26 de setembro de 2012

Artigo recomendado: Postoperative Urinary Retention

Anesthetic and Perioperative Considerations

Gabriele Baldini, Hema Bagry, Armen Aprikian, Franco Carli

Anesthesiology, V 110, No 5, May 2009

Urinary retention is common after anesthesia and surgery, reported incidence of between 5% and 70%. Comorbidities, type of surgery, and type of anesthesia influence the development of postoperative urinary retention (POUR). The authors review the overall incidence and mechanisms of POUR associated with surgery, anesthesia and analgesia. Ultrasound has been shown to provide an accurate assessment of urinary bladder volume and a guide to the management of POUR. Recommendations for urinary catheterization in the perioperative setting vary widely, influenced by many factors, including surgical factors, type of anesthesia, comorbidities, local policies, and personal preferences. Inappropriate management of POUR may be responsible for bladder overdistension, urinary tract infection, and catheter-related complications. An evidence-based approach to prevention and management of POUR during the perioperative period is proposed.

BLADDER catheterization is a common procedure during inpatient major surgery that allows monitoring of urine output, guides volume resuscitation, and serves as a surrogate marker of hemodynamic stability. With an increase in outpatient and fast-track surgical procedures, perurethral catheterization is restricted to fewer procedures and for a limited time. Awareness and identification of patients at risk of developing postoperative urinary retention (POUR) thus assumes greater significance. POUR has been defined as the inability to void in the presence of a full bladder. The widely varying reported incidence of POUR reflects its multifactorial etiology and the lack of uniform defining criteria. This paper reviews the physiology of micturition and analyzes the perioperative factors that contribute to POUR. Evidence-based guidelines for the management of POUR are also provided.

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21 de setembro de 2012

Artigo recomendado: Prevention of Intraoperative Awareness with Explicit Recall in an Unselected Surgical Population

A Randomized Comparative Effectiveness Trial

George A. Mashour, Amy Shanks, Kevin K. Tremper, Sachin Kheterpal, Christopher R. Turner, Satya Krishna Ramachandran, Paul Picton, Christa Schueller, Michelle Morris, John C. Vandervest, Nan Lin, Michael S. Avidan

Anesthesiology, V 117 • No 4 717 October 2012

Background: Intraoperative awareness with explicit recall occurs in approximately 0.15% of all surgical cases. Efficacy trials based on the Bispectral Index® (BIS) monitor (Covidien, Boulder, CO) and anesthetic concentrations have focused on high-risk patients, but there are no effectiveness data applicable to an unselected surgical population.

Methods: We conducted a randomized controlled trial of unselected surgical patients at three hospitals of a tertiary academic medical center. Surgical cases were randomized to alerting algorithms based on either BIS values or anesthetic concentrations. The primary outcome was the incidence of definite intraoperative awareness; prespecified secondary outcomes included postanesthetic recovery variables.

Results: The study was terminated because of futility. At interim analysis the incidence of definite awareness was 0.12% (11/9,376) (95% CI: 0.07–0.21%) in the anesthetic concentration group and 0.08% (8/9,460) (95% CI: 0.04–0.16%) in the BIS group (P=0.48). There was no significant difference between the two groups in terms of meeting criteria for recovery room discharge or incidence of nausea and vomiting. By post hoc secondary analysis, the BIS protocol was associated with a 4.7-fold reduction in definite or possible awareness events compared with a cohort receiving no intervention (P=0.001; 95% CI: 1.7–13.1).

Conclusion: This negative trial could not detect a difference in the incidence of definite awareness or recovery variables between monitoring protocols based on either BIS values or anesthetic concentration. By post hoc analysis, a protocol based on BIS monitoring reduced the incidence of definite or possible intraoperative awareness compared with routine care.

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18 de setembro de 2012

Artigo recomendado: Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia

Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L, Kurz A, Greenwald S.

Anesthesiology, V 116 • No 6 1195 June 2012

Background: Low mean arterial pressure (MAP) and deep hypnosis have been associated with complications and mortality. The normal response to high minimum alveolar concentration (MAC) fraction of anesthetics is hypotension and low Bispectral Index (BIS) scores. Low MAP and/or BIS at lower MAC fractions may represent anesthetic sensitivity. The authors sought to characterize the effect of the triple low state (low MAP and low BIS during a low MAC fraction) on duration of hospitalization and 30-day all-cause mortality.

Methods: Mean intraoperative MAP, BIS, and MAC were determined for 24,120 noncardiac surgery patients at the Cleveland Clinic, Cleveland, Ohio. The hazard ratios associated with combinations of MAP, BIS, and MAC values greater or less than a reference value were determined. The authors also evaluated the association between cumulative triple low minutes, and excess length-of-stay and 30-day mortality.

Results: Means (±SD) defining the reference, low, and high states were 87 ± 5 mmHg (MAP), 46 ± 4 (BIS), and 0.56 ± 0.11 (MAC). Triple lows were associated with prolonged length of stay (hazard ratio 1.5, 95% CI 1.3-1.7). Thirty-day mortality was doubled in double low combinations and quadrupled in the triple low group. Triple low duration ≥60 min quadrupled 30-day mortality compared with ≤15 min. Excess length of stay increased progressively from ≤15 min to ≥60 min of triple low.

Conclusions: The occurrence of low MAP during low MAC fraction was a strong and highly significant predictor for mortality. When these occurrences were combined with low BIS, mortality risk was even greater. The values defining the triple low state were well within the range that many anesthesiologists tolerate routinely.

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14 de setembro de 2012

Artigo recomendado: Home Noninvasive Ventilation: What Does the Anesthesiologist Need to Know?

Karen A. Brown, Gianluca Bertolizio, Marisa Leone, Steven L. Dain

Anesthesiology, V 117 • No 3 657 September 2012


Treatment of chronic respiratory failure with noninvasive ventilation (NIV) is standard pediatric practice, and NIV systems are commonly used in the home setting. Although practice guidelines on the perioperative management of children supported with home NIV systems have yet to be published, increasingly these patients are referred for consultation regarding perioperative management. Just as knowledge of pharmacology underlies the safe prescription of medication, so too knowledge of biomedical design is necessary for the safe prescription of NIV therapy. The medical device design requirements developed by the Organization for International Standardization provide a framework to rationalize the safe prescription of NIV for hospitalized patients supported at home with NIV systems. This review article provides an overview of the indications for home NIV therapy, an overview of the medical devices currently available to deliver it, and a specific discussion of the management conundrums confronting anesthesiologists.

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5 de setembro de 2012

Artigo recomendado: Developing Leaders in Anesthesiology - A Practical Framework

Pascal H. Scemama, Jeffrey W. Hull

Anesthesiology, V 117 • No 3 651 September 2012

The call for more effective leadership in medicine, and specifically in anesthesiology, is not new. In 1999, Dr. Francis M. James III, in his Rovenstine lecture, outlined both the importance of leadership in medicine as well as the breadth of leadership opportunities available both inside and outside anesthesiology. Eleven years later, Dr. Peter J. Pronovost, also in his Rovenstine lecture, turned up the volume by setting out an agenda focused on accountability, performance measurement, teamwork, peer-to-peer reviews, and the need for participation from anesthesiologist-leaders in change initiatives within and outside the specialty.

Driven by a heightened focus on cost reduction, quality improvement, patient safety, performance measurement, and technological innovation, anesthesiology is going through a period of upheaval. Effective leadership is essential to the success of this transformation, because leadership is all about envisioning and guiding people through change. If anesthesiology is to continue to thrive as a medical specialty within a rapidly evolving healthcare system, anesthesiologists will need to envision and manifest change beyond simply providing efficient care.

The specialty is confronting what has been coined an “adaptive” challenge, i.e., a challenge for which there is no preexisting solution. Furthermore, there is evidence both inside and outside of medicine that organizations that focus exclusively on cost reduction and efficiency during times of rapid change ultimately do not fare well. As a result, anesthesiologists need to become change agents who envision, lead, and implement initiatives that ultimately result in greater patient safety, better patient outcomes, improved quality, and sustainable finances.

Medicine, however, as a whole underinvests in leadership development because, according to Dr. Wiley W. Souba, a surgeon and a prolific writer about leadership, the profession is not sure where to invest or how to “prepare people for the practice of leadership.” He points out that although leadership training is available, the focus on “managerial skills” fails to get at the heart of leadership. More recently, a qualitative study of emergency medicine residents at a major academic center found that the approaches to learning leadership are underdeveloped, resulting in a narrow view of leadership. What is still missing is a roadmap for cultivating leadership behaviors in clinicians and relevant tools to guide their actions. In this article, with the help of a case scenario, we propose a practical framework for turning anesthesiologists into leaders.

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