Train-of-Four: To Use or Not to Use

A pattern of nerve stimulation called train-of-four (TOF) is frequently used to monitor therapy with nondepolarizing neuromuscular blocking agents in patients treated in intensive care units. Based on our experience with TOF monitoring in several critically ill patients, we believe its application as an indicator of neuromuscular blockade may be problematic in this setting.     

IgD monoclonal gammopathy with long-term follow-up

Summary. The presence of a serum IgD monoclonal protein (M-protein) is usually indicative of a malignant plasma cell disorder. However, one case of well-documented benign monoclonal gammopathy (BMG) of IgD type has been reported. We describe another patient with IgD monoclonal gammopathy of undetermined significance (MGUS) with long-term follow-up. In this patients an IgD λ M-protein was found on routine serum electrophoresis. She is alive and has no evidence of multiple myeloma or amyloidosis after 8 years of follow-up. Although IgD MGUS is exceedingly rare, this case demonstrates that the presence of a serum IgD M-protein is not necessarily synonymous with a malignant plasma cell process.     

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

PURPOSE: The purpose of this study was to compare the number and type of medication errors reported before and after the implementation of computerized prescriber order entry (CPOE); the involvement of a pharmacy resident in the CPOE implementation process will be described. METHODS: CPOE implementation in the neurosurgical intensive care unit (ICU) began on September 14, 2004. The critical care pharmacy resident, pharmacy faculty preceptor on service, critical care pharmacy team, CPOE implementation team, and director of pharmacy were integral parts of this process. Protocols and order sets were developed before CPOE implementation to standardize frequent orders, expedite their entry, and potentially decrease errors. The number of medication errors reported each month from October 2002 through November 2004 was calculated and compared, the type and severity of medication errors between September and October 2003 and September and October 2004 were compared, and the personnel reporting medication errors were compared for time points before and after CPOE implementation. RESULTS: The number of ordering errors on this service, most of which were presumed to have originated from physicians, demonstrated a fivefold increase over the same month the previous year. However, despite this increase in quantity, the majority of medication errors did not result in harm to the patient. The greatest number of medication errors was reported by the pharmacy resident on service, far exceeding the number of errors reported by pharmacists the previous year. CONCLUSION: An increase in the number of medication errors reported was observed during the initial transition period after CPOE implementation. Pharmacy departments and pharmacy residents can have a significant effect on the ease and safety of CPOE implementation.     

Acoustic analysis of gradient-coil noise in MR imaging

A survey was conducted of acoustic noise levels in magnetic resonance (MR) imaging systems. Static magnetic flux and radio-frequency pulses did not affect the function of shielded sound-pressure detection equipment. Noise levels were measured at bore isocenter during a variety of imaging sequences in six MR imaging systems with magnetic fields of 0.35-1.5 T. Measured noise ranged from 82 to 93 dB on the A-weighted scale and from 84 to 103 dB on the linear scale. Noise levels increased during sequences employing thinner section thickness and shorter repetition and echo times and were independent of field strength. Gradient-coil noise in MR imaging is an annoyance but is well within safety guidelines.