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.

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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.

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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.

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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.

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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.

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