Outcomes from wake up safe, the pediatric anesthesia quality improvement initiative

BACKGROUND

Wake Up Safe, a Patient Safety Organization founded by the Society for Pediatric Anesthesia, collects data on serious adverse events along with demographic data from all pediatric patients receiving anesthesia care at participating institutions. This report reviews all events occurring between 2010 and 2015 and focuses on common adverse events that are anesthesia-related.

AIMS

Determine which adverse events were most common from 2010 to 2015 among participating Wake Up Safe institutions. Determine how many anesthesia-related events were deemed to be preventable.

METHODS

This is a descriptive report. The Wake Up Safe registry data were queried on September 29, 2017. Institutions were included if they had complete demographic data and at least 5 adverse events per year reported. At that time, 19 out of 29 institutions had complete demographic data for events from 2010 to 2015. This study describes demographic data and adverse events from these nineteen institutions. Descriptive data were extracted, and event rate was calculated for each adverse event category. In events that were assessed as primarily related to anesthesia, further detailed analysis was performed.

RESULTS

Of all reported adverse events (2544 events), the most common were cardiac arrests (646, 31.6%), respiratory complications (598, 29.2%), and medication events (345, 16.9%). Of all anesthesia-related events (612 events), medication events were the most common (239, 31.9%), followed by respiratory complications (181, 24.1%), and cardiac arrests (139, 18.5%). Overall, 85% of anesthesia-related serious adverse events were deemed somewhat or almost certainly preventable.

CONCLUSIONS

The majority of anesthesia-related serious adverse events reported to the Wake Up Safe database are preventable. Medication events are the most common anesthesia-related adverse events. Innovations aimed at decreasing medication events may be the most impactful.

Long-Term Intravenous Ketamine for Analgesia in a Child with Severe Chronic Intestinal Graft versus Host Disease

Ketamine is reported to be an effective adjuvant to opioids in the treatment of refractory cancer pain; however, the use of high doses of ketamine for extended periods in pediatric patients has not been described. We present a five-year-old male with grade IV intestinal GVHD whose abdominal pain required both hydromorphone and ketamine for a period of over four months. There was no evidence of hepatotoxicity, hemorrhagic cystitis, or other adverse effects. Possible withdrawal symptoms were mild and were readily mitigated by gradually weaning ketamine.

Silicon based tandem cells: novel photocathodes for hydrogen production

A photovoltaic tandem cell made of amorphous silicon (a-Si) and microcrystalline silicon (μc-Si) was investigated as a photocathode for hydrogen evolution in a photoelectrochemical device. The electronic and electrochemical properties of the samples were characterized using X-ray photoemission spectroscopy (XPS) and cyclic voltammetry (CV), whereas the morphology of the surface in contact with the electrolyte was investigated by scanning electron microscopy (SEM). The electric efficiency of the tandem cell was determined to be 5.2% in a photoelectrochemical (PEC) setup in acidic solution which is only about half of the photovoltaic efficiency of the tandem cell. A significant improvement in efficiency was achieved with platinum as a catalyst which was deposited by physical vapour deposition (PVD) under ultra-high vacuum (UHV) conditions.

Targeting the actin cytoskeleton: selective antitumor action via trapping PKCɛ

Targeting the actin cytoskeleton (CSK) of cancer cells offers a valuable strategy in cancer therapy. There are a number of natural compounds that interfere with the actin CSK, but the mode of their cytotoxic action and, moreover, their tumor-specific mechanisms are quite elusive. We used the myxobacterial compound Chondramide as a tool to first elucidate the mechanisms of cytotoxicity of actin targeting in breast cancer cells (MCF7, MDA-MB-231). Chondramide inhibits cellular actin filament dynamics shown by a fluorescence-based analysis (fluorescence recovery after photobleaching (FRAP)) and leads to apoptosis characterized by phosphatidylserine exposure, release of cytochrome C from mitochondria and finally activation of caspases. Chondramide enhances the occurrence of mitochondrial permeability transition (MPT) by affecting known MPT modulators: Hexokinase II bound to the voltage-dependent anion channel (VDAC) translocated from the outer mitochondrial membrane to the cytosol and the proapoptotic protein Bad were recruited to the mitochondria. Importantly, protein kinase C-ɛ (PKCɛ), a prosurvival kinase possessing an actin-binding site and known to regulate the hexokinase/VDAC interaction as well as Bad phosphorylation was identified as the link between actin CSK and apoptosis induction. PKCɛ, which was found overexpressed in breast cancer cells, accumulated in actin bundles induced by Chondramide and lost its activity. Our second goal was to characterize the potential tumor-specific action of actin-binding agents. As the nontumor breast epithelial cell line MCF-10A in fact shows resistance to Chondramide-induced apoptosis and notably express low level of PKCɛ, we suggest that trapping PKCɛ via Chondramide-induced actin hyperpolymerization displays tumor cell specificity. Our work provides a link between targeting the ubiquitously occurring actin CSK and selective inhibition of pro-tumorigenic PKCɛ, thus setting the stage for actin-stabilizing agents as innovative cancer drugs. This is moreover supported by the in vivo efficacy of Chondramide triggered by abrogation of PKCɛ signaling shown in a xenograft breast cancer model.

Life-threatening postoperative blood loss in a Jehovah's Witness, treated with high-dose erythropoietin

Six hours after an uncomplicated extended resection of ovarian cancer, postoperative arterial bleeding led to life-threatening blood loss in a 44-yr-old Jehovah's Witness who refused blood transfusion. Haemoglobin (Hb) decreased from 2.5 g dl(-1) directly after the emergency laparotomy, followed by a 10 h immeasurable period (below detectable minimum value of the analyser), to a measurable minimum of 1.5 g dl(-1) after 20 h. Haematopoiesis was induced by high-dose i.v. erythropoietin therapy (600 IU kg(-1)) and continued on days 3, 6, 8, 10 and 13. Iron, folic acid and vitamins were given as supplements. The patient needed ventilatory assistance for 18 days and some inotropic support. Complications included increases in pancreatic enzymes and liver enzymes, jaundice and skin necrosis at the fingertips and toes. Myopathy led to transient tetraparesis. Haemoglobin rose from 1.5 to 3.4 g dl(-1) (day 10) and the patient was discharged from the intensive care unit with haemoglobin 6.5 g dl(-1) on day 24. She made a full recovery and is still free of cancer in remission.

Chromatography and electrophoresis on chips: critical elements of future integrated, microfluidic analytical systems for life science

Liquid chromatography and electrophoresis played a major role in the life-science revolution, most strikingly in protein purification, peptide fractionation and sequencing, amino acid analysis, and DNA sequencing. The objective of this article is to examine the potential role of separation systems in the continuing evolution of biochemistry, biotechnology and molecular biology. Very small chip-based systems may change how chemical analyses in biology, medical research and health care evolve over the next decade.

[Distal femoro-popliteal bypass using Esmarch tourniquet ischemia]

The Esmarch bandage is an effective substitute for vascular clamps in distal femoro-popliteal or tibial bypass surgery. Intimal trauma caused by clamping is avoided, vasa vasorum are preserved due to only semicircumferential dissection of vessels. This method is particularly suitable for heavy calcified rigid vessel walls. We demonstrate this technique, which was employed in 8 patients (10 bypasses). The use of this technique requires neither a longer operation- nor clamping time. The postoperative course of all but one patients develops normally and the technique does not provoke any pathological results in the area of operation. Advantages of the procedure compared to conventional techniques will be discussed.

Receptor affinity purification of a lipid-binding adhesin from Haemophilus influenzae

Thirteen clinical strains of Haemophilus influenzae, including types b, d, and untypeable, in vitro specifically recognize phosphatidylethanolamine (PE), gangliotetraosylceramide, gangliotriosylceramide (Gg3), sulfatoxygalactosylceramide, and to a lesser extent sulfatoxygalactosylglycerol. A PE affinity matrix was used to purify an adhesin of approximately 46 kDa from both type b and untypeable H. influenzae. This adhesin was a potent inhibitor of H. influenzae Gg3 and PE binding in vitro, and polyclonal antibodies specific for this protein prevented the attachment of H. influenzae Gg3 and PE and cultured HEp-2 epithelial cells in vitro.

Cyanide toxicity of sodium nitroprusside in therapeutic use with and without sodium thiosulphate

Sodium nitroprusside (SNP) as a mono-infusion was administered to 51 patients for periods of a few hours. A further group of 19 patients received SNP for periods of several days as a combination solution of SNP mixed with sodium thiosulphate. The concentrations of cyanide and of thiocyanate in the blood of all patients were measured. In seven of the patients the level of thiosulphate was also measured. Infusion of SNP on its own at levels exceeding 2 microgram/kg/min led to the rising of cyanide levels in the blood being proportional to dosage. Infusion of SNP mixed with thiosulphate showed no such accumulation of cyanide in any patient, irrespective of dosage level and duration. The efficacy at lowering blood pressure was fully maintained in the mixed infusion. The elimination half-life for thiosulphate was 16.5 min. Pharmacokinetic calculation of the rise in cyanide level showed that mono-infusions of 5-10 micrograms SNP/kg/min could within 5-10 h cause a life-threatening cyanide level in the blood. By contrast, mixed infusion of SNP together with thiosulphate, for which light-opaque syringes and tubing must be used, is a procedure free of danger and should become the technique of choice when therapeutically administering SNP in order to lower blood pressure.

[The computerized anaesthetic record of the 'Universitätsklinik Köln' (author's transl)]

Some of the main arguments are presented which led us to develop our present anaesthetic record. This record system and a part of its voluminous code is described. The new version provides for the documentation of arbitrarily complicated status, which are due to the preoperative condition of the patient. Furthermore, the course of aneaesthesia and its effects upon the patient can be numerically recorded in a detailed fashion. The punching is affected by a small rate of error only.

In situ carcinoma of the vocal cords

Eighty-one patients with preinvasive carcinoma of the vocal cord, seen over a thirteen year period, were reviewed histologically and analyzed for response to treatment. Sixty-seven cases were clinically T1 and fourteen cases T2 (by virtue of extension of disease beyond the vocal cord). All patients had mobile cords. Histological criteria for in situ carcinoma and the spectrum of microscopic patterns are presented. Sixty-nine patients were treated by external beam radiotherapy--the remainder by a variety of surgical procedures. Five and ten year actuarial, recurrence-free rates 83% and 75%, respectively for the group treated by irradiation. No difference in local control was observed when analyzed for: 1) dose response, 2) initial extent of disease, 3) treatment plan, or 4) histologic diagnosis. Analysis of failures reveals that 15/17 patients with local failure were salvaged, eleven of these patients requiring laryngectomy. Time to appearance of recurrence ranged from seven to one hundred and seven months.

[Cardiovascular effects produced by prophylactic digitalization during introduction of anaesthesia (author's transl)]

The narrow field of non-controversial indications concerning the application of digitalis glycosides is pointed out. Problems of routine digitalization of older patients not suffering from cardiac insuffiency are discussed with special regard to preparing them for operations. Up to now, from the viewpoint of anaesthesiologists no benefits of prophylactic digitalization have been found. In a retrospective computerized study, clinical hemodynamic parameters during introduction of anaesthesia have been investigated by means of anaesthetic data recorded during three years. Nondigitalized patients older than fifty years showed satisfactory cardiac functions, whereas prophylactically digitalized patients--compared with the control group--have been treated with plasma expanders earlier and at a double rate. Furthermore, higher heart frequencies and greater tendency to arrythmias were observed. Consequently, prophylactic digitalization cannot be recommended in general.

[Anaesthetic problems during resection of the carina (author's transl)]

Benigne tracheo-bronchial constriction is an infrequent indications for resection of the bifurcation of the trachea. In former times resection and reconstruction of the bifurcation have been performed using extracorporal oxygenation. Nowadays, the method of separate ventilation of both lungs is used more frequently. Pathophysiological variations should be taken into consideration, which may occur during interruption of the ventilation of one side of lung caused by operating procedures. Rapidly developing atelectasis of the non-ventilated but perfused lung endangers the patient, as a result of an increased intrapulmonary right-to-left-shunt. Hypoxaemia can be prevented by temporary occlusion of the pulmonary artery of the nonventilated lung. This procedure is to be recommended in view of the fact that there is no prompt constriction of the vessels. Investigations with dogs show that a slightly developing accommodation of the perfusion can be disturbed by variations of cardiac output or mean pressure of ventilation.

Mobile velocity-controlled respirometer: description and performance capabilities

An apparatus modeled after the Scram respirometer designed by Corcoran is described in terms of design, specifications and performance capabilities. The results with the use of this apparatus in a study of 14 able-bodied adults of five controlled walking speeds are compared to those of a similar study previously reported by Corcoran and Brengelmann. Oxygen consumption (ml O2/kg body wt/min) increases proportionately to the square of the velocity of walking. Results of the two investigations are parallel, although the present report demonstrates a greater male-female difference at all speeds. Uses and limitations of the apparatus are considered.

Immobilization error: some theoretical considerations

The consequences of immobilization error are explored through a model involving the tumor dose-response characteristics. The quantitative effect of such an error depends upon the field size, the shape of the dose-response function, and the position of the nominal dose being delivered on the dose-response function. Squamous-cell carcinoma of the supraglottis and Hodgkin's disease are discussed and values are calculated for the change in tumor control probability which might accompany immobilization error.

A simple afterloading applicator for intracavitary irradiation of carcinoma of the nasopharynx

A simple, disposable afterloading applicator for intracavitary irradiation of carcinoma of the nasopharynx has been found useful as a supplementary radiation boost to the primary site. Hopefully, local tumor control can be enhanced by employing this technique.

Lactic acid permeation rate in working gastrocnemii of dogs during metabolic alkalosis and acidosis

In isolated, blood perfused, supramaximally stimulated, isotonically working gastrocnemii of dogs lactic acid (LA) output and O2-consumption (V O2) were measured according to the Fick principle. Simultaneously concentration of muscle tissue was determined at rest and at different times during exercise. In one series of experiments metabolic alkalosis was induced by infusions of THAM of Na bicarbonate. As a result arterial pH increased to about 7.5 and standard [HCO3-1] to 31-35 mmol per 1. In another group of experiments metabolic acidosis was induced by HCl infusions. In these experiments pH decreased to 7.0-7.1 and standard [HO301] to 8-11 mmol per 1. During the first 3-4 min after the onset of exercise LA concentration of muscle tissue rose to 18-19 mumol per g wet weight in both series of experiments. During acidosis the highest average values for LA release from the muscle were about 1.1 mumoles per g per minute. During alkalosis LA permeation rate was nearly three times as high. As a consequence of increased rate of permeation, LA concentration of muscle tissue decreased more rapidly in alkalosis than in acidosis. In both series of experiments work per time and VO2 were practically equal during the first 5-6 min of exercise. Thereafter work per time and VO2 decreased more rapidly in acidosis than in alkalosis, a result which probably is due to higher LA concentration in muscle at this time in acidosis. It is concluded that LA permeation rate across muscle cell membrane is increased by high extracellular HCO3- concentration in combination with low H+ activity and vice versa.