Eventos quirúrgicos prevenibles/Surgical never events

Diciembre 29, 2015. No. 2190

Carga de trabajo quirúrgico y el riesgo de eventos quirúrgicos prevenibles en Inglaterra. Surgical caseload and the risk of surgical Never Events in England. Moppett IK, Moppett SH. Anaesthesia. 2016 Jan;71(1):17-30. doi: 10.1111/anae.13290. Epub 2015 Nov 23. Abstract Never Events are medical errors that are believed to be preventable with appropriate measures. We surveyed all English acute NHS trusts to determine the number of surgical Never Events and surgical caseload for 2011-2014. There were 742 surgically related Never Events in three years, with no change in the number annually. The risk of a surgical Never Event was 1 in 16 423 operations (95% CI 1 in 15 283 to 1 in 17 648) or 1 NeverEvent per 12.9 operating theatres per year (95% CI 1 in 12.1 to 1 in 13.9). The risk of severe harm due to a Never Event was approximately 1 in 238 939 operations. There was no meaningful association between number of Never Events and other safety indicators. Surgical Never Events are undoubtedly important to individual patients, but they are not a useful metric to judge quality of care. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Fuego en quirófano / Fire in the surgical room

Diciembre 26, 2015. No. 2187

Fuego en el quirófano Operating room fires: a closed claims analysis. Mehta SP, Bhananker SM, Posner KL, Domino KB. Anesthesiology. 2013 May;118(5):1133-9. doi: 10.1097/ALN.0b013e31828afa7b. Abstract BACKGROUND: To assess patterns of injury and liability associated with operating room (OR) fires, closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database since 1985 were reviewed.METHODS: All claims related to fires in the OR were compared with nonfire-related surgical anesthesia claims. An analysis of fire-related claims was performed to identify causative factors.RESULTS: There were 103 OR fire claims (1.9% of 5,297 surgical claims). Electrocautery was the ignition source in 90% of fire claims. OR fire claims more frequently involved older outpatients compared with other surgical anesthesia claims (P < 0.01). Payments to patients were more often made in fire claims (P < 0.01), but payment amounts were lower (median $120,166) compared to nonfire surgical claims (median $250,000, P < 0.01). Electrocautery-induced fires (n = 93) increased over time (P < 0.01) to 4.4% claims between 2000 and 2009. Most (85%) electrocautery fires occurred during head, neck, or upper chest procedures (high-fire-risk procedures). Oxygen served as the oxidizer in 95% of electrocautery-induced OR fires (84% with open delivery system). Most electrocautery-induced fires (n = 75, 81%) occurred during monitored anesthesia care. Oxygen was administered via an open delivery system in all high-risk procedures during monitored anesthesia care. In contrast, alcohol-containing prep solutions and volatile compounds were present in only 15% of OR fires during monitored anesthesia care.CONCLUSIONS: Electrocautery-induced fires during monitored anesthesia care were the most common cause of OR fires claims. Recognition of the fire triad (oxidizer, fuel, and ignition source), particularly the critical role of supplemental oxygen by an open delivery system during use of the electrocautery, is crucial to prevent OR fires. Continuing education and communication among OR personnel along with fire prevention protocols in high-fire-risk procedures may reduce the occurrence of OR fires. PDF Fuego y quemaduras con electrocauterio después de preparar la piel con alcohol en neurocirugía Fires and Burns Occurring in an Electrocautery after Skin Preparation with Alcohol during a Neurosurgery. Chae SB, Kim WK, Yoo CJ, Park CW. J Korean Neurosurg Soc. 2014 Apr;55(4):230-3. doi: 10.3340/jkns.2014.55.4.230. Epub 2014 Apr 30. Abstract While there are reports regarding burns occurring to patients during the surgery, there are little reports concerning the incidents of the burns related to neurosurgical operations. Moreover, in Korea, even surveys and statistics on the incidents of burns in operating rooms are not known. This report explores burns occurring to a patient in an electrocautery scenario after disinfecting the surgical site with alcohol during the preparation of a neurosurgical operation in an operating room where there is much exposure to oxygen. The authors show a case of a 33-year-old male patient who undergoing evacuation of hematoma on occipital lesion, suffered second degree burns as a result of surgical fires. KEYWORDS: Alcohol; Burns; Electrocautery; Neurosurgery PDF Usos comunes y complicaciones de la energía en cirugía Common uses and cited complications of energy in surgery. Sankaranarayanan G, Resapu RR, Jones DB, Schwaitzberg S, De S. Surg Endosc. 2013 Sep;27(9):3056-72. doi: 10.1007/s00464-013-2823-9. Epub 2013 Apr 23. Abstract BACKGROUND: Instruments that apply energy to cut, coagulate, and dissect tissue with minimal bleeding facilitate surgery. The improper use of energy devices may increase patient morbidity and mortality. The current article reviews various energy sources in terms of their common uses and safe practices.METHODS: For the purpose of this review, a general search was conducted through NCBI, SpringerLink, and Google. Articles describing laparoscopic or minimally invasive surgeries using single or multiple energy sources are considered, as are articles comparing various commercial energy devices in laboratory settings. Keywords, such as laparoscopy, energy, laser, electrosurgery, monopolar, bipolar, harmonic, ultrasonic, cryosurgery, argon beam, laser, complications, and death were used in the search.RESULTS: A review of the literature shows that the performance of the energy devices depends upon the type of procedure. There is no consensus as to which device is optimal for a given procedure. The technical skill level of the surgeon and the knowledge about the devices are both important factors in deciding safe outcomes.CONCLUSIONS: As new energy devices enter the market increases, surgeons should be aware of their indicated use in laparoscopic, endoscopic, and open surgery. PDF

Anestesiología y Medicina del Dolor 52 664 6848905 vwhizar@anestesia-dolor.org anestesia-dolor.org Copyright © 2015

Síndrome de HELLP

Diciembre 24, 2015. No. 2185

Manejo de las complicaciones quirúrgicas del síndrome de HELLP The management of the surgical complications of HELLP syndrome. Wilson SG1 White AD, Young AL, Davies MH, Pollard SG. Ann R Coll Surg Engl. 2014 Oct;96(7):512-6. doi: 10.1308/003588414X13946184901362. Abstract INTRODUCTION: Complications from HELLP (Haemolysis, Elevated Liver enzymes and Low Platelet) syndrome may present as an emergency to any surgeon. We review the ten-year experience of a tertiary hepatobiliary centre managing HELLP patients. Three selected cases are described to highlight our management strategy and a systematic review of the recent literature is presented. METHODS: All patients with HELLP syndrome were identified from a prospectively maintained database and their details collated. Subsequently, a detailed search of PubMed was carried out to identify all case series of HELLP syndrome in the literature in the English language since 1999. RESULTS: On review of 1,002 cases, 10 patients were identified with surgical complications of HELLP syndrome. Seven of these patients had a significant liver injury. Only three of these required surgical intervention for liver injury although four other patients required surgical intervention for other complications. There was no maternal mortality in this series. Review of the literature identified 49 cases in 31 publications. The management approaches of these patients were compared with ours. CONCLUSIONS: We have presented a large series of patients with surgical complications resulting from HELLP syndrome managed without maternal mortality. This review has confirmed that haemodynamically stable patients with HELLP syndrome associated hepatic rupture can be conservatively treated successfully. However, in unstable patients, perihepatic packing and transfer to a specialist liver unit is recommended. PDF Aspectos genéticos de preeclampsia y síndrome de HELLP Genetic aspects of preeclampsia and the HELLP syndrome. Haram K, Mortensen JH, Nagy B. J Pregnancy. 2014;2014:910751. doi: 10.1155/2014/910751. Epub 2014 Jun 2. Abstract Both preeclampsia and the HELLP syndrome have their origin in the placenta. The aim of this study is to review genetic factors involved in development of preeclampsia and the HELLP syndrome using literature search in PubMed. A familial cohort links chromosomes 2q, 5q, and 13q to preeclampsia. The chromosome 12q is coupled with the HELLP syndrome. The STOX1 gene, the ERAP1 and 2 genes, the syncytin envelope gene, and the -670 Fas receptor polymorphisms are involved in the development of preeclampsia. The ACVR2A gene on chromosome 2q22 is also implicated. The toll-like receptor-4 (TLR-4) and factor V Leiden mutation participate both in development of preeclampsia and the HELLP syndrome. Carriers of the TT and the CC genotype of the MTHFR C677T polymorphism seem to have an increased risk of the HELLP syndrome. The placental levels of VEGF mRNA are reduced both in women with preeclampsia and in women with the HELLP syndrome. The BclI polymorphism is engaged in development of the HELLP syndrome but not in development of severe preeclampsia. The ACE I/D polymorphism affects uteroplacental and umbilical artery blood flows in women with preeclampsia. In women with preeclampsia and the HELLP syndrome several genes in the placenta are deregulated. Preeclampsia and the HELLP syndrome are multiplex genetic diseases. PDF Terapia con esteroides en el manejo del síndrome de hemólisis, enzimas hepáticas elevadas y plaquetopenia (HELLP). Meta-análisis Corticosteroid Therapy for Management of Hemolysis, Elevated Liver Enzymes, and Low Platelet Count (HELLP) Syndrome: A Meta-Analysis. Mao M, Chen C. Med Sci Monit. 2015 Dec 3;21:3777-83. Abstract BACKGROUND Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a severe condition of pregnancy that is associated with significant morbidity and mortality. Corticoteroid (CORT) therapy is common in the management of HELLP syndrome. This study evaluates the efficacy of CORT therapy to patients with HELLP Syndrome. MATERIAL AND METHODS A literature search was carried out in multiple electronic databases. Meta-analyses of means difference and odds ratio were carried under the random-effects model. RESULTS Fifteen studies (675 CORT treated and 787 control HELLP patients) were included. CORT treatment significantly improved platelet count (mean difference between CORT treated and controls in changes from baseline, MD: 38.08 [15.71, 60.45]×109; p=0.0009), lactic dehydrogenase (LDH) levels (MD: -440 [-760, -120] IU/L; p=0.007), and alanine aminotransferase (ALT) levels (MD: -143.34 [-278.69, -7.99] IU/L; p=0.04) but the decrease in aspartate aminotransferase (AST) levels was not statistically significant (MD: -48.50 [-114.32, 17.32] IU/L; p=0.15). Corticosteroid treatment was also associated with significantly less blood transfusion rate (odds ratio, OR: 0.42 [0.24, 0.76]; p=0.004) and hospital/ICU stay (MD: -1.79 [-3.54, -0.05] days; p=0.04). Maternal mortality (OR: 1.27 [0.45, 3.60]; p=0.65), birth weight (MD: 0.09 [-0.11, 0.28]; p=0.38) and the prevalence of morbid conditions (OR: 0.79 [0.58, 1.08]; p=0.14) did not differ significantly between both groups. CONCLUSIONS Corticosteroid administration to HELLP patients improves platelet count, and the serum levels of LDH and ALT, and reduces hospital/ICU stay and blood transfusion rate, but is not significantly associated with better maternal mortality and overall morbidity. PDF

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