultrasound improves procedure safety and reduces time to diagnosis in clinical ultrasound applications, as demonstrated primarily in adult patients. Translating these applications to the PICU requires thoughtful integration of the technology into practice and would best be informed by dedicated ultrasound research in critically ill children.

The Role of Liver Transplantation in Alcoholic Hepatitis

Acute alcoholic hepatitis is a syndrome of jaundice and hepatic decompensation that occurs with excessive alcohol consumption. The diagnosis can be made with a combination of clinical characteristics and laboratory studies, though biopsy may be required in unclear cases. Acute alcoholic hepatitis can range from mild to severe disease, as determined by a Maddrey discriminant function ≥32. Mild forms can be managed with supportive care and abstinence from alcohol. While mild form has an overall good prognosis, severe alcoholic hepatitis is associated with an extremely high short-term mortality of up to 50%. Additional complications of severe alcoholic hepatitis can include hepatic encephalopathy, gastrointestinal bleeding, renal failure, and infection; these patients frequently require intensive care unit admission. Corticosteroids may have short-term benefit in this group of patients if there are no contraindications; however, a subset of patients do not respond to steroids. New emerging therapies, which target hepatic regeneration, bile acid metabolism, and extracorporeal liver support, are being investigated. Liver transplantation for alcoholic liver disease was traditionally only considered in patients who have achieved 6 months of abstinence, in part due to social and ethical concerns regarding the use of a limited resource. However, the majority of patients with severe alcoholic hepatitis who fail medical therapy will not live long enough to meet this requirement. Recent studies have demonstrated that early liver transplantation in carefully selected patients with severe alcoholic hepatitis who fail medical therapy can provide a significant survival benefit and yields survival outcomes comparable to liver transplantation for other indications, with 6-month survival rates ranging from 77% to 100%. Alcohol relapse posttransplantation remains an important challenge, and heavy consumption can contribute to graft loss and mortality. Future investigation should address the substantial post-liver transplantation recidivism rate, from improving selection criteria to increasing posttransplantation substance abuse treatment resources.

Point-of-care ultrasound in pediatric anesthesiology and critical care medicine

Ultrasound has increasingly become a clinical asset in the hands of the anesthesiologist and intensivist who cares for children. Though many applications for ultrasound parallel adult modalities, children as always are not simply small adults and benefit from the application of ultrasound to their management in various ways. Body composition and size are important factors that affect ultrasound performance in the child, as are the pathologies that may uniquely afflict children and aspects of procedures unique to this patient population. Ultrasound simplifies vascular access and other procedures by visualizing structures smaller than those in adults. Maturation of the thoracic cage presents challenges for the clinician performing pulmonary ultrasound though a greater proportion of the thorax can be seen. Moreover, ultrasound may provide unique solutions to sizing the airway and assessing it for cricothyroidotomy. Though cardiac ultrasound and neurosonology have historically been performed by well-developed diagnostic imaging services, emerging literature stresses the utility of clinician ultrasound in screening for pathology and providing serial observations for monitoring clinical status. Use of ultrasound is growing in clinical areas where time and diagnostic accuracy are crucial. Implementation of ultrasound at the bedside will require institutional support of education and credentialing. It is only natural that the pediatric anesthesiologist and intensivist will lead the incorporation of ultrasound in the future practice of these specialties.RésuméL’échographie est devenue de plus en plus un outil clinique dans les mains des anesthésiologistes et des intensivistes qui prennent soin d’enfants. Bien que de nombreuses applications échographiques suivent le modèle des modalités pour adultes, les enfants ne sont pas simplement de petits adultes et bénéficient d’applications échographiques propres à la gestion de leur situation. La composition et la taille de leur corps sont des facteurs importants qui affectent la performance de l’échographie, de même que les maladies des enfants ainsi que les procédures qui sont uniques à cette population. L’échographie simplifie l’accès vasculaire et d’autres procédures en visualisant des structures qui sont plus petites que celle des adultes. La maturation de la cage thoracique présente des défis pour le clinicien effectuant une échographie pulmonaire bien qu’il puisse voir une plus grande proportion du thorax. De plus, l’échographie peut fournir des réponses uniques aux dimensions des voies respiratoires et à leur évaluation en vue d’une cricothyroïdotomie. Historiquement, les échographies cardiaques et neurologiques ont été réalisées par des services d’imagerie diagnostique bien développés, mais des publications de plus en plus nombreuses soulignent la pertinence de la pratique de l’échographie par des cliniciens pour dépister des troubles et fournir des observations répétées dans le cadre d’une surveillance clinique. L’utilisation de l’échographie est en progression dans des domaines cliniques où le temps et l’exactitude diagnostique sont essentiels. La mise en œuvre de l’échographie au point d’intervention nécessitera un soutien institutionnel en matière de formation et de reconnaissance des compétences. Il est tout à fait naturel que les anesthésiologistes et Intensivistes pédiatriques soient à la tête de l’incorporation de l’échographie dans la pratique future de ces spécialités.

Return of Viable Cardiac Function after Sonographic Cardiac Standstill in Pediatric Cardiac Arrest

Abstract Sonographic cardiac standstill during adult cardiac arrest is associated with failure to get return to spontaneous circulation. This report documents 3 children whose cardiac function returned after standstill with extracorporeal membranous oxygenation. Sonographic cardiac standstill may not predict cardiac death in children.

Pro: Antifibrinolytics Should Be Used in Routine Cardiac Cases Using Cardiopulmonary Bypass (Unless Contraindicated)

From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Address reprint requests to Aliaksei Pustavoitau, MD, MHS, Johns Hopkins University School of Medicine, 600 N. Wolfe St., Meyer 297, Baltimore, MD 21287. E-mail: apustav1@jhmi.edu

Perioperative Care for Liver Transplantation: A Review

I am quite honored to be editing the third volume of International Anesthesiology Clinics on the topic of liver transplantation. The first 2 were published in 2006, with significant clinical expertise and input from foreign centers. For this volume, I have invited Dr A. Pustavoitau, a faculty intensivist and anesthesiologist at the Johns Hopkins Hospital, to share in the selection and editing process. After extensive animal research, the first human liver transplant was performed in 1963. At that time, roughly 15,000 people between 5 and 60 years of age were dying of liver-related illness annually in the United States, 90% from cirrhosis. It was an experimental surgical procedure through the 1970s: the recipients were profoundly ill—1-year survival did not occur until 1967—and by the mid-1970s, the 1-year survival had improved to only around 25%. Techniques were in development; merely getting out of the operating room was a demanding effort for both surgeons and anesthesiologists, not to mention the significant preoperative and postoperative issues. By 1981, after considerable debate, guidelines were improved for the declaration of death, and thus the potential for organ donation both cardiopulmonary death and brain death. Even with revised criteria for the declaration of death and more available organs, immunosuppression was inadequate. With the approval of cyclosporine in 1983, a new era for transplantation began to emerge and major advances in immunosuppression have continued. Recipient selection has continued to improve, intraoperative management of hemodynamics and hypocoagulability/hypercoagulability progressed, and pretransplant and posttransplant ICU care has advanced.