Robert I. Katz

Defining Quality of Perioperative Care by Statistical Process Control of Adverse Outcomes

Background: Through peer review, we separated the contributions of system error and human (anesthesiologist) error to adverse perioperative outcomes. In addition, we monitored the quality of our perioperative care by statistically defining a predictable rate of adverse outcome dependent on the system in which practice occurs and respondent to any special causes for variation. Methods: Traditional methods of identifying human errors using peer review were expanded to allow identification of system errors in cases involving one or more of the anesthesia clinical indicators recommended in 1992 by the joint Commission on Accreditation of Healthcare Organizations. Outcome data also were subjected to statistical process control analysis, an industrial method that uses control charts to monitor product quality and variation. Results: Of 13,389 anesthetics, 110 involved one or more clinical indicators of the joint Commission on Accreditation of Healthcare Organizations. Peer review revealed that 6 of 110 cases involved two separate errors. Of these 116 errors, 9 (7.8%) were human errors and 107 (92.2%) were system errors. Attribute control charts demonstrated all indicators, excepting one (fulminant pulmonary edema), to be in statistical control. Conclusions: The major determinant of our patient care quality is the system through which services are delivered and not the individual anesthesia care provider. Outcome of anesthesia services and perioperative care is in statistical control and therefore stable. A stable system has a measurable, communicable capability that allows description and prediction of the quality of care we provide on a monthly basis

Factors influencing the reporting of adverse perioperative outcomes to a quality management program.

Quality management programs have used several data reporting sources to identify adverse perioperative outcomes. We compared reporting sources and identified factors that might improve data capture. Adverse perioperative outcomes between January 1, 1992, and December 31, 1994, were reported to the Department of Anesthesiology Quality Management program by anesthesiologists, hospital chart reviewers, and other hospital personnel using incident reports. The reports were compared for preoperative health status, severity of outcome, and associated human error. Subsequently, personnel representing the various sources were surveyed regarding factors that might affect their reporting of adverse outcomes. Of 37,924 anesthetics, 734 (1.9%) adverse outcomes were reported, 519 (71%) of which were identified by anesthesiologists, 282 (38%) by chart reviewers, and 67 (9.1%) by incident report. There was no statistically significant difference in reporting rates by anesthesiologists according to preexisting disease, severity of outcome, or presence of human error. Thirteen cases involving human error, however, resulted in disabling patient injury, with a higher rate of self-reporting for these cases (92%, P < 0.05). Rates of reporting by chart reviewers varied (P < 0.05) according to severity of patient illness and severity of outcome. Incident reports identified only 67 adverse outcomes (9.1%), but included a significantly higher percentage of the adverse outcomes involving human error (23.3%, P < 0.05). Twenty attending anesthesiologists, 15 resident anesthesiologists, 29 operating room nurses, 19 postanesthesia care unit nurses, and 6 hospital chart reviewers responded to the survey. Only the potential to improve quality of patient care influenced or strongly influenced a decision by all groups to report an adverse outcome to a peer review process. Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Implications Physician self-reporting is a more reliable method of identifying adverse outcomes than either medical chart review or incident reporting. Reporting by chart reviewers is biased both by the severity of outcome and severity of patient illness, whereas incident reports tend to focus on human error. All groups feel compelled to report adverse outcomes when the data may result in improved patient care.

A comparison of cocaine, lidocaine with epinephrine, and oxymetazoline for prevention of epistaxis on nasotracheal intubation

The alpha-adrenergic agonist oxymetazoline was compared to cocaine and to lidocaine with epinephrine with respect to prevention of epistaxis on nasotracheal intubation. The nares of three groups of 14 patients each were topically pretreated with 4% lidocaine with 1:100,000 epinephrine (group 1), 10% cocaine (group 2), or 0.05% oxymetazoline (group 3) prior to nasotracheal intubation. After intubation, epistaxis was estimated on a scale of 0 to 3, with 0 indicating no bleeding, 1 representing blood on the nasotracheal tube only, 2 indicating blood pooling in the pharynx, and 3 representing blood in the pharynx sufficient to impede intubation. Only 29% of the patients in group 1 displayed no bleeding, whereas 57% of those in group 2 and 86% of those in group 3 had no bleeding. Nonparametric analysis showed a statistically significant difference (p less than 0.013) between oxymetazoline and lidocaine with epinephrine. In addition, heart rate (HR) and blood pressure (BP) were examined prior to administration of the medications; at 5 minutes, 10 minutes, and 15 minutes after administration of the medications; and after intubation. No significant differences were noted (p greater than 0.05) between the medications except for a slightly higher systolic BP for cocaine than for lidocaine with epinephrine at 15 minutes. The results of this double-blind, randomized trial demonstrate that the alpha-adrenergic agonist oxymetazoline is as effective as cocaine, and more effective than lidocaine with epinephrine, for the prevention of epistaxis associated with nasotracheal intubation.

Preoperative medical consultations: impact on perioperative management and surgical outcome

PurposeThis study was designed to assess the effect of preoperative medical consults on both perioperative management and surgical outcome.MethodsThe charts of 387 consecutive patients over the age of 50 undergoing non-cardiac, elective surgery during a six-week period were retrospectively examined. Patient factors including age, ASA status, gender, type of surgery, outcome (death, unexpected intensive care unit admission or uncomplicated discharge), presence of medical consult, and, in those cases where a medical consult was present, stated reason for the consult, the ordering physician, and recommendations of the consultant, were recorded.Results138 patients receiving medical consults (35.7%) were identified (a total of 146 consults). The most common stated purpose of the consults examined was “preoperative evaluation.” In only five consults (3.4%) did the consultant identify a new finding. Sixty-two consults (42.5%) contained no recommendations. There was no statistically significant difference in outcome between those patients who received a medical consult and those who did not.ConclusionA review of 146 medical consults suggests that the majority of such consults give little advice that truly impacts either perioperative management or outcome of surgery.RésuméObjectifÉvaluer ľeffet des consultations médicales préopératoires sur la prise en charge périopératoire et les suites opératoires.MéthodeNous avons procédé à ľexamen rétrospectif des dossiers de 387 patients consécutifs de plus de 50 ans qui, au cours de six semaines, ont été admis pour une intervention chirurgicale réglée non cardiaque. Nous avons noté ľâge, ľétat physique ASA, le type ďintervention chirurgicale, les suites (décès, admission imprévue à ľunité des soins intensifs ou absence de complications), la présence de con sultation médicale et la raison de la consultation, le médecin référant et les recommandations du consultant.RésultatsNous avons trouvé 138 patients (35,7 %) vus en consultation médicale pour un total de 146 consultations. Le motif de consultation le plus courant était «ľévaluation préopératoire». Dans cinq cas seulement (3,4 %) le consultant a découvert un nouveau problème. Soixante-deux consultations (42,5 %) ne contenaient aucune recommandation. Les suites opératoires n’étaient pas statistiquement différentes entre les patients vus ou non en consultation médicale.ConclusionUne revue de 146 consultations médicales montre que la majorité donne peu ďavis à incidence véritable sur la prise en charge périopératoire ou sur les suites postopératoires.

Exposure to Halothane and Enflurane Affects Learning Function of Murine Progeny

This study was conducted to assess the learning function of murine progeny born of mothers that had received either 1 % or 2% halothane or 2% or 4% enflurane, on days 6 and 10 or days 14 and 17 of gestation. Their timed performance at the age of 6 to 7 weeks was compared in a maze with that of control mice of similar ages that had not been exposed to anesthetics prenatally. All mice exposed to halothane in utero performed poorly at first, especially the group with mothers exposed to 2% halothane on days 14 and 17 of pregnancy. By the 10th training period, the performance of all mice improved but remained significantly slower than control mice. The offsprings of mice exposed to enflurane also performed poorly on the first training period, but between the fifth and seventh training periods, made statistically significant progress. However, they too remained slower in maze performance than control mice. Although blood pressure and arterial blood gas studies were only performed on two pregnant mice, data obtained suggest that the anesthetics did not have sufficient effect on respiration to affect our results. Second generation offspring, born to dams exposed to 2% halothane in utero late in pregnancy and sired by normal unexposed males, were also consistently slower than control mice, indicating a possible genetic effect induced by the anesthetic.

Ventricular tachycardia during general anesthesia in a patient with congenital long QT syndrome

PurposeCongenital long QT syndrome is characterized by a corrected QT interval of at least 440 msec on the electrocardiogram and has been associated with recurrent syncope, documented ventricular arrhythmia and sudden death. There have been numerous articles over the past 20 years describing isolated instances of surgical and anesthesia related complications but the general anesthetic management of the condition remains unclear.Clinical featuresAn 11-yr-old female with documented long QT syndrome, with two episodes of syncope in the past, was admitted for emergency drainage of left periorbital cellulitis. Anesthesia was induced with propofol, fentanyl and rocuronium, and initially maintained with nitrous oxide and halothane. After 20 min, the patient developed ventricular tachycardia (torsade de pointes). Lidocaine 1 mg·kg−1 iv was given and the rhythm reverted to normal sinus. Halothane was discontinued and the surgery proceeded without further incident.ConclusionsOur review of the literature revealed that patients with long QT syndrome whose symptoms are well controlled prior to surgery tend to do well regardless of the anesthetic chosen. There are, however, theoretical reasons to avoid anesthetics which either sensitize the myocardium to catecholamines or which cause an increase in circulating levels of catecholamines.RésuméObjectifLe syndrome congénital du QT long est caractérisé par un intervalle QT corrigé d’au moins 440 msec à l’électrocardiogramme et est associé à des syncopes récurrentes, de l’arythmie ventriculaire reconnue et la mort subite. Au cours des 20 dernières années, de nombreux articles ont présenté des cas isolés de complications reliées à la chirurgie et à l’anesthésie, mais la prise en charge anesthésique est encore indéterminée dans ces conditions.Éléments cliniquesUne fillette de 11 ans atteinte du syndrome du QT long, ayant subi deux épisodes de syncope dans le passé, a été admise pour un drainage de cellulite périorbitaire gauche en urgence. L’anesthésie a été induite avec du propofol, du fentanyl et du rocuronium et maintenue d’abord avec du protoxyde d’azote et de l’halothane. Après 20 min, une tachycardie ventriculaire (torsade de pointes) s’est développée. Une dose iv de 1 mg·kg−1 de lidocaïne a été administrée et le rythme est revenu à la normale. L’halothane a été stoppé et l’intervention chirurgicale s’est déroulée sans incident.ConclusionNotre examen des publications a révélé que les patients atteints du syndrome du QT long, dont les symptômes sont bien contrôlés avant une opération, réagissent bien, peu importe l’anesthésique choisi. Il y a, toutefois, des raisons théoriques d’éviter l’anesthésie qui sensibilise le myocarde ou cause une augmentation des niveaux de catécholamines sériques.

Prolonged Neuromuscular Blockade Following Vecuronium Infusion

Administration of vecuronium by infusion is an increasingly common technique, both in the operating room and in the intensive care unit (ICU), for patients requiring prolonged neuromuscular blockade and mechanical ventilation. The major advantage of vecuronium over older neuromuscular blocking agents is its rapid excretion and intermediate duration of action. Prior to the current case report, the longest reported continuous paralysis after the cessation of a vecuronium infusion was 90 hours. A case of an 81-year-old patient with renal failure and subclinical chronic cirrhosis of the liver, who remained paralyzed for 13 days following a vecuronium infusion, is described. Intensive monitoring of neuromuscular function is recommended whenever muscle relaxants are administered by continuous infusion.

Perioperative Pacemaker-mediated Tachycardia in the Patient with a Dual Chamber Implantable Cardioverter-defibrillator

Patients with cardiac implantable electronic devices are at additional risk for arrhythmias while undergoing surgical procedures. In this case report, we present a patient with a dual chamber implantable cardioverter-defibrillator who developed intraoperative pacemaker-mediated tachycardia causing significant hemodynamic instability. Management of this arrhythmia can be particularly challenging, because standard application of a magnet does not affect the pacing functions of an implantable cardioverter-defibrillator. Awareness by the anesthesiologist and timely coordination with the cardiac electrophysiology team helped to optimize care for this patient.

Intraoperative management of a patient with a chronic, previously undiagnosed traumatic diaphragmatic hernia

Traumatic diaphragmatic hernia (TDH) occurs in approximately 5% of hospitalized motor vehicle accident victims and 10% of victims of penetrating chest injury. Although most such injuries are diagnosed at the time of initial trauma, approximately 10% become apparent only months or years later. The TDH patient is at risk for surgical complications, including pulmonary aspiration, hypoxemia, and hemodynamic instability. Diagnosis and proper management of TDH is essential in order to minimize such complications. The anesthetic management of a patient with a preexisting TDH presenting for lumbar laminectomy is discussed.

The effect of sublingual nifedipine on coronary venous graft resistance immediately following cardiopulmonary bypass.

The purpose of this study was to determine the effects of sublingual nifedipine administered immediately after discontinuation of cardiopulmonary bypass on coronary graft resistance and systemic hemodynamics. Twenty patients were prospectively randomized into two groups; one given 10 mg sublingal nifedipine after weaning from bypass, the other given a placebo. Coronary graft blood flow was measured under blinded conditions and graft resistance calculated from measurements obtained with an electromagnetic flow probe applied directly to the graft prior to and 15 minutes after drug administration. Serum nifedipine levels were determined immediately before and 15, 30, and 60 minutes after sublingal administration. All patients receiving nifedipine had therapeutic serum levels. Graft resistance in patients given nifedipine decreased a statistically significant average of 27% and increased slightly, but not statistically significantly so, in patients given sublingual placebos. There were no differences between the two groups in cardiac index or pulmonary capillary wedge pressures. We conclude that the administration of sublingual nifedipine to patients in the immediate postbypass period results in therapeutic serum nifedipine levels and decreases coronary graft resistance without affecting cardiac performance.