Fourteen year's ago Dennis Parker lost his son as a consequence of an OR airway fire. His first person account was recently published in AORN connections and is reproduced here.
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Reprinted with permission from AORN connections (September 2007) newsletter. Copyright 2007 AORN, Inc., 2170 S Parker Rd, Suite 300, Denver, CO 80231. All rights reserved
“It is unfortunately common for a patient to be caught up in a parade of tests, treatments and subspecialists with no physician clearly responsible for the whole problem. Patients find themselves required to be their own physicians, making lonely decisions about high technology matters that doctors have trouble figuring out. On occasion the patient is cared for by a “team” and cannot figure out the politics of responsibility and leadership – with the result that despite so many caregivers, the patient may be essentially alone at critical junctures.” From Chapter 5, The mysterious relationship between doctor and patient. In Cassell EJ: The Nature of Suffering and the Goals of Medicine (2nd edition), Oxford University Press, 2004 page 65
David S. Smith, M.D., Ph.D.
AIMS is a large, anonymous, multicenter, reporting system of anesthesia incidents that is in widespread use in Australia and parts of Asia. Bergman et al examined the data base when there were 8372 abstracted reports collected between 1988 and 2001. The authors queried on the keyword “awareness.” Using specific definitions of awareness they found 81 reports of which there were 50 cases of definite awareness and 31 with a high probability of awareness. They could find no obvious cause for awareness in 13 (16%) of the cases. Low inspired volatile agent concentration appeared to be responsible for 36 (44%) of the 81 cases. In 14 of these cases there was no agent monitor present. Five of these cases appeared to be due to prolonged attempts at intubation and four cases were due to reducing delivered anesthetic secondary to hypotension or cardiovascular instability. Thirty two cases were due to inadvertent paralysis of an awake patient. Case review suggested that inattention or distraction were contributory in 20 cases, haste in 14 and fatigue in 5.
This study covers a later period than did the closed claims analysis study of awareness (Domino KM et al: Anesthesiology 1999;90:053-61). In my opinion, at least in the United States, the 1988 – 2001 period is reasonably similar to current practice yet awake paralysis persists and in Bergman et al awake paralysis was the most common cause for awareness. Picking up the wrong syringe (a paralytic instead of the desired drug) was a recurrent cause of awareness. Keeping syringes of paralytic drugs away from other drugs might help reduce this problem. The authors expressed particular concern about the incidents of awareness with no apparent cause. Two of the 13 cases had agent analyzers and apparently adequate doses of volatile agent. Two cases occurred during ECT when no volatile agent is typically used.
Neither this study nor the closed claims study allows calculation of incidence since the total number of cases from which these reports are drawn is not known. In addition reporting is voluntary and the threshold for reporting most likely varied from practitioner to practitioner. Finally if patient report was the major source of information then there was most likely underreporting as most patients do not volunteer awareness information unless repeatedly asked. However, despite these weaknesses, this paper provides an intensive study of a serious of events providing conclusions as to cause and approaches for decreasing the risk of the occurrence of awareness.
The authors presented eight suggestions based on their data that they feel will help reduce awareness (table 4 modified): 1) Check the anesthesia machine before each use; ensure a correctly mounted and filled vaporizer. 2) When using a volatile agent use an end-tidal agent monitor. Use a low level alarm set for a sufficient volatile agent concentration to prevent awareness. 3) Provide further hypnotic doses for repeated intubation attempts. 4) Be aware of the potential for awareness in hypovolemic patients receiving low concentrations of anesthetic. Restore appropriate anesthetic concentration as soon as possible. 5) Routinely use a peripheral nerve stimulator and ensure sufficient anesthetic concentration until muscle power returns. 6) When using total intravenous anesthetics, ensure a patent intravenous line and periodically check the infusion pump to confirm drug administration. 7) Clearly label all drug syringes immediately when they are drawn up. Check this label carefully before administration. Do not rely on recognition of syringe size to confirm its contents. Consider newer methods of ensuring that the correct drug is given. 8) Consider a depth of anesthesia monitor, if not routinely then for selected cases.
Bergman IJ et al: Awareness during general anesthesia: a review of 81 cases from the Anesthetic incident monitoring study (AIMS). Anaesthesia 2002;57:549-556
David S. Smith, M.D., Ph.D.
Ochroch and associates (Anesth Analg 2007;105:1787) used a survey of patients scheduled for elective surgery to determine rates of acceptance of post operative epidural analgesia. Over a four month period a trained research technician contacted the patients the day prior to their scheduled admission and then conducted a standard survey by telephone. 3739 patients were called at home, 1265 were contacted and 1193 consented to participate in the study. 64% of the study participants said that they would accept an epidural if recommended by an anesthesiologist and 36% said they would refuse. The rate of acceptance increased to 78% if the epidural was recommended by both the surgeon and anesthesiologist with 22.5% still refusing. A univariate logistic regression showed that patients with higher incomes, more education and who where employed full or part time were more likely to accept an epidural. African Americans were far less likely then Caucasians to accept an epidural. When controlling for gender, education level, employment type income and marital status, African American race predicted refusal of epidural analgesia. (OR 0.58, 95 % 0.32 – 0.78) The authors attempted to determine some of the reasons for refusal but were unable to do so. Of concern then is a group of patients who for some reason absent themselves from a proven form a post operative pain therapy that may have benefits with respect to reduced pain and improved recovery. Of interest, from my observations, is the high acceptance of epidural analgesia on the HUP labor floor in a patient population that has a large number of African Americans (DSS comment).
Edward Andrew Ochroch M.D., MSCE is Associate Professor of Anesthesiology and Critical Care at the Hospital of the University of Pennsylvania
David S. Smith, M.D., Ph.D.
Wei and associates continue their investigations into isoflurane toxicity in this paper from Anesthesiology (2008;108:251 – 260). Using a variety of cultured cell types they showed that isoflurane activates the endoplasmic reticulum membrane inositol 1,4,5-triphosphate (IP3) receptor. This activation produces excessive calcium first in the cytosol and then in mitochondria. It is this higher calcium level that triggers apoptosis. There was considerable variability in the sensitivity of the various cell lines to isoflurane induced apoptosis. The authors note that certain cases of familial Alzheimer’s or Huntington disease have enhanced IP3 receptor activity and thus may be more sensitive to the toxic effects of isoflurane. Recognize the difficulty of extrapolating from cell cultures, to organs or whole animals. Thus, it is my belief, that further work is necessary before clinical practice is altered by findings such as these (DSS comment).
Huafeng Wei, M.D., Ph.D. is Assistant Professor of Anesthesiology and Critical Care at the University of Pennsylvania
David S. Smith, M.D., Ph.D.
A recent paper and an editorial in the Lancet discussed the high rate of complications from venous thromboembolism (VTE) in both surgical and medical hospitalized patients and the relatively low rate of VTE prophylaxis. They note that pharmacological prophylaxis reduces the risk of pulmonary embolism in general surgical patients by 75% and by 57% in medical patients. However a cross sectional survey of nearly 70,000 hospitalized patients in 32 countries revealed that though 66% of surgical patients and 40% of medical patients were eligible for VTE prophylaxis only 59% and 40% of the at risk patients received this potentially lifesaving therapy. Data from United States Centers appeared better than the overall. Of the at risk surgical patients 80% were receiving some sort of prophylaxis and 71% were receiving the American College of Chest Physicians recommended prophylaxis. However only 64% of at risk medical patients were receiving any sort of prophylaxis. From 1) Cohen AT et al: Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study); a multinational cross-sectional study. Lancet 2008;371:381- 394 2) Ageno W, Dentali F: Prevention of in-hospital VTE: why can’t we do better? Lancet 2008;371:361-362
David S. Smith, M.D., Ph.D.
A low ratio of fresh frozen plasma to RBCs decreases mortality in patients receiving massive transfusions at a combat support hospital (Borgmann MA et al, J Trauma 2007;63:805 – 813). The authors performed a retrospective review of the records from 246 soldiers with combat injuries who received massive transfusions (> 10 units of RBC in 24 h). In the paper’s introduction the authors note that about 5% of patients admitted to Iraq US combat support hospitals require massive transfusion. They note that mortality rates among these patients is more than 30% and that a considerable portion of this mortality appears related to the lethal triad of hypothermia, metabolic acidosis and coagulopathy. Penetrating injuries were present in 94% of the group, 1% of the injured were female, and the median age was 24. The median injury severity score (ISS) was 18 and the overall mortality was 28%. The authors used a statistical process to divide the group into low, medium and high plasma to RBC groups with the low group having a plasma to RBC ratio of 1:8, the medium having a ratio of 1:2.5 and high with a ratio of 1:1.4. Mortality decreased as the ratio of fresh frozen plasma to RBCs increased with a mortality of 65% in the low, 34% in the medium and 19% in the high group. With respect to primary cause of death, hemorrhage related death was less in the high ratio group (37%) compared to the low ratio group (92.5%) producing a relative reduction of 60%. The authors concluded that for patients with significant traumatic injuries requiring massive transfusion survival improved when fresh frozen plasma and RBCs are administered in near equal volumes (a ratio of 1:1.4). The authors noted that those patients who received large amounts of fresh frozen plasma early required less total fluid in the first 24 hours. They also noted that those in the low or medium plasma to RBC ratio groups often died of hemorrhage with a median time of death of 2 to 4 hours. Remember however that this is a retrospective study with the high, medium and low ratio group created after the fact.
David S. Smith, M.D., Ph.D.
Barry Fuchs (Medical Director of MICU, HUP, UPENN) calls our attention to a recent paper on the use of the recruitment maneuver to reverse lung collapse. The new information in this paper relates to the degree and duration of the recruitment maneuver. From the abstract: Objectives: To test if a bedside recruitment strategy, capable of reversing hypoxemia and collapse in 95% of lung units, is clinically applicable in early acute respiratory distress syndrome. Measurements and Main Results: Twenty-six patients received sequential increments in inspiratory airway pressures (5 cm water steps) until the sum of PaO2 + PaCO2 was greater than or equal to 400 mm Hg or preset stopping criteria of mixed venous saturation less than 80%, mean arterial pressure less than 60 mmHg or barotrauma identified by CT was met. Whenever the primary target was not met, despite inspiratory pressures reaching 60 cm H2O, the maneuver was considered incomplete. Late assessment of recruitment efficacy was performed by computed tomography (9 patients) or by online continuous monitoring in the intensive care unit (15 patients) for up to 6 h. It was possible to open the lung and to keep the lung open in the majority (24/26) of patients, at the expense of transient hemodynamic effects and hypercapnia but without major clinical consequences. No barotrauma directly associated with the maneuver was detected. There was a strong and inverse relationship between arterial oxygenation and percentage of collapsed lung mass (R 0.91; p < 0.0001). From Borges JB et al: Am J Respir Critic Care Med 2006;174:268.
David S. Smith, M.D., Ph.D.
It can be difficult to discern the exact nature of events from the initial news stories however it appears that physicians and nurses in an outpatient endoscopy clinic located in Las Vegas Nevada improperly drew doses of sedatives for patients from a single multi dose vial possibly exposing 40,000 patients to a risk of hepatitis C or aids. Apparently they did not use a fresh syringe and needle for each entry into the vial so that transmission between patients via the vial contents was possible. I cannot believe this has happened – it seems so contrary to every teaching on disease transmission and current safe practice. Do not even consider reusing the same syringes or needles between patients. Any item that is used on more than one patient should be designed for such use and properly disinfected between uses.
However the above is not a unique event. On several occasions in the recent past anesthesiologists have been identified with transmitting Hepatitis C through the misguided practice of syringe/needle reuse and multi dose vials. In 2002 there was a hepatitis C outbreak in Norman Oklahoma related to needle and syringe reuse. About 71 people were infected there. In 2007, an anesthesiologist from Dix Hills New York was associated with a cluster of Hepatitis C infections related to his practice. As a result 11,000 of his former patients were contacted about infection risk. Also in 2007 another anesthesiologist, was sued for Hepatitis C transmission from faulty infection control practice while giving anesthesia for colonoscopy. This last anesthesiologist practiced at about 10 different physician offices and about 4,500 of his former patients were placed at risk because of his failure to use reasonable infection control.
The ASA newsletter (66:2002) provides a summary of the ASA infection control guidelines: 1) Syringes and needles are sterile, single-patient-use items. 2) After entry into or connection with a patient’s intravenous infusion, the syringe and needle should be considered contaminated and used only for that patient. 3) Medication from a syringe must not be administered to multiple patients even if the needle on the syringe is changed. 4) All infusion fluids, administration sets (intravenous tubing and connections) and pressure transducer setups are single-patient-use items. Absence of blood contamination cannot be guaranteed by visual inspection. 5) Sterile needles and syringes should always be used to aspirate the contents of an ampule or vial. 6) Each time a multidose vial is entered, aseptic techniques should be used, including cleansing the rubber stopper with alcohol and using a sterile needle and syringe. If visible contamination of a multidose vial has occurred or if sterility is questionable, the vial should be discarded. 7) Immediately after use, or at least at the end of each patient’s anesthetic, all used syringes and needles should be discarded in an appropriate puncture-resistant sharps container. Unused syringes, needles and related items should be stored in a clean area to avoid contamination by contaminated syringes and equipment. 8) Health care workers with breaks in the skin or exudative or weeping lesions should refrain from direct patient contact and from handling patient care equipment unless the open area can be protected. Strict attention to hand washing, hand antisepsis, aseptic technique and use of gloves and other barrier precautions is important to avoid transmission of pathogenic microorganisms to patients and health care workers.
There apparently persists the misguided concept that injecting high on the iv tubing is safe. This is wrong! The ASA Newsletter article cited above notes the following: In 1990, Trepanier et al. investigated the risk of cross-infection related to the multiple use of disposable syringes for anesthesia in the operating room. The rate of blood contamination in the intravenous (I.V.) tubing was 3.3 percent at the injection site closest to the I.V. catheter and 0.3 percent at the furthest site. The presence of a one-way check-valve did not affect the contamination rate. Trepanier and his group also found that changing the needle alone on a used syringe was useless for preventing contamination of blood into the syringe.
Considering the difficulty in maintaining sterility and preventing contamination of multi dose containers several states are considering a ban on their use for most medications. Once a syringe is connected to a patient’s IV it is by definition contaminated and should never be used on another patient. If a multidose vial has been entered by a syringe and needle that has been in contact with a patient that vial is also contaminated and should be discarded once the care of that patient is over. It would be prudent not to use multidose vials between patients but to discard the remaining drug at the end of each case. A Google news search on any of the key words mentioned will bring up the innumerable newspaper sources for this material.
Reference: Trepanier CA et al: Risk of cross-infection related to the multiple use of disposable syringes. Can J Anaesth 1990;37:156-159
David S. Smith, M.D., Ph.D.
The Joint Commission has just issued Sentinel Event Alert #38 on MRI accidents. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_38.htm
Based on the FDA’s accident reporting database (believed to represent significantly less than 10% of events), accidents in the MRI suite have experienced a dramatic increase. This increase is believed to reflect a number of combined risk factors including (1) greater attractive forces from newer magnet systems, (2) higher patient acuity levels, (3) increasing interventional applications and (4) growing numbers of sedation / anesthesia patients.
The current Sentinel Event Alert identifies risks associated with several issues, including heating, implants that are contraindicated in the MR environment, and projectile / missile events.
Heating:
Heating incidents can arise from improper positioning of the patient during the exam or incorrect settings on the MRI for a particular scan. Corrective actions can include providing insulation between the patient and the MRI, proper body positioning, and review of scan parameters.
Implants:
A number of implants, both active devices such as pacemakers and passive implants such as aneurysm clips, can present significant dangers to patients when exposed to either static (unchanging) or time-varying magnetic fields. Other implants, such as the leads used in cardiac devices or nerve stimulators, can experience significant local heating as a product of the normal radiofrequency (RF) energies used during the MRI examination process. Corrective actions to prevent scanning of patients with contraindicated implants include a careful review of the patient’s medical record, patient interviews, education of referring physicians, and scrutiny of all identified surgical procedures. (For up-to-date information on the safety of implants, please visit http://www.MRIsafety.com or http://www.doctordoctor.biz )
Projectiles:
Despite the near-universal awareness of MRI magnets’ extreme power of attraction, objects containing steel are regularly brought into MRI rooms where they are ‘sucked’ into the MRI scanner. Often, these objects are small enough to be removed by hand, but larger objects often require very expensive service calls to have them removed from the scanner. Small objects such as bobby pins and nail clippers, however, can – and do – cause injuries when drawn into MRI magnets, striking patients and/or staff. Corrective actions to prevent projectile accidents include increased vigilance in screening patients and objects, as well as the gowning of all patients. One specific recommendation of the Sentinel Event Alert is for the use of contemporary ferromagnetic detection (FMD) systems specifically designed to find projectile threats in the MRI suite. (For links to all three manufacturers of FMD systems, see http://www.MRI-Planning.com/vendor_links.html ) (from the NPSF patient safety foundation list server).
Some background information for those unfamiliar with the ASA closed claims project (this background information is taken from the closed claim website http://depts.washington.edu/asaccp/ASA/index.shtml ): Since 1985 the ASA has sponsored this project. At the time the project was initiated, professional liability insurance was expensive for anesthesiologists and in some states difficult to obtain. The intention of the Closed Claims Project was to identify causes of loss, improve patient safety, and thereby relieve the insurance problem for anesthesiologists. The project consists of an in-depth investigation of 7328 closed insurance claims resulting from anesthetic mishaps. Data is gathered in the form of detailed case summaries collected by ASA member anesthesiologists from insurance company claim files. Claims for dental injury, a very common, well understood, and in most cases minor injury, are excluded. Claims in which the basic sequence of events and/or nature of the injury cannot be reconstructed from the information in the insurance files are also been excluded. This results in most cases being collected from mishaps resulting in lawsuits, as files in these cases contain the most extensive information. Cases are collected from throughout the United States on a continuous basis. The database consists of standardized summaries of each case, including patient information (e.g. age, physical status), surgical procedure and positioning, anesthetic evaluation and technique, events leading to the injury or claim, type and severity of injury, outcome of litigation, and physician evaluations of potential for prevention and appropriateness of anesthesia care. The database also includes a brief narrative summary of each claim, describing the sequence of events and adding any pertinent information not contained in the standardized data collection form.
In my opinion the closed claims project provides a unique resource of intensively studied case experiences in which there was an outcome that was not satisfactory to the patient or their family. It does not allow the calculation of incidence as the denominator is not known. Because of the length of time from law suit to settlement, the data in the closed claims project tends to be old. Thus new areas of risk or trends in settlement costs are, in my opinion, difficult to determine from this data.
The ASA closed claims analysis of awareness during anesthesia was published in 1999 and included claims for adverse outcomes that occurred between 1961 and 1995. A total of 4183 claims were in the database. Seventy nine claims were for awareness with a greater proportion occurring in the 1990s compared to earlier decades. The proportion of claims in the database was similar to burns, aspiration pneumonia and myocardial infarction. Compared to other claims awareness more often involved women, patients younger than 60 years of age, and elective surgery. The severity of injury for awareness claims was lower than for the other claims. Eighteen of the claims were for awake paralysis and 61 claims were for recall during general anesthesia.
Claims for awake paralysis were related to intravenous infusion errors or syringe swaps. Succinylcholine drips accounted for 10 of the 18 claims (unlabelled, mislabeled, failure to check the label). The period of risk was preinduction or during induction when a muscle relaxant was given instead of a sedative or hypnotic.
The highest frequency of recall during general anesthesia was during the maintenance phase (49 of 61 claims). Recollection included recollection of conversation, feeling surgery without pain, pain, paralysis, tracheal intubation, and severe panic. Eighty four percent sustained temporary emotional distress; 10% developed posttraumatic stress disorders. Recurrent nightmares were described in 16% of claims and psychotherapy was described in 13%.
Factors associated with recall during general anesthesia included: nitrous – narcotic relaxant technique without volatile anesthetic (11 of 61 claims), hypotension requiring discontinuation of the anesthetic agent (11 instances), inadequate dose of anesthetic for no obvious reason (8), difficult intubation (5), failure to adjust anesthetic dose for morbid obesity (8), vaporizer leak (5) and failure to turn on the vaporizer (3). In 10 cases no obvious factor could be determined. The classic cues for light anesthesia were absent in most cases. Five factors were significantly associated with claims for recall compared to other general anesthesia claims: no volatile anesthetic agent, female gender, obstetric or gynecologic procedure, intraoperative opioid, and intraoperative muscle relaxant. After adjusting for risk factors and application of multiple logistic analyses – female gender and anesthetic techniques using intra operative opioid and muscle relaxants without a volatile anesthetic increased the relative frequency of claims of recall. OB/Gyn procedures were not an independent risk factor. (From Domino KB et al: Awareness during anesthesia: A closed claims analysis. Anesthesiology 1999;90:1053-1061.)
DSS comments: The separation of “awake paralysis” from “recall” is not done in most subsequent studies. Notice the frequency of a drug error with respect to the occurrence of awake paralysis. Changes in practice (decreased use of succinylcholine infusions) may decrease this incidence. However bags of non depolarizing muscle relaxants for infusion present the same potential risk unless clearly labeled and kept away from other intravenous solutions until the time of use. Several of the instances of awake paralysis occurred because of a syringe swap or mislabeled syringe. An argument might be made to keep syringes containing muscle relaxant separate from antibiotics, anxiolytics, narcotics and anesthesia induction drugs. Finally using nitrous oxide without a volatile agent was associated with a large number of instances of recall. Fortunately that practice has almost disappeared (at least at Hospital of the University of Pennsylvania).
David S. Smith, M.D., Ph.D.
Dr. Kofke calls our attention to a review of the FDA surveillance data on the association of propofol infusions for non procedural, long term sedation and death in both children and adults. Wysowski and Pollock (1) reviewed the reported adverse event data for children and adults >16 years old) in which propofol was thought to the suspect drug from the time of marketing through April, 2005. Particular emphasis was placed on identification of patients with propofol infusion syndrome which was defined as metabolic acidosis and/or rhabdomyolysis with progressive myocardial failure. With respect to the adult data there were 68 reports of patients who died after administration of propofol for non procedural sedation. The mean duration of propofol use was reported as 7.3 days (the median duration was 4.4 days and the range was < 1 h to 42 days). The peak propofol dose was about 120 mcg/kg/min with a median of 90 and a range of 10 – 416. Twenty-one of the 68 patients had disorders consistent with propofol infusion syndrome and 6 more had disorders probably or possibly related to this syndrome.
The authors compared their findings from the FDA surveillance data with some of the published case reports. They found five reports involving adults published from the United States and two from other countries. The patients typically received propofol for an extended period at a high dose. Studies of propofol exposure typically identify hypotension ad the most frequent and serious acute adverse event. However the studies typically used lower infusion rates of propofol.
Of greater concern to me are two reports of intraoperative metabolic acidosis that the authors associated with an anesthetic infusion of propofol (2,3). In one case (2) a 31 year old, 217 lb woman developed a metabolic acidosis during radiofrequency ablation for pulmonary vein isolation. The propofol infusion ranged from 50 to 125 mcg/kg/min. The patient was breathing spontaneously by face mask. The authors noted that the patient developed a metabolic acidosis during the course of the procedure and 7 hours into the surgery the pH was 7.30 and the BE was – 8. During the course of the procedure to that point she had received normal saline 2 – 3l. Serum chloride, glucose or lactate concentrations were not measured, no other instability was noted. The fact that the patient got a mild metabolic acidosis during a propofol infusion and that the acidosis resolved when the propofol was stopped is a very weak association in the absence of laboratory studies to eliminate the more likely causes of the metabolic abnormality.
In the second report (3) a 64 y/o, 156 lb male underwent a radical prostatectomy using infusions of propofol, remifentanil and mevacurium. 2.5 g of propofol and 6 mg of remifentanil was used during the 4.5 h case. The authors note that 3 hours into the case the patient became tachycardic. As the case proceeded the authors noted a progressive metabolic acidosis which they attributed to propofol. At one point (hour 4) they found the following ABG values: pH 7.28, PO2 177, PCO2 43.5, lactate 6.99 mM, HCO3 20.8 mM. base excess -5.1 mM, glucose 136 mg/dl. They provided no information about fluid replacement or blood loss, nor did they test for the more common causes of intraoperative metabolic acidosis such as hyperchloremia.
The editorial that discussed these two reports (4) addressed briefly some of the criticisms I raised, but did not address the key logical flaw of both reports. Just because event “A” occurs at the same time as event “B” does not mean that A and B are related. At UPENN I have given a very large number of intraoperative propofol infusions for long duration surgery yet this phenomena of intraoperative propofol induced intraoperative metabolic acidosis has never been noticed. However I do see a significant number of patients both with and without propofol infusions who develop intra operative base deficits in the range of -4 to -8. Most of these appear to be associated with intraoperative use of 2 to 6 liters of 0.9% sodium chloride for volume replacement with resulting serum chloride levels of 105 – 115 mEq/l. Perhaps if the authors of the two case reports had been able to measure serum chloride the cause of intraoperative acidosis might have seemed less ominous? Of interest is a recent letter to the editor by Rozert and Lam (5) which also addresses some of the concerns I have raised in reference to a more recent retrospective study in which the term “propofol infusion syndrome” was used, to my way of thinking, inappropriately.
The AstraZenica package insert for propofol 1% dated August 2005 notes that “very rare reports of metabolic acidosis, rhabdomyolysis, hyperkalemia and/or cardiac failure, in some cases with a fatal outcome, have been received concerning seriously ill patients receiving propofol for ICU sedation. However the package insert does not mandate dose or infusion duration limitations.
I have not mentioned issues related to propofol infusions in children as my practice is limited to adults. However, the propofol infusion syndrome appears to be more frequent in the younger age group.
References:
WA Kofke is Professor of Anesthesiology and Critical Care at the University of Pennsylvania
David S. Smith, M.D., Ph.D.
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8. Augoustides JG, Abdullah I, Pochettino A, Hanson CW: Inhaled prostacyclin for the management of pneumonia in a patient with cyanotic heart disease with superior cavo-pulmonary connection. Ann Card Anaesth 2007;10:51-53
9. Augoustides JG, Fleisher LA: Advancing perioperative prediction of cardiac risk after vascular surgery: does postoperative N-terminal pro-brain natriuretic peptide do the trick? Anesthesiology 2007;106:1080-1082
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11. Augoustides JG: Bispectral index monitoring during aortic arch repair. J Cardiothorac Vasc Anesth 2007;21:479-480
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17. Augoustides JG: Independent lung ventilation in adult single-lung transplantation: is it time for fast-track anesthesia and early tracheal extubation (letter). J Thorac Cardiovasc Surg 2007;134:825
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20. Augoustides JG: Letter by Augoustides regarding article, “Risk index for perioperative renal dysfunction/failure: critical dependence on pulse pressure hypertension.” Circulation 2007;116:e119
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25. Augoustides JG: The conduct of experimental circulatory arrest: the search for clinical relevance (letter). J Thorac Cardiovasc Surg 2007;134;1381-1382
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