Der Anaesthesist
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The German Social Law has required quality assurance (QA) procedures since 1989. The measures must be suitable to allow "comparing investigations". In 1992 the German Society of Anaesthesiology and Intensive Care Medicine published recommendations for QA in anaesthesia: most problems during an anaesthetic should be documented in a standardised manner, and thus, a list of 63 pitfalls, events, and complications (PECs) and five degrees of severity were defined. ⋯ The types of PECs in our study had a similar distribution to those in other investigations, but there was a tendency to less frequent fatal PECs in ASA classes I to IV and more frequent ones in ASA class V. We expect better comparability when multicenter studies are done using identical methods in the next few years. Perhaps different patients collectives with special risks will be detected; efforts in quality improvement could focus on these patients.
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After rapid changes in transfusion practice over the past few years, blood conservation techniques have become standard in modern perioperative management. As a result, the amount of homologous blood products transfused has been markedly reduced in some types of surgical procedures. Provided that skillful surgical technique is applied and the use of blood products is restricted, autologous transfusion techniques (predonation of autologous blood, preoperative plasmapheresis, acute normovolaemic haemodilution, and intra- and postoperative blood salvage) can be performed with an acceptable risk for patients. ⋯ If storage is necessary, autologous blood products should be preparated like homologous products. The feasibility of predonation and retransfusion of autologous blood in patients with infectious diseases like hepatitis or acquired immune deficiency syndrome and the amount of labaratomy testing are still under discussion. Although blood conservation programs are time-consuming and more expensive, they reduce the various risks of using homologous blood products.
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Propofol is commercially available as Disoprivan. It is formulated as an aqueous emulsion with 1% 2,6-diisopropylphenol, 10% soya bean oil, 2,5% glycerol and 1.2% egg phosphatide. Since 1986, propofol has been used as a sedative drug in the ICU and is highly valued for its numerous positive qualities. ⋯ First, cardiovascular depression, especially if potentiated by drugs such as beta- and Ca-entry blockers, may lead to hypotensive episodes. Potential problems (drug tolerance, hypertriglyceridaemia) may be revealed in long-term studies. As long as no such studies have been presented, the authors believe that it is too early to consider propofol the ideal drug for long-term sedation.
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Comparative Study
[Narcotic gas burden of personnel in pediatric anesthesia].
To assess the occupational exposure of the anaesthetist to anaesthetic gases, a total of 1 German and 25 Swiss hospitals were investigated. A Brüel & Kjaer Type 1302 multi-gas monitor was used to measure concentrations of nitrous oxide and halogenated anaesthetic agents in the anaesthetist's breathing zone. Measurements were performed during 114 general anaesthetic, 55 of which were in patients under 11 years of age. In these 55 patients, the influence of various factors on the exposure (time-weighted average concentrations) was estimated by comparing different data groups. The efficiency of the applied scavenging equipment was examined by surveying the exhalation valve with a leak detector (type TIF 5600, TIF Instruments, Miami). ⋯ The exposure levels of anaesthetic gases are generally higher during anaesthesia in children up to 10 years of age than in older patients. Nevertheless, the measurements showed that exposure during paediatric anaesthesia can be kept below the recommended limit (8-h TWA in Switzerland) of 100 ppm nitrous oxide and 5 ppm halothane or 10 ppm enflurane or isoflurane. Causes of high exposures were particularly high fresh gas flows often applied without scavenging or together with inefficient scavenging devices and the high part of mask anaesthesia and inhalation induction with a loosely held mask. To achieve an effective reduction of occupational exposure, well-adjusted and maintained scavenging systems and low-leakage work practices are of primary importance. As leakage can never be completely avoided, a ventilation rate of at least ten air changes per h should be maintained in operating rooms and rooms where anaesthesia is induced to keep down concentrations of waste anaesthetic gases. High exposure during mask anaesthesia and inhalation induction can be prevented by further measures. Using a LMA instead of a standard mask reduces the exposure to the same level as endotracheal intubation.
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The safety of blood and blood components is an important aspect of transfusion medicine. Even if absolute safety of blood products cannot be achieved, this goal has come closer due to significant improvements. These include: (1) exact donor registration; (2) component preparation according to legal requirements and GMP guidelines; (3) determination of all relevant diagnostic parameters according to GMP/GLP guidelines; (4) adequate storage of products; and (5) and often underestimated parameter ensuring safety, strict guidelines for the use of blood products in the treatment of patients. Some of the results of the first Graz Consensus Conference on Transfusion Medicine are presented.