22 de dezembro de 2011

O SMA deseja a todos um Feliz Natal e um Próspero Ano Novo!

Artigo recomendado: Is it Possible to Measure and Improve Patient Satisfaction with Anesthesia?


Maurizia Capuzzo, MD, Raffaele Alvisi, MD

Anesthesiology Clin 26 (2008) 613–626

The anesthesiologist has many customers, with the patient being the most important. Despite that, most of the scientific literature is devoted only to assessing and managing objective outcomes, such as pain, nausea, and vomiting, whereas patient satisfaction is less often taken into account.1,2 This finding is surprising if one considers the great value given to the ‘‘customers’’ by other industries besides health care, which organize their activities around the customer.

Patient satisfaction with anesthesia depends on subjective patient values, and can be viewed as the indicator of the quality of anesthesia from the point of view of the patient.3 Patient satisfaction with anesthesia has not been widely investigated because of several reasons:

  • The analysis is complicated by the triangular relationship of the patient-clinicianorganization
  • Patient judgment is strongly affected by the final result, which depends on factors other than anesthesia (ie, surgery)
  • The single patient report of satisfaction appears as a subjective anecdote, which may be separate from quantifiable measurements of clinical outcomes (ie, incidence of sore throat)
  • Patient satisfaction is confounded and influenced by many known variables, and unknown variables, making its measurement even more difficult

Nevertheless, the difficult task of measuring and improving patient satisfaction with anesthesia does not mean it is an impossible task. 

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

20 de dezembro de 2011

Artigo recomendado: EuroSCORE Predicts Intensive Care Unit Stay and Costs of Open Heart Surgery


Johan Nilsson, MD, Lars Algotsson, MD, PhD, Peter Ho¨ glund, MD, PhD, Carsten Lu¨ hrs, MD, and Johan Brandt, MD, PhD

Ann Thorac Surg 2004;78:1528 – 35



Background: This study aimed to determine whether the preoperative risk stratification model EuroSCORE predicts the different components of resource utilization in open heart surgery.

Methods: Data for all adult patients undergoing heart surgery at the University Hospital of Lund, Sweden, between 1999 and 2002 were prospectively collected. Costs were calculated for the surgery and intensive care and ward stay for each patient (excluding transplant cases and patients who died intraoperatively). Regression analysis was applied to evaluate the correlation between EuroSCORE and costs. The predictive accuracy for prolonged postoperative intensive care unit (ICU) stay was assessed by the Hosmer-Lemeshow goodnessof-fit test. The discriminatory power was evaluated by calculating the areas under receiver operating characteristics curves.

Results: The study included 3,404 patients. The mean cost for the surgery was $7,300, in the ICU $3,746, and in the ward $3,500. Total cost was significantly correlated with EuroSCORE, with a correlation coefficient of 0.47 (p < 0.0001); the correlation coefficient was 0.31 for the surgery cost, 0.46 for the ICU cost, and 0.11 for the ward cost. The Hosmer-Lemeshow p value for EuroSCORE prediction of more than 2 days’ stay in the ICU was 0.40, indicating good accuracy. The area under the receiver operating characteristics curve was 0.78. The probability of an ICU stay exceeding 2 days was more than 50% at a EuroSCORE of 14 or more.

Conclusions: In this single-institution study, the additive EuroSCORE algorithm could be used to predict ICU cost and also an ICU stay of more than 2 days after open heart surgery.



Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

16 de dezembro de 2011

Artigo recomendado: Challenges in Perioperative Management of Morbidly Obese Patients: How to Prevent Complications


José Otávio Costa Auler Junior, TSA, Cindy Galvão Giannini, Daniel Fernandes Saragiotto

Revista Brasileira de Anestesiologia Vol. 53, Nº 2, Março - Abril, 2003

Background and Objectives: The incidence of morbid obesity has significantly increased in recent years, especially in developed countries. Excellent results of the surgical treatment of such condition have raised the interest in the anesthetic management of such patients. This study aimed at emphasizing critical issues for anesthesiologists dealing with morbidly obese patients.

Contents: Cardiovascular, respiratory, endocrine and metabolic changes have been frequently associated to obesity and may cause significant clinical repercussions in the perioperative period of such patients. Some practical anesthetic issues are discussed in this review.

Conclusions: In addition to emphasizing most significant and frequent complications and their prevention, the importance of PEEP and adequate tidal volumes is also highlighted.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

13 de dezembro de 2011

Artigo recomendado: ASPAN’S Evidence-Based Clinical Practice Guideline for the Prevention and/or Management of PONV/PDNV

Journal of PeriAnesthesia Nursing, Vol 21, No 4 (August), 2006: pp 230-250

Problem: Postoperative and post-discharge nausea and vomiting (PONV/PDNV) is one of the most commonly occurring postoperative complications, frequently resulting in prolonged postoperative stay, unanticipated admission and increased health care costs. Yet, health care providers have yet to reach consensus regarding an evidence-based multi-disciplinary, multi-model treatment approach to PONV/PDNV.

Purpose: To develop a multi-modal, multi-disciplinary evidence-based resource for anesthesia providers and nurses involved in the care of patients in inpatient and outpatient settings who are having procedures performed in the operating room, as well as in other locations where sedation or anesthesia may be administered, who are at risk for, or experiencing PONV and/or PDNV.

Method: ASPAN organized a Strategic Work Team (SWT) consisting of 18 multi-disciplinary, multi-specialty experts charged with the review and analysis of published evidence related to the prevention and/or management of PONV/PDNV. The evidence was summarized and presented at a consensus conference in March, 2006, with small group discussions among participants to critique and stratify all available evidence. Consensus based decision making techniques were then used to establish multi-disciplinary, multi-modal evidence-based recommendations regarding risk factor identification and stratification, traditional (pharmacological, hydrations, NPO status, etc) and complimentary (acustimulation, aromatherapy, etc) treatment modalities.

Results: One hundred percent consensus was reached on all guideline recommendations. Multi-disciplinary, multi-modal evidence-based recommendations were made regarding risk factor identification and stratification, traditional, and complimentary prophylaxis and management of PONV/PDNV. Areas of needed research in the prevention and management of PONV/PDNV were also identified and prioritized.

Implications for Practice: Translation of this multi-disciplinary, multi-modal evidence-based practice guideline into practice to direct the prevention and/or management of PONV/ PDNV should improve health outcomes in adult surgical patients.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

9 de dezembro de 2011

Artigo recomendado: Diastolic heart failure in anaesthesia and critical care

R. Pirracchio, B. Cholley, S. De Hert, A. Cohen Solal and A. Mebazaa

Br J Anaesth 2007; 98: 707–21

Diastolic heart failure is an underestimated pathology with a high risk of acute decompensation during the perioperative period. This article reviews the epidemiology, risk factors, pathophysiology, and treatment of diastolic heart failure. Although frequently underestimated, diastolic heart failure is a common pathology. Diastolic heart failure involves heart failure with preserved left ventricular (LV) function, and LV diastolic dysfunction may account for acute heart failure occurring in critical care situations.

Hypertensive crisis, sepsis, and myocardial ischaemia are frequently associated with acute diastolic heart failure. Symptomatic treatment focuses on the reduction in pulmonary congestion and the improvement in LV filling. Specific treatment is actually lacking, but encouraging data are emerging concerning the use of renin–angiotensin–aldosterone axis blockers, nitric oxide donors, or, very recently, new agents specifically targeting actin–myosin cross-bridges.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

6 de dezembro de 2011

Artigo recomendado: Injuries associated with anaesthesia. A global perspective

A. R. Aitkenhead

Br J Anaesth 2005; 95: 95–109

The anaesthetized patient is at risk of complications resulting from the actions, or inaction, of the anaesthetist, from the actions of the surgeon, and from failure or malfunction of anaesthetic equipment. The state of anaesthesia may be considered to be intrinsically unsafe. Patients are subjected to administration of drugs which have side-effects, particularly on the cardiovascular and respiratory systems.

Unconsciousness carries with it risks of airway obstruction, soiling of the lungs, and inability to detect peripheral injury. Pharmacological muscle paralysis necessitates the use of artificial ventilation, making the patient dependent on the anaesthetist and his equipment for the fundamental functions of oxygenation and excretion of carbon dioxide. The anaesthetist may deliberately alter physiological functions, for example by inducing hypotension or ventilating only one lung.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

2 de dezembro de 2011

Artigo recomendado: Goal-directed Intraoperative Fluid Administration Reduces Length of Hospital Stay after Major Surgery


Tong J. Gan, M.B., B.S, F.R.C.A.,* Andrew Soppitt, B.Sc., M.B., B.S., F.R.C.A.,† Mohamed Maroof, M.D.,‡ Habib El-Moalem, Ph.D.,§ Kerri M. Robertson, M.D.,* Eugene Moretti, M.D.,† Peter Dwane, M.D.,‡ Peter S. A. Glass, M.B., F.F.A. (S.A.)

Anesthesiology, V 97, No 4, Oct 2002

Background: Intraoperative hypovolemia is common and is a potential cause of organ dysfunction, increased postoperative morbidity, length of hospital stay, and death. The objective of this prospective, randomized study was to assess the effect of goal-directed intraoperative fluid administration on length of postoperative hospital stay.

Methods: One hundred patients who were to undergo major elective surgery with an anticipated blood loss greater than 500 ml were randomly assigned to a control group (n = 50) that received standard intraoperative care or to a protocol group (n = 50) that, in addition, received intraoperative plasma volume expansion guided by the esophageal Doppler monitor to maintain maximal stroke volume. Length of postoperative hospital stay and postoperative surgical morbidity were assessed.

Results: Groups were similar with respect to demographics, surgical procedures, and baseline hemodynamic variables. The protocol group had a significantly higher stroke volume and cardiac output at the end of surgery compared with the control group. Patients in the protocol group had a shorter duration of hospital stay compared with the control group: 5 ± 3 versus 7 ± 3 days (mean ± SD), with a median of 6 versus 7 days, respectively (P = 0.03). These patients also tolerated oral intake of solid food earlier than the control group: 3 ± 0.5 versus 4.7 ± 0.5 days (mean ± SD), with a median of 3 versus 5 days,respectively (P = 0.01).

Conclusions: Goal-directed intraoperative fluid administration results in earlier return to bowel function, lower incidence of postoperative nausea and vomiting, and decrease in length of postoperative hospital stay.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

29 de novembro de 2011

Artigo recomendado: Using Information Technology to Improve the Quality and Safety of Emergency Care


Daniel A. Handel, MD, MPH, Robert L. Wears, MD, MS, Larry A. Nathanson, MD, and Jesse M. Pines, MD, MBA, MSCE

ACADEMIC EMERGENCY MEDICINE 2011; 18:e45–e51

ABSTRACT

With the 2010 federal health care reform passage, a renewed focus has emerged for the integration of electronic health records (EHRs) into the U.S. health care system. A consensus conference in October 2009 met to discuss the future research agenda with regard to using information technology (IT) to improve the future quality and safety of emergency department (ED) care. The literature is mixed as to how the use of computerized provider order entry (CPOE), clinical decision support (CDS), EHRs, and patient tracking systems has improved or degraded the safety and quality of ED care. Such mixed findings must be considered in the national push for rapid implementation of health IT.

We present a research agenda addressing the major questions that are posed by the introduction of IT into ED care; these questions relate to interoperability, patient flow and integration into clinical work, real-time decision support, handoffs, safety-critical computing, and the interaction between IT systems and clinical workflows.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

25 de novembro de 2011

Artigo recomendado: Adding ketamine to morphine for intravenous patient-controlled analgesia for acute postoperative pain: a qualitative review of randomized trials

M. Carstensen, A. M. Møller

Br J Anaesth 2010; 104: 401–6

Introduction

In experimental trials, ketamine has been shown to reduce hyperalgesia, prevent opioid tolerance, and lower morphine consumption. Clinical trials have found contradictory results. We performed a review of randomized, double-blinded clinical trials of ketamine added to opioid in i.v. patient-controlled analgesia (PCA) for postoperative pain in order to clarify this controversy.

Our primary aim was to compare the effectiveness and safety of postoperative administered ketamine in addition to opioid for i.v. PCA compared with i.v. PCA with opioid alone. Studies were identified from the Cochrane Library 2003, MEDLINE (1966–2009), and EMBASE (1980– 2009) and by hand-searching reference lists from review articles and trials. Eleven studies were identified with a total of 887 patients. Quality and validity assessment was performed on all trials included using the Oxford Quality Scale with an average quality score of 4.5. Pain was assessed using visual analogue scales or verbal rating scales. Six studies showed significant improved postoperative analgesia with the addition of ketamine to opioids. Five studies showed no significant clinical improvement. For thoracic surgery, the addition of ketamine to opioid for i.v. PCA was superior to i.v. PCA opioid alone. The combination allows a significant reduction in pain score, cumulative morphine consumption, and postoperative desaturation.

The benefit of adding ketamine to morphine in i.v. PCA for orthopaedic or abdominal surgery remains unclear. Owing to huge heterogeneity of studies and small sample sizes, larger double-blinded randomized studies showing greater degree of homogeneity are required to confirm these findings.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

21 de novembro de 2011

Artigo recomendado: Anestesia para Obesidade Mórbida

Michelle Nacur Lorentz, TSA1, Viviane Ferreira Albergaria, TSA1, Frederico Augusto Soares de Lima

Rev Bras Anestesiol 2007; 57: 2: 199-213

RESUMO
Lorentz MN, Albergaria VF, Lima FAS — Anestesia para Obesidade Mórbida.

Justificativa e objetivos: A obesidade mórbida é uma doença muito freqüente em nosso meio, enquanto nos EUA já assumiu caráter epidêmico. O paciente obeso apresenta uma série de alterações fisiopatológicas, além de importantes comorbidades, o que exige do anestesiologista pleno conhecimento da fisiopatologia da doença. O procedimento cirúrgico de redução gástrica tem sido cada vez mais realizado e o período perioperatório apresenta características únicas com alterações cardiovascular e pulmonar que o tornam um verdadeiro desafio para os profissionais envolvidos. O hospital também deve estar preparado para receber esses pacientes, com equipamentos adequados, equipe multidisciplinar e cuidados pós-operatórios. O objetivo deste estudo foi demonstrar que o paciente obeso mórbido não é apenas um paciente com excesso de peso, e, portanto, procurou-se nortear as principais condutas a serem observadas.

Conteúdo: São apresentadas neste artigo as principais alterações fisiopatológicas do obeso mórbido, bem como dados de epidemiologia e doenças correlacionadas. É realizada uma revisão das doses dos medicamentos usados na anestesia, bem como a melhor abordagem pré-, intra- e pós-operatória pelo anestesiologista.

Conclusões: A abordagem do paciente com obesidade mórbida exige um planejamento minucioso que se inicia na seleção dos pacientes, tem continuidade com pré-operatório detalhado e intraoperatório individualizado, e se estende até o pós-operatório, quando a incidência de complicações pulmonar, cardiovascular e infecciosa é maior que na população não-obesa. Para que os resultados sejam favoráveis é extremamente importante o envolvimento de uma equipe multiprofissional que inclui Clínica Geral, Anestesiologia, Cirurgia Geral, Enfermagem, Psicologia, Fisioterapia, Nutrologia e Terapia Intensiva.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

16 de novembro de 2011

Artigo recomendado: High mortality rate in patients with advanced liver disease independent of exposure to general anesthesia


Ramsey C. Cheung MD (Associate Professor), Ryan J. McAuley BS (Research Assistant), John B. Pollard MD (Associate Professor)

Journal of Clinical Anesthesia (2005) 17, 172–176

ABSTRACT

Study Objective: To evaluate the survival of patients with advanced liver disease to determine if known exposure to general anesthesia within a 5-year period has a measurable effect on mortality.

Design: Retrospective survival analysis of male veterans with advanced liver disease.

Setting: Tertiary referral VA Medical Center and university-affiliated teaching hospital.

Measurements: One hundred twenty-seven patients with a history of alcoholic cirrhosis and documented hepatitis C infection and stable platelet counts were identified and then divided into 3 groups. The 5-year survival rates in all 3 groups were compared using Kaplan-Meier survival curves.

Main Results: Ninety patients had marked thrombocytopenia (b100000/mm3). Their survival rates with and without known exposure to general anesthesia were compared with those of control subjects with alcoholic cirrhosis and hepatitis C infection but with platelet counts greater than 100000/mm3. The 5-year survival rate of 57% in the group that received general anesthesia was comparable to the 58% rate observed in the group without this exposure. Both groups’ rates were statistically lower than the 5-year survival rate of 77% in the group with advanced liver disease but without thrombocytopenia.

Conclusion: Comparably high mortality rates were observed in patients with advanced liver disease with or without exposure to general anesthesia. Higher survival rates were noted in patients with advanced liver disease who were not thrombocytopenic.

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10 de novembro de 2011

Artigo: A review of patients with pulmonary aspiration of gastric contents during anesthesia reported to the Departmental Quality Assurance Committee

Gundappa Neelakanta MD*, Anand Chikyarappa MBBS

Journal of Clinical Anesthesia (2006) 18, 102–107

ABSTRACT

Study Objective: Preoperative risk factors for pulmonary aspiration of gastric contents during anesthesia are well studied. There is lack of information as to factors or circumstances leading to aspiration.

Design: A retrospective review of cases of pulmonary aspiration reported to the Departmental Quality Assurance (QA) Committee was undertaken.

Setting: This study took place at a large tertiary care university hospital based in a metropolitan city.

Patients: The study identified all patients reported to the QA Committee as having pulmonary aspiration during January 1991 to December 1994 and July 1996 to December 2000.

Interventions: No interventions were done.

Measurements: The medical records of all patients thus identified were reviewed to see if they had pulmonary aspiration according to strict criteria. Presence of preoperative known risk factors, prophylactic measures used against pulmonary aspiration, and perioperative events were noted.

Main Results: A total of 47 patients were reported to the QA Committee as having pulmonary aspiration during this period. Upon review, 23 patients had pulmonary aspiration (definite aspiration, n = 12; probable aspiration, n = 11) and 24 patients did not meet the criteria for pulmonary aspiration of gastric contents. The incidence of pulmonary aspiration overall was 1 per 8671 anesthetics and 1 per 4385 anesthetics in patients younger than 16 years. If all 47 cases reported to QA Committee are presumed to have had pulmonary aspiration, then the overall incidence of aspiration is 1 in 4243 anesthetics. Eighteen of 23 patients had a preoperative risk factor, but preventive measures against aspiration had been used in only 4 patients. Five patients did not have any apparent preoperative risk factor.

Conclusions: This study confirms that pulmonary aspiration of gastric contents is a rare complication during modern anesthesia. Preoperative risk factor was present in most patients who had pulmonary aspiration. A clear understanding of risk factor/s is needed to prevent further cases of pulmonary aspiration.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

7 de novembro de 2011

Artigo recomendado: Part-Time Clinical Anesthesia Practice: a Review of the Economic, Quality and Safety Issues

Catherine A. McIntosh, MBBS, FANZCA, Alex Macario, MD, MBA

Anesthesiology Clin 26 (2008) 707–727

Many anesthesiologists would like to work part-time for various personal, financial, or other reasons. Many private anesthesia groups have no system in place for part-time practice to occur. The following list indicates some of the questions that arise when this topic is discussed.

  • What is the minimum work level required of a part-time practitioner to remain competent? (For example, 1 or 2 days a week?)
  • Is the part time clinician assigned more simple cases and fewer complex cases? If so, how does this impact his or her ability to take call?
  • Is the clinical competence of a part-time practitioner reduced because he or she is part time? Even more fundamentally, how is competence in patient care defined? How is competence affected by what the part-timer does (eg, research, administration, stay at home with family) when not working clinically?
  • How is the frequency of overnight call and in-house call distributed to the parttime person?
  • How are health and retirements benefits apportioned to the part-time practitioner?
  • Who qualifies in a group for part-time practice and why?
  • Is there a limit on how long one can be on such a part-time track? How long can one take a break from practice before needing to consider some type of re-training?
  • How many group members can be on the part-time track simultaneously? Does age matter?
Surprisingly little is known about these issues. The goals of this article are to review the economic, quality, and safety issues surrounding part-time clinical anesthesia practice. Anesthesia groups need to be aware of the range of attitudes in the workplace regarding the increasing fraction of the anesthesia workforce that is part-time.

Variability in how part-time practice is viewed affects issues such as perceived competence, job satisfaction, scheduling, and compensation of the part-time practitioner.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

26 de outubro de 2011

Artigo recomendado: Human Factors Research in Anesthesia Patient Safety: Techniques to Elucidate Factors Affecting Clinical Task Performance and Decision Making


MATTHEW B. WEINGER, MD, JASON SLAGLE, MS.

J Am Med Inform Assoc. 2002; 9(Nov-Dec suppl):S58–S63. DOI 10.1197/jamia.M1229.

A b s t r a c t:  Patient safety has become a major public concern. Human factors research in other high-risk fields has demonstrated how rigorous study of factors that affect job performance can lead to improved outcome and reduced errors after evidence-based redesign of tasks or systems. These techniques have increasingly been applied to the anesthesia work environment. This paper describes data obtained recently using task analysis and workload assessment during actual patient care and the use of cognitive task analysis to study clinical decision making. A novel concept of “non-routine events” is introduced and pilot data are presented. The results support the assertion that human factors research can make important contributions to patient safety. Information technologies play a key role in these efforts.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e enviaremos o artigo completo.

20 de outubro de 2011

2º Simpósio Interdisciplinar de Segurança do Paciente (SISEPA) - USP

Não percam!  Será no dia 27/10/2011 no Centro de Convenções Rebouças em São Paulo SP.

Texto Recomendado: General Anesthesia — Minding the Mind during Surgery


Gregory Crosby, M.D.

Editorials N Engl J Med 365;7 nejm.660 org August 18, 2011

William Morton’s demonstration of the use of ether in 1846 was powerful in part because the patient had no memory of the procedure; nowadays, patients expect to have amnesia with general anesthesia. But conscious awareness — the ability to remember and explicitly recall events that transpire during surgery — still occurs on occasion, sometimes with devastating psychological consequences. The easy explanation is that awareness is due to underdosing of the anesthetic agent. This explanation provides a sense of control and a ready fix (administer more anesthesia) but conveniently overlooks a secret: the state of consciousness is typically not monitored directly during general anesthesia. There simply is no accepted way to do it.

13 de outubro de 2011

Segurança dos pacientes, profissionais e organizações: um novo padrão de assistência à saúde

Patient, professional, and organization safety: a new Healthcare Standard

RAS _ Vol. 8, No 33 – Out-Dez, 2006 153

Antonio Quinto Neto - Médico, Mestre em Administração, especialista em avaliação de sistemas e serviços de saúde, docente de vários cursos de pós-graduação em gestão de saúde, Diretor Superintendente do Hospital Banco de Olhos de Porto Alegre, RS.


RESUMO

O autor tece considerações sobre o conceito de segurança do paciente e suas implicações para os pacientes, profissionais e organizações. Destaca a importância de substituir a cultura da culpa e castigo pela cultura da aprendizagem a partir da identificação e análise das falhas e acidentes.

Apresenta algumas medidas de segurança já disponíveis e dá ênfase à aplicação do protocolo universal que previne, no caso das cirurgias/procedimentos invasivos, local errado, cirurgia/procedimento errado e paciente errado. Menciona a acreditação de organizações de saúde como uma estratégia global de redução de risco para os clientes/pacientes.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

 

5 de outubro de 2011

2º Simpósio Interdisciplinar de Segurança do Paciente (SISEPA) - FMUSP


Main Concerns of Patients Regarding the Most Common Complications in the Post-Anesthetic Care Unit

Eduardo Toshiyuki Moro, TSA, M.D., Renato César Senne Godoy, M.D., Alexandre Palmeira Goulart, M.D., Leopoldo Muniz, M.D., Norma Sueli Pinheiro Modolo, M.D.

Revista Brasileira de Anestesiologia Vol. 59, No 6,
Novembro-Dezembro, 2009
INTRODUCTION

Preoperative anxiety is frequently associated with anticipation of anesthesia - or surgery-related damages. Severe complications that can be attributed to anesthesia such as death are rare. On the other hand, “minor” events such as pain, nausea, or vomiting have assumed a fundamental role in the determination of the quality provided by the Anesthesiology service1.

When postoperative fears are analyzed regarding low morbidity events that should be avoided the most, anesthesiologists have not always been capable to determine the priorities of the patients2. Thus, successful treatment of postoperative pain, for example, is not necessarily related with higher satisfaction with anesthesia, since the consequences of pain treatment, such as nausea and vomiting, should be considered.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

Artigo: Accidents by ABO incompatibility and other main complications related to blood transfusion in surgical patients

Data from the French national survey on anaesthesia-related deaths


Dan Benhamou, André Lienhart, Yves Auroy, Françoise Péquignot, Eric Jougla

Transfusion clinique et biologique 12 (2005) 389–390

Blood red cell transfusion often occurs in the perioperative setting and is a frequently performed activity in routine anaesthetic practice. Blood transfusion (including any technique of autologous blood transfusion is performed in nearly 3% of all surgical procedures in France, representing more than 200,000 transfusion procedures each year [1]. Because homologous blood transfusion is performed alone or is associated with any other technique of autologous blood salvage in 48% of cases (i.e. 107,000 patients) and because a mean of three units of red blood cells is used in each patient, it has been estimated that 295,000 packs of red cells are transfused in this country each year. Nearly 50% of these blood transfusion procedures are done during orthopaedic surgery, mainly total hip or knee replacement but one third of the procedures during which blood transfusion is used are emergency procedures [1] and this may have a link with the risk of errors (see below). Along with this, it should be noted that incidents are more often recorded in hospitals in which a small blood bank is used only for emergency situations than in large institutions in which blood transfusion is a routine activity and is used night and day for a large number of patients [2].

Data collected during a national French survey performed in 1997–1998 were aimed at assessing anaesthetic activity but recorded also several indicators reflecting transfusion activities in surgical patients. However, only intraoperative (and recovery room) activities were recorded. As it is well known that nearly 50% of perioperative blood transfusion episodes occur in the first postoperative week [3], it can be estimated that blood transfusion associated with surgical procedures represents more than 500,000 packed red cell units each year in France. These numbers explain why anaesthetists have long been interested in this activity and why the French Society of Anaesthesia and Intensive Care (SFAR) has been involved in (and sometimes has led) many expert conferences on blood transfusion.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

30 de setembro de 2011

Artigo recomendado: Estudo Comparativo entre o Uso de Laringoscópio e Estilete Luminoso para Intubação Traqueal


Matheus Felipe de Oliveira Salvalaggio, Rogério Rehme, TSA, Robson Fernandez, Suelen Vieira, Paulo Nakashima

Revista Brasileira de Anestesiologia
Vol. 60, No 2, Março-Abril, 2010

JUSTIFICATIVA E OBJETIVOS: A abordagem das vias aéreas com o uso do laringoscópio pode causar diversos tipos de traumatismos. Este estudo teve como objetivo tentar esclarecer se o método de intubação que utiliza o estilete luminoso pode ser uma alternativa menos traumática para o paciente em comparação ao método por laringoscopia direta.

MÉTODO: O presente estudo envolveu 98 pacientes de 16 a 88 anos, estado físico ASA I e II. Os pacientes foram divididos em dois grupos: Grupo L, submetido à intubação com laringoscópio, com 54 pacientes, e Grupo E, intubado com estilete luminoso, com 44 pacientes. Foram avaliados o número de tentativas para intubação, tempo de intubação, variação de pressão arterial e frequência cardíaca, dor de garganta (odinofagia), disfagia e rouquidão pós-operatória.

RESULTADOS: Os dados demográficos e os parâmetros hemodinâmicos foram semelhantes entre os grupos. Não houve diferença estatística significativa na pesquisa de dor de garganta e disfagia entre os dois grupos. A rouquidão foi o único dado estudado em que se observou diferença estatística significativa, mais predominante no grupo E (p = 0,05).

CONCLUSÕES: Ambas as técnicas de intubação são semelhantes em relação ao comportamento hemodinâmico dos dois grupos. No entanto, o grupo com estilete luminoso apresentou maior frequência do sintoma rouquidão.

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27 de Outubro: 2º SISEPA - Simpósio Interdisciplinar de Segurança do Paciente

Tema Central: Segurança e Qualidade no atendimento perioperatório: Como Melhorar?

27 de setembro de 2011

Artigo recomendado: Thoracic sympathetic block reduces respiratory system compliance


Fábio Ely Martins Benseñor, Joaquim Edson Vieira, José Otávio Costa Auler Júnior (Anesthesia Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil)

Sao Paulo Med J. 2007;125(1):9-14


CONTEXT AND OBJECTIVE
Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefi ts. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these benefi cial and undesirable effects on intraoperative respiratory mechanics.

DESIGN AND SETTING
Randomized, doubleblind clinical study at a tertiary public hospital.

METHODS
Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5% bupivacaine, n = 9) or placebo (15 ml 0.9% saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, fl ows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. Student’s t test was performed, including confidence intervals (CI).

RESULTS
Bupivacaine rose 5 ± 1 dermatomes upwards and 6 ± 1 downwards. LIP was higher in the bupivacaine group (6.2 ± 2.3 versus 3.6 ± 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 ± 31.7 versus 70.2 ± 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference.

CONCLUSION
TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

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23 de setembro de 2011

Artigo recomendado: Clinical consequences of red cell storage in the critically ill


Alan Tinmouth, Dean Fergusson, Ian Chin Yee, and Paul C. Hébert for the ABLE Investigators and the Canadian Critical Care Trials Group

TRANSFUSION 2006;46:2014-2027

Over the past 25 years, we have witnessed a dramatic “paradigm shift” whereby red blood cell (RBC) transfusions, once regarded as “one of the great advances in modern medicine,” are now considered harmful in some clinical situations. This paradigm shift has focused attention on the quality of stored transfused blood. Changes accompanying the storage of red cells (RBCs) are known as the “storage lesion,” which can be defined as a series of biochemical and biomechanical changes in the RBC and storage media during ex vivo preservation that reduce RBC survival and function. Although the storage lesion has been well documented for decades,1 our understanding of the mechanisms involved in these changes and clinical consequences remains incomplete. Recent clinical trials and animal experiments have raised fundamental questions about the efficacy of stored RBCs, 2,3 which may haveimportant implications for the future of transfusion research.

In critically ill patients, clinical studies have reported an association between RBC transfusions and increased morbidity and mortality, an effect that may increase with the age of the transfused RBCs. Anemia is very common in the critically ill with 95 percent of patients admitted to the intensive care unit (ICU) experiencing a hemoglobin (Hb) level below normal by the third day 4,5 and 40 percent to 45 percent of critically ill patients receive 5 units of RBCs during their ICU admission.4,5 More recently, a seminal multicenter randomized controlled clinical trial in critically ill patients (TRICC, Transfusion Requirements in Critical Care) demonstrated a lower 30-day mortality rate in the patients randomly assigned to the restrictive transfusion strategy6 (23.3% vs. 18.7%, p = 0.11; Fig. 1). Plausible explanations for the increased morbidity and mortality seen in TRICC may be that prolonged storage renders RBCs ineffective oxygen (O2) carriers and/or modifies RBCs, which cause harm when transfused into vulnerable patients via either a proinflammatory effect or the direct toxic effects of by-products of RBC storage. To date, the mechanisms of action accounting for increased morbidity and mortality remain unknown. In this article, we will review the laboratory and clinical studies evaluating changes to RBCs with prolonged storage followed by a review of studies evaluating the clinical consequences of prolonged RBC storage.

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20 de setembro de 2011

Artigo recomendado: Hemorrhage and operation cause a contraction of the extracellular space needing replacement—evidence and implications?

A systematic review

Birgitte Brandstrup, MD, PhD, Christer Svensen, MD, PhD, and Allan Engquist, MD.

Surgery 2006;139:419-32.

Background
Hemorrhagic hypotension or operative trauma is believed to cause a contraction of the extracellular fluid volume (ECV) beyond the measured fluid losses. The aim of this review was to explore the evidence and implications of ECV loss.

Methods
We performed a systematic review of original trials measuring ECV changes during hemorrhage or operation. PubMed, relevant periodicals, and reference lists were searched until no further original articles appeared. The quality of both the scientific and the technical methods of the trials were evaluated.

Results
A total of 61 original articles were found. The pattern appeared that all investigators reporting shock or operation to cause a disparate reduction of the ECV had measured the ECV with the same method. The ECV was calculated from very few blood samples that were withdrawn after 20 to 30 minutes of equilibration of a tracer (the 35SO4-tracer). Trials calculating ECV from multiple blood samples, after longer equilibration times, or using other tracers did not find a contraction of the ECV. On the contrary, trials using a bromide tracer found the ECV to be expanded after operation.

Conclusions
The evidence supporting the idea that hemorrhage or operation cause a contraction of the ECV is weak, and probably a result of flawed methodology.

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19 de setembro de 2011

23 de Setembro: Seminário sobre "Erro médico e as consequências administrativas e judiciais"


Este evento será promovido pela Central Prática no dia 23 de setembro, das 9h às 17h55, no auditório da instituição, em São Paulo na Rua Frei Caneca, 159.
A proposta do seminário é promover a discussão entre médicos, advogados, diretores, gerentes e empresários do setor hospitalar e clínico.


16 de setembro de 2011

Artigo recomendado: Assessing the risk of surgery in patients with liver disease


Amitabh Suman, MD, William D. Carey, MD

Cleveland Clinic Journal of Medicine V.73 n.4 April 2006

ABSTRACT
Recent studies have defined objective criteria for determining whether surgery is safe for patients with liver disease. Using these criteria, we may extend the benefit of surgery to more patients with liver disease without increasing the risk.

KEY POINTS
  • Patients with liver disease are at higher risk of death and hepatic decompensation if they undergo surgery than people without liver disease.
  • Liver disease is often undiagnosed before surgery unless it is specifically looked for.
  • Liver disease does not exclude surgery; certain types of surgery can be undertaken safely if patients are chosen carefully.
  • A recent study has suggested a Child-Pugh score of 8 and a Model for End-Stage Liver Disease (MELD) score of 14 as the cutoff values above which surgery poses too much risk for patients with cirrhosis.
  • Surgery is usually not advisable in patients with acute hepatitis, but it appears safe in mild chronic hepatitis.
Because Liver Disease is common, many patients undergoing surgery have it. Patients with liver disease face a higher risk of surgical complications, including death from surgery and anesthesia, but the level of risk is hard to assess because all liver disease is not the same, and neither is all surgery. Uncertainty has led some physicians to be reluctant to send any patient with liver disease to surgery, and others to take unjustified risks.

Although risk assessment has often been based on anecdote, a number of studies can provide guidance in this respect. The goal is to avoid surgery in patients at high risk without denying the benefits of surgery to those at reasonable risk. This review provides the clinician an up-to-date guide to risk assessment for anesthesia and surgery in patients with liver disease.

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13 de setembro de 2011

Artigo recomendado: Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery


Kathrine Holte, MD, Henrik Kehlet, MD, PhD, FACS(HON)

J Am Coll Surg Vol. 202, No. 6, June 2006

Principles in perioperative fluid management and their implications for outcomes in elective surgery are controversial because there are limited data from randomized studies.1,2 Although numerous previous studies and several systematic reviews have compared different types of fluids for resuscitation, the results so far have been inconclusive.3-8 Importantly, the vast majority of studies included in these reviews focused on critically ill patients, with conclusions not necessarily applicable for patients undergoing elective surgical procedures.

Recent data suggest that not only the type of fluid, but also the amount of fluid administered perioperatively may influence surgical outcomes,1,2,9-12 a factor not often recognized in previous studies on perioperative fluid management. Recent data have demonstrated that amultimodal revision of principles for postoperative caremay improve outcomes after major surgical procedures (eg, fast-track surgery),13-15 findings that might also have implications for fluid management practices.

We conducted a systematic review of randomized, controlled trials with a focus on the influence of the types of fluid (eg, crystalloids, colloids, and hypertonic solutions) and the amounts of fluid administered perioperatively for fluid resuscitation purposes on surgical outcomes in elective noncardiac surgical procedures. The aim of this review was to examine the evidence from randomized trials concerning the effects of perioperative fluid administration (type and amounts) on surgical outcomes in elective surgical procedures.

These results are discussed within the concept of fast-track surgery, with proposals for improved design of future studies of perioperative fluid management to determine its role in postoperative recovery.

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8 de setembro de 2011

Artigo recomendado: The Influence of Propofol Versus Sevoflurane Anesthesia on Outcome in 10.535 Cardiac Surgical Procedures

Carl-Johan Jakobsen, MD, Henrik Berg, MD, Karsten B. Hindsholm, MD, Nicolas Faddy, RN, and Erik Sloth, MD

Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 5 (October), 2007: pp 664-671

Objective: The purpose of this study was to evaluate the possible cardioprotective effect of sevoflurane versus propofol anesthesia in patients undergoing cardiac surgery.

Methods: Ten thousand five hundred thirty-five consecutive single cardiac surgical procedures from 3 cardiac centers were reported to a common registry from 1999 to 2005. The registry was established by the National Board of Health, and reporting was obligatory for all public heart centers in Denmark. The patients were stratified according to preoperative risk factors (EuroSCORE parameters). The outcome parameters were 30-day mortality, the incidence of postoperative myocardial infarction, and the incidence of postoperative arrhythmias.

Results: Overall, the 30-day mortality was lower after sevoflurane (2.84%) versus propofol (3.30%), although not significantly so (p 0.18). No difference was found in the incidence of postoperative myocardial infarction (sevoflurane, 7.76%/propofol, 7.47%). Patients with preoperative unstable angina and/or recent myocardial infarction, and thus already “preconditioned,” did not show any difference in mortality between anesthetic groups, whereas patients without these predictors showed a lower postoperative mortality after sevoflurane (2.28% v 3.14%, p 0.015), which can at least partly be explained by a preconditioning-like effect. The data suggest that patients suffering relatively severe preoperative ischemic stress benefited from propofol anesthesia, which can be related to the antioxidant effects of propofol. Patients in the sevoflurane group had a higher incidence of postoperative atrial fibrillation (28.75% v 24.87%, p < 0.001), whereas patients in the propofol group showed a higher incidence of all other arrhythmias.

Conclusion: Sevoflurane and propofol both possess some, although different, cardioprotective properties. Sevoflurane appears to be superior to propofol in patients with little or no ischemic heart disease, such as noncoronary artery bypass graft (CABG) surgery and CABG surgery without severe preoperative ischemia, whereas propofol seems superior in patients with severe ischemia, cardiovascular instability, or in acute/urgent surgery.

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