Anaesthesia
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The Department of Health aims to eliminate the use of devices with a Luer connector firstly from 'single shot' neuraxial procedures (April 2012) and subsequently from all neuraxial and regional anaesthesia procedures (April 2013). This initiative is important for all anaesthetists, oncologists, paediatricians and neurologists. Once achieved, non-Luer connectors for neuraxial procedures will create one more barrier to wrong-route errors. ⋯ A structured evaluation of all five current connectors is urgently needed. Non-Luer connectors, however successful, will not create barriers to several type of wrong-route error and solutions to these should also be actively sought. It is clear that the initiative has been more complex than the Health Select Committee, the National Patient Safety Agency and the External Reference Group anticipated, but while there is still much work to be done, we should acknowledge that much progress has been made.
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Ultrasound guidance is now common in regional anaesthesia practice, but remains limited by poor visibility of the needle tip and poor quantification of local anaesthetic spread. Sonoelastography based on tissue compression is a technique depicting tissue strain. Hitherto used largely for tumour diagnosis, we used it in both Thiel embalmed cadavers and two patients receiving interscalene and femoral blocks to observe changes in tissue strain during local anaesthetic injection. ⋯ Post-hoc analysis showed greater spread with 1 and 2.5 ml volumes compared with 0.25 ml. In patients, visibility of strain during injection was better with sonoelastography than with B-Mode ultrasound and showed a dose response from 1 to 5 ml volumes of local anaesthetic. Colour strain recognition using sonoelastography offers the ability to differentiate between nerve and surrounding tissue during local anaesthetic injection by improving visibility of spread (p = 0.04).
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This prospective observational study investigated the effect of focused transthoracic echocardiography in 99 patients who had suspected cardiac disease or were ≥ 65 years old, and were scheduled for emergency non-cardiac surgery. The treating anaesthetist completed a diagnosis and management plan before and after transthoracic echocardiography, which was performed by an independent operator. Clinical examination rated cardiac disease present in 75%; the remainder were asymptomatic. ⋯ Cardiac disease was identified by echocardiography in 64% of patients, which led to a step-up of treatment in 36% (4% delay for cardiology referral, 2% altered surgery, 4% intensive care and 26% intra-operative haemodynamic management changes). Absence of cardiac disease in 36% resulted in a step-down of treatment in 8% (no referral 3%, intensive care 1% or haemodynamic treatment 4%). Pre-operative focused transthoracic echocardiography in patients admitted for emergency surgery and with known cardiac disease or suspected to be at risk of cardiac disease frequently alters diagnosis and management.
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Comparative Study
Clinical evaluation of a new tracheal impedance cardiography method.
Non-invasive cardiac output measurement by means of impedance cardiography has been evaluated before, and agreement with other methods has been variable. We decided to study a newly developed tracheal impedance device, that is claimed to be more accurate and reliable. This incorporates new software and mathematical formulae, that are designed to reduce signal noise from diathermy, leading to improved accuracy. ⋯ Mean cardiac output, bias and 95% limits of agreement were 5.3, 0.03 and -2.8 to 2.8 l.min(-1) , respectively. Tracheal impedance showed good correlation with measurement trends using thermodilution in 88% of measurements, with a mean (95% limit of agreement) angular bias of -9.0° (-83.3 to 65.3°). However, the wide limits of agreement and high percentage error of 53% that were apparent in this study mean that, in its present guise, tracheal impedance is not an acceptable alternative to thermodilution in cardiac surgical patients.
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Multicenter Study
Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010.
We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127, 467 calendar days of critical care with a median (IQR [range]) of 31 (26-45 [20-57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7-13 [3.5-27]) incidents per 1000 days were associated with harm. ⋯ Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced.