Annika Takala

First year with WHO Surgical Safety Checklist in 7148 otorhinolaryngological operations: use and user attitudes

Dear Editor, The World Health Organisation (WHO) developed The Surgical Safety Checklist to improve patient safety in the operating room (OR) (http://www.who.int/patientsafety/ safesurgery/en/index.html). This checklist has reduced complications and deaths significantly. The checklist has taken into use in various surgical surroundings around the world. We have recently reported promising preliminary experiences of the checklist in otolaryngology. The aim of this study was to evaluate use activity and user opinions about the checklist in otolaryngology 1 year after its implementation. In addition, we wanted to assess safety attitudes within an operating department.

Procalcitonin, soluble interleukin-2 receptor, and soluble E-selectin in predicting the severity of acute pancreatitis.

ObjectiveTo investigate whether marker(s) of systemic inflammation detect, at an early stage of acute pancreatitis, patients who may ultimately develop severe disease. DesignProspective study. SettingUniversity hospital emergency unit. PatientsThirty patients with mild acute pancreatitis (SEV0 group) and 27 with severe acute pancreatitis. Of the latter, 11 did not develop organ failure (SEV1 group), whereas the other 16 patients developed acute respiratory failure and 9 of them also developed renal failure (SEV2 group). InterventionsBlood samples were collected at admission to the hospital (T0), and at 12 hrs (T12) and 24 hrs (T24) after admission. Measurements and Main Results The plasma concentrations of procalcitonin (PCT), soluble E-selectin (sE-selectin), soluble interleukin-2 receptor (sIL-2R), and the serum concentration of C-reactive protein (CRP) were monitored. PCT levels at T0 were significantly higher in the SEV1 group (median 0.4 ng/mL, range 0.2–2.3) and the SEV2 group (0.8 ng/mL, 0.2–73.5) than in the SEV0 group (0.3 ng/mL, 0.1–3, p < .05 and p < .001, respectively). At T12, PCT level in the SEV2 group was significantly higher than that in the SEV1 group (2.2 ng/mL, 0.2–86.6 vs. 0.4 ng/mL, 0.3–2.8, p = .05), as it also was at T24 (2.2 ng/mL, 0.4–73.3 vs. 0.5 ng/mL, 0.3–4, p < .01). Among SEV2 patients, PCT concentration correlated negatively with the time elapsed between admission and the diagnosis of organ failure. At T12, sIL-2R levels of the SEV1 group (1011 U/mL, range 334–2211) and the SEV2 group (1495 U/ml, range 514–4526) both differed significantly from the SEV0 group (636 U/ml, range 356–1678, p < .05 and p < .001, respectively) as they also did at T24. Although CRP level in the SEV1 group at T12 did not differ from the SEV0 group, the difference between SEV2 (272 &mgr;g/mL, range 46–462) and SEV0 was significant (53 &mgr;g/mL, range 5–243, p < 0.01). sE-selectin levels did not differ between groups. ConclusionsAt admission to hospital, concentrations of PCT, but not those of CRP, sE-selectin, or sIL-2R, are higher in patients with severe acute pancreatitis than in patients with mild pancreatitis. PCT test had sensitivity of 94% and specificity of 73% for development of organ failure. PCT may be useful to identify the patients who benefit from novel therapies aimed at modifying the course of systemic inflammation.

Markers of inflammation in sepsis.

Pathophysiology of sepsis is characterised by a whole body inflammatory reaction and concurrent activation of the hosts anti-inflammatory mechanisms. The balance between pro- and anti-inflammatory reactions is critical for the outcome of the patient. Strongly activated phagocytes and high levels of proinflammatory cytokines occur in patients who are at risk of developing circulatory shock and multiple organ dysfunction. Extensive anti-inflammatory reaction, which is characterised by the presence of high levels of circulating anti-inflammatory cytokines and impaired innate and adaptive immune functions, renders critically ill patients prone to secondary infections. Evaluation of the immune-inflammatory status on admission to the hospital may be helpful in the early identification of patients who are bound to develop organ dysfunction. Such patients could possibly benefit from a mode of therapy aimed at modifying the course of inflammatory response. The use of inflammatory markers may also improve diagnosis of severe infection. The present review summarises the studies on markers of inflammation and immune suppression used, first, as predictors of organ dysfunction in patients with systemic inflammation, and, second, as indicators of infection in adults and neonates.

A prospective study of inflammation markers in patients at risk of indirect acute lung injury.

Systemic inflammation triggered by insults like sepsis and acute pancreatitis may play a role in development of indirect acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Because little is known about the course of systemic inflammation on the days preceding diagnosis of ARDS, we prospectively monitored immune inflammatory status in 52 patients at risk and we assessed the presence of ALI and ARDS on day 7 after admission to the intensive care unit. On admission, serum interleukin (IL) 8, IL-6, and soluble IL-2 receptor concentrations were significantly higher in patients with subsequent ALI (n = 18) than in patients without ALI (n = 30). During a 4-day follow-up, IL-8 and IL-6 levels of ALI patients remained high and those of non-ALI patients decreased. None of the markers discriminated ARDS patients (n = 9) from non-ARDS ALI patients (n = 9). Among 11 patients with acute pancreatitis, ALI patients had significantly higher IL-8, IL-6, and phagocyte CD11b expression levels than did non-ALI patients, whereas among 14 patients with massive transfusion, respective findings in ALI and non-ALI patients were comparable. Results give credence to the view that systemic inflammation plays a role in development of ALI triggered by pancreatitis, but not in that by massive transfusion. This finding, if confirmed in studies with sufficient statistical power, suggests that the patients with massive transfusion do not necessarily benefit from novel biotherapies aimed at altering the course of systemic inflammation.

Decreased HLA (human leucocyte antigen)-DR expression on peripheral blood monocytes predicts the development of organ failure in patients with acute pancreatitis

Immune suppression plays an important role in the pathogenesis of acute pancreatitis. Monocyte expression of HLA (human leucocyte antigen)-DR, a cellular marker of immune suppression, was determined in relation to the development of organ dysfunction in patients with acute pancreatitis. A total of 310 consecutive patients with acute pancreatitis, admitted to a university hospital within 72 h of pain onset, were studied; 194 (63%) had mild disease (group I), 87 (28%) had severe disease without organ dysfunction (group II), and 29 (9%) had severe disease with organ dysfunction (group III). HLA-DR expression, defined both as the proportion of monocytes that were HLA-DR-positive and as monocyte HLA-DR fluorescence intensity, was determined at admission, using whole-blood flow cytometry. Of the patients in group III, 13 (45%) developed organ dysfunction within 24 h of admission. The proportion of HLA-DR-positive monocytes and monocyte HLA-DR density were both related to the severity of pancreatitis (P<0.001 for linear trend). In predicting organ dysfunction, the sensitivity, specificity and positive-likelihood ratio for the proportion of HLA-DR-positive monocytes were 83% [95% CI (confidence interval) 64-94%], 72% (67-77%) and 3.0 respectively, and for monocyte HLA-DR density the respective values were 69% (49-85%), 84% (79-88%) and 4.3. In conclusion, monocyte HLA-DR expression predicts the development of organ dysfunction that occurs early in patients with acute pancreatitis.

Systemic inflammatory response syndrome without systemic inflammation in acutely ill patients admitted to hospital in a medical emergency.

Criteria of the systemic inflammatory response syndrome (SIRS) are known to include patients without systemic inflammation. Our aim was to explore additional markers of inflammation that would distinguish SIRS patients with systemic inflammation from patients without inflammation. The study included 100 acutely ill patients with SIRS. Peripheral blood neutrophil and monocyte CD11b expression, serum interleukin-6, interleukin-1beta, tumour necrosis factor-alpha and C-reactive protein were determined, and severity of inflammation was evaluated by systemic inflammation composite score based on CD11b expression, C-reactive protein and cytokine levels. Levels of CD11b expression, C-reactive protein and interleukin-6 were higher in sepsis patients than in SIRS patients who met two criteria (SIRS2 group) or three criteria of SIRS (SIRS3 group). The systemic inflammation composite score of SIRS2 patients (median 1.5; range 0-8, n=56) was lower than that of SIRS3 patients (3.5; range 0-9, n=14, P=0.013) and that of sepsis patients (5.0; range 3-10, n=19, P<0.001). The systemic inflammation composite score was 0 in 13/94 patients. In 81 patients in whom systemic inflammation composite scores exceeded 1, interleukin-6 was increased in 64 (79.0%), C-reactive protein in 59 (72.8%) and CD11b in 50 (61.7%). None of these markers, when used alone, identified all patients but at least one marker was positive in each patient. Quantifying phagocyte CD11b expression and serum interleukin-6 and C-reactive protein concurrently provides a means to discriminate SIRS patients with systemic inflammation from patients without systemic inflammation.

Post-tonsillectomy haemorrhage more common than previously described – an institutional chart review

Abstract Conclusions: Risk of post-tonsillectomy haemorrhage (PTH) was higher compared with previous studies and may be associated with the criteria used. Male gender and the use of haemostatic agents in the primary operation were associated with increased risk of PTH, whereas the use of non-steroidal anti-inflammatory drugs (NSAIDs) or dexamethasone was not. Objectives: The aim of the study was to investigate the risk of PTH in adult patients, and its association with the use of NSAIDs, dexamethasone, paracetamol, serotonin (5-HT3) receptor antagonists, haemostatic agents, age and gender during preceding tonsillectomy (TE). Methods: All PTH complications that resulted in an adult TE patient re-contacting the hospital were retrospectively recorded during a 12-month period. PTH types were allocated into three categories: (I) a history of bleeding, (II) bleeding requiring direct pressure or electrocautery under local anaesthesia or (III) reoperation under general anaesthesia. Results: A total of 842 adult TE patients (aged between 16 and 85.8 years) were included in the study. Of these, 122 patients experienced PTH (risk 14.5%). Risk of category III PTH was 1.5%. Risk factors for PTH were the use of haemostatic agents (p = 0.006) and male gender (p = 0.011). The use of NSAID, opioid, 5-HT3 receptor antagonist and dexamethasone medication did not significantly alter the number of postoperative bleeding events.

Systemic Inflammation in Hemorrhagic Fever with Renal Syndrome Correlates with Hypotension and Thrombocytopenia but Not with Renal Injury

Systemic inflammation is common in patients with nephropathia epidemica (NE), a European form of hemorrhagic fever. Markers of inflammation were studied in a patient with NE with respiratory insufficiency (patient 1), 18 other patients with NE, and 13 patients with a viral infectious disease other than NE. Neutrophil and monocyte CD11b expression levels, determined by flow cytometry; soluble interleukin (IL)-2 receptor (sIL-2R), IL-6, and IL-8 concentrations, determined by means of Immulite; and soluble E-selectin, determined by ELISA, were higher in patients with NE than in healthy subjects. The findings were not specific for NE and did not correlate with serum creatinine levels, but the findings correlated inversely with mean arterial pressure (sIL-2R and monocyte CD11b expression) and minimum platelet count (sIL-2R, IL-6, neutrophil, and monocyte CD11b expression). Monocyte CD11b expression in patient 1 was extremely high, suggesting that monocytes may contribute to development of lung injury. Severity of inflammation in patients with NE is related to hypotension and platelet consumption but not to renal injury.

Time course of β2-integrin cd11b/cd18 (mac-1, αmβ2) upregulation on neutrophils and monocytes after coronary artery bypass grafting: CD11b upregulation after CABG surgery

Although upregulation of CD11b/CD18 receptor, i.e. activation of neutrophils and monocytes, during cardiopulmonary bypass is well documented, the duration of the active state after uncomplicated operation is less understood. We therefore investigated CD11b expression of phagocytes in blood samples collected 2-4, 24, 48 and 72 h after coronary artery bypass grafting. CD11b expression on neutrophils was significantly elevated at 2-4 and 24 hours after operation as compared with baseline. On monocytes, expression peaked at 24 h and returned to baseline by 72 h. Because CD11b is a sensitive marker, effects of different sampling techniques on its expression were also studied. CD11b expression was similar in samples collected with a syringe from arterial or central venous catheter or with open technique from cubital vein. On neutrophils from healthy subjects, sampling with syringe caused small (10%) but statistically significant increase of expression. We conclude that activated neutrophils disappear from circu...

WHO Surgical Safety Checklist in otorhinolaryngology-head and neck surgery: specialty-related aspects of check items.

Abstract Conclusion: The WHO surgical checklist is well suited to otorhinolaryngology-head and neck surgery (ORL-HNS) and the users are satisfied with its content. Objectives: Use of the checklist will improve safety in operating rooms (ORs). The checklist has been taken into use in ORL-HNS, and preliminary experiences are promising. However, the checklist must be specific to the specialty in which it is used. The aim of this study was to evaluate the utility of the check items for ORL-HNS operations, with special reference to outpatient surgery. Methods: The questionnaire study for the OR personnel was conducted at a tertiary academic hospital. Every item on the WHO checklist was evaluated and responders could provide freehand comments on the subject. Results: In all, 101 responses were received from OR staff; the response rate was 95.3%. The users were mainly satisfied with the checklist’s content for ORL-HNS operations. Mean scores of the importance of check items varied from 4.08 to 4.89 on a five-point scale. The item ‘Allergy’ had the highest score and ‘Team members introduced’ the lowest. A need to modify the checklist for in-hospital patients did not emerge. However, a more compact checklist for outpatient surgery carried out under local anaesthesia was suggested.