16 de setembro de 2014

Artigo recomendado: Effects of Dexamethasone on Cognitive Decline after Cardiac Surgery

A Randomized Clinical Trial

Thomas H. Ottens, Jan M. Dieleman, Anne-Mette C. Sauër,Linda M. Peelen, Arno P. Nierich, Welmer J. de Groot, Hendrik M. Nathoe, Marc P. Buijsrogge, Cor J. Kalkman, Diederik van Dijk.


ABSTRACT

Background: Cardiac surgery can be complicated by postoperative cognitive decline (POCD), which is characterized by impaired memory function and intellectual ability. The systemic inflammatory response that is induced by major surgery and cardiopulmonary bypass may play an important role in the etiology of POCD. Prophylactic corticosteroids to attenuate the inflammatory response may therefore reduce the risk of POCD. The authors investigated the effect of intraoperative high-dose dexamethasone on the incidence of POCD at 1 month and 12 months after cardiac surgery.

Methods: This multicenter, randomized, double-blind, placebo-controlled trial is a preplanned substudy of the DExamethasone for Cardiac Surgery trial. A total of 291 adult patients undergoing cardiac surgery with cardiopulmonary bypass were recruited in three hospitals and randomized to receive dexamethasone 1 mg/kg (n = 145) or placebo (n = 146). The main outcome measures were incidence of POCD at 1- and 12-month follow-up, defined as a decline in neuropsychological test performance beyond natural variability, as measured in a control group.

Results: At 1-month follow-up, 19 of 140 patients in the dexamethasone group (13.6%) and 10 of 138 patients in the placebo group (7.2%) fulfilled the diagnostic criteria for POCD (relative risk, 1.87; 95% CI, 0.90 to 3.88; P = 0.09). At 12-month follow-up, 8 of 115 patients in the dexamethasone group (7.0%) and 4 of 114 patients (3.5%) in the placebo group had POCD (relative risk, 1.98; 95% CI, 0.61 to 6.40; P = 0.24).

Conclusion: Intraoperative high-dose dexamethasone did not reduce the risk of POCD after cardiac surgery.

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28 de março de 2014

Artigo recomendado: Cardiac Resuscitation and Coagulation

Joseph L. Weidman, Douglas C. Shook, Jan N. Hilberath

Anesthesiology 2014; 120:1009-14

ABSTRACT

Cardiac arrest occurs with an estimated annual incidence of 92 to 189 cases per 100,000 individuals and carries a poor prognosis despite advances in modern medicine. Even for patients in whom spontaneous circulation is restored, their subsequent hospital course is fraught with potential complications. Derangements in the coagulation and fibrinolytic systems frequently occur as a result of cardiac arrest and cardiopulmonary resuscitation (CPR). These changes play a significant role in the spectrum of conditions classified as “post–cardiac arrest syndrome.” In addition to the endogenous changes in blood coagulation after cardiac arrest, iatrogenic coagulopathies can be seen at various time points as ancillary effects of certain treatment options for these patients. In this article, we review the changes in the coagulation systems of patients experiencing cardiac arrest and CPR and further discuss coagulopathies potentially associated with hypothermia, thrombolysis, and extracorporeal membrane oxygenation (ECMO) therapy.

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24 de fevereiro de 2014

Artigo recomendado: Ultrasound-guided Multilevel Paravertebral Blocks and Total Intravenous Anesthesia Improve the Quality of Recovery after Ambulatory Breast Tumor Resection

Faraj W. Abdallah, Pamela J. Morgan, Tulin Cil, Andrew McNaught, Jaime M. Escallon, John L. Semple, Wei Wu, Vincent W. Chan

Anesthesiology 2014; 120:703-13

ABSTRACT

Background: Regional anesthesia improves postoperative analgesia and enhances quality of recovery (QoR) after ambulatory surgery. This randomized, double-blinded, parallel-group, placebo-controlled trial examines the effects of multilevel ultrasound-guided paravertebral blocks (PVBs) and total intravenous anesthesia on QoR after ambulatory breast tumor resection.

Methods: Sixty-six women were randomized to standardized general anesthesia (control group) or PVBs and propofol-based total intravenous anesthesia (PVB group). The PVB group received T1–T5 PVBs with 5 ml of 0.5% ropivacaine per level, whereas the control group received sham subcutaneous injections. Postoperative QoR was designated as the primary outcome. The 29-item ambulatory QoR tool was administered in the preadmission clinic, before discharge, and on postoperative days 2, 4, and 7. Secondary outcomes included block success, pain scores, intra- and postoperative morphine consumption, time to rescue analgesia, incidence of nausea and vomiting, and hospital discharge time.

Results: Data from sixty-four patients were analyzed. The PVB group had higher QoR scores than control group upon discharge (146 vs. 131; P < 0.0001) and on postoperative day 2 (145 vs. 135; P = 0.013); improvements beyond postoperative day 2 lacked statistical significance. None of the PVB group patients required conversion to inhalation gas–based general anesthesia or experienced block-related complications. PVB group patients had improved pain scores on postanesthesia care unit admission and discharge, hospital discharge, and postoperative day 2; their intraoperative morphine consumption, incidence of nausea and vomiting, and discharge time were also reduced.

Conclusion: Combining multilevel PVBs with total intravenous anesthesia provides reliable anesthesia, improves postoperative analgesia, enhances QoR, and expedites discharge compared with inhalational gas- and opioid-based general anesthesia for ambulatory breast tumor resection.

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6 de fevereiro de 2014

Artigo recomendado: Current concepts in the understanding of malignant hyperthermia

Tae W. Kim, Henry Rosenberg, Nina Nami

Anesthesiology News - February 2014

Malignant hyperthermia (MH) is a pharmacogenetic disorder triggered by exposure to halogenated volatile anesthetic gases and succinylcholine. The underlying mechanism for this potentially lethal condition involves the unregulated release of calcium from the sarcoplasm reticulum into the myoplasm. The ryanodine receptor protein encoded by the RYR1 gene on chromosome 19q.13.1 forms the calcium channel.

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31 de janeiro de 2014

Artigo recomendado: Automated Near–Real-time Clinical Performance Feedback for Anesthesiology Residents

One Piece of the Milestones Puzzle


Jesse M. Ehrenfeld, Matthew D. McEvoy, William R. Furman, Dylan Snyder, Warren S. Sandberg

Anesthesiology 2014; 120:172-84

ABSTRACT
Background: Anesthesiology residencies are developing trainee assessment tools to evaluate 25 milestones that map to the six core competencies. The effort will be facilitated by development of automated methods to capture, assess, and report trainee performance to program directors, the Accreditation Council for Graduate Medical Education and the trainees themselves.

Methods: The authors leveraged a perioperative information management system to develop an automated, near–real-time performance capture and feedback tool that provides objective data on clinical performance and requires minimal administrative effort. Before development, the authors surveyed trainees about satisfaction with clinical performance feedback and about preferences for future feedback.

Results: Resident performance on 24,154 completed cases has been incorporated into the authors’ automated dashboard, and trainees now have access to their own performance data. Eighty percent (48 of 60) of the residents responded to the feedback survey. Overall, residents “agreed/strongly agreed” that they desire frequent updates on their clinical performance on defined quality metrics and that they desired to see how they compared with the residency as a whole. Before deployment of the new tool, they “disagreed” that they were receiving feedback in a timely manner. Survey results were used to guide the format of the feedback tool that has been implemented.

Conclusion: The authors demonstrate the implementation of a system that provides near–real-time feedback concerning resident performance on an extensible series of quality metrics, and which is responsive to requests arising from resident feedback about desired reporting mechanisms.

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29 de janeiro de 2014

Artigo recomendado: Pharyngeal Function and Breathing Pattern during Partial Neuromuscular Block in the Elderly

Effects on Airway Protection

Anna I. Hårdemark Cedborg, Eva Sundman, Katarina Bodén, Hanne Witt Hedström, Richard Kuylenstierna, Olle Ekberg, Lars I. Eriksson

Anesthesiology 2014; 120:312-25

ABSTRACT

Background: Intact pharyngeal function and coordination of breathing and swallowing are essential for airway protection and to avoid respiratory complications. Postoperative pulmonary complications caused by residual effects of neuromuscularblocking agents occur more frequently in the elderly. Moreover, elderly have altered pharyngeal function which is associated with increased risk of aspiration. The purpose of this study was to evaluate effects of partial neuromuscular block on pharyngeal function, coordination of breathing and swallowing, and airway protection in individuals older than 65 yr.

Methods: Pharyngeal function and coordination of breathing and swallowing were assessed by manometry and videoradiography in 17 volunteers, mean age 73.5 yr. After control recordings, rocuronium was administered to obtain steady-state trainof-four ratios of 0.70 and 0.80 followed by spontaneous recovery to greater than 0.90.

Results: Pharyngeal dysfunction increased significantly at train-of-four ratios 0.70 and 0.80 to 67 and 71%, respectively, compared with 37% at control recordings, and swallowing showed a more severe degree of dysfunction during partial neuromuscular block. After recovery to train-of-four ratio of greater than 0.90, pharyngeal dysfunction was not significantly different from the control state. Resting pressure in the upper esophageal sphincter was lower at all levels of partial neuromuscular block compared with control recordings. The authors were unable to demonstrate impaired coordination of breathing and swallowing.

Conclusion: Partial neuromuscular block in healthy elderly individuals causes an increased incidence of pharyngeal dysfunction from 37 to 71%, with impaired ability to protect the airway; however, the authors were unable to detect an effect of partial neuromuscular block on coordination of breathing and swallowing.

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22 de janeiro de 2014

Artigo recomendado: Regional Blood Acidification Enhances Extracorporeal Carbon Dioxide Removal

A 48-hour Animal Study

Alberto Zanella, Paolo Mangili, Sara Redaelli, Vittorio Scaravilli, Marco Giani, Daniela Ferlicca, Diletta Scaccabarozzi, Federica Pirrone, Mariangela Albertini, Nicolò Patroniti, Antonio Pesenti.

Anesthesiology 2014; 120:416-24

ABSTRACT

Background: Extracorporeal carbon dioxide removal has been proposed to achieve protective ventilation in patients at risk for ventilator-induced lung injury. In an acute study, the authors previously described an extracorporeal carbon dioxide removal technique enhanced by regional extracorporeal blood acidification. The current study evaluates efficacy and feasibility of such technology applied for 48 h.

Methods: Ten pigs were connected to a low-flow veno-venous extracorporeal circuit (blood flow rate, 0.25 l/min) including a membrane lung. Blood acidification was achieved in eight pigs by continuous infusion of 2.5 mEq/min of lactic acid at the membrane lung inlet. The acid infusion was interrupted for 1 h at the 24 and 48 h. Two control pigs did not receive acidification. At baseline and every 8 h thereafter, the authors measured blood lactate, gases, chemistry, and the amount of carbon dioxide removed by the membrane lung (VCO2ML). The authors also measured erythrocyte metabolites and selected cytokines. Histological and metalloproteinases analyses were performed on selected organs.

Results: Blood acidification consistently increased VCO2ML by 62 to 78%, from 79 ± 13 to 128 ± 22 ml/min at baseline, from 60 ± 8 to 101 ± 16 ml/min at 24 h, and from 54 ± 6 to 96 ± 16 ml/min at 48 h. During regional acidification, arterial pH decreased slightly (average reduction, 0.04), whereas arterial lactate remained lower than 4 mEq/l. No sign of organ and erythrocyte damage was recorded.

Conclusion: Infusion of lactic acid at the membrane lung inlet consistently increased VCO2ML providing a safe removal of carbon dioxide from only 250 ml/min extracorporeal blood flow in amounts equivalent to 50% production of an adult man.

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14 de janeiro de 2014

Artigo recomendado: Medical Error - The Personal Cost

Alison S. Clay

AnnalsATS Volume 10 Number 6 - December 2013

In July 2005, Dr. Alison Clay was treated for an acute systemic reaction to a bee sting at the medical center where she worked. The encounter was not routine, shaking Alison’s confidence in hospital medicine and causing her to question the very health care system that had trained her.

On a beautiful summer day the July after I finished my fellowship, I prepared for an inaugural ride on a new bike. The bike was a gift to myself to celebrate the end of my formal training in pulmonary and critical care medicine. The sky was clear, a deep “Carolina” blue. There was no wind to warn of a change in weather, no premonition of just how ugly this beautiful day might become.

Then, a seemingly insignificant event: a slight irritation on my left toe and a tiny honeybee stuck to my sock. I had no allergy to bees. My breathing was fine. But as the erythema crept up my foot and past my ankle, I grudgingly drove to the emergency department. I parked my car in the deck across the street and started to walk. The entrance to the emergency department felt like it was miles away. I vomited profusely, and sweat dripped down my brow. Despite my “training,” I had underestimated the situation...

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8 de janeiro de 2014

Artigo recomendado: Hamilton Acute Pain Service Safety Study

Using Root Cause Analysis to Reduce the Incidence of Adverse Events

James E. Paul, Norman Buckley, Richard F. McLean, Karen Antoni, David Musson, Marianne Kampf, Diane Buckley, Michelle Marcoux, Rosemary Frketich, Lehana Thabane

Anesthesiology 2014; 120:97-109

ABSTRACT

Background: Although intravenous patient-controlled analgesia opioids and epidural analgesia offer improved analgesia for postoperative patients treated on an acute pain service, these modalities also expose patients to some risk of serious morbidity and even mortality. Root cause analysis, a process for identifying the causal factor(s) that underlie an adverse event, has the potential to identify and address system issues and thereby decrease the chance of recurrence of these complications.

Methods: This study was designed to compare the incidence of adverse events on an acute pain service in three hospitals, before and after the introduction of a formal root cause analysis process. The “before” cohort included all patients with pain from February 2002 to July 2007. The “after” cohort included all patients with pain from January 2009 to December 2009.

Results: A total of 35,384 patients were tracked over the 7 yr of this study. The after cohort showed significant reductions in the overall event rate (1.47 vs. 2.35% or 1 in 68 vs. 1 in 42, the rate of respiratory depression (0.41 vs. 0.71%), the rate of severe hypotension (0.78 vs. 1.34%), and the rate of patient-controlled analgesia pump programming errors (0.0 vs. 0.08%). Associated with these results, the incidence of severe pain increased from 6.5 to 10.5%. To achieve these results, 26 unique recommendations were made of which 23 being completed, 1 in progress, and 2 not completed.

Conclusions: Formal root cause analysis was associated with an improvement in the safety of patients on a pain service. The process was effective in giving credibility to recommendations, but addressing all the action plans proved difficult with available resources.

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3 de janeiro de 2014

Artigo recomendado: Ultrasonography of the Cervical Spine

An In Vitro Anatomical Validation Model

Maarten van Eerd, Jacob Patijn, Judith M. Sieben, Mischa Sommer, Jan Van Zundert, Maarten van Kleef, Arno Lataster

Anesthesiology 2014; 120:86-96

ABSTRACT

Background: Anatomical validation studies of cervical ultrasound images are sparse. Validation is crucial to ensure accurate interpretation of cervical ultrasound images and to develop standardized reliable ultrasound procedures to identify cervical anatomical structures. The aim of this study was to acquire validated ultrasound images of cervical bony structures and to develop a reliable method to detect and count the cervical segmental levels.

Methods: An anatomical model of a cervical spine, embedded in gelatin, was inserted in a specially developed measurement device. This provided ultrasound images of cervical bony structures. Anatomical validation was achieved by laser light beams projecting the center of the ultrasound image on the cervical bony structures through a transparent gelatin.

Results: Anatomically validated ultrasound images of different cervical bony structures were taken from dorsal, ventral, and lateral perspectives. Potentially relevant anatomical landmarks were defined and validated. Test/retest analysis for positioning showed a reproducibility with an intraclass correlation coefficient for single measures of 0.99. Besides providing validated ultrasound images of bony structures, this model helped to develop a method to detect and count the cervical segmental levels in vivo at long-axis position, in a dorsolateral (paramedian) view at the level of the laminae, starting from the base of the skull and sliding the ultrasound probe caudally.

Conclusions: Ultrasound bony images of the cervical vertebrae were validated with an in vitro model. Anatomical bony landmarks are the mastoid process, the transverse process of C1, the tubercles of C6 and C7, and the cervical laminae. Especially, the cervical dorsal laminae serve best as anatomical bony landmarks to reliably detect the cervical segmentallevels in vivo.

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