BACKGROUND:An unplanned admission to the intensive care unit within 24 h of a procedure (UIA) is a recommended clinical indicator in surgical patients. Often regarded as a surrogate marker of adverse events, it has potential as a direct measure of patient safety. Its true validity for such use is currently unknown.METHODS:The authors validated UIA as an indicator of safety in surgical patients in a prospective cohort study of 44,130 patients admitted to their hospital. They assessed the association of UIA with intraoperative incidents and near misses, increased hospital length of stay, and 30-day mortality as three constructs of patient safety.RESULTS:The authors identified 201 patients with a UIA; 104 (52.2%) had at least one incident or near miss. After adjusting for confounders, these incidents were significantly associated with UIA in all categories of surgical procedures analyzed; odds ratios were 12.21 (95% confidence interval [CI], 6.33-23.58), 4.06 (95% CI, 2.74-6.03), and 2.13 (95% CI, 1.02-4.42), respectively. The 30-day mortality for patients with UIA was 10.9%, compared with 1.1% in non-UIA patients. After risk adjustment, UIA was associated with excess mortality in several types of surgical procedures (odds ratio, 3.89; 95% CI, 2.14-7.04). The median length of stay was increased if UIA occurred: 16 days (interquartile range, 10-31) versus 2 days (interquartile range, 0.5-9) (P < 0.001). For patients with a UIA, the likelihood of discharge from hospital was significantly decreased in most surgical categories analyzed, with adjusted hazard ratios of 0.41 (95% CI, 0.23-0.77) to 0.58 (95% CI, 0.37-0.93).CONCLUSIONS:These findings provide strong support for the construct validity of UIA as a measure of patient safety.

Patient satisfaction after anaesthesia is an important outcome of hospital care. We analysed our anaesthetic database to identify potentially modifiable factors associated with dissatisfaction. At the time of analysis, our database contained information on 10,811 in-patients interviewed on the first day after operation. The major subjective outcome measure was patient satisfaction. We also measured other predetermined outcomes, such as nausea, vomiting, pain and complications. The overall level of satisfaction was high (96.8%); 246 (2.3%) patients were 'somewhat dissatisfied' and 97 (0.9%) were 'dissatisfied' with their anaesthetic care. After adjustment for patient and surgical factors, there was a strong relation between patient dissatisfaction and: (i) intraoperative awareness (odds ratio (OR) 54.9, 95% confidence intervals (CI) 15.7-191); (ii) moderate or severe postoperative pain (OR 3.94, 95% CI 3.16-4.91); (iii) severe nausea and vomiting (OR 4.09, 95% CI 3.18-5.25); and (iv) any other postoperative complications (OR 2.04, 95% CI 1.61-2.56). Several factors associated with dissatisfaction may be preventable or better treated.

Quality of recovery after an operation is an important dimension of the patient's experience and may be related to the quality of anaesthesia care. Satisfaction with anaesthesia is a vital component of quality care but difficult to measure. We examined our database of 5672 adult patients to determine if quality of recovery is associated with satisfaction with anaesthesia and to identify the perioperative factors that might influence both these outcome measures. We found that a nine-item quality of recovery score (“QoR Score”) was related to satisfaction with anaesthesia (P<0.0005): the overall level of satisfaction was high (97.2%; median QoR Score 16); 106 patients (2.1%; median QoR Score 14) were “somewhat dissatisfied” and 32 patients (0.6%; median QoR Score 13) were “dissatisfied” with their anaesthesia care. Patients who experienced any of a number of perioperative complications had lower QoR Scores (P<0.0005). We have further demonstrated the validity and clinical utility of the QoR Score, and in particular, its relationship to patient satisfaction in adult surgical patients.

Objective: To determine the accuracy and clinical utility of a continuous arterial blood gas (ABG) monitor during lung transplantation.Design: Prospective, observational cohort study.Setting: University hospital.Participants: Eleven patients undergoing bilateral sequential lung transplantation (BSLTx).Interventions: Repeated ABG sampling.Measurements and Main Results: Agreement was measured by the bias (limits of agreement): pH, 0.006 (-0.10 to 0.10); PaO2, -22 mmHg (-130 to 86 mmHg); and PaCO2, -1.6 mmHg (-13.4 to 10.2 mmHg). Sensitivity and specificity of the Paratrend 7 (Biomedical Sensors, Ltd, Malvern, PA) PaO2 measurements (to detect PaO2 < 100 mmHg) were 84.6% and 97.6%, respectively.Conclusion: Continuous ABG monitoring with the Paratrend 7 shows sufficiently good agreement with laboratory blood gas analysis during BSLTx and thus is a convenient alternative to intermittent laboratory blood gas measurement. Because of the potential for significant (and sometimes rapid) acid-base disturbances, continuous ABG monitoring may have a role during most lung transplantation procedures. Copyright (C) 1999 by W.B. Saunders Company.

Bilateral lung volume reduction surgery was introduced into Australia in 1995 for treatment of selected patients with emphysema. We present our experience of the anaesthetic management of our first 55 cases and describe factors associated with outcome. There were four postoperative deaths (7%). Mean (SD) total operation time was 231 (72) minutes. Median intensive care unit (ICU) stay was 26 hours. There was a significant improvement in postoperative lung function (FEV1, VC, 6-minute walk test, all P < 0.001). Eight patients (15%) required reintubation for respiratory failure; three of these patients subsequently died. With multivariate analysis, total operation time was the only significant predictor of length of ICU stay R-2 = 0.25, P = 0.001), which itself was the only significant predictor of hospital stay duration (R-2 = 0.36, P < 0.001).

The lessons learned in industry can be applied to anaesthetic departments. Progress and development are part of improving quality, and evidence is emerging that improved quality can reduce costs. Improving quality requires anaesthetic departments to develop a clear customer focus. Education, training, research and quality improvement are essential components of a quality anaesthetic department. Some of the cost reductions are achieved by development of partnerships with customers and suppliers. The emphasis is likely to shift from cost reduction to quality improvement and anaesthetic departments should anticipate this change.

Recent interest in earlier tracheal extubation after coronary artery bypass graft (CABG) surgery has focused attention on the potential benefits of a propofol-based technique. We randomized 124 patients (34 with poor ventricular function) undergoing CABG surgery to receive either a propofol-based (5 mg [center dot] kg-1 [centered dot] h-1 prior to sternotomy, 3 mg [center dot] kg-1 [center dot] h (-1) thereafter; n = 58) or enflurane-based (0.2%-1.0%, n = 66) anesthetic. Induction of anesthesia consisted of fentanyl 15 micro g/kg and midazolam 0.05 mg/kg intravenously in both groups. The enflurane group received an additional bolus of fentanyl 5 micro g/kg prior to sternotomy and fentanyl 10 micro g/kg with midazolam 0.1 mg/kg at commencement of cardiopulmonary bypass (CPB). Patients receiving propofol were extubated earlier (median 9.1 h versus 12.3 h, P = 0.006), although there was no difference in time to intensive care unit (ICU) discharge (both 22 h, P = 0.54). Both groups had similar hemodynamic changes throughout (all P > 0.10), as well as metaraminol (P = 0.49) and inotrope requirements (P > 0.10), intraoperative myocardial ischemia (P = 0.12) and perioperative myocardial infarction (P = 0.50). The results of this trial suggest that a propofol-based anesthetic, when compared to an enflurane-based anesthetic requiring additional dosing of fentanyl and midazolam for CPB, can lead to a significant reduction in time to extubation after CABG surgery, without adverse hemodynamic effects, increased risk of myocardial ischemia or infarction. (Anesth Analg 1997;84:12-9)

We studied the hemodynamic effects of left atrial (LA) administration of epinephrine in 10 patients after cardiac transplantation, using a prospective, randomized, double-blind, cross-over design. After allograft implantation, a LA catheter was inserted and epinephrine infusion commenced at 100 ng.kg-1.min-1. Each trial period consisted of 20 min, with the LA and right atrial (RA) lines switched over between each period; hemodynamic measurements were taken after each time period. Whether epinephrine was administered via the RA or LA did not significantly alter hemodynamics (RA versus LA): mean (SD) arterial blood pressure 67 (7.5) vs 64 (9.5) mm Hg (P = 0.16), mean pulmonary artery pressure 22 (4.0) vs 21 (9.4) mm Hg (P = 0.67), cardiac index 3.2 (1.1) vs 3.2 (1.1) L.min-1.m-2 (P = 0.83), pulmonary vascular resistance index 308 (157) vs 345 (157) dynes.s.cm-5/m-2 (P = 0.30) or right ventricular ejection fraction 35% (11%) vs 32% (9.8%) (P = 0.23). Arterial epinephrine plasma levels were similar (P = 0.16). There was no significant pulmonary extraction of measured catecholamines. We observed no hemodynamic benefit of LA epinephrine administration. It may be that the cardiac transplantation population reacts differently compared with other cardiac surgical patients (possibly because pulmonary extraction of catecholamines is reduced). Because we did not observe a hemodynamic advantage in patients immediately after cardiac transplantation, we would not recommend the use of LA epinephrine at the dose studied.

A 22-year-old, 40-kg man with end-stage infective lung disease secondary to cystic fibrosis, presented for bilateral sequential lung transplantation (BSLTx). He had chronic hypercapneic respiratory failure with cor pulmonale and was dependent on home oxygen therapy. He had been admitted to the hospital 3 days earlier with a severe exacerbation of his condition. His preoperative values were as follows: hemoglobin 13.3 g/dL; arterial blood gases (room air) pH 7.36, arterial oxygen tension (Pao2) 50 mmHg, arterial carbon dioxide tension (Paco2) 72 mmHg, bicarbonate 41 mmol/L; and pulmonary function testing (forced vital capacity 1.76 L [37% predicted], forced expriatory volume in 1 second 0.84 [20% predicted], midexpiratory flow rate 0.21 L/s [4% predicted]). Other monitors included chest x-ray (gross cystic bronchiectasis with patchy consolidation), electrocardiogram (sinus rhythm and right-axis deviation), transthoracic echocardiogram (normal left ventricular function, mild right ventricular enlargement, and mild tricuspid regurgitation), and gated cardiac blood pool scan (at rest) (left ventricular ejection fraction 43%, right ventricular ejection fraction 40%). The patient was premedicated with temazepam and 0.3 M of sodium citrate and was transferred to the operating room with oxygen administered by face mask. A midthoracic epidural catheter and intravascular catheters were inserted with local anesthesia, although no epidural agents were used until after the procedure, and routine invasive monitoring was established. A low-dose dopamine infusion, 3 pg/kg/min, was then commenced to optimize renal blood flow, and methylprednisolone, 500 rag, was slowly administered.

Positive pressure ventilation in patients with obstructive lung disease may result in over-inflation of the relatively compliant lungs, resulting in dynamic hyperinflation (DHI). Using a crossover trial design, we compared high-frequency jet ventilation (HFJV) versus “optimal” intermittent positive pressure ventilation (IPPV) in ten patients undergoing lung transplantation for severe, end-stage obstructive lung disease. We measured haemodynamics and the degree of DHI after both modes of ventilation. There were no significant differences between IPPV and HFJV, with respect to efficiency of ventilation (PaCO2), haemodynamic effects (stroke volume, blood pressure and cardiac output), or lung hyperinflation (trapped gas volume). This study suggests that HFJV, when compared with optimal IPPV, is no better at minimizing DHI in patients with severe, end-stage obstructive lung disease.

OBJECTIVES:To review the experience of anesthesia for bilateral sequential lung transplantation (BSLTx) and describe factors associated with outcome. DESIGN:Case series. SETTING:University hospital. PARTICIPANTS:Sixty-four adult patients undergoing BSLTx. INTERVENTIONS:Descriptive and inferential statistical analysis. MEASUREMENTS AND MAIN RESULTS:Details of anesthetic technique, patient, and perioperative characteristics are presented. Mean (SD) lung allograft ischemic times were 320 (81) minutes for the first lung and 446 (93) minutes for the second lung. Mean (SD) duration of surgery was 8.5(2) hours, and median time to extubation was 28 hours. There was a reduction in the use of cardiopulmonary bypass, from 10 of 19 (53%) in 1992 to 1993 to 10 of 45 (22%) in 1994 to 1996, p = 0.016. There was an association between time to extubation and duration of surgery (Spearman rank correlation, p = 0.33, p = 0.008), but no association with intraoperative fluid administration (p = 0.18, p = 0.16), or inotrope requirements (p = 0.06, p = 0.65). Predictors of in-hospital mortality were preoperative renal impairment (p = 0.034), early reoperation (p = 0.005), and delay in extubation (p = 0.013); and for 12-month mortality was patient age (p = 0.01). The actuarial survival rates were 90%, 73%, and 58% at 30 days, 1 year, and 2 years, respectively. CONCLUSIONS:Anesthesia for BSLTx is a most challenging procedure, for which maintenance of tissue oxygenation and right ventricular perfusion are essential. Recent advances include use of inhaled nitric oxide, ventilator management that reduces dynamic hyperinflation, and permissive hypercapnia. Analysis of outcome from a large case series such as this enables the anesthesiologist to be more aware of the important features of anesthesia for BSLTx, as well as identify potential areas of improvement.

Objective: To document changes in serum lipids and glucose with a propofol infusion technique for cardiac surgery.Design: Prospective cohort.Setting: University teaching hospital.Participants: 22 elective cardiac surgical patients.Interventions: Frequent venous blood sampling.Measurements and Main Results: Serum lipids and glucose were measured at 10 time periods perioperatively, from preinduction until 4 hours post-cardiopulmonary bypass. Plasma propofol concentrations were also measured in 10 of these patients, There was a significant increase in glucose (P < 0.0005) and decreases in cholesterol (P < 0.0005), high-density lipoprotein (P = 0.004), and low-density lipoprotein (P < 0.0005); there was no significant change in triglycerides (P = 0.39). The propofol infusion resulted in acceptable plasma levels throughout the procedure and allowed early extubation in the intensive care unit, after a mean (SD) of 7.14 (5.9) hours. There was a strong correlation between triglyceride and propofol levels at most time periods (r = 0.38 to 0.98).Conclusions: This study demonstrates that a propofol infusion technique does not result in elevation of serum lipids and supports its increased popularity in maintenance of anesthesia for cardiac surgery. Copyright (C) 1995 by W.B. Saunders Company