28 de fevereiro de 2011

Artigo recomendado: Noninvasive Temperature Monitoring in Postanesthesia Care Units

Anesthesiology 2009; 111:90–6

Geoffrey E. Langham, B.S.,* Ankit Maheshwari, M.D.,† Kevin Contrera,‡ Jing You, M.S.,§ Edward Mascha, Ph.D.,  Daniel I. Sessler, M.D.

Background: Initial postoperative core temperature is a physician and hospital performance measure. However, the extent to which core temperature changes during emergence from anesthesia and transport from the operating room to the postanesthesia care unit (PACU) remains unknown. Similarly, the accuracy of many noninvasive temperature-monitoring methods used in the PACU has yet to be quantified. This study, therefore, quantified the change in core temperature occurring during emergence and transport and evaluated the accuracy and precision of eight noninvasive thermometers in the PACU.

Methods: In 50 patients having laparoscopic surgery, the authors measured temperatures upon PACU arrival and 30 and 60 min thereafter. Monitoring methods included oral, axillary, temporal artery, forehead skin-surface, forehead liquid-crystal display, infrared aural canal, deep forehead, and deep chest. Bladder temperature was used as the reference and was also measured at the end of surgery. The primary outcome was agreement between individual temperatures from each method and bladder temperature in the PACU. A priori, the authors chose 0.5°C as a clinically important temperature deviation.

Results: Bladder temperature increased 0.2 0.3°C (95% confidence interval 0.1 to 0.3°C), P < 0.001, during transport. None of the tested noninvasive thermometers was consistently within 0.5°C of bladder emperature. However, oral, deep forehead, and temporal artery temperatures were significantly better than other methods and agreed reasonably well with bladder temperature.

Conclusions: Invasive temperature monitoring available intraoperatively is more accurate than any generally available postoperative methods. Physician performance measures should therefore not be based exclusively on postoperative temperatures. Among the generally available postoperative monitoring methods, electronic oral thermometry appears to be the best.

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24 de fevereiro de 2011

8º Passo para a Anestesia Segura: Planejando a Monitorização Adequada


Caros leitores, hoje iniciamos a apresentação do 8º Passo do programa Segurança no Período Perioperatório: 10 Passos para a Anestesia Segura

Este passo (Planejando a Monitorização Adequada) tem por objetivo discutir e apoiar o desenvolvimento de diretrizes assistenciais que sistematizam a monitorização para procedimentos anestésicos cirúrgicos e diagnósticos, de acordo com a gravidade do paciente e a complexidade do procedimento, garantindo a qualidade no cuidado e aumentando a segurança dos processos assistenciais. 

Diversos estudos demonstram que a determinação da monitorização adequada consegue prevenir e reduzir os riscos por meio do reconhecimento precoce de um erro, ou até mesmo por demonstrar deterioração das condições clínicas do paciente de maneira precoce por qualquer outro motivo. A prevenção de danos ao paciente, por sua vez, também pode ajudar a minimizar as ações jurídicas relacionadas à anestesia. A implementação de recomendações padronizadas de monitorização resultou em redução real de complicações em diversos hospitais e instituições, como aconteceu na Harvard Medical School, na década de 80 (Standards for patient monitoring during anesthesia at Harvard Medical School, 1986). 

A monitorização consiste na vigilância contínua a qual os pacientes sob anestesia e sedação devem ser submetidos, sendo considerado o monitoramento das diversas funções orgânicas por meio da integração entre os dados obtidos pelos aparelhos e a avaliação clínica do paciente. A monitorização abrange diversos aspectos: hemodinâmicos, respiratórios/ ventilatórios, consciência, analgesia, relaxamento muscular, atividade neural, temperatura, entre outras. 

A intenção do 8º Passo é apresentar artigos que são referência sobre o assunto, não somente abordando os tipos de monitorização e equipamentos, mas também seus riscos, complicações e alternativas de monitorização básica e avançada no período perioperatório. Iniciamos com a postagem de dois clássicos: Standards for Patient Monitoring during Anesthesia at Harvard Medical School (JAMA, 1986) e Monitoring the monitors - beyond risk management (British Journal of Anaesthesia, 2006).

Se você tiver algum artigo referente ao tema e quiser publicá-lo no blog Anestesia Segura, entre em contato conosco por meio dos comentários abaixo desta postagem. Boa leitura!

Dra. Fabiane Cardia Salman
Comitê de Qualidade e Segurança - SMA

Standards for Patient Monitoring During Anesthesia at Harvard Medical School  
Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG
From the Department of Anaesthesia, Harvard Medical School, Boston.
JAMA. 1986; 256(8):1017-1020. 

As part of a major patient safety/risk management effort, the Department of Anaesthesia of Harvard Medical School, Boston, has devised specific, detailed, mandatory standards for minimal patient monitoring during anesthesia at its nine component teaching hospitals. Such standards have not previously existed, and resistance to the concept was anticipated but not seen. The standards are technically achievable in all settings and affordable in terms of effort and cost. Early detection of untoward trends or events during anesthesia will result in prevention or mitigation of patient injury; this, in turn, may also help counter the explosive increases in anesthesia-related malpractice actions, settlements, judgments, and insurance premiums. The committee process used is applicable to the promulgation of standards of practice for all medical specialties and any organized group of medical practitioners. 

Monitoring the monitors—beyond risk management
J. P. Thompson, R. P. Mahajan
University Department of Cardiovascular Sciences - Division of Anaesthesia Critical Care and Pain Management Leicester Royal Infirmary - Leicester, UK. University Hospitals NHS Trust Queen’s Medical Centre - Nottingham, UK
British Journal of Anaesthesia 97 (1): 1–3 (2006) Editorial

Monitoring, to health care professionals and in particular anaesthetists, usually means the continuous measurement of patient variables over time. However, the word monitor derives from the Latin monere (to warn) and modern English dictionaries include almost a dozen different connotations. These range from an observational warning or recording device (or individual) to audiovisual terminology, a senior school pupil and types of lizard or warship. In a similar way, the term monitor in anaesthesia, critical care, pain management or perioperative medicine actually encompasses a variety of technologies that address diverse but overlapping aspects of anaesthesia and medical care. Over the past two decades, these technologies have advanced greatly and the availability of monitoring devices has multiplied exponentially. This has occurred in conjunction with the developments in electronics, computing, information technology and mobile communications, which has characterized the past 20 yr. This issue of the British Journal of Anaesthesia is based on the symposium held in March 2006 and organized jointly by The Royal College of Anaesthetists and British Journal of Anaesthesia. The articles range from the interaction between humans and machines, new and emerging technologies and their application not only inside and outside the operating room but also at the extremes of environments where medical care may be needed.

23 de fevereiro de 2011

Artigo: Impact of deep hypothermic circulatory arrest on the BIS index

Journal of Clinical Anesthesia (2010) 22, 340–345

Stephan Ziegeler MD (Staff Anesthesiologist)ª, Heiko Buchinger MD (Staff Anesthesiologist)ª, Wolfram Wilhelm MD (Director)b, Reinhard Larsen MD (Director)ª, Sascha Kreuer MD (Staff Anesthesiologist)ª

ªDepartment of Anesthesiology, Intensive Care Medicine and Pain Therapy, University of Saarland, 66421 Homburg/Saar, Germany
bDepartment of Anesthesiology and Intensive Care Medicine, Klinikum Luenen-St.-Marien-Hospital, 44534 Luenen, Germany

Received 7 January 2008; revised 4 September 2009; accepted 26 September 2009

Keywords: Bispectral index; Deep hypothermic circulatory arrest; Extracorporeal circulation; Hypothermia


Abstract
Study Objective: To investigate the influence of duration of deep hypothermic circulatory arrest (DHCA) on recovery of the bispectral index (BIS).
Design: Prospective cohort study.
Setting: Operating room of university teaching hospital.
Patients: 30 adult, ASA physical status III and IV patients scheduled for cardiac surgery with extracorporeal circulation (ECC) and DHCA.
Interventions: There were no study-specific interventions undertaken with the study patients.
Measurements: After induction of anesthesia, propofol and sufentanil were used for maintenance. Duration until BIS values reached indices of 10, 20, and 30 after DHCA was measured. ΔBIS was defined as the difference between BIS before the start of ECC and after DHCA at the same nasopharyngeal body temperature. Data are means ± SD (ranges).
Main Results: Duration of DHCA was 24 ± 15 min (8-71 min). The deepest nasopharyngeal temperature was 20.1 ± 2.7°C at the end of DHCA. BIS reduction was 1.8/°C. At the end of DHCA, BIS was 2 ± 6 and at the end of ECC, BIS was 33 ± 11. Duration until BIS reached a value of 10 (BIS10) was 23 ± 21 min (0-83 min); until BIS reached 20 (BIS20): 36 ± 36 min (0-140 min); and until BIS reached 30 (BIS30): 43 ± 29 min (1-130 min). Regression analysis between duration of DHCA and BIS10 was R = 0.76; BIS20: R = 0.67; and BIS30: R = 0.54.
Conclusion: Deep hypothermia influences BIS linearly. In addition, there appears to be a reasonable correlation between recovery of BIS values and duration of DHCA.

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21 de fevereiro de 2011

Estudo do Johns Hopkins Children's Center sugere que antibióticos podem não ser sempre o melhor tratamento

Careful cleaning of children's skin wounds key to healing, regardless of antibiotic choice

Hopkins Children's study suggests antibiotics may not always be best therapy

When it comes to curing skin infected with the antibiotic-resistant bacterium MRSA (methicillin-resistant Staphylococcus aureus), timely and proper wound cleaning and draining may be more important than the choice of antibiotic, according to a new Johns Hopkins Children's Center study. The work is published in the March issue of Pediatrics.

Researchers originally set out to compare the efficacy of two antibiotics commonly used to treat staph skin infections, randomly giving 191 children either cephalexin, a classic anti-staph antibiotic known to work against the most common strains of the bacterium but not MRSA, or clindamycin, known to work better against the resistant strains. Much to the researchers' surprise, they said, drug choice didn't matter: 95 percent of the children in the study recovered completely within a week, regardless of which antibiotic they got.

The finding led the research team to conclude that proper wound care, not antibiotics, may have been the key to healing. 

"The good news is that no matter which antibiotic we gave, nearly all skin infections cleared up fully within a week," says study lead investigator Aaron Chen, M.D., an emergency physician at Hopkins Children's. "The better news might be that good low-tech wound care, cleaning, draining and keeping the infected area clean, is what truly makes the difference between rapid healing and persistent infection."

Chen says that proper wound care has always been the cornerstone of skin infection treatment but, the researchers say, in recent years more physicians have started prescribing antibiotics preemptively.

Although the Johns Hopkins investigators stop short of advocating against prescribing antibiotics for uncomplicated MRSA skin infections, they call for studies that directly measure the benefit — if any — of drug therapy versus proper wound care. The best study, they say, would compare patients receiving placebo with those on antibiotics, along with proper wound cleaning, draining and dressing.

Antibiotics can have serious side effects, fuel drug resistance and raise the cost of care significantly, the researchers say.

"Many physicians understandably assume that antibiotics are always necessary for bacterial infections, but there is evidence to suggest this may not be the case," says senior investigator George Siberry, M.D., M.P.H., a Hopkins Children's pediatrician and medical officer at the Eunice Kennedy Shriver Institute of Child Health & Human Development. "We need studies that precisely measure the benefit of antibiotics to help us determine which cases warrant them and which ones would fare well without them."

The 191 children in the study, ages 6 months to 18 years, were treated for skin infections at Hopkins Children's from 2006 to 2009. Of these, 133 were infected with community-acquired MRSA, and the remainder had simple staph infections with non-resistant strains of the bacterium. Community-acquired (CA-MRSA) is a virulent subset of the bacterium that's not susceptible to most commonly used antibiotics. Most CA-MRSA causes skin and soft-tissue infections, but in those who are sick or have weakened immune systems, it can lead to invasive, sometimes fatal, infections.

At 48-hour to 72-hour follow-ups, children treated with both antibiotics showed similar rates of improvement — 94 percent in the cephalexin group improved and 97 percent in the clindamycin group improved. By one week, the infections were gone in 97 percent of patients receiving cephalexin and in 94 percent of those on clindamycin. Those younger than 1 year of age and those whose infections were accompanied by fever were more prone to complications and more likely to be hospitalized.

Fonte: EurekAlert!

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