22 de dezembro de 2011

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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. 

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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.

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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.

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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.

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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.

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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.

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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.

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