Anesthesia Articles in JBGSR

Malpractice in the Intensive Care Unit by Evangelia Michail Michailidou* in Open Access Journal of Biogeneric Science and Research (JBGSR)

Abstract

     Error in the Intensive Care Unit (ICU) is a welldocumented and frequent problem. This is understandable as one looks at the complexities of serious disease along with the number of invasive and potentially harmful procedures that are commonly used there. Until recently, allegations of medical malpractice resulting from suspected mismanagement in the ICU were unusual, but there has been a rise the last years.

It is difficult to determine whether the increase in lawsuits is due to a real increase in adverse incidents or to a shift in media perception. There is no question that the aggressive cover-up by law companies dealing in personal injury lawsuits offering to initiate claims on a contingency fee basis has become more common. The Medical Protection Society is experiencing an increasing number of claims generally, and the value of damages awarded is skyrocketing [1].

This includes the insufficient number of ICU beds in the public sector and the acute lack of appropriate nurses in both the public and private sectors. More troubling are the obstacles faced by nurses to apply for critical care and the limited number of critical care nurses graduating. Coupled with a high rate of turnover due to burn-out and greater work openings in other industries and overseas, this leads to a situation where even private ICUs fail to staff their units and retain standards. The mixture of high bed occupancy, chronically ill patients and novice nurses provides the ideal atmosphere for errors and incidents that can lead to lawsuits for damages. The condition is not any different on the medical side. The quality of treatment is that critically ill patients should be treated in ICUs by a team of health providers headed by critical care practitioners with specialty in Intensive Care. Not only surgeons, internists or anesthesiologists without specialization in Intensive Care, which they close holes in the gaps of the health system and do not have the proper education. We are all accustomed to thinking in terms of our primary specialty but this carries many risks. Intensive care training offers the skill to treat the patient comprehensively and systematically, something very important in patients of ICU. Although, we have to mention that there were few unexpected variations in malpractice claims occurring in ICU because of specific medical specialty. Preventive efforts should concentrate on procedures, regardless of the medical specialty, including:
1. Retaining procedural skills,
2. Well-framing of procedural hazards, and
3. Adequately describing post-procedural complications. Skills that are either innate or can be developed through ICU specialization training.

While critically ill patients in the private sector are frequently handled by separate and not suitable always, physicians, these doctors prefer to see the patient at different times of the day, give contradictory orders, and make their own private records. There is no team work usually. Also, under the best of conditions, ICU management often – one would say eventually – results in 'iatrogenic' disorders. John Marshall pointed out that critical disease is potentially iatrogenic and it only exists in people who have survived a life-threatening medical procedure. In addition, the entire structure of serious illness is focused on the effects of original resuscitation attempts or the outcomes of procedures that are regularly conducted in the ICU. It is

Introduction

The plants are part of a rich ecosystem in the soil [1], where bacteria generally colonize the plant rhizosphere and, sometimes, the endosphere. Some beneficial effects for plants may include assistance in getting nutrients and promoting plant growth by modulating growth-related hormones [2]. Other benefits include the reduction of damage caused by phytopathogen [3]. Filamentous plant pathogens can severely attack plants, and in agriculture, this could lead to high economic annual losses [4]. The suppressive soils support soil microorganisms as the first defense against soilborne pathogens. General suppressive soils have a high total microbial biomass, resulting in low protection against multiple pathogens. This strategy is dependent on the quality and quantity of soil organic matter and cover crops that enhance populations of beneficial microbes intended to antagonize associated crop pathogens primarily by occupying plant infection sites [5]. However, specific suppressive soils have a high concentration of specific microbial species and result in high protection against specific pathogens [6].

 

Cultural practices in agriculture have a strong influence on soil health through physicochemical characteristics and soil microbial communities. Beneficial cultural practices are used to improve soil health and can, in some cases, increase soil disease suppression [7]. According to Schlatter et al. [6], the relationship between soil properties and soil suppressiveness has not been deeply studied. Many different abiotic or biotic soil characteristics have been used to describe suppressiveness, but there is a lack of reliable descriptors.

 

The plant protection of certain bacteria against pathogens includes a wide range of mechanisms: antibiosis, competition for colonization sites, nutrients and minerals, parasitism, and cell lysis [8]. The protection can be caused by direct action due to antibiotic compounds or indirectly by promoting plant defense as induced systemic resistance [9]. The biological activity is also related to secondary metabolites production, low molecular mass products not essential for bacteria survival produced by secondary metabolism during the late growth phase (idiophase) [10]. These compounds are generally involved in the antibiosis or perform synergism with other inhibitors [11].

 

This mini-review focuses on some conditions needed to maintain a suppressive soil and the antibiotic compounds produced by the most studied bacteria groups. Because of these molecules' wide diversity, the classification is complex, and several criteria could be taken [12]. In this overview, the work description considers the bioactive metabolites as volatile compounds and non-ribosomal peptides in an integrated and general way difficult to determine the limits between cause and effect and between acceptable complications and preventable negligence [2-5].

 

Patients who survive a lengthy stay in the ICU are rarely left with life-long complications as a result. Prolonged muscle fatigue, neurological disabilities, and post-traumatic stress disorder involving both the patient and the family are usually described. Who can blame the patient for his anger?

 

Patients are most frequently admitted to intensive care as a result of an iatrogenic case. Researches showing that more than 21 per cent of admissions had a previous iatrogenic case, the most common being adverse drug disorders, postoperative illnesses and complications of surgical procedures. Personal injury attorneys extend the net extensively and ICU workers may be accused, particularly if the long-term condition is not specifically linked to the initial injury [6].

 

How do we defend ourselves from legal action that can be both socially and psychologically crippling, not to mention financially catastrophic, if one is not insured? Guidelines and protocols are not always solutions. Hospital managers appreciate directives because they transfer the responsibility to either the writer or the person who failed to obey [7].

 

The instructions have a position, but are of no value if they are out of date, so impractical that they cannot be complied with or agreed by the workers. There will never be a rule for any case, and there can be no formula for intensive care. By all means have basic rules, but they must be practical, versatile, approved and revised on a regular basis. The most critical thing is to uphold high professional expectations. This means ensuring that all medical professionals and nurses who treat chronically ill patients are critical care experts. In addition, they need to remain up to date with the constantly evolving field of critical care medicine. A multidisciplinary in-house academic curriculum is a positive start [8].

 

Second, intensive care administration should be focused on a team. The ICU team includes nurses, surgeons, dieticians, physiotherapists and others who contribute to patient care on a regular basis [9]. The team needs a leader, preferably an intensivist, who supports a 'flat hierarchy' and a transparent and efficient contact mechanism. This includes a joint management round where the different practitioners will offer feedback and remind, criticize and help each other [10].

 

Even a supreme chief cannot defeat a team when it comes to decision-making. Harmonious teaming often ensures that the patient and the family do not get mixed reports about the patient’s success and anticipated results. Holding good notes is necessary, not only as the most effective defensive tool in the (no doubt unlikely) case of a legal problem, but also as part of the contact on patient management. Notes should not only document clinical observations and incidents, but also the explanation why decisions have been taken. It is advisable to retain a copy of one's own reports and share them with colleagues in the patient's hospital folder [11-13].

 

Finally, maintaining a positive relationship with the patient's family is incredibly necessary, not only to get them navigate emotionally tough times, but also because they are the patient's proxy decision makers. Families need details, but the mistake of overwhelming them with medical care should be avoided. It is more important to give them time to pose questions. It is not generally possible to build a connection with the patient when they are seriously ill, so a follow-up visit after they have left the ICU is an important way to link with them at a personal level and at the same time give them an explanation of what has happened and what the potential effects are. In the case of patients who have died in the ICU, the interpersonal relationship that has developed with their relatives throughout their hospitalization [14].

 

We ought to have in our mind that most of malpractice cases are brought not out of malpractice or even because of concerns about the quality of medical treatment, but as an indication of frustration about any aspect of patient-doctor or doctor-relatives relations and contact. Intensivists who consider and will react adequately to the emotional needs of their patients are less likely to be sued [15,16]. This can also be transformed into a more accomplished practice of medicine by those doctors who are most mindful of the importance of a positive relationship.

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Anesthesia Articles in JBGSR

Anesthesia Management in Citoreductive Surgery and Hypertermic Intraperitoneal Chemotherapy Cases by Ugur Koca in Open Access journal of Biogeneric Science and Research (OAJBGSR)

Abstract

Hyperthermic intraperitoneal chemotherapy (HIPEC) applied in conjunction with cytoreductive surgery (SRC) is an effective multimodal treatment option that has been applied in recent years, especially in selected cases of peritoneal malignancies such as peritoneal carcinomatosis, pseudomixoma peritonei and primary peritoneal tumors [1,2]. Cytoreductive Surgery involves the excision of macroscopic tumors and visceral and / or parietal peritonectomy in a single session or a series of operations, ranging from isolated omentectomy to removal of the gastrointestinal tract, pancreas, spleen, bladder, uterus, ovaries and liver. The purpose is to clean all tumor tissue up to 2.5 mm, and to ensure that the rest is affected with a cytotoxic agent. The success of cytoreductive surgery and the prediction of 5-year survival depend on the peritoneal cancer index [3] and abdominal eksplorasyon depends on the time it was made [4-7].

 

In hyperthermic intraperitoneal chemotherapy, the purpose is to eliminate the tumor tissue at microscopic level by applying chemotherapeutic perfusate prepared to all quadrants at 41-42 °C via a special pump.This major surgery and HIPEC application, which has high morbidity (25-41%) and mortality (0-8%), is not only for surgeons and oncologists, but also for anesthesiologists. Conditions of interest to an anesthesiologist are the purpose and objectives of the operation, the anticipated metabolic and physiological disturbances, and sthe possible chemotherapeutic toxicity [7]. For this reason, between surgeon and anesthesiologist’s cooperation and information sharing is very important. The team must be alert to the cardiovascular status, oxygen consumption, hypo and, or hyperthermia, pain management, and coagulation status in these patients and must be able to make collective decisions in perioperative management.

Hyperthermic Intraperitoneal Chemotherapy

It is the maximum exposure of tissues exposed to chemotherapeutic agents at doses 20-1000 times higher than the targeted plasma levels during hyperthermic intraperitoneal chemotherapy procedure and minimum exposure of normal tissue. HIPEC drugs, they are high molecular weight hydrophilic agents that cannot cross the peritoneal fluid-plasma barrier and their peritoneal clearance is slow. It shows its effect by creating a direct cytotoxic effect and immune-mediated attack in tumor cells through hyperthermia, inhibition of DNA repair mechanisms, protein denaturation and activation of heat shock proteins. Hyperthermic intraperitoneal chemotherapy is more effective when applied immediately after SRC. When this procedure is applied before the gastrointestinal tract reconstruction, it prevents the maling cells from settling into the scar tissue, adhesion and anastomosis sites. HIPEC can be applied with a closed or open abdominal technique (the abdomen remains open during the procedure) Advantages of the closed technique: Reduced heat loss, Increased tissue penetration with the effect of increased intra-abdominal pressure and Reduced contamination risk [8,9].

 

In the intraoperative period in HIPEC application with the closed abdomen technique, following peritonectomy procedures, it is performed in the abdomen with one / two suprahepatic inflow and two / three pelvic outflow catheters. Perfusate circulates in the abdominal cavity using a Roller pump at 42-43 °C [10]. The temperature is monitored throughout the procedure with multiple probes placed in different areas within the peritoneal cavity. Heated cytotoxic agents are added to the perfusate and HIPEC application takes 30-90 minutes according to different protocols. Following the perfusion of the chemotherapeutic agent, abdominal lavage, drainage and closure of the abdomen are performed. Compared to early postoperative intraperitoneal chemotherapy, it is more effective on survival time. The results are better than normotermic intraperitoneal chemotherapy, and compared to systemic chemotherapy, the average survival time is prolonged by 16-24 months and the 5-year survival rate is increased by 30-45% [11].

 

 During this procedure, the toxic effects of chemotherapeutics, which type of carrier solution is used and how much is important for an anesthesiologist. Although isotonic solutions or dextrose-based peritoneal fluids are generally used, 5% dextrose-based water solutions are used, as chloride ions for Oxaliplatin alone will reduce Oxaliplatin to less cytotoxic metabolites. This can cause hyperglycemia, metabolic acidosis, and hyponatraemia [11,12]. There is also an increased risk of intraperitoneal bleeding and thrombocytopenia for hypertonic carrier solutions [12-14]. In addition, due to the use of Cisplatinium (half-life 20-30 minutes), as a result of renal loss of Mg, prolongation of QT (pre and intraoperative Mg levels are important) and deterioration in hemodynamic functions with direct cardiotoxic effect may occur [14,15]. 

Physiopathological Changes During Cytoreductive Surgery and Hipec

During this aggressive treatment, many physiopathological changes occur in vital function and parameters within hours. These initially develop secondary to major surgery, and eventually due to hyperthermia and increased intraabdominal pressure. Hypothermia due to excessive fluid loss in the cytoreductive phase. During hyperthermic intraperitoneal chemotherapy, intraperitoneal application of hot solutions increases body temperature up to 40.5°C (mean 37.5 °C). Increased body temperature increases the metabolic rate: increased heart rate, end tidal CO2 level, metabolic acidosis and arterial lactate levels increase in systemic oxygen demand, which reaches maximum levels at the end of the HIPEC period. In the cytoreductive phase, excessive fluid loss may occur due to acid drainage. Afterwards, filling the abdomen with perfusate during the closed HIPEC period causes an increase in intra-abdominal pressure. This causes the diaphragm to shift towards the cranial, leading to a decrease in functional residual capacity and an increase in airway pressure.

These changes cause a sudden increase in central venous pressure by affecting the decrease in oxygenation and cardiac output.

 

This is also associated with decreased abdominal blood volume and increased splenic vascular resistance. Cardiac output and heart rate can be measured as high due to the hyperthermic intraperitoneal solution used during hyperthermic intraperitoneal chemotherapy and the increased metabolic rate. The initial response to heat stress is peripheral vascular dilatation, which increases heat loss from the center to the periphery. Heart rate increases in order to maintain the increased cardiac output due to decreased peripheral resistance. Due to increased intraabdominal pressure, central venous pressure (CVP) is considered to be a poor indicator of reflecting the volume status. Cardiac output measurement may be required with a swan-Ganz catheter and thermodilution method, transesephageal echocardiography or Picco device. In half of the patients intraoperative, and one third of them postoperatively, there is blood loss that requires replacement. Large fluid shifts and protein loss due to excessive fluid turnover can cause coagulation disorders. Fibrinogen, INR and AT III levels decrease, prolongation of aAPTZ level and thrombocytopenia may be seen.

Preoperative Preparation

What is important in the preoperative anesthesia care of these patients is that the systemic absorption of peritoneal fluid caused by this type of operation, blood loss, aAcute kidney damage, aAcid presence / evacuation, eElectrolyte imbalances, hHypothermia and hHyperthermia, as well as surgery and anesthesia maintenance can be difficult. It is to be borne in mind that it can cause failure. Cardiac risk in this group of patients is the same as in other patient groups. What is important is whether these patients can compensate for the operation-specific physiological changes, such as tachycardia, increased cardiac index and increased oxygen consumption. In patients with advanced age or risk in cardiac tests, the American College of Cardiology / American Heart Association Noncardiac Surgery Quideline should be followed [15,16]. Preoperative mandatory laboratory examination consists of electrolytes, blood urea nitrogen and creatinine level, albumin, bilirubin, hemogram, coagulation levels and glucose levels.

 

 

Although the renal damage associated with HIPEC is reversible, the level of the preoperative calculated glomerular filtration rate in these cases is also accepted as a postoperative renal damage indicator. Also, the presence of preoperative renal dysfunction was found to be associated with perioperative cardiovascular events [16,17].

Conditions to be Considered In Intraoperative Anesthesia Management

In the cytoreductive phase, hypothermia develops due to excessive fluid loss. One of the most important issues in the intraoperative anesthesia management of these patients is the risk of hyperthermia that may occur by bringing the carrier solution to 42-43 °C (mean 37.7 °C, sometimes 40.5 °C). Hyperthermia; Iit can cause coagulopathy, arrhythmia, liver / kidney damage, peripheral neuropathy and convulsions. Therefore, controlled hypothermia application before HIPEC may be preferred by methods such as reducing the operating room temperature, application of cooled intravenous fluid or not using a surface warmer. However, although the risk of hypothermia is more tolerable against hyperthermia, it should be kept in mind that hypothermia may lead to changes in anesthetic drug pharmacokinetics and increase in blood loss, the risk of surgical site infection and adverse cardiovascular effects [17-21].

 

With total body hyperthermia, heart rate, cardiac index and oxygen consumption increase, systemic vascular resistance decreases. Plasma norepinephrine levels increase in parallel with the increase in temperature. Therefore, radial artery catheter and invasive arterial monitoring should be added to the standard monitoring recommended by ASA in these patients. Central venous pressure monitoring due to increased intraabdominal pressure is considered a poor indicator in reflecting the volume status. Cardiac output measurement may be required with a swan-Ganz catheter and thermodilution method, transesephageal echocardiography or Picco device [19-23].

 

In the cytoreductive phase, excessive fluid loss may occur due to acid drainage. Afterwards, filling the abdomen with perfusate during the closed HIPEC period causes an increase in intra-abdominal pressure. This causes the diaphragm to shift cranially, resulting in a decrease in functional residual capacity and an increase in peak airway pressure. As a result, deterioration in oxygenation, sudden increase in central venous pressure, Vena cava inferior compression, decrease in abdominal blood volume, increase in splenic vascular resistance, decrease in preload and increase in gastric pCO2 and pH decrease (microcirculation effect) are observed. Intraabdonminmal pressure can reach up to 12-26 mmHg and this requires good muscle relaxation [24].

 

These changes cause a decrease in oxygenation and a sudden increase in central venous pressure by affecting cardiac output. This is also associated with decreased abdominal blood volume and increased splenic vascular resistance. In half of the patients intraoperative, and one third of them postoperatively, there is blood loss that requires replacement. Bleeding is not only associated with surgical reasons, but also with large fluid shifts, hyperthermic chemotherapy and protein loss due to excessive fluid turnover. There is a decrease in Fibrinogen and AT III level, prolongation in Fibrinogen, INR and aPTT, and a decrease in coagulation factors such as Thrombocytopenia and F XIII [25-27].

 

 

In these cases, blood volume plays a major role in the maintenance of systemic and regional perfusion in the intraoperative period. Decreased regional perfusion is a cause of acute renal failure. For the prevention of acute renal failure, administration of Ffurosemide (mean 25 mg), diuresis control and normovolemia are important. Acid drainage and excessive debulking can cause protein loss of up to 700 g / dayG. Therefore, in some centers, coagulopathy and accompanying albumin deficiency - if albumin <1.5-2 g - are also performed with fresh frozen plasma and albumin replacement [28-29].

Features of the Postoperative Period

In these cases, follow-up in the intensive care or recovery unit may be considered due to multiple organ failure that may develop due to disorders in the perioperative period or physiological changes. The important thing is to monitor the organ functions with constant close monitoring and to start continous positive airway pressure (CPAP) application in order to provide adequate oxygenation in these cases when necessary. In this period, management of intraoperative complications and, if any, coagulopathy and / or metabolic disorders should be corrected in the early period. In order to maintain pneumatic compression initiated in the operating room for deep vein thrombosis prophylaxis until mobilization and to prevent postoperative ileus, it is important to start oral intake early and to provide postoperative pain with epidural analgesia, if possible [30-32].

 

Expected risks specific to the postoperative period; Intestinal perforation, Anastomotic leak, Bile leak, Fistula, Pancreatitis, Postoperative bleeding, Deep vein thrombosis, Pulmonary embolism and wound opening. Also, Volume expanders and / or Norepinephrine or vasopressin may be used depending on the post-HIPEC vasodilation (SIRS). However, regardless of fluid response, aggressive fluid loading It may cause an increase in cardiac filling pressures and pulmonary edema [33].

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