Local anesthetic systemic toxicity (LAST) is a life-threatening adverse event that may occur after the administration of local anesthetic drugs through a variety of routes. Increasing use of local anesthetic techniques in various healthcare settings makes contemporary understanding of LAST highly relevant. Recent data have demonstrated that the underlying mechanisms of LAST are multifactorial, with diverse cellular effects in the central nervous system and cardiovascular system. Although neurological presentation is most common, LAST often presents atypically, and one-fifth of the reported cases present with isolated cardiovascular disturbance. There are several risk factors that are associated with the drug used and the administration technique. LAST can be mitigated by targeting the modifiable risk factors, including the use of ultrasound for regional anesthetic techniques and restricting drug dosage. There have been significant developments in our understanding of LAST treatment. Key advances include early administration of lipid emulsion therapy, prompt seizure management, and careful selection of cardiovascular supportive pharmacotherapy. Cognizance of the mechanisms, risk factors, prevention, and therapy of LAST is vital to any practitioner using local anesthetic drugs in their clinical practice.

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Local anesthetic systemic toxicity: current perspectives.

Background The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery. Methods This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient. Results In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, -0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 μg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively. Conclusions Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.

/pdf/individualized-fluid-management-using-the-pleth-variability-40j0yteuwr.pdf

Individualized Fluid Management Using the Pleth Variability Index: A Randomized Clinical Trial.

Patients continue to suffer from medication harm despite 40 years of research; anesthesia providers have been slow to recognize the implications and acknowledge the extent of the problem. Research efforts to define the incidence, causes, and associated human factors, after a slow start in the 1980s and 1990s, have taken off. The Anesthesia Patient Safety Foundation (APSF), under Dr Ellison “Jeep” Pierce, along with the American Society of HealthSystem Pharmacists (ASHP), the Institute of Safe Medication Practices (ISMP), and other national and international professional societies, support an emerging literature that has become more difficult to ignore or refute. In a recent literature review, Abrishami et al reported that the number of studies reporting medication errors has increased exponentially over the past 2 decades. The American Society of Anesthesiologists is actively working to educate the anesthesia community in finding new ways to prevent errors from reaching or harming patients.

Medication Safety in Anesthesia: Epidemiology, Causes, and Lessons Learned in Achieving Reliable Patient Outcomes.

Resumo Justificativa As demandas por servicos de saude tem crescido de forma acentuada. Consequentemente, crescem tambem os custos das instituicoes para sua manutencao operacional e investimentos. O desafio da gestao hospitalar e conseguir conquistar padroes de qualidade e seguranca para o paciente, aumentar sua produtividade e minimizar os custos. Lean Seis Sigma e uma metodologia bem estruturada que visa a eliminar os desperdicios e atividades que nao agregam valor, focada na reducao da variacao nos processos, elimina as causas do defeito, melhora o desempenho. Como resultado, observa‐se reducao de custo, maior qualidade e satisfacao do consumidor. Objetivos Definir metodologia Lean Seis Sigma e buscar na literatura referencias do uso da metodologia em saude e especificamente na anestesiologia. Conteudo Descreve‐se como sao frequentes os desperdicios de medicamentos, materiais e tempo (retrabalho), bem como os erros que acontecem no dia a dia do anestesiologista. O anestesiologista deve conhecer o impacto de sua pratica profissional, com o objetivo de fazer escolhas mais apropriadas e reduzir assim o dano ao ambiente, melhorar a saude global e reduzir os custos com assistencia a saude. Sugere‐se o uso da metodologia Lean Seis Sigma para tornar a anestesia mais sustentavel, com melhoria dos processos, sem prejuizo ao paciente. Conclusao A metodologia Lean Seis Sigma e uma estrategia de gerenciamento de negocio de fato nova na area da saude. Insere‐se perfeitamente no contexto atual de qualidade e seguranca ao paciente, relevante, portanto, na pratica da anestesiologia.

Lean Seis Sigma e anestesia

Background The present study aimed at evaluating the effect of a haemodynamic algorithm using SV maximisation by non-invasive photoplethysmography (interventional group) on the incidence of postoperative complications compared with a control group using intermittent mean arterial pressure. Methods The non-blinded parallel-group trial randomised low-risk patients undergoing colorectal surgery into either interventional group or control group. The primary outcome was the incidence of patients with at least one complication during the 30 days following surgery. The secondary outcomes were the total number of complications, the length of hospital stay and postoperative mortality. A meta-analysis of randomised trials comparing perioperative haemodynamic optimisation (interventional group) using photoplethysmography with control group was performed to assess the external validity. Results Among 160 randomised patients, 159 were analysed (80 and 79 in interventional and control groups, respectively). Demographic characteristics were similar in both groups. Postoperative complications occurred in 40 (50%) and 34 (43%) patients in the interventional and control groups, respectively (P = 0.471). There were no significant differences between the two groups regarding the total number of complications (P = 0.078), the hospital length of stay (P = 0.960), or postoperative mortality (P = 1.000). In the meta-analysis including 1089 patients in 7 randomised controlled studies, 203 (38%) and 221 (40%) patients suffered from at least one complication following surgery [risk ratio 0.89 (95% CI 0.68–1.17), P = 0.407] in interventional and control groups, respectively. Conclusions Based on the findings of the present study and meta-analysis, a haemodynamic perioperative algorithm using SV maximisation by non-invasive photoplethysmography cannot reduce postoperative morbidity.

Perioperative non-invasive haemodynamic optimisation using photoplethysmography: a randomised controlled trial and meta-analysis

Drug medication errors remain a major safety issue in anaesthesia and intensive care, and prevention measures need to be strengthened. This is why the French Society of Anaesthesia and Intensive Care and the French Society of Clinical Pharmacy have profoundly reviewed their previous recommendations published in 2007. The 2017 recommendations are based on the literature but also on feedback from field professionals targeting patient safety. They share many similarities with recommendations issued from other countries (European countries, North America and Australia in particular) on this subject. Specific measures to prevent preparation, reconstitution and administration errors are detailed. Medical products using small bore connectors specified in the ISO 80369 series allow the prevention of administrtion errors. Specific labeling should be used according to an international color-coding of syringes, routes of administration, preparation bags, PCAs and PCEAs, trolleys or drug storage devices. A risk mapping must be established a priori and medication errors reporting is imperative in order to analyze them a posteriori in departmental meetings (REMED). Self-assessment, or external assessment, must be conducted. All of the proposed recommendations reinforce the culture of safety, which is essential to the practice of anaesthesia and intensive care.

Preventing medication errors in anesthesia and critical care (abbreviated version)

Prévention des erreurs médicamenteuses en anesthésie et en réanimation (texte court)

Stratégie d’optimisation de la prise en charge médicamenteuse péri-opératoire

An intravenous perfusion is a procedure which comprises infection and medication risks. To manage these risks, caregivers must respect, in addition to the usual hygiene rules, a series of best practices, ensuring the proper use and management of the medical devices and administered drugs.

Perfusions IV de médicaments : principes de sécurisation

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Preventing medication errors in anesthesia and critical care (abbreviated version)

Prévention des erreurs médicamenteuses en anesthésie et en réanimation (texte court)

Stratégie d’optimisation de la prise en charge médicamenteuse péri-opératoire

Perfusions IV de médicaments : principes de sécurisation