Search

Introduction: The impact of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on obesity and obesity-related diseases is unquestionable. Up to now, the technical descriptions of these techniques in animals/rats have not been very comprehensive., Methods: For SG and RYGB, operating time, learning curve, and intraoperative mortality in relation to weight of the rat and type of anesthesia were recorded. Furthermore, a review of the literature on experimental approaches towards SG and RYGB in rats was carried out, merging in a detailed technical description for both procedures., Results: The data presented here revealed that the mean operating time for SG (69.4 ± 22.2 min (SD)) was shorter than for RYGB (123.0 ± 20.7 min). There is a learning curve for both procedures, resulting in a reduced operating time of up to 60% in SG and 35% in RYGB (p < 0.05; t-test). However, with increased weight, operating time increases to about 80 min for SG and about 120 min for RYGB. Obese rats have an increased intraoperative mortality rate of up to 50%. After gaseous anesthesia the mortality can be even higher. The literature search revealed 40 papers dealing with SG and RYGB in rats. 18 articles (45%) contained neither photographs nor illustrations; 14 articles (35%) did not mention the applied type of anesthesia. The mortality rate was described in 15 papers (37.5%)., Conclusion: Experimental obesity surgery in rats is challenging. Because of the high mortality in obese rats operated under gaseous anesthesia, exercises to establish the techniques should be performed in small rats using intraperitoneal anesthesia.

The vasoconstrictive and antidiuretic physiologic properties of vasopressin (antidiuretic hormone) have long been known. Until recently however, vasopressin was mostly used for diabetes insipidus and noctournal enuresis. This review summarizes the growing body of evidence regarding the perioperative use of vasopressin and its analogues in the management of certain forms of cardiovascular collapse. Physiologically, vasopressin is involved in regulating osmotic, volemic, and cardiovascular homeostasis. It acts via several specific vasopressin receptors that are variably distributed in the heart, kidneys and vasculature etc. Under normal conditions, its antidiuretic effect predominates and vasopressin only induces vasoconstriction at high concentrations. Regarding catecholamine-resistant vasodilatory shock, current evidence suggests that with adequate volume resuscitation, exogenous vasopressin in low "physiologic" doses (0.01-0.04 units/min) safely supports mean arterial pressure without adversely affecting myocardial function and splanchnic circulation. One possible explanation is that metabolic acidosis impairs the function of alpha-adrenergic (but not vasopressin) receptors, thus diminishing the response to catecholamines. Although there is yet no clear cut mortality benefit, vasopressin is now recommended as a second-line agent in septic shock for its catecholamine-sparing effect and as an alternative to epinephrine in cardiopulmonary resuscitation. It has also demonstrated efficacy in ameliorating vasoplegia after cardiopulmonary bypass as well as perioperative hypotension in patients on renin-angiotensin system antagionists preoperatively. In summary, accumulating clinical experience and formal studies indicate that vasopressin has a role in restoring vascular tone in refractory vasodilatory shock states with minimal adverse effects provided that euvolemia is assured.

The operating room offers a unique setting where anesthetics, preoperative medications, patient comorbidities, and surgery all merge. Anesthesiologists are responsible for combining these concerns into a dependable and safe approach. From formulation to administration, enhancements in nearly every aspect of a given drug have improved the ability of anesthesiologists to accomplish this. Some of these methodologies, including novel anesthetics and analgesics, drug delivery and administration including infusion pumps, antithrombotics, and a reappraisal of previous medications are highlighted in this review. While these advancements are significant, patients and healthcare systems globally are rightfully demanding safer application of drugs at every level. On May 1, 2012, a report issued by the Institute of Medicine advised the United States Food and Drug Administration to undertake a much more rigorous patient-centered effort to evaluate a drug's safety over its entire life-cycle. This recommendation is in agreement with the objectives of the Anesthesia Patient Safety Foundation. With these mutual goals shared by many stakeholders and their continued efforts, the future of the estimated 200 million global surgeries to be undertaken this year hopefully provides a safer experience while under anesthesia.

The Anesthesia Quality Institute has created the National Anesthesia Clinical Outcomes Registry to automatically capture electronic data specific to anesthesia cases. Data come from billing systems, quality management systems, hospital electronic health care records, and anesthesia information management systems. Aggregation of this data will allow for calculation of national and cohort-specific benchmarks for anesthesia outcomes of interest. Provision of this data to anesthesia practitioners through periodic private reports will motivate improvements in the quality of care., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Objectives/aims: We aimed to identify and analyze critical incidents relating to pediatric anesthesia from the National Reporting and Learning System (NRLS) in England and Wales., Background: Critical incident reporting plays a key role in learning from problems and so enhancing patient safety. There has been no previous analysis of pediatric anesthetic incidents in the NRLS., Methods: We obtained potentially relevant records from the UK National Patient Safety Agency. Eligible incidents were classified according to patient age, degree of harm sustained, and clinical category., Results: A total of 606 incidents met the inclusion criteria. Six deaths were reported and 48 incidents resulted in severe harm. In many reports, sufficient detail was lacking for a full understanding of what had happened. However, the broad focus of the NRLS revealed a wide spectrum of clinical and organizational incidents relating to pediatric anesthesia. Medication issues predominated (35.6%), notably inadvertent duplication of dosing in operating theater and ward. Airway/ventilation incidents formed 18.8% of the total, cardiovascular incidents 5.9%, and equipment-related incidents (failure or unavailability) 15.7%. Communication and organizational problems made up 8.6% of reports., Conclusions: We make a number of recommendations for practice. In addition, anesthetists should be encouraged to take ownership and contribute high-quality descriptions of incidents to national systems., (© 2010 Blackwell Publishing Ltd.)

Risk in pediatric anesthesia can be conveniently classified as minor or major. Major morbidity includes cardiac arrest, brain damage and death. Minor morbidity can be assessed by clinical audits with small patient samples. Major morbidity is rare. It is best assessed by very large clinical studies and by review of closed malpractice claims. Both minor and major morbidity occur most commonly in infants and children under three, especially those with severe co-morbidities. Knowledge of risk profiles in pediatric anesthesia is a starting point for the reduction of risk., (© 2010 Blackwell Publishing Ltd.)

When a patient is injured or dies during anesthesia care, both the family of the patient and the health care providers suffer. The family needs to know what happened. The family can benefit from personal contact with the involved physicians. Apology to the injured is very important. The health care providers must report adverse events. Systematic review of adverse events can provide improved patient safety. Mechanisms exist to support the health care providers recovering from these potentially devastating experiences, but useful support is often not immediately available., (© 2011 Blackwell Publishing Ltd.)

Since 1960, the collection and analysis of mortality data for anesthesia in Australia has been of significant benefit to practising anesthetists. These figures include pediatric deaths which fortunately have been rare and often inevitable because of severe underlying disease and patient risk factors. The reporting of critical incidents and serious morbidity, on the other hand, has been far less impressive. Only one state in Australia, Victoria, currently has a committee that collects morbidity data and, as this reporting is voluntary, is likely to under-represent the true numbers of critical events. There is no specific pediatric morbidity database in Australia so much of this discussion will be regarding overall anesthesia critical event reporting which includes pediatrics as a subset., (© 2011 Blackwell Publishing Ltd.)

Based on results recorded of perioperative mortality, anaesthetic care is often cited as a model for its improvements with regard to patient safety. However, anaesthesia-related morbidity represents a major burden for patients as yet in spite of major progresses in this field since the early 1980s. More than 1 out of 10 patients will have an intraoperative incident and 1 out of 1000 will have an injury such as a dental damage, an accidental dural perforation, a peripheral nerve damage or major pain. Poor preoperative patient evaluation and postoperative care often contribute to complications. Human error and inadequate teamwork are frequently identified as major causes of failures. To further improve anaesthetic care, high-risk technical procedures should be performed after systematic training, and further attention should be focussed on preoperative assessment and post-anaesthetic care. To minimise the impact of human errors, guidelines and standardised procedures should be widely implemented. Deficient teamwork and communication should be addressed through specific programmes that have been demonstrated to be effective in the aviation industry: crew resource management (CRM) and simulation. The impact of the overall safety culture of health-care organisations on anaesthesia should not be minimised, and organisational issues should be systematically addressed., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Mortality is a basic measure for quality and safety in anesthesia. There are few anesthesia-related mortality data available for pediatric practice. Our objective for this study was to determine the incidence of 24-hour and 30-day mortality after anesthesia and to determine the incidence and nature of anesthesia-related mortality in pediatric practice at a large tertiary institution., Methods: Children ≤ 18 years old who had an anesthetic between January 1, 2003, and August 30, 2008, at the Royal Children's Hospital, Melbourne, Australia, were included for this study. Data were analyzed by merging a database for every anesthetic performed with an accurate electronic record of mortality of children who had ever been a Royal Children's Hospital patient. Cases of children dying within 30 days and 24 hours of an anesthetic were identified and the patient history and anesthetic record examined. Anesthesia-related death was defined as those cases whereby a panel of 3 senior anesthesiologists all agreed that anesthesia or factors under the control of the anesthesiologist more likely than not influenced the timing of death., Results: During this 68-month period, 101,885 anesthetics were administered to 56,263 children. The overall 24-hour mortality from any cause after anesthesia was 13.4 per 10,000 anesthetics delivered and 30-day mortality was 34.5 per 10,000 anesthetics delivered. The incidence of death was highest in children ≤ 30 days old. Patients undergoing cardiac surgery had a higher incidence of 24-hour and 30-day mortality than did those undergoing noncardiac surgery. From 101,885 anesthetics there were 10 anesthesia-related deaths. The incidence of anesthesia-related death was 1 in 10,188 or 0.98 cases per 10,000 anesthetics performed (95%confidence interval, 0.5 to 1.8). In all 10 cases, preexisting medical conditions were identified as being a significant factor in the patient's death. Five of these cases (50%) involved children with pulmonary hypertension., Conclusions: Anesthesia-related mortality is higher in children with heart disease and in particular those with pulmonary hypertension. The lack of anesthetic-related deaths in children who did not have major comorbidities reinforces the safety of pediatric anesthesia in healthy children.

Purpose of Review: To provide recent evidence of safety in anesthesia and appraise the role of established tools of safety improvement in anesthesia practice., Recent Findings: The current incidence of minor events or complications during anesthesia is estimated at 18-22%, for severe complications 0.45-1.4%, and for mortality of 1: 100 000. Evidence suggests that despite such low complication rates, further improvements can still be made by addressing systemic factors which are known to set up conditions for adverse events. In particular, improvements can be made in the areas of drug errors, and inadequate or lack of communication between different clinical teams during the process of handovers. In addition, the evidence is growing which highlights the importance of established tools such as critical incident reporting, quality management using plan-do-check-act cycles, use of checklists and use of simulation in training clinical staff in the areas of nontechnical skills., Summary: Anesthesia is one of the safest clinical specialties and remains at the top among leaders of patient safety. This review provides evidence for the areas in which further progress can be made, and usefulness of certain tools, such as critical incident reporting, checklists, plan-do-check-act cycles and simulation, can be used for continued improvements.

This special article provides an introduction to the World Health Organization (WHO) Emergency and Essential Surgical Care (EESC) program. The program was launched by the WHO in December of 2005 to address the lack of adequate surgical capacity as a global public health issue. The overall objective is to reduce death and disability from trauma, burns, pregnancy-related complications, domestic violence, disasters, and other surgically treatable conditions. The program and materials have spread to over 35 countries and focus on providing (1) basic education and training materials; (2) enhancement of surgical infrastructure at the governmental and health facility level; and (3) resources for monitoring and evaluating surgical, obstetrical, and anesthetic capacity. Additionally, a global forum for program members was established that collaborates with ministries of health, WHO country offices, nongovernmental organizations, and academia. The results of the third biennial meeting of global EESC members in Mongolia are outlined as well as future challenges.

Quality and safety in anesthesia is usually monitored by analysis of perioperative mortality-morbidity and incidents. Clinical quality indicator, death within 48 hours of anaesthesia exposure is considered to be a flag that can alert to possible problems in individual patient care. The measurement of perioperative mortality as a quality indicator is a continuous peer reviewed quality improvement activity. Medical records and morbidity and mortality files were reviewed to see the trends and finding the benchmark of mortality in ASA-1 and 2 patient who died between 1992-2006 within 48 hours of anaesthesia exposure. Mortality in class 1 was nil. Anaesthetic mortality in ASA-1 and 2 patients was 0.35 per 10,000 and 0.74 per 10,000 of ASA-2 patient's volume. Anaesthesia-related mortality was 0.17 per 10,000 and 0.37 per 10,000 of ASA-2 patient's volume which is almost double of the overall calculated incidence. We suggest continuing monitoring of anaesthesia related mortality as a continuous quality indicator in developing countries. The reporting and analyzing of data according to the ASA status volume should be taken as a denominator. The available benchmark will help in evaluating the confounding factors and perioperative care of a particular group of patients.

The purpose of this descriptive cohort study was to identify perioperative risk factors associated with postoperative outcome up to 4 months after surgery in elderly patients with hip fracture. Data were collected prospectively through the Swedish National Hip Fracture, the local Acute and Emergency, and Anesthesia registers, and retrospectively from medical and nursing records. The 428 patients (aged > or = 65 years) with hip fracture were consecutively included. Multiple logistic regression analyses were used to identify factors predicting each of 4 outcomes. Perioperative risk factors predicting death within 4 months after surgery were fasting time of 12 or more hours and blood transfusion of 1 U or more. Risk factors predicting postoperative confusion were postoperative oxygen saturation less than 90% and fasting time 12 hours or longer. Risk factors predicting in-hospital complications were transfusion of 1 or more units of blood, preoperative oxygen saturation less than 90%, and fasting time 12 hours or more. Risk factor predicting length of stay longer than 10 days was blood transfusion of 1 U or more. To minimize morbidity and mortality, providers should increase efforts to optimize the patients' oxygen saturation and hemoglobin level and reduce fasting time and waiting time for surgery.

Background: Patient safety has been gained much more attention in recent years. The authors reviewed patients who had cardiac arrest in the operating rooms undergoing noncardiac surgery between January 1989 and December 2001 at the University of Pittsburgh Medical Center, USA. The main objectives of the study were to determine the incidence of intraoperative cardiac arrest, to identify possible causes of cardiac arrest and to explore amenable modifications., Methods: With approval by the University of Pittsburgh Institutional Review Board, patients experienced cardiac arrest during surgery were retrieved from medical records, surgical operation and anesthesia records and pathological reports by searching the Medical Archival Retrieval System (MARS), a hospital electronic searching system. Cases of cardiac arrest were collected over a period of thirteen years from the Presbyterian University Hospital (PUH), USA., Results: We found 23 cases of intraoperative cardiac arrests occurred in 218 274 anesthesia cases (1.1 per 10 000). Fourteen patients (60.8%) died in the operating room, leading to a mortality rate from all causes of 0.64 per 10 000 anesthetics. Immediate overall survival rate after arrest was 39% (9/23). Half of the patients (12/23) were emergency cases with 41% survival rate (5/12). One fourth of the arrests were trauma patients (6/23). Most arrest patients (87%, 20/23) were American Society of Anesthesiologists Physical Status (ASA PS) IV and V, while only three patients were ASA PS-I, II and III, respectively. One case was attributable to an anesthesia-related cardiac arrest and recovered after successful resuscitation., Conclusions: Most intraoperative cardiac arrests were not due to anesthesia-related causes. Anesthesia-related cardiac arrests might have a higher survival rate when compared to other possible causes of cardiac arrest in the operating room.

The "perioperative" period for elderly patients is prone to a significant level of morbidity and mortality. Chronological age and comorbidities are the main causes of mortality. Loco-regional anaesthesia is used in 50% of cases. When general anaesthesia is used, invasive monitoring is the rule, with titration of medication and pain treatment. Cognitive dysfunctions are related to age rather than the anaesthetic technique. The aim is for early rehabilitation perhaps through ambulatory care.

Anesthetic complications appear relatively rare, though recent work suggests they are more common in cats than dogs. Current estimates indicate that approximately 0.11% (1 in 895 anesthetics) of healthy cats die of an anesthetic-related death, which is more than twice as frequent as has been recently reported in dogs (0.05% or 1 in 1849). Most of these deaths occurred in the postoperative period. A number of risk factors have been associated with death, including patient health status, age, weight, and procedure type and urgency. Endotracheal intubation and fluid therapy have been reported to be associated with increased odds of anesthetic death in cats and may reflect higher risk techniques in cats compared with dogs. Monitoring patient pulse and the use of a pulse oximeter were also recently reported to be associated with reduced risk of anesthetic death. These data can help veterinarians care for their patient under anesthesia and address greater attention to patient assessment and management before anesthesia, as well as more careful fluid administration and patient monitoring during and after anesthesia, which could reduce perioperative complications in cats., (Copyright © 2010 Elsevier Inc. All rights reserved.)

We measured intra- and postoperative mortality rates of captive and free-ranging Harlequin Ducks (Histrionicus histrionicus) undergoing surgical liver biopsy sampling for determination of the induction of cytochrome P4501A, a biomarker of oil exposure. Liver biopsies were taken from and radio transmitters were implanted into 157 free-ranging Harlequin Ducks over three winters (55 in 2000, 55 in 2001, and 47 in 2002). No birds died during surgery, but seven (4.5%) died during recovery from anesthesia (three in 2001 and four in 2002). None of the deaths could be attributed directly to the liver biopsy. Four of the 150 (2.7%) birds that were released died in the 2 wk period after surgery. All post-release deaths occurred in 2001; no birds died after release in 2000 or 2002. No mortalities of 36 captive birds occurred during surgery or recovery or in the 2 wk period following surgery. Hemorrhage was a minor problem with one captive bird. Surgical liver biopsies appear to be a safe procedure, but anesthetic complications may occur with overwintering ducks.

Various studies have shown that the use of a checklist in the operating room lowers mortality and morbidity related to the act of anaesthesia and surgery. The WHO launched a program in June 2008 to improve the safety of surgical care; the main point is the rational use of a simple tool: the Surgical Safety Checklist. Therefore, the HAS, with various representatives of colleges and professional associations of surgeons, anaesthesiologists and operating room nurses including CNGOF and SCGP, established recommendations and proposed a single checklist for all. This list should be used by any team of operative room: nurses, anaesthesiologists, surgeons before anaesthetic induction and before surgery and after the last act before leaving the room. This checklist can of course be supplemented by other checklists specific from specialty teams or places but it can never be abridged or altered. The HAS provides for the promotion of the implementation of this checklist, the certification of health facilities with its introduction into the V2010 and accreditation of doctors., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Aims: To describe the practice of pediatric anesthesia in the main University Hospitals in Benin., Patients and Methods: We conduct a retrospective study involving 512 children at the 'Centre National Hospitalier et Universitaire' and the 'Hôpital de la Mère et de l'Enfant Lagune' in Cotonou. All children less than 15 years of age undergoing surgery from January to December 2007 were included. Patient demographics, anesthetic technique, perioperative monitoring and complications were analyzed., Results: General anesthesia was used in 94% of children. Regional anesthesia was used in 1.7% of children at CNHU and 17% of children at Hôpital de la Mère et de l'Enfant Lagune. Inhalational induction was the commonest technique used. Halothane was the only inhalational agent available for induction. Seventy-two percent of children having general anesthesia were intubated. Muscle relaxation was used in 48% of cases, only with pancuronium. The available perioperative monitoring equipment was not used regularly. All children having general anesthesia breathed spontaneously with manual assistance. There were eight cardiac arrests recorded, giving an incidence of 156 cardiac arrests per 10,000 anesthetics. Hypoxia was the commonest cause of cardiac arrest. The mortality associated with cardiac arrest was very high (62%). There were three prognostic factors that predicted a poor outcome: age <1 year, emergency surgery and an ASA score of three or more., Conclusion: Pediatric anesthesia in the two University Hospitals is far from satisfactory. Morbidity and mortality are unacceptably high. Suggestions are made to improve the safety of children undergoing anesthesia.

Purpose of Review: The purpose of this review is to summarize recommendations for the safe and efficient conductance of sedation and anesthesia at remote locations; and to define safety standards, monitoring techniques, quality of care and procedural eligibility., Recent Findings: Anesthesia outside of the operating room is rapidly increasing in numbers, which has seen a growth of older and sicker patients. These circumstances have created a need for guidelines, for both specialist anesthesia providers and nonanesthesia-trained practitioners, that define patient selection, minimum monitoring (hemodynamics and respiration), facility design and equipment, policy framework, recovery facilities and policies. The patient's safety throughout all stages of sedation and/or anesthesia is the most pertinent goal. Recent data emphasize the importance of monitoring pulse oximetry and end-tidal carbon dioxide for any sedating or anesthetic procedure. Substandard monitoring combined with oversedation and subsequent respiratory depression are implicated as the main reasons for catastrophic sedation and anesthetic outcomes at remote locations., Summary: Patient selection, procedure appropriateness and location appropriateness are the key elements defining the provision of safe anesthesia care outside the operating room. Titratable, short-acting intravenous drugs are preferred such as propofol and remifentanil.

Anaesthesiology, which includes anaesthesia, perioperative care, intensive care medicine, pain therapy and emergency medicine, has always participated in systematic attempts to improve patient safety. Anaesthesiologists have a unique, cross-specialty opportunity to influence the safety and quality of patient care. Past achievements have allowed our specialty a perception that it has become safe, but there should be no room for complacency when there is more to be done. Increasingly older and sicker patients, more complex surgical interventions, more pressure on throughput, new drugs and devices and simple chance all pose hazards in the work of anaesthesiologists. In response to this increasingly difficult and complex working environment, the European Board of Anaesthesiology (EBA), in cooperation with the European Society of Anaesthesiology (ESA), has produced a blueprint for patient safety in anaesthesiology. This document, to be known as the Helsinki Declaration on Patient Safety in Anaesthesiology, was endorsed by these two bodies together with the World Health Organization (WHO), the World Federation of Societies of Anaesthesiologists (WFSA), and the European Patients' Federation (EPF) at the Euroanaesthesia meeting in Helsinki in June 2010. The Declaration represents a shared European view of that which is worthy, achievable, and needed to improve patient safety in anaesthesiology in 2010. The Declaration recommends practical steps that all anaesthesiologists who are not already using them can successfully include in their own clinical practice. In parallel, EBA and ESA have launched a joint patient safety task-force in order to put these recommendations into practice. It is planned to review this Declaration document regularly.

Purpose of Review: The worldwide adoption of live liver donors as a source of donor organs for transplantation has been curtailed by the very real risk of complications in otherwise healthy people. Our objective in this review is to outline the perioperative management of the live liver donor for adult-to-adult transplantation., Recent Findings: The incidence and severity of complications following live liver donation is extremely variable, and reporting needs to be standardized if we are to improve the perioperative management and outcomes. Agreed definitions would clarify the incidence and severity of postoperative complications, allow identification of areas in which management can be improved and suggest areas for future investigation. Such an effort will require the cooperation of centers around the world., Summary: Live liver donation is a valuable option for organ donation that can be conducted safely with a multidisciplinary perioperative approach. Future considerations should focus on the recovery period and how the intraoperative management can be optimized to minimize the impact of surgery on donors' quality of life.

Benzo(alpha)pyrene (B(alpha)P) is a potent multiorgan carcinogen released into the atmosphere from commercial, domestic, and industrial sources. Studies using animal models have shown that giving B(alpha)P parenterally to pregnant animals (i.e., dams) led to increased tumor frequency and sensitivity to tumorigenesis in their progeny. The authors' studies also showed that the progeny of the B(alpha)P-exposed dams displayed increased deficiencies in cell-mediated and humoral immune functions, changes among T-cell subsets in developing lymphoid tissues, and significant expression of B(alpha)P-7,8-dihydrodiol-9,10-epoxide (BPDE)-DNA adducts in thymic, splenic, and (fetal) liver tissues. The authors evaluated whether similar biologic/immunologic effects of B(alpha)P seen earlier in parenterally exposed mouse dams (and offspring) occurred if dams were exposed to B(alpha)P via the lungs. Pregnant dams were subjected to intratracheal instillation of B(alpha)P (at 1 mg/ml corn oil, 0.1 ml/instillate) beginning on day 11 of pregnancy (GD 11) and again on GDs 12 and 14. In each case, the dams were anesthetized with metofane. Other dams were left untreated (controls), anesthetized only, or anesthetized and then instilled with vehicle. Effects of the B(alpha)P exposures included lower dam body weights during gestation, decreased postbirth pup survival, increased pup tumor frequency, and decreased mixed-lymphocyte responses by pup lymphocytes. These studies also revealed that metofane imparted effects on the dams and progeny. These effects equaled the B(alpha)P treatments alone; in other instances, the metofane had no impact, and thus questions the observed biologic/immunologic effects of B(alpha)P induced in pregnant mice (and their progeny), which might have been confounded by use of this (or potentially other) anesthesia.

Objective: In developed countries, the societies of anesthesiologists have published reports of anesthesia quality. However, there are still no publications on anesthesia quality in Taiwan, even though the Taiwan Society of Anesthesiologists (TSA) was founded in 1956. This study was designed to evaluate the quality of anesthesia in Taiwan using databases maintained by the TSA and the Bureau of National Health Insurance-Taiwan (BNHI-T)., Methods: The TSA published annual reports in 1995-1998 and 2002-2008 (with a 3-year interval), which included a survey on anesthesia-related mortality and morbidity, the manpower and composition of anesthesia teams, and the causes of anesthesia-related complications. Since 2002, the BNHI-T has collaborated with the National Health Research Institute-Taiwan to establish a database of health care service. To understand anesthesia quality in Taiwan, we collected data from the annual TSA surveys and the BNHI-T, and analyzed trends in anesthesia-related mortality, causes of anesthesia complications, and relative manpower composition., Results: The rate of anesthesia-related mortality was 11.9 deaths/100,000 cases. More than 50% of all anesthesia-related complications were preventable. About 1500 anesthetic procedures were performed annually by each anesthesiologist in Taiwan. The ratio of anesthesiologists to nurse anesthetists was 1:3-5., Conclusion: Anesthesia-related mortality was about 10-fold higher in Taiwan than in the United States, Japan and the United Kingdom. Mortality related to quality of anesthesia in Taiwan must be reduced. To achieve this target, we have recommended the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase reimbursement by the BNHI-T for anesthesia; (3) improve the training quality of anesthetist residents; (4) strengthen the quality of board examinations; (5) improve the training quality of nurse anesthetists; and (6) standardize monitoring procedures and equipment. Only once these measures are introduced, in combination with effective quality assurance and subjective improvement systems, can we expect an improvement in the quality of anesthesia in Taiwan., (2010 Taiwan Society of Anesthesiologists. Published by Elsevier B.V. All rights reserved.)

Background: Paediatric anaesthesia comprises newborn, infants and children, necessitating a variety of techniques and approaches., Material and Methods: This review is based on textbooks in paediatric anaesthesia, papers from major anaesthetic journals and many years of clinical experience., Results: Only a few Norwegian university hospitals have full-time paediatric anaesthesiologists. Anaesthesia in infants is associated with a higher frequency of morbidity and mortality than in adults; laryngospasm and emergency delirium are more common. Calculation of the amount of intravenous fluid and medication doses must be based on weight. Techniques such as mask inhalation for induction and caudal regional anaesthesia are used more frequently in children. Disease and congenital malformations can lead to anaesthetic problems. It is therefore important for the anaesthesiologist to have all available information preoperatively., Interpretation: Paediatric anaesthesia presents special challenges. Safe practice requires experience and knowledge of age-related anatomy, physiology and pathology.

Background: Modern anaesthesia is still associated with a risk of serious complications. This article focuses on frequency, causes, and prevention of the most important anaesthetic complications., Material and Methods: The article is based on literature identified through a non-systematic search in Pub-Med, and the author's research and experience in this field., Results: The risk of death associated with anaesthesia is closely related to patient age and physical status. In otherwise healthy patients (ASA 1), the risk of such deaths is approximately 1:250 000. Medication errors occur in approximately 1:1 000 anaesthetic procedures. The risk of awareness during general anaesthesia is approximately 1:650. Neural injury from epidural and spinal anaesthesia is rare, even more so in obstetrics. Anaphylaxis caused by muscle relaxant drugs is more common in Norway than in many other industrialized countries. Pulmonary aspiration occurs in approximately 1:7 000 anaesthetic procedures, but with low morbidity in healthy patients. The incidence of anaesthetic accidents is higher in infants than older children, and requires special competence. Serious anaesthetic complications are most often related to the cardiovascular and respiratory system. The complications are often multicausal, and human errors and organizational factors contribute in 50-70 % of the cases., Interpretation: Optimization of the patient's preoperative health is important to improve safety. The focus of the anaesthesiology department should be education and guidelines. Systems and routines for improved safety must also take into account that human and organizational factors may cause anaesthetic accidents.

Background: The concept of the morbidity and mortality (M&M) review is almost 100 years old, yet no standards describe "good practice" of M&M in clinical departments. Few reports measure output and impact of M&M reviews. The M&M activities were developed in a university-affiliated pediatric anesthesia department as part of a departmental quality improvement (QI) initiative. The process was designed to identify problems within the M&M program and to introduce interventions and actions to increase the program's efficiency and impact., Methods: Through a series of interviews and consultation with hospital management, existing problems and inefficiencies were identified, a framework for developing the M&M program was established, and reportable outcome measures, such as increased meeting attendance, participation, self-reporting, and change to practice, were developed. Through appointment of specific M&M personnel, appointment ofa specific departmental M&M coordinator, meeting more regularly, stressing the review of system errors and close calls, and encouraging anonymous reporting, the department's M&M activities were redesigned., Results: From the (July 1) 2001-(June 30) 2006 to (July 1) 2006-(June 30) 2009 periods, case reviews and case presentations increased from a mean of 1.9 to 3.4 cases presented per M&M meeting. Meeting attendance increased from a mean of 5.1 to 25, and self-reporting from a mean of 22% of all safety reports received to 40%. Findings and recommendations were effectively disseminated throughout the department and hospital, reflecting the unique structure of the M&M program and personnel's efforts., Discussion: M&M QI with respect to data gathering, case review, and ongoing medical education is an efficient way to demonstrate quality assurance and creative professional development.

The Scottish Audit of Surgical Mortality is a voluntary, peer reviewed, critical event analysis of patients who die under the care of consultant surgeons in acute hospitals in Scotland. The anaesthetic contribution to surgical mortality over a 10-year period from 1996 was reviewed. The total number of deaths was 44 230 or 1.5% of all admissions. Forty thousand, eight hundred and ninety-six deaths (92%) were audited. Deaths after elective surgery declined over 10 years. Over 80% of deaths followed emergency admission. The number of deaths where an anaesthetist was present was 16 981 or 0.6% of all admissions. Anaesthetic areas of concern were identified in 8% of deaths. Of these, 43% were related to pre-operative assessment. Anaesthesia also played a part in a further 18% of deaths where decision making was shared with the surgical team. Of these, 41% were related to access to critical care. A further 24% related to communication failures, principally when the operation should not have been done or was unnecessary.

Anaesthetic complications have been studied intermittently in small animal practice. Current estimates suggest that approximately 0.1-0.2% of healthy and 0.5-2% of sick dogs and cats die of an anaesthetic-related death. This is substantially greater than the risk of mortality reported in human anaesthesia. Recent work has identified the post-operative period as the highest risk period and has documented a number of risk factors for mortality. Knowledge of factors associated with anaesthetic-related death and high risk peri-operative periods could aid patient management and reduce complications.

Objective: There is little information on adverse anaesthetic outcomes from the Caribbean. The aim of this study was to investigate the occurrence of anaesthetic morbidity and mortality at the University Hospital of the West Indies (UHWI) and to identify possible risk factors., Methods: All anaesthetic procedures at the UHWI were monitored for adverse events and patient outcomes for the 12-month period from March 2004 to February 2005. Possible risk factors for these adverse events were assessed using logistic regression., Results: Of 3185 anaesthetic procedures, the incidence of intra-operative events was 201 per 1000 (95% CI 187, 215); 151 per 1000 being cardiovascular and 26 per 1000 respiratory. Others included excess blood loss and equipment failure, hyperglycaemia, nausea and vomiting. Patients with intraoperative complications were three times more likely to have complications during recovery (OR = 3.35; 95% CI 2.59, 4.33, p < 0.001). The incidence of complications among paediatric patients was 139 per 1000 (95% CI 104, 174) intra-operatively and 58 per 1000 (95% CI 34, 81) during recovery. Risk factors for developing complications (p < 0.05) included age > 50 years, ASA status > or = II, prolonged anaesthesia, high surgical risk, general or combined anaesthetic techniques, senior anaesthetist, intubated patients and co-morbidities. There were 14 operative mortalities, none of which was anaesthesia-related, Conclusion: Anaesthetic complication rates at the UHWI are comparable to those in developed countries, except for higher paediatric complication rates and ICU admissions and lower rates of postoperative nausea and vomiting.

Obesity is a global epidemic, and approximately 20 % of the German population are obese. Therefore anaesthesiologists will be increasingly involved in the care of obese and morbidly obese patients in the near future. As a prerequisite, the hospital must focus on this patient population with respect to facilities and the availability of tailored medical equipment and supplies. Comorbidities such as diabetes, hypertension, coronary heart disease and sleep apnea considerably increase the risk of obese patients. A thorough preoperative evaluation of comorbidities, an anaesthesia induction and intraoperative ventilation tailored to the pathophysiological sequelae of obesity and a sound knowledge of pharmokocinetics are necessary to ensure optimal care for obese patients.