25 de abril de 2012

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery


H. G. Wakeling, M. R. McFall, C. S. Jenkins, W. G. A. Woods, W. F. A. Miles, G. R. Barclay and S. C. Fleming

Br J Anaesth 2005; 95: 634–42

Background: Occult hypovolaemia is a key factor in the aetiology of postoperative morbidity and may not be detected by routine heart rate and arterial pressure measurements. Intraoperative gut hypoperfusion during major surgery is associated with increased morbidity and postoperative hospital stay. We assessed whether using intraoperative oesophageal Doppler guided fluid management to minimize hypovolaemia would reduce postoperative hospital stay and the time before return of gut function after colorectal surgery.

Methods: This single centre, blinded, prospective controlled trial randomized 128 consecutive consenting patients undergoing colorectal resection to oesophageal Doppler guided or central venous pressure (CVP)-based (conventional) intraoperative fluid management. The intervention group patients followed a dynamic oesophageal Doppler guided fluid protocol whereas control patients were managed using routine cardiovascular monitoring aiming for a CVP between 12 and 15 mm Hg.

Results: The median postoperative stay in the Doppler guided fluid group was 10 vs 11.5 days in the control group P<0.05. The median time to resuming full diet in the Doppler guided fluid group was 6 vs 7 for controls P<0.001. Doppler patients achieved significantly higher cardiac output, stroke volume, and oxygen delivery. Twenty-nine (45.3%) control patients suffered gastrointestinal morbidity compared with nine (14.1%) in the Doppler guided fluid group P<0.001, overall morbidity was also significantly higher in the control group P=0.05.

Conclusions: Intraoperative oesophageal Doppler guided fluid management was associated with a 1.5-day median reduction in postoperative hospital stay. Patients recovered gut function significantly faster and suffered significantly less gastrointestinal and overall morbidity.

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20 de abril de 2012

Artigo recomendado: Segurança do paciente em cirurgia oncológica: experiência do Instituto do Câncer do Estado de São Paulo

Regiane Cristina Rossi Vendramini, Elaine Aparecida da Silva, Karine Azevedo São Leão Ferreira, João Francisco Possari, Wânia Regina Mollo Baia

Rev Esc Enferm USP 2010; 44(3):827-32

A preocupação com a segurança do paciente em centro cirúrgico (CC) tem sido crescente, devido à elevada frequência de erros e eventos adversos, que muitas vezes poderiam ser prevenidos. A Joint Commission on Accreditation of Healthcare Organizations (JCAHO) propôs o Protocolo Universal (PU) para a prevenção do lado, procedimento e paciente errado.

No Brasil foram poucas as instituições que o implantaram, sendo necessária a divulgação e avaliação da sua efetividade. O objetivo foi relatar a experiência do Instituto do Câncer do Estado de São Paulo (ICESP) na implantação do PU-JCAHO. O protocolo inclui três etapas: verificação préoperatória, marcação do sitio cirúrgico (lateralidade) e TIME OUT. O CC do ICESP está em funcionamento desde novembro de 2008. O PU-JCAHO é aplicado integralmente a todas as cirurgias. Até junho de 2009 foram realizadas 1019 cirurgias, sem registro de erro ou evento adverso. A implantação do PU-JCAHO é simples, sendo ferramenta útil para prevenir erros e eventos adversos em CC.

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17 de abril 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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13 de abril de 2012

Artigo recomendado: Categorizing Errors and Adverse Events for Learning: A Provider Perspective


Liane R. Ginsburg, You-Ta Chuang, Julia Richardson, Peter G. Norton, Whitney Berta, Deborah Tregunno and Peegy Ng

Healthcare Quarterly Vol. 12 Special Issue 2009


Abstract
There is little agreement in the literature as to what types of patient safety events (PSEs) should be the focus for learning, change and improvement, and we lack clear and universally accepted definitions of error. In particular, the way front-line providers or managers understand and categorize different types of errors, adverse events and near misses and the kinds of events this audience believes to be valuable for learning are not well understood.

Focus group of front-line providers, managers and patient safety officers were used to explore how people in healthcare organizations understand and categorize different types of PSEs in the context of bringing about learning from such events. A typology of PSEs was developed from the focus group data and then mailed, along with a short questionnaire, to focus group participants for member checking and validation.

Four themes emerged from our data: (1) incidence study categories are problematic for those working in organizations; (2) preventable events should be the focus for learning; (3) near misses are an important but complex category, differentiated based on harm potential and proximity to patients; (4) staff disagree on whether events causing severe harm or events with harm potential are most valuable for learning. A typology of PSEs based pon these themes and checked by focus group participants indicates that staff and their managers divide events into simple categories of minor and major events, which are differentiated based on harm or harm potential.

Confusion surrounding patient safety terminology detracts from the abilities of providers to talk about and reflect on a range of PSEs, and from opportunities to enhance learning, reduce event reoccurrence and improve patient safety at the point of care.

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10 de abril de 2012

Artigo recomendado: What next targets for anaesthesia safety?


François Clergue

Current Opinion in Anaesthesiology 2008, 21:360–362

Among the different medical specialties, anaesthesia is frequently identified as an example for its achievements in the field of safety: its efforts have permitted decreasing anaesthesia mortality by tenfold within the last decades, and stabilizing, or even decreasing, insurance premiums in most European or North American countries [1]. Our discipline can be proud of this achievement. Before setting new goals for anaesthesia safety, however, some important questions should be raised. What are the causes of the remaining deaths that can be identified in the last surveys?

Has the rate of anaesthesia-related nonlethal complications been decreased to levels as low as those obtained for anaesthesia mortality? Is it meaningful to pursue our progress in anaesthesia safety if similar advances are not obtained for the safety of surgery?

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5 de abril de 2012

Artigo recomendado: Efficacy and safety of activated recombinant factor VII in cardiac surgical patients

Jean-François Hardy, Sylvain Bélisle and Philippe Van der Linden

Current Opinion in Anaesthesiology 2009,22:95–99

Purpose of review
Excessive bleeding is a common and morbid problem after cardiac surgery. There is no doubt a need for an effective and safe hemostatic agent in order to minimize transfusions and avoid surgical reintervention for hemostasis. Recombinant activated factor VII (rFVIIa) is being used (off-label) increasingly after cardiac surgery to prevent or to control hemorrhage, but its efficacy and safety remain unclear.

Recent findings
Several case reports, case series and registries would tend to support the use of activated recombinant factor VII to control excessive bleeding after cardiac operations. On the contrary, two randomized controlled trials have produced negative results whereas a third has not been published yet. Adverse thrombotic events are reported with increasing frequency.

Summary
At present, the generalized use of rFVIIa to prevent or to control excessive bleeding after cardiac surgery cannot be recommended. The decision to administer a potent hemostatic such as rFVIIa outside its recognized prescribing indications should be made with caution by well informed physicians and discussed with the patient. Patients should be informed about knowledge gaps and pertinent risks, which are both important in the case of rFVIIa.

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3 de abril de 2012

Artigo recomendado: Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts



Thomas C. Mort, MD

Anesth Analg 2004;99:607–13


Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room.

There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (≤ 2 versus > 2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events.

These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.

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16 a 18 de Agosto de 2012: 18º Congresso de Anestesia Regional e Controle da Dor - LASRA

Centro de Eventos do Hospital Sírio-Libanês

IEP - Instituto de Ensino e Pesquisa
Rua Cel. Nicolau dos Santos, 69 - Bela Vista - São Paulo - SP

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