As in high reliability systems , also in surgery the causes of adverse events are primarily correlated to deficiencies in Non Technical Skills (individual and social skills), that contribute with Technical Skills to a safe surgical procedure. Non Technical Skills are cognitive behavioural and interpersonal abilities, that are not specific to the expertise of one profession, but very important to guarantee the patient safety and to reduce risk of errors and adverse events. The Observational Teamwork Assessment for Surgery (OTAS) is an useful tool to assess teamwork of the whole surgical team (surgeons, anaesthetists, nurses) in real time and through the surgical procedure (pre-intra-postoperative phases). OTAS consists of the two following parts: a) teamwork-related task checklist to fill by a surgeon, b) teamwork-related behaviours rated by a psychologist/human factors expert. Back translation in Italian language of the eight task checklists and of the rating scales of the five behavioural areas was performed by two Italian surgeons with certified English language knowledge. The OTAS model in Italian language was applied in four surgical procedures : the test-retest reliability was found to be acceptable with K- Pearson index. The internal consistency of behavioural scales appeared sound using Cronbach ?. OTAS is an useful tool to assess the risk factors correlated to patient and team and to detect the vulnerability areas where changes to reduce errors and improve surgical outcomes might be introduced.

In 2007 the Study Group "Clinical Risk Management" of the Italian Society of Anaesthesia and Intensive Care Unit (SIAARTI) performed a multicentric study in Intensive Care Unit (ICU) to assess the feasibility and efficacy of the Safety WalkRound (SWR) as a tool for the risk assessment. As the environment and organization of ICU are more complex than anaesthesia ones, mainly due to the severity of patients, high number of involved healthcare givers and different kinds of procedures, the Study Group decided that a check list is not fit for ICU and , after a careful review of the literature, chose to test the Safety WalkRound. in four Italian General ICUs. The SWR was born in 2003 when Frankel plans a structured interview of 15 questions (about 50% open) to collect operators' opinion about rate and type of errors, near misses, communication, problems regarding the report of adverse events and suggestions to increase patient safety. Consequently SWR is a tool of risk assessment alternative to the Incident Reporting which is marked by a diffuse underreporting of operators. Although the SWR is a new tool not validated in Italian language neither published in Italy on PubMed journals , the Study Group has decided that it might be fit for the organization of Italian Healthcare System. A back translation of the validated model of Joint Commission was provided and the translated version has been lightly changed to be employed in hospitals with and without Incident Reporting . The questions have been changed or introduced on the basis of the organization vulnerabilities detected with observational techniques or Focus Group. The interview performed in Italy contains 16 questions classified into five groups: a) error, b) error prevention, c) communication, teamwork and leadership, d) error discussion and e) relationship with patients and their families. The answers collected have been analyzed to detect the vulnerabilities in the organizations and specify the improvements to implement in every ICU. A statistical analysis was performed to verify the correlation between the answers collected and the results of the other techniques of risk assessment previously used ( observations and Focus Group ) . The value of k Pearson found ( mean value 0,976) has demonstrated this correlation and the efficacy of SWR in detecting system vulnerabilities already found with the other assessment techniques. The value of a Cronbach ( mean value 0,798) has demonstrated an internal consistency reliability. The results of this study have demonstrated that the Italian translation is fit for the model by Frankel and makes available a lot of information useful to improve patient safety. The study has demonstrated the sensibility, efficacy and efficiency of this tool in detecting the vulnerabilities in every ICU of the four ones. SWR is marked by feasibility, high compliance of operators and low costs; besides increases safety culture in the staff and demonstrating.

Levati, A.1; Bevilacqua, L.1; Petrini, F.2; Adrario, E.3; Cabrini, L.4; Paccagnella, F.5; Barneschi, M. G.6; Pietrini, D.7; Borrometi, F.8; :, M. Author Information

Levati, A.; Moretti, M. P.; Meregalli, S.; Orsini, C.; Vesconi, S.; Facco, E. Author Information

D. PIETRINI 1, A. SAVIOLI 2, R. GROSSETTI 3, M. A. BARBIERI 4, A. BUSCALFERRI 5 M. CALAMANDREI 6, A. CHIARETTI 7, A. DAVID 8, C. DI ROCCO 9, M. P. DUSIO 10, G. FEBI 10 C. GALLINI 11, F. GIORDANO 12, V. GIRASOLE 8, E. LAMPUGNANI 13, R. LAVIANI MANCINELLI 2 A. LEVATI 14, C. MAZZA 15, L. MENEGHINI 16, F. PACCAGNELLA 17, M. PIASTRA 7, E. PROCACCINI 18 A. PUSATERI 1, R. SCIELZO 19, G. STOFELLA 20, F. STOPPA 21, G. TAMBURRINI 9, C. TESTONI 22 M. TUMOLO 12, F. VELARDI 18, E. ZEI 5, N. LATRONICO 23

Riganti, M.; Chiara, O.; Cimbanassi, S.; Moretti, M.; Levati, A.; Vesconi, S. Author Information

378 PREVALENCE AND MOLECULAR TYPING OF ACINETOBACTER BAUMANNII IN AN ICU-PRELIMINARY RESULTS Paramythiotou E1, Mylona Petropoulou D2, Vagiakou-Voudri H2, Tassios P T3, Tzouvelekis L S3, Legakis N J3, Malamou-Lada H1, Karabinis A1 1ICU, 2Microbiology Department, G.Gennimatas Hospital, 3Department of Microbiology, Medical School, National and Kapodestrian University, Athens, Greece 382 VANCOMYCIN – RESISTANT ENTEROCOCCI IN AN INTENSIVE CARE UNIT Paramythiotou E1,Kontopidou F1,, Mylona-Petropoulou D2, Kalogeromitros A1, Poularas I1, Krikos V1, Ntagiopoulos P1, Katsarellis N1, Karabinis A1 1ICU, 2Microbiology Department, G. Gennimatas Hospital, Athens, Greece

TRAUMA REGISTRY AT THE NIGUARDA CA' GRANDA HOSPITAL OF MILANO: EPIDEMIOLOGY AND QUALITY ASSESSMENT Objective: In a Trauma System, Trauma Registry allows the assessment of epidemiology and quality of patient care. Materials and Methods: Data about trauma patients admitted to Ospedale Niguarda Emergency Department from October 1, 2002 to June 30, 2003 with ICD9CM code 800-939.9 and 950-959.9 were prospectively recor- ded. Injury severity score (ISS) and revised trauma score (RTS) were calculated and probability of survival (Ps) was derived. Results: During the study period 1811 trauma patients were admitted, and 271 (14.96%) were consistent with triage criteria of severity. Among these, survivors were 220 (81.18%) and blunt trauma 95.94%. Injuries of the cen- tral nervous system with (11.76%) or without (50.98%) hemodynamic instability or hemodynamic instability alone (31.37%), were the principal causes of death. An ISS grea- ter than 15 was observed in 61.25% with an overtriage of 38.75%. Seventy seven patients accepted without triage criteria of severity died or were admitted to intensive care unit with an undertriage of 5%. Ps among victims was 22.35±27.19 and possible preventable deaths were 6 (11.76%). No frankly preventable death was recorded. Discussion: Standard pre-hospital triage criteria are asso- ciated with significant over and undertriage. Data collec- tion using large population-based data base increases epi- demiologic value of trauma registry. Analysis of Ps identi- fies cases who need clinical discussion to assess adequacy of

1Neuroanesthesia and NICU Niguarda Hospital, Milan, Italy 2 Department of Anesthesia and Intensive Care Santa Maria dei Battuti Hospital, Treviso, Italy 3Department of Anesthesia and Intensive Care, UCSC, Rome, Italy 4Department of Anesthesia and Intensive Care University of Siena, Siena, Italy 5Intensive Care Unit Meyer Hospital, Florence, Italy 6Anesthesia and Intensive Care Unit Regina Margherita Hospital, Turin, Italy 7Anesthesia and Intensive Care Unit Gaslini Hospital, Genoa, Italy 8Anesthesia and Intensive Care Unit Borgotrento Hospital, Verona, Italy 9DEA, Anesthesia and Intensive Care Unit IRCCS Bambino Gesu Hospital, Rome, Italy 10Department of Anesthesia and Intensive Care University of Brescia, Brescia, Italy B of the increasing indications for neuroradiologic imaging in pediatrics and the recent improvement in diagnostic and interventional procedures, the need of developing guidelines for sedation in pediatric neuroradiology has become imperative for the NeuroAnesthesia and Neurointensive Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (Societa Italiana di Anestesia Analgesia Rianimazione e Terapia Intensiva, SIAARTI). Guidelines are useful when: a) the problem is relevant; b) there is a variety of clinical practices; c) reference studies are available; d) improvement in clinical practice is required. These issues are present addressed in Pediatric Neuroradiology Sedation.

In spite of the availability of the new endovascular technique (GDC) to manage cerebral aneurysms, to date, the crucial question "which is the proper treatment in a given patient?" still remains unsettled. In order to check whether an answer is possible, we retrospectively reviewed a personal series of 192 consecutive patients with cerebral aneurysms (1993-1995). We found 164 patients who had been considered eligible for active aneurysm treatment. Treatment modality has been chosen case by case on the basis of patient conditions, and aneurysm size and location. Four groups of patients were identified: Group 1: 104 patients (63.4%) with subarachnoid hemorrhage (SAH) in whom the treatment of choice was surgery; Group 2: 27 SAH patients (16.4%) in whom the first choice was GDC; Group 3: 7 SAH patients (4.2%) who died before the scheduled treatment; Group 4: 26 patients (15%) with not ruptured aneurysm who had either surgery or GDC. Based on the results of this series (improvement of the overall results through the multidisciplinary approach), we have developed the guidelines to prospectively manage future cases of cerebral aneurysms with the purpose to rationalize the management, thus further improving the overall results.

Cerebral vasospasm is a frequent and severe complication of SAH. Angiographic vasospasm may be seen in 70% of patients and delayed cerebral ischemic deficits are observed in 30% of patients. Since vasodilator drugs cannot reverse cerebral vasospasm, treatment is directed to prevent vasospasm and to prevent or reverse ischemic deficits. The mainstay of treatment of vasospasm is the hypertensive hypervolemia dilution (triple H therapy); the mainstay of prevention is the calcium channel blocker nimodipine. The efficacy of triple H therapy has not been demonstrated in randomized clinical trials, while several randomized trials have demonstrated that nimodipine reduces poor outcome due to vasospasm in all grades of patients. Some randomized, clinical trials are recently performed on the efficacy of rTPA (on the basis of the correlation between the amount of cisternal blood and the incidence and severity of vasospasm) and of tirilazed (on the basis of the role of lipidic peroxidation and free radical generation in the pathogenesis of spasm). Balloon angioplasty and/or super-selective intra-arterial infusion of papaverine can be considered when patient is refractory to medical and pharmacological treatment.

Early surgery after SAH is frequently performed. The most important problems for anesthesiologists are the risk of rebleeding, the alteration of autoregulation and CO2 responsiveness, cardiac, respiratory and electrolytic alterations. In this phase the brain may be ischemic-edematous or haemorrhagic-compressive and the choice of anesthetic agent is made on the basis of cerebral conditions. The main goal is to control ICP and maintain adequate CPP. The endovascular treatment with Guglielmi detachable coils is usually performed in patients with poor neurologic and/or medical conditions. General anaesthesia under aggressive monitoring is advisable to control systemic pressure and to avoid movements.

During the last years embolization with Guglielmi detachable coils has provided a new alternative of treatment of intracranial aneurysms. Neuroanesthesiologists and neurointensivists have an important role in the selection of the patients to traditional surgical treatment or endovascular treatment. This selection must be a team decision on the basis of the patient's conditions. The main contribution of neuroanesthesiologists is to evaluate the patient's medical and neurologic conditions and to prospect the anesthesiological problems in each technique, especially when the patient is treated in acute phase after SAH.

BACKGROUND:The aim of this study was to evaluate the use of propofol to induce and maintain anaesthesia in spontaneously breathing paediatric patients (age 2 weeks-11 years) during Magnetic Resonance Imaging (MRI) of the CNS. METHODS:All patients were spontaneously breathing, without intubation, and received supplemental O2. Pulse rate, blood pressure (BP), electrocardiogram and EtCO2 were recorded in all patients, and in 38 subjects SpO2 was also monitored. Patients were divided in 2 groups according to their body weights: Group A (n = 34, bwt < or = 10 kg), and Group B (n = 48, bwt > 10 kg). RESULTS:Dosage of propofol during the time of induction (from insertion of the i.v. cannula to positioning on the MRI table) was significantly higher in smaller children (Group A; 5.4 +/- 2.2 (SD) mg/kg) as compared to children with bwt above 10 kg (Group B; 3.7 +/- 1.6 mg/kg). Propofol dosage for maintenance of anaesthesia was significantly higher in smaller children (Group A: 10.1 +/- 5.7 vs Group B: 7.1 +/- 3.0 mgkg-1 h-1, P = 0.003). During the time of induction, transient episodes of reduced BP (< or = 20%) occurred in 6 patients in Group A and 2 patients in Group B. During anaesthesia in Group B there was 1 episode of oxygen desaturation (95%), and 3 episodes of short and mild increases of EtCO2(< or = 52 mmHg). No other side effects occurred in any patient. MRI studies were successfully completed, only 3 sequences (Group A) had to be restarted. CONCLUSION:Propofol can be safely used for total intravenous anaesthesia in children undergoing MRI.

OBJECTIVE The Intensive Care Units of Milano metropolitan area are characterized by difficulties of hospitalization for acutely injured patients due to the low bed availability. We evaluated the problem trying to find out possible solutions. DESIGN On the day of achieved neurological and neurosurgical stability-defined as the day when the intracranial pressure and jugular venous oxygen saturation monitoring, hyperventilation, osmotic therapy were considered no longer needed--the monitoring procedures and instrumental and/or pharmacological treatments that the patients received were recorded and classified as follows: 1) intensive, 2) intermediate, 3) non-intensive. PATIENTS All the acutely injured patients admitted at five Neurosurgical ICUs during June-July and October-November 1994 have been studied. Only one of these ICUs had a "sub-intensive unit". MEASUREMENTS AND MAIN RESULTS 391 patients (29.9%) aneurysms and arteriovenous malformations, 25.1% tumours, 2.8% head injuries, 8.7% spontaneous intracranial haematomas, 13.5% various pathologies) were studied. Out of them 358 had an acute brain failure. 16.5% died during brain failure and 83.5% reached neurological stability within 3 days. When neurological stability was reached 32.1% of patients could be classified as "intensive", 63.6% as "intermediate" and 4.3% as "unintensive". In the four ICUs, without sub-intensive ward facilities, 361 patients were admitted with a total amount of 2292 days of hospitalization. Among them 61.9% were spent for a) patients with no brain injury (32 pts/113 days), b) postoperative patients (113 pts/167 days), c) patients in stable neurological conditions (159 pts/1139 days). Therefore, only 38% of the days recorded were given to patients that needed neurointensive care. CONCLUSION Out data suggest that the receptivity for acute injured patients could be increased creating recovery room units and intermediate post-intensive units together with a better interchange between general and neurosurgical ICUs.