30 de maio de 2011

Artigo: Minimum Standards for Intrahospital Transport of Critically Ill Patients


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INTRODUCTION

Critically ill patients may have absent or small physiological reserves. Adverse physiological changes in these patients during intrahospital transport are common and can be life-threatening. Ventilator-dependent and haemodynamically unstable patients are at particular risk. Careful planning is required to move these patients between hospital facilities such as operating theatres, ICU, Emergency Department, imaging rooms, and wards. Such intrahospital transport is usually elective, but a need for urgency must also be anticipated (such as moving the patient to the operating theatres after a diagnostic procedure).

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25 de maio de 2011

Minimum standards for transport of critically ill patients

Promulgated as FICANZCA: 1992
Reviewed: 1996, 2003 (JFICM)
Republished by CICM: 2010

Introduction

Safe transport of the critically ill patient requires accurate assessment and stabilisation of the patient before transport. There should be appropriate planning of transport and optimum utilisation of communications. Safe transport requires the deployment of appropriately trained staff with essential equipment, and effective liaison between referring, transporting and receiving staff at a senior level.

Clinical management during transport must aim to at least equal management at the point of referral and must prepare the patient for admission to the receiving service.

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23 de maio de 2011

Artigo: Transporte intra-hospitalar do paciente crítico

Medicina (Ribeirão Preto) 2007; 40 (4): 500-8, out./dez. http://www.fmrp.usp.br/revista
Pereira Júnior GA, Carvalho JB,  Ponte Filho AD, Malzone DA,  Pedersoli CE

RESUMO: O avanço do conhecimento médico e o desenvolvimento da tecnologia para diagnóstico e tratamento das doenças que afligem os seres humanos têm permitido um aumento da longevidade das pessoas hígidas e daquelas que possuem agravos agudos ou crônicos. Embora estes avanços estejam heterogeneamente distribuídos, há uma nítida melhora das condições de atendimento médico em nosso meio e isto tem feito com que pacientes que anteriormente evoluíssem para o óbito, tenham condições de se manterem vivos em diferentes condições de qualidade de vida. Isto tem feito com que os hospitais tenham que aumentar as áreas de atendimento e cuidados de pacientes críticos. Estes pacientes têm sido beneficiados pela tecnologia de diagnóstico, principalmente, de imagem existente e, quase sempre, para ter acesso a estes benefícios, estes pacientes precisam ser transportados para fora da área de cuidados intensivos e manter o mesmo nível de monitorização para que não haja problemas. É aí que está a grande importância do transporte do paciente crítico que, no geral, vem sendo muito negligenciada pelos profissionais de saúde. O objetivo deste artigo é fazer uma reflexão dos vários momentos, fases e cuidados envolvidos no transporte intra-hospitalar, discutindo as suas diversas modalidades.

Descritores: Transporte de Pacientes. Cuidados Intensivos. Monitoramento. Transferência de Pacientes.

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18 de maio de 2011

Leitura recomendada: Guidelines for the transport of the critically ill adult


INTRODUCTION

1.1 The Intensive Care Society first published guidelines on the transport of the critically ill adult in 1997. These attempted to rationalise advice from a number of sources and encourage an improvement in standards of care during patient transport in the UK. The Department of Health’s publication ‘Comprehensive Critical Care’ lists a number of recommendations regarding the transfer of critically ill patients and makes the development of transport protocols a priority. The Intensive Care Society has therefore reviewed its guidelines on transport in order to provide its members with up to date advice.

1.2 Guidelines have previously been published by a number of organisations including the American College of Critical Care Medicine, the Australian and New Zealand College of Anaesthetists, and the Neuroanaesthesia Society of Great Britain and Ireland. These revised Intensive Care Society guidelines draw on these and other published works. 

1.3 These guidelines apply to the transport of critically ill adult patients in the UK outside of the normal critical care environment. They apply both to patients transferred between hospitals, and to patients moved between departments within a hospital (e.g. from the intensive care unit to magnetic resonance or computed tomography scanner) since the same level of preparation, supervision and care is required for each. They are not intended however to apply to truly mobile intensive care units, as for example, operated by the military services. 

1.4 Standards of practice for the transport of the critically ill child have been published by the Paediatric Intensive Care Society. 

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16 de maio de 2011

10º Passo para a Anestesia Segura: Transporte Seguro


No início desta segunda quinzena de maio, finalmente chegamos ao 10º Passo do programa Segurança no Período Perioperatório: 10 passos para a Anestesia Segura. A partir de hoje, os posts trarão indicações de textos e artigos relacionados ao tema e se você também quiser sugerir algum material interessante ou enviar um texto de sua autoria sobre o assunto, mande um e-mail para anestesiasegura@sma.com.br. Ficaremos contentes com sua participação!

O artigo que indicamos hoje é:

Fanara et al. Critical Care 2010, 14:R87
Recomendations for the intra-hospital transport of critically ill patients
Benoît Fanara, Cyril Manzon, Olivier Barbot, Thibaut Desmettre and Gilles Capellier

Abstract

Introduction: This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intrahospital transport (IHT).

Methods: Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied.

Results: This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified.

Conclusions: Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of  such preventive measures.

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13 de maio de 2011

Planejando a Reposição Volêmica: highlights


Para encerrar os posts referentes ao tema Reposição Volêmica, hoje publicamos os highlights do 9º Passo da Anestesia Segura, escritos pelo Dr. Arthur Vitor Rosenti Segurado, anestesiologista do SMA. Os highlights funcionam como um checklist e norteiam a verificação de itens essenciais para a segurança do paciente, devendo serem adotados na prática diária da assistência anestésico-cirúrgica.

O planejamento da reposição volêmica deve ser feito sempre antes do início do procedimento cirúrgico. As dúvidas em relação ao plano cirúrgico devem ser adequadamente discutidas com a equipe cirúrgica e as condições clínicas do paciente devem ser verificadas na visita pré-anestésica. Com essas informações, podemos dar início ao planejamento da reposição volêmica.

- Checar reserva de CH se necessário.

- Planejar reposição volêmica:
  • Considerar solicitar embalagem térmica com cristalóides previamente aquecidos;
  • Considerar o uso de colóides;
  • Considerar o uso de hemoderivados;
  • Considerar o uso de dispositivos de aquecimento, como o Hotline, caso planeje administração significativa de colóides/hemoderivados ou caso a superfície coberta pela manta térmica seja insuficiente;
  • Considerar acessos calibrosos (jelcos > 16, duplo lúmen 8F, RIC) em caso de necessidade de grande reposição volêmica;
  • Considerar o uso de infusores de volume sob pressão (Level 1) em caso de possível perda sanguínea abrupta ou cirurgias arteriais de grande porte.

- Planejar administração de drogas vasoativas:
  • Disponibilizar antecipadamente inotrópicos, vasopressores e vasodilatadores, conforme possível necessidade;
  • Checar número de bombas de infusão necessárias, baterias, cabos de energia e extensões necessárias.

- Voltar ao 8º Passo e reconsiderar monitorização frente ao planejado para reposição volêmica.

Esses foram os highlights desenvolvidos pelo Dr. Arthur Segurado para o planejamento da reposição volêmica. Agradecemos mais uma vez sua colaboração e convidamos todos os leitores a participarem também. Na próxima semana iniciaremos as publicações do 10º Passo da Anestesia Segura: Transporte Seguro. Acompanhem!

12 de maio de 2011

Artigo: Contrasting Effects of Colloid and Crystalloid Resuscitation Fluids on Cardiac Vascular Permeability

Matthias Jacob, M.D., Dirk Bruegger, M.D., Markus Rehm, M.D., Ulrich Welsch, M.D., Ph.D., Peter Conzen, M.D., Bernhard F. Becker, M.D., Ph.D.
Anesthesiology 2006; 104:1223–31

Background: Fluid extravasation may lead to myocardial edema and consequent reduction in ventricular function. Albumin is presumed to interact with the endothelial glycocalyx. The authors’ objective was to compare the impact of different resuscitation fluids (human albumin, hydroxyethyl starch, saline) on vascular integrity. 

Methods: In an isolated perfused heart model (guinea pig), Krebs-Henseleit buffer was augmented with colloids (one third volume 5% albumin or 6% hydroxyethyl starch 130/0.4) or crystalloid (0.9% saline). Perfusion pressure and vascular fluid filtration (epicardial transudate formation) were assessed at different flow rates. After global, stopped-flow ischemia (37°C, 20 min), hearts were reperfused with the same resuscitation fluid additives. In a second series, the authors applied the respective perfusates after enzymatic digestion of the endothelial glycocalyx (heparinase, 10 U over 15 min).

Results: Both 5% albumin and 6% hydroxyethyl starch decreased fluid extravasation versus saline (68.4 +- 5.9, 134.8 +- 20.5, and 436.8 +- 14.7 l/min, respectively, at 60 cm H2O perfusion pressure; P < 0.05), the corresponding colloid osmotic pressures being 2.95, 5.45, and 0.00 mmHg. Digestion of the endothelial glycocalyx decreased coronary integrity in both colloid groups. After ischemia, a transient increase in vascular leak occurred with Krebs-Henseleit buffer containing hydroxyethyl starch and saline, but not with albumin. The authors observed no difference between intravascular and bulk interstitial colloid concentration in the steady state. Notwithstanding, electron microscopy revealed an intact endothelial glycocalyx and no interstitial edema in the albumin group. 

Conclusion: Ex vivo, albumin more effectively prevented fluid extravasation in the heart than crystalloid or artificial colloid. This effect was partly independent of colloid osmotic pressure and may be attributable to an interaction of albumin with the endothelial glycocalyx.

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2 de maio de 2011

Should we really be more ‘balanced’ in our fluid prescribing?

Anaesthesia, 2009, 64, pages 703–705

Editorial

The use of intravenous fluid to maintain the extracellular fluid compartment composition and circulating volume is a fundamental component of modern medicine either as synthetic fluids containing either a dissolved solute osmotic load (crystalloid) or suspensions of largely insoluble macromolecules (colloids). It is also big business with intravenous fluid use worldwide running into hundreds of millions of pounds. The composition of intravenous fluids is quite rightly coming under intense scrutiny as concerns regarding efficacy and perhaps safety surface. While it is beyond the scope of this editorial to consider the ‘crystalloid vs colloid’ debate further, it is of note that many fundamental ‘truths’ regarding intravenous fluid therapy have not been validated by research [1] and it is in this environment of physiological dogma and research drought that clinicians find themselves evaluating intravenous fluids.

The anion composition of crystalloid (or base solution in the case of colloid suspensions) is increasingly being considered. While close to plasma, ‘normal’ (0.9%) saline is relatively hyperchloraemic 154mEq.l)1 (plasma 95–105mEq.l)1), hypertonic and acidic in plasma. The replacement of chloride with alternative anions is not new and Ringer’s lactate solution attempted to recreate physiological conditions by substituting excess chloride with another anion (racemic lactate), arguably the first ‘balanced’ solution. Increasingly other anions beside lactate are used and some commercial examples are in Table 1. The current generation of ‘balanced’ intravenous fluids share this reduction in chloride as their principal aim but they carry many other implications. While ‘balanced’ may be an appealing term it is also potentially misleading; that they are close to plasma in terms of pH, (effective) osmolality, or chloride concentration can be challenged. ‘Balanced’ intravenous solutions are receiving a lot of clinician attention and the manufacturers are marketing these agents hard. It is also likely that more balanced solutions will become available with time. While increasingly promoted as ‘state of the art’, we would argue that such claims are premature and furthermore, while the superiority of these new agents is largely unproven, so is their safety.

[Continua...]

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