30 de janeiro de 2013

Artigo recomendado: Prevention of Intraoperative Awareness with Explicit Recall - Making Sense of the Evidence

Michael S. Avidan, George A. Mashour

Anesthesiology 2013; 118:449-56, M. S. Avidan and G. A. Mashour

Unintended intraoperative awareness with subsequent explicit recall (AWR) is a major concern for patients undergoing general anesthesia and has persisted as a complication despite modern anesthetic techniques. In order to eliminate this complication, it would be helpful if anesthesia practitioners could determine reliably and accurately when patients were unaware. Although voluntary patient movement in response to commands reliably reflects awareness, the absence of such movement does not guarantee unawareness. Patients might have received paralytic agents or anesthetic agents that lead to unresponsiveness but not unconsciousness. There is ongoing debate whether the prevention of all intraoperative awareness episodes, even those without explicit recall, should be a therapeutic goal for anesthesiologists. In this clinical commentary, we are not addressing this controversy, but are restricting the discussion to the prevention of AWR.

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23 de janeiro de 2013

Practice Guidelines for Management of the Difficult Airway

An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway

Anesthesiology 2013; 118:251-70- Practice Guidelines

Practice Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open-forum commentary, and clinical feasibility data.

This document updates the “Practice Guidelines for Management of the Difficult Airway: An Updated Report by the Task Force on Difficult Airway Management,” adopted by the ASA in 2002 and published in 2003.*

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*American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: An updated report. Anesthesiology 2003; 98:1269–1277.

18 de janeiro de 2013

Artigo recomendado: Association between Anesthesiologist Age and Litigation

Michael J. Tessler, Ian Shrier, Russell J. Steele

Anesthesiology 2012; 116:574 –9 Tessler et al.

Background: The threat of being sued is a concern for many anesthesiologists. This paper asks whether litigation brought against anesthesiologists is associated with the age of the

Methods: Institutional research ethics approval was granted. We obtained billing data for all procedures performed byspecialist anesthesiologists stratified into three age groups (less than 51, 51–64, and 65 and older) from British Columbia, Quebec, and Ontario for the 10-yr period from Jan. 1, 1993 to Dec. 31, 2002. We also obtained all litigations (including disability weighted claims) handled by the Canadian Medical Protective Association during the same time period in which the Canadian Medical Protective Association experts considered the anesthesiologist cited to be at least partially responsible for the adverse event leading to the complaint.

Results: In univariate analysis with the less than 51 age group as the reference category, the litigation rate ratio for the 51–64 age group was 1.14 (95% CI: 0.99 –1.32) and for the

65 and older age group was 1.50 (95% CI: 1.14 –1.97). Our analyses using disability weighted claims showed the 51–64 group to have 1.31 (95% CI: 0.95–1.80) and 65 and older
group to have 1.94 (95% CI: 1.41–2.67) relative increase in disability compared to the less than 51 age group.

Conclusions: We found a higher frequency of litigation and a greater severity of injury in patients treated by anesthesiologists in the 65 and older group. The reasons for these findings should become an active field of research.

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14 de janeiro de 2013

Artigo recomendado: Capnography Outside the Operating Rooms

Bhavani Shankar Kodali

Anesthesiology 2013; 118:192–201, Kodali, BS

Historically, anesthesiologists seem to be the forerunners in implementing tools and standards for safety in the medical fraternity. In the United States, since 1985, there has been a dramatic decrease in the malpractice insurance premiums of anesthesiologists. Such a decrease has not been seen in other medical or surgical specialties over this time frame. Thanks to the foresight of the American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Association of Anesthesiologists in Holland, capnography was embraced and incorporated into the standards of monitoring during anesthesia to enhance patient safety. Currently, anesthesiologists in many developing countries follow these recommendations (India, Government of Andhra Pradesh Order, AST/775/F25/dated September 2011. 
Capnography is mandatory for laparoscopic surgeries for reimbursement). Although capnography has become an integral part of anesthesia care in operating rooms for more than 25 yr, its value has been limited to these situations and is not well appreciated beyond these confinements. It is not uncommon in our practice to observe an intubated and ventilated patient, originally monitored with capnography in the operating room, but then transported to the intensive care unit (ICU) without capnography. It is even more surprising that many ICUs do not have capnography either to confirm endotracheal intubation or to continually monitor ventilation. As anesthesiologists, we use capnography to monitor sedation in the operating room because we appreciate that the line between consciousness and unconsciousness is very thin, and the patient can drift from one state to another. However, in many institutions, capnography is not used to monitor ventilation during sedation for procedures performed particularly by nonanesthesiologists outside of the operating rooms. 
One of the obvious reasons seems to be a lack of a single society overseeing the safety of outside-the-operating-room procedures the way ASA and AAGBI do in the operating room. Nonetheless, in the last 2 yr there has been a surge in understanding and recognizing the value of capnography outside of the operating rooms.1,2 This “Clinical Concepts and Commentary” will summarize physiology and clinical interpretation of capnography and update the current status of capnography outside of the operating rooms, including public and media awareness, and suggest probable future directions.

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10 de janeiro de 2013

Residência Médica em Anestesiologia - Hospital Alemão Oswaldo Cruz

Inscrições abertas para os Programas de 2013

Os programas de Residência Médica em Medicina Intensiva e Anestesiologia terão início em Março de 2013, sendo duas vagas para cada um.

Os candidatos poderão se inscrever até às 16h do dia 17/01/2013.

8 de janeiro de 2013

Artigo recomendado: Postoperative Urinary Retention - Anesthetic and Perioperative Considerations

Gabriele Baldini, Hema Bagry, Armen Aprikian, Franco Carli.

REVIEW ARTICLES - Anesthesiology 2009; 110:1139–57

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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