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

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


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


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


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


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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