27 de fevereiro de 2012

Artigo recomendado: Patterns of Communication during the Preanesthesia Visit

Raymond A. Zollo, M.D., Stephen J. Lurie, M.D., Ph.D.,† Ronald Epstein, M.D.,‡ Denham S. Ward, M.D., Ph.D.§

Anesthesiology 2009; 111:971–8

Background: Effective communication in the preanesthesia clinic is important in patient-centered care. Although patientphysician communication has been studied by recordings in other contexts, there have been no observational studies of the communication patterns of anesthesiologists and patients during the preanesthesia interview.

Methods: Two experienced standardized patients were trained to portray the same clinical situation by using different coping styles (maximizing information or “monitoring” vs. minimizing information or “blunting”). Interviews of standardized patients by anesthesiologists took place in the preanesthesia clinic and recorded with the knowledge of the subjects. Audio recordings were analyzed, and the visit was separated into nine components. Discussion of the risks/informed consent process was examined, looking for discussion of common morbidities. The standardized patients completed a survey on the patient-centeredness of the interview.

Results: Twenty-seven subjects participated in this study. Interviews with the monitor required more time: 17.4 min (confidence interval [CI] 15.2–19.6, n= 24) versus 14.5 min (CI 13.1–16.0, n= 25), P < 0.05. Most interview time was spent in obtaining the history; 2.4 min (CI 1.8 –3.1) was spent discussing risks with the monitor, and only 1.6 min (CI 1.2–2.0) was spent with the blunter (P < 0.05). Neither the monitor nor the blunter scored the interview highly for involving the patient in determining the goals of the anesthetic and recovery.

Conclusions: Direct recording of interactions with standardized patients is a feasible method of studying the communication skills of anesthesiologists. For this study, the anesthesia providers were able to modify their approach depending on patient type, but the monitor received more information.

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22 de fevereiro de 2012

Artigo recomendado: Epidemiology of Anesthesia-related Mortality in the United States, 1999–2005

Guohua Li, M.D., Dr.P.H., Margaret Warner, Ph.D.,† Barbara H. Lang, B.S.,‡ Lin Huang, M.S.,§ Lena S. Sun, M.D.

Anesthesiology 2009; 110:759–65

Background: Previous research on anesthesia-related mortality in the United States was limited to data from individual hospitals. The purpose of this study was to examine the epidemiologic patterns of anesthesia-related deaths at the national level.

Methods: The authors searched the International Classification of Diseases, 10th Revision manuals for codes specifically related to anesthesia/anesthetics. These codes were used to identify anesthesia-related deaths from the US multiple-causeof-death data files for the years 1999–2005. Rates from anesthesia-related deaths were calculated based on population and hospital surgical discharge data.

Results: The authors identified 46 anesthesia/anesthetic codes, including complications of anesthesia during pregnancy, labor, and puerperium (O29.0–O29.9, O74.0–74.9, O89.0–O89.9), overdose of anesthetics (T41.0–T41.4), adverse effects of anesthetics in therapeutic use (Y45.0, Y47.1, Y48.0 – Y48.4, Y55.1), and other complications of anesthesia (T88.2–T88.5, Y65.3). Of the 2,211 recorded anesthesia-related deaths in the United States during 1999–2005, 46.6% were attributable to overdose of anesthetics; 42.5% were attributable to adverse effects of anesthetics in therapeutic use; 3.6% were attributable to complications of anesthesia during pregnancy, labor, and puerperium; and 7.3% were attributable to other complications of anesthesia. Anesthesia complications were the underlying cause in 241 (10.9%) of the 2,211 deaths. The estimated rates from anesthesia-related deaths were 1.1 per million population per year (1.45 for males and 0.77 for females) and 8.2 per million hospital surgical discharges (11.7 for men and 6.5 for women). The highest death rates were found in persons aged 85 yr and older.

Conclusion: Each year in the United States, anesthesia/anesthetics are reported as the underlying cause in approximately 34 deaths and contributing factors in another 281 deaths, with excess mortality risk in the elderly and men.

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17 de fevereiro de 2012

The Effect of Detailed, Video-Assisted Anesthesia Risk Education on Patient Anxiety and the Duration of the Preanesthetic Interview: A Randomized Controlled Trial

Cornelie Salzwedel, Cand. Med., Corinna Petersen, Irmgard Blanc, Uwe Koch, 
Alwin E. Goetz, Martin Schuster

Anesth Analg 2008;106:202–9

BACKGROUND: Video-assisted patient education during the preanesthetic clinic visit is a new intervention to increase knowledge transfer to the patient regarding anesthesia procedure and risks. However, little is known about whether videobased patient education influences patient anxiety and the duration of the preanesthetic visit.

METHODS: Two hundred nine consecutive patients, who visited the anesthesia clinic before major operations, were randomly assigned to one of three groups: no-video (Group 1), video-before-interview (Group 2), and video-after-interview (Group 3). Anxiety levels were measured before and after the interview using the state trait anxiety inventory and a visual analog scale (anxiety). Patient knowledge regarding anesthesia technique, anesthesia-related risks, and patient satisfaction were assessed after the interview using standardized questionnaires.

RESULTS: There were no significant differences in anxiety levels and patient satisfaction among the three groups. Patient knowledge was significantly higher in the video groups compared with the no-video group. The duration of the preanesthetic interview was significantly extended in Group 2 (video-before) (23.1 ± 14.0 min), compared with Group 1 (no-video) (17.6 ± 7.2 min), and Group 3 (video-after) (18.3 ± 9.6 min). This difference was even more profound in subgroups of patients scheduled for anesthesia techniques with invasive monitoring.

CONCLUSION: Our study suggests that the use of a video for detailed anesthesia risk education does not change patient anxiety, but leads to a better understanding of the procedure and risks of anesthesia. When the video is shown before the preanesthetic interview, the interview is longer.

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14 de fevereiro de 2012

Artigo recomendado: Ultrasound-Guided Regional Anesthesia and Analgesia - A Qualitative Systematic Review

Spencer S. Liu, MD, Justin E. Ngeow, BA, and Jacques T. YaDeau, MD, PhD

Reg Anesth Pain Med 2009;34: 47-59


Ultrasound guidance has become popular for performance of regional anesthesia and analgesia. This systematic review summarizes existing evidence for superior risk to benefit profiles for ultrasound versus other techniques. Medline was systematically searched for randomized controlled trials (RCTs) comparing ultrasound to another technique, and for large (n 9 100) prospective case series describing experience with ultrasound-guided blocks. Fourteen RCTs and 2 case series were identified for peripheral nerve blocks. No RCTs or case series were identified for perineural catheters. Six RCTs and 1 case series were identified for epidural anesthesia. 
Overall, the RCTs and case series reported that use of ultrasound significantly reduced time or number of attempts to perform blocks and in some cases significantly improved the quality of sensory block. The included studies reported high incidence of efficacy of blocks with ultrasound (95%Y100%) that was not significantly different than most other techniques. No serious complications were reported in included studies. Current evidence does not suggest that use of ultrasound improves success of regional anesthesia versus most other techniques. However, ultrasound was not inferior for efficacy, did not increase risk, and offers other potential patient-oriented benefits. All RCTs are rather small, thus completion of large RCTs and case series are encouraged to confirm findings.

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10 de fevereiro de 2012

Artigo recomendado: Influence of Respiratory Rate on Stroke Volume Variation in Mechanically Ventilated Patients

De Backer, Daniel M.D., Ph.D.; Taccone, Fabio Silvio M.D.; Holsten, Roland M.D.; Ibrahimi, Fayssal M.D.; Vincent, Jean-Louis M.D., Ph.D.

Anesthesiology 2009; 110:1092–7


Background: Heart-lung interactions are used to evaluate fluid responsiveness in mechanically ventilated patients, but these indices may be influenced by ventilatory conditions. The authors evaluated the impact of respiratory rate (RR) on indices of fluid responsiveness in mechanically ventilated patients, hypothesizing that pulse pressure variation and respiratory variation in aortic flow would decrease at high RRs.

Methods: In 17 hypovolemic patients, thermodilution cardiac output and indices of fluid responsiveness were measured at a low RR (14-16 breaths/min) and at the highest RR (30 or 40 breaths/min) achievable without altering tidal volume or inspiratory/expiratory ratio.

Results: An increase in RR was accompanied by a decrease in pulse pressure variation from 21% (18-31%) to 4% (0-6%) (P < 0.01) and in respiratory variation in aortic flow from 23% (18-28%) to 6% (5-8%) (P < 0.01), whereas respiratory variations in superior vena cava diameter (caval index) were unaltered, i.e., from 38% (27-43%) to 32% (22-39%), P = not significant. Cardiac index was not affected by the changes in RR but did increase after fluids. Pulse pressure variation became negligible when the ratio between heart rate and RR decreased below 3.6.

Conclusions: Respiratory variations in stroke volume and its derivates are affected by RR, but caval index was unaffected. This suggests that right and left indices of ventricular preload variation are dissociated. At high RRs, the ability to predict the response to fluids of stroke volume variations and its derivate may be limited, whereas caval index can still be used.

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6 de fevereiro de 2012

Controle da Hiperglicemia intra-hospitalar em pacientes críticos e não críticos

Posicionamento Oficial SBD nº 02/2011 - Maio de 2011

A Sociedade Brasileira de Diabetes vem sendo solicitada por instituições públicas e privadas para se posicionar oficialmente quanto a vários conceitos e recomendações relativos a importantes aspectos da assistência à pessoa com diabetes na prática clínica diária.

Além disso, médicos especialistas e clínicos não especialistas têm uma urgente necessidade de atualizar seus conhecimentos e suas condutas clínicas, recorrendo a orientações da SBD sob a forma de atividades presenciais de atualização, consensos e, mais recentemente, através de Posicionamentos Oficiais sobre os aspectos mais importantes relacionados à boa prática clínica na assistência ao portador de diabetes.

Os Posicionamentos Oficiais SBD-2011 terão por objetivo divulgar os pareceres oficiais da SBD em relação a aspectos preventivos, diagnósticos e terapêuticos do diabetes e das doenças comumente associadas.

Outro objetivo igualmente importante é o de propiciar aos associados o recebimento, via correio, dos Posicionamentos Oficiais da SBD, como mais uma prestação de serviços que visa atualizar continuamente os médicos e os gestores de serviços de atenção ao portador de diabetes.

Presidente da Sociedade Brasileira de Diabetes

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2 de fevereiro de 2012

Guidelines - Management of adults with diabetes undergoing surgery and elective procedures: improving standards

Ketan Dhatariya, Daniel Flanagan, Louise Hilton, Anne Kilvert, Nicholas Levy, Gerry Rayman and Bev Watson

NHS Diabetes, April 2011

These guidelines have been commissioned by NHS Diabetes and written by the Joint British Diabetes Societies Inpatient Care Group and representatives from the specialist societies surgeons and anaesthetists. The document has also been informed by focus groups from Diabetes UK. The aim of the guidelines is to improve standards of care for people with diabetes undergoing operative or investigative procedures requiring a period of starvation.

Target audience
The guidelines emphasise the need for patient centred care at every stage and we hope that they will be of use to all healthcare professionals whose work brings them into contact with this vulnerable group of patients.
The target audience specifically includes:
• General practitioners, practice nurses and district nurses
• Pre-operative assessment nurses
• Anaesthetists
• Surgeons
• Trainee medical staff
• Post-operative recovery and surgical ward nurses
• Diabetologists
• Diabetes inpatient specialist nurses, diabetes specialist nurses and educators
• Hospital pharmacists
• Hospital managers
• Commissioners
• Patients.

Most importantly, this document is addressed to those writing and implementing local perioperative care policies and to medical and nursing educators. Managers have a responsibility to ensure that guidelines based on these recommendations are put in place. The guidelines aim to cover all stages of the patient pathway but are not designed to be read from cover to cover. Recommendations for each stage are intended to stand alone so that individual health care professionals can identify their role in the process.

These are the first UK national guidelines in this area of diabetes care and the first to address the whole pathway from referral to discharge. They will be a resource for those responsible at every stage of the pathway for the care of the surgical patient with diabetes.

We wish to congratulate the authors on producing clearly written, comprehensive, practical and easy to follow documents in a complex area of diabetes care. We thoroughly recommend the guidelines to diabetes, surgical, anaesthetic and primary care colleagues.

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