30 de março de 2012

Artigo recomendado: A Series of Anesthesia-related Maternal Deaths in Michigan, 1985–2003

Jill M. Mhyre, M.D.,* Monica N. Riesner, M.D.,* Linda S. Polley, M.D.,† Norah N. Naughton, M.D., M.B.A.‡

Anesthesiology 2007; 106:1096–104

Background: Maternal Mortality Surveillance has been conducted by the State of Michigan since 1950, and anesthesiarelated maternal deaths were most recently reviewed for the years 1972–1984.

Methods: Records for pregnancy-associated deaths between 1985 and 2003 were reviewed to identify 25 cases associated with a perioperative arrest or major anesthetic complication. Four obstetric anesthesiologists independently classified these cases, and disagreements were resolved by discussion. Precise definitions of anesthesia-related and anesthesia-contributing maternal death were constructed. Anesthesia-related deaths were reviewed to identify the chain of medical errors or care management problems that contributed to each patient death.

Results: Of 855 pregnancy-associated deaths, 8 were anesthesia-related and 7 were anesthesia-contributing. There were no deaths during induction of general anesthesia. Five resulted from hypoventilation or airway obstruction during emergence, extubation, or recovery. Lapses in either postoperative monitoring or anesthesiology supervision seemed to contribute to 5 of the 8 anesthesia-related deaths. Other characteristics common to these cases included obesity (n = 6) and African-American race (n = 6).

Conclusions: The 8 anesthesia-related and seven anesthesiacontributing maternal deaths in Michigan between 1985 and 2003 illustrate three key points. First, all anesthesia-related deaths from airway obstruction or hypoventilation took place during emergence and recovery, not during the induction of general anesthesia. Second, system errors played a role in the majority of cases. Of concern, lapses in postoperative monitoring and inadequate supervision by an anesthesiologist seemed to contribute to more than half of the deaths. Finally, this report confirms previous work that obesity and African-American race are important risk factors for anesthesia-related maternal mortality.

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27 de março de 2012

Artigo recomendado: How Much Work is Enough Work? Results of a Survey of US and Australian Anesthesiologists’ Perceptions of Part-Time Practice and Part-TimeTraining

Catherine A. McIntosh, Alex Macario, Keith Streatfeild

Anesthesiology Clin 26 (2008) 693–705

The trend for part-time practice in medicine will likely increase because of the feminization of the medical workforce, the effect of the aging workforce, with practitioners wishing to reduce their hours as they approach retirement,and the intention of recent graduates - male and female - to work fewer hours than their predecessors.Part-time clinical practice also refers to physicians who dedicate a portion of their professional time to research, administration, and teaching.

The demand for part-time or flexible training in anesthesia also may increase and prove an important strategy in recruiting the best and brightest trainees of both genders. Part-time practice impacts important issues, such as how other professionals perceive a practitioner who is part-time (which in turn influences job satisfaction,3) continuing professional development, perceptions of clinical competence, career development opportunities, insurance premiums, practice scheduling, and compensation, including benefits. Better understanding of attitudes toward part-time anesthesia practice in Australia and the United States is necessary to optimally manage the increasing fraction of the anesthesia workforce that works part-time.

The purpose of this study was to administer a written survey to anesthesiologists in Australia and the United States to assess opinions toward part-time clinical practice and training. The effect of part-time clinical practice on competence and skill development in anesthesia is unknown. We were curious to determine anesthesiologists’ opinions about part-time training and work, however, particularly with regard to perceptions of competence. We also expected that the reasons for a practitioner choosing to work or train part-time might be perceived differently in the United States and Australia.

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23 de março de 2012

Artigo recomendado: Iatrogenic tracheal rupture: A case report and indications for conservative management

Miguel S. Guerra, José António Miranda, António Caiado, José Almeida, João Moura e Sá,
Francisco Leal, Luís Vouga

Rev Port Pneumol 2006; XII (1): 71-78


Tracheal rupture after endotracheal intubation requires inmediate intervention. There have been an increasing number of reports that describe nonsurgical manangement of this issue. We report the case of a 47-year-old woman who experienced an iatrogenic tracheal rupture during endotracheal intubation for a surgical procedure with general anaesthesia. She was successfully managed conservatively with a broad-spectrum antibiotic. We managed it non-operatively, because the patient had a small tear, was hemodynamically stable, show no evidence of infection or respiratory failure, and the diagnosis was not immediate.

Broncoscopy was a good diagnostic tool and it was used to make decisions regarding conservative management, and to detect granulation tissue and rule out any tracheal stenosis after treatment. We review available literature on conservative management of tracheal rupture. Immediate recognition and adequate treatment are very important in managing this potentially fatal situation. The final decision should be based on clinical, radiologic and broncoscopic findings.

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20 de março de 2012

Artigo recomendado: Acute lung injury: significance, treatment and outcome

Gilman B. Allen and Polly Parsons

Current Opinion in Anaesthesiology 2005, 18:209–215

Purpose of review
This paper aims to provide a condensed review of the most essential and current research findings in the field of acute lung injury over the past year.

Recent findings
We review the most recent important findings in both laboratory-based and clinical research in the field of acute lung injury. Significant advances have been made in the past year with respect to our understanding of the pathogenesis of acute lung injury, and how key pathological events relateto prognosis, outcomes, and the promise of new potential therapeutic interventions. In particular, significant advances have been made in our understanding of the prognostic roles of neutrophil recruitment and clearance, fibrinogenesis, inflammatory cytokines, alveolar fluid clearance, and endothelial injury and activation. Paramount studies have provided greater skepticism over the efficacy of prone positioning and the currently available surfactant replacement therapies. In addition, new research has fostered an improved appreciation of the long-term sequelae of acute lung injury.

Recent advances in our understanding of the pathogenesis of acute lung injury have provided the promise of exciting potential interventions to modify intravascular and extravascular fibrinogenesis, neutrophil activation and clearance, and alveolar fluid clearance. Our new understanding of prolonged disability and post-traumatic stress in acute lung injury survivors will ultimately change the standard for how these patients are managed in the intensive care unit and followed beyond their hospital stay.

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16 de março 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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13 de março de 2012

Artigo recomendado: Patient Safety in Surgery

Martin A. Makary, MD, MPH,*‡ J. Bryan Sexton, PhD,†‡ Julie A. Freischlag, MD,* E. Anne Millman, MS, David Pryor, MD,§ Christine Holzmueller, BLA,† and Peter J. Pronovost, MD, PhD*†‡

Ann Surg 2006;243: 628–635

Background: Improving patient safety is an increasing priority for surgeons and hospitals since sentinel events can be catastrophic for patients, caregivers, and institutions. Patient safety initiatives aimed at creating a safe operating room (OR) culture are increasingly being adopted, but a reliable means of measuring their impact on front-line providers does not exist.

Methods: We developed a surgery-specific safety questionnaire (SAQ) and administered it to 2769 eligible caregivers at 60 hospitals. Survey questions included the appropriateness of handling medical errors, knowledge of reporting systems, and perceptions of safety in the operating room. MANOVA and ANOVA were performed to compare safety results by hospital and by an individual’s position in the OR using a composite score. Multilevel confirmatory factor analysis was performed to validate the structure of the scale at the operating room level of analysis.

Results: The overall response rate was 77.1% (2135 of 2769), with a range of 57% to 100%. Factor analysis of the survey items demonstrated high face validity and internal consistency (α = 0.76). The safety climate scale was robust and internally consistent overall and across positions. Scores varied widely by hospital [MANOVA omnibus F (59, 1910) = 3.85, P < 0.001], but not position [ANOVA F (4, 1910) = 1.64, P = 0.16], surgeon (mean = 73.91), technician (mean = 70.26), anesthesiologist (mean = 71.57), CRNA (mean = 71.03), and nurse (mean = 70.40). The percent of respondents reporting good safety climate in each hospital ranged from 16.3% to 100%.

Conclusions: Safety climate in surgical departments can be validly measured and varies widely among hospitals, providing the opportunity to benchmark performance. Scores on the SAQ can serve to evaluate interventions to improve patient safety.

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9 de março de 2012

Case Reports: Cardiopulmonary Resuscitation in the Lateral Position: Is It Feasible during Pediatric Intracranial Surgery?

Abraham, Mary M.D., D.N.B.*; Wadhawan, Manju M.D.†; Gupta, Vikas M.S., M.C.H.‡; Singh, Anil K. M.S., M.C.H.§

Anesthesiology 2009; 110:1185–6

INTRAOPERATIVE cardiac arrest during neurosurgical operations can occur after massive blood loss in adults and in children.1,2,3,4 Many of these procedures are performed in positions other than supine, and this could pose a major hurdle in successful resuscitation.3

The practice of turning the patient supine for cardiopulmonary resuscitation (CPR) during neurosurgical operations has recently been questioned.5
Although successful resuscitation has been reported in the prone position, there are no studies available on the feasibility of CPR in the lateral position. This is a case report of cardiac arrest due to massive blood loss in a child undergoing excision of a large brain tumor in the lateral position followed by successful resuscitation in the same position.

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6 de março de 2012

Artigo recomendado: Survey of anesthesia-related mortality in France

Lienhart A, Auroy Y, Péquignot F, Benhamou D, Warszawski J, Bovet M, Jougla E.

Anesthesiology 2006; 105:1087–97

Background: This study describes a nationwide survey that estimates the number and characteristics of anesthesia-related deaths for the year 1999.

Methods: Death certificates from the French national mortality database were selected from the International Classification of Diseases, Ninth Revision codes using a variable sampling fraction. Medical certifiers were sent a questionnaire (response rate, 97%), and the anesthesiologist in charge was offered a peer review (acceptance rate, 97%). Files were reviewed to determine the mechanism of each perioperative death and its relation to anesthesia. Mortality rates were calculated using the number of anesthetic procedures estimated from a national 1996 survey and compared with a previous (1978-1982) nationwide study.

Results: Among the 4,200 certificates analyzed, 256 led to a detailed evaluation. The death rates totally or partially related to anesthesia for 1999 were 0.69 in 100,000 (95% confidence interval, 0.22-1.2 in 100,000) and 4.7 in 100,000 (3.1-6.3 in 100,000), respectively. The death rate increased from 0.4 to 55 in 100,000 for American Society of Anesthesiologists physical status I and IV patients, respectively. Rates increased with increasing age. Although concerns regarding aspiration of gastric contents remain, intraoperative hypotension and anemia associated with postoperative ischemic complications were the associated factors most often encountered. Deviations from standard practice and organizational failure were often found to be associated with death.

Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process.

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2 de março de 2012

Consulta pública da ANVISA: Proposta de INSTRUÇÃO NORMATIVA que dispõe sobre padronização de cores para a gravação nas embalagens primárias das Soluções Parenterais de Pequeno Volume (SPPV)

Consulta pública nº 13, 30 de janeiro de 2012

Proposta de INSTRUÇÃO NORMATIVA que dispõe sobre padronização de cores para a gravação nas embalagens primárias das Soluções Parenterais de Pequeno Volume (SPPV), em Anexo.

Fica aberto, a contar da data de publicação desta Consulta Pública (30 de janeiro de 2012), o prazo de 60 (sessenta) dias para que sejam apresentadas críticas e sugestões relativas à proposta de INSTRUÇÃO NORMATIVA que dispõe sobre padronização de cores para a gravação nas embalagens primárias das Soluções Parenterais de Pequeno Volume (SPPV).

Envie seu comentário no site da ANVISA pelo link.

1 de março de 2012

Artigo recomendado: Main Concerns of Patients Regarding the Most Common Complications in the Post-Anesthetic Care Unit

Eduardo Toshiyuki Moro, TSA, M.D., Renato César Senne Godoy, M.D., Alexandre Palmeira Goulart, M.D., Leopoldo Muniz, M.D., Norma Sueli Pinheiro Modolo, M.D.

Revista Brasileira de Anestesiologia - Vol. 59, No 6, Nov-Dez, 2009

Preoperative anxiety is frequently associated with anticipation of anesthesia- or surgery-related damages. Severe complications that can be attributed to anesthesia such as death are rare. On the other hand, “minor” events such as pain, nausea, or vomiting have assumed a fundamental role in the determination of the quality provided by the Anesthesiology service1.

When postoperative fears are analyzed regarding low morbidity events that should be avoided the most, anesthesiologists have not always been capable to determine the priorities of the patients2Thus, successful treatment of postoperative pain, for example, is not necessarily related with higher satisfaction with anesthesia, since the consequences of pain treatment, such as nausea and vomiting, should be considered.

In a study undertaken in the United States, Macario et al.evaluated the opinion of patients on the subject. Possible undesirable effects in the immediate postoperative period based on data from the literature (MEDLINE between 1986 and 1997) were listed. Since the list generated by this search was extensive, the authors decided to select the nine most frequent events, besides a tenth item described as “normal” (without any undesirable effects) to evaluate the reliability of the answers, since understanding of the questionnaire by the patients interviewed presupposed that the “normal” item would always be classified as “the least undesirable” or the “most desirable” (Chart I).

However, the study population was composed mainly by individuals with high socioeconomical and cultural level, which might not represent the reality of health services in regions where social indicators usually show a higher inequality rate. The objectives of the present study included: 1) to evaluate the main concerns of patients regarding the post-anesthetic period and to compare them with those observed by Macario et  al.3; and 2) to test the hypothesis that the most undesirable effects, according to the opinion of the patients interviewed, could be influenced by demographic characteristics like educational level and family income.

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