RESUMEN
Application of cricoid pressure (CP) during rapid sequence induction and intubation sequence has been a "standard" of care for many decades, despite limited scientific proof of its efficacy in preventing pulmonary aspiration of gastric contents. While some of the current rapid sequence induction and intubation guidelines recommend its use, other international guidelines do not, and many clinicians argue that there is insufficient evidence to either continue or abandon its use. Recently published articles and accompanying editorials have reignited the debate on the efficacy and safety of CP application and have generated multiple responses that pointed out the various (and significant) limitations of the available evidence. Thus, a critical discussion of available data must be undertaken before making a final clinical decision on such an important patient safety issue. In this review, the authors will take an objective look at the available scientific evidence about the effectiveness and safety of CP in patients at risk of pulmonary aspiration of gastric contents. We suggest that current data are inadequate to impose clinical guidelines on the use of CP because we acknowledge that currently there is not, and there may never be, a method to prevent aspiration in all patients. In addition, we reiterate that a universally accepted medical-legal standard for approaching the high-risk aspiration patient does not exist, discuss the differences in practice between the US and international practitioners regarding use of CP, and propose 5 recommendations on how future studies might be designed to obtain optimal scientific evidence about the effectiveness and safety of CP in patients at risk for pulmonary aspiration.
Asunto(s)
Manejo de la Vía Aérea/métodos , Cartílago Cricoides/diagnóstico por imagen , Intubación Intratraqueal/métodos , Presión , Aspiración Respiratoria/prevención & control , Manejo de la Vía Aérea/efectos adversos , Cartílago Cricoides/anatomía & histología , Humanos , Intubación Intratraqueal/efectos adversos , Aspiración Respiratoria/etiologíaRESUMEN
Minutes count in the operating room when it comes to treatment guidance and therapies. On a daily basis, anesthesiologists make hundreds of decisions, some based on laboratory results, when guiding patient therapies. When time is crucial, point-of-care testing is often utilized for expediency. However, point-of-care testing has its limitations. Providers should be aware of the limitations, including the potential for error in results-errors that could lead to improper treatment and possible patient harm. This article outlines the technical aspects and summarizes pitfalls in accuracy for 2 of the most commonly utilized point-of-care testing devices: glucose meters and hemoglobin meters.
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Análisis Químico de la Sangre/instrumentación , Glucemia/metabolismo , Hemoglobinas/metabolismo , Sistemas de Atención de Punto , Pruebas en el Punto de Atención , Biomarcadores/sangre , Humanos , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Factores de Tiempo , Flujo de TrabajoRESUMEN
Type 1 diabetes mellitus is a lifelong condition. It requires intensive patient involvement including frequent glucose measurements and subcutaneous insulin dosing to provide optimal glycemic control to decrease short- and long-term complications of diabetes mellitus without causing hypoglycemia. Variations in insulin pharmacokinetics and responsiveness over time in addition to illness, stress, and a myriad of other factors make ideal glucose control a challenge. Control-to-range and control-to-target artificial pancreas devices (closed-loop artificial pancreas devices [C-APDs]) consist of a continuous glucose monitor, response algorithm, and insulin delivery device that work together to automate much of the glycemic management for an individual while continually adjusting insulin dosing toward a glycemic target. In this way, a C-APD can improve glycemic control and decrease the rate of hypoglycemia. The MiniMed 670G (Medtronic, Fridley, MN) system is currently the only Food and Drug Administration-cleared C-APD in the United States. In this system, insulin delivery is continually adjusted to a glucose concentration, and the patient inputs meal-time information to modify insulin delivery as needed. Data thus far suggest improved glycemic control and decreased hypoglycemic events using the system, with decreased need for patient self-management. Thus, the anticipated use of these devices is likely to increase dramatically over time. There are limited case reports of safe intraoperative use of C-APDs, but the Food and Drug Administration has not cleared any device for such use. Nonetheless, C-APDs may offer an opportunity to improve patient safety and outcomes through enhanced intraoperative glycemic control. Anesthesiologists should become familiar with C-APD technology to help develop safe and effective protocols for their intraoperative use. We provide an overview of C-APDs and propose an introductory strategy for intraoperative study of these devices.
Asunto(s)
Diabetes Mellitus Tipo 1/terapia , Hipoglucemia/terapia , Sistemas de Infusión de Insulina , Páncreas Artificial , Periodo Perioperatorio , Algoritmos , Anestesia por Circuito Cerrado/métodos , Anestesiología/métodos , Anestesiología/normas , Glucemia , Automonitorización de la Glucosa Sanguínea/métodos , Diabetes Mellitus Tipo 1/sangre , Diseño de Equipo , Humanos , Hiperglucemia , Hipoglucemiantes/administración & dosificación , Pacientes Internos , Insulina/administración & dosificación , Monitoreo Ambulatorio/métodos , Pacientes Ambulatorios , Resultado del TratamientoRESUMEN
PURPOSE: To evaluate the accuracy and reproducibility of quantitative chemical shift-encoded (CSE) MRI to quantify proton-density fat-fraction (PDFF) in a fat-water phantom across sites, vendors, field strengths, and protocols. METHODS: Six sites (Philips, Siemens, and GE Healthcare) participated in this study. A phantom containing multiple vials with various oil/water suspensions (PDFF:0%-100%) was built, shipped to each site, and scanned at 1.5T and 3T using two CSE protocols per field strength. Confounder-corrected PDFF maps were reconstructed using a common algorithm. To assess accuracy, PDFF bias and linear regression with the known PDFF were calculated. To assess reproducibility, measurements were compared across sites, vendors, field strengths, and protocols using analysis of covariance (ANCOVA), Bland-Altman analysis, and the intraclass correlation coefficient (ICC). RESULTS: PDFF measurements revealed an overall absolute bias (across sites, field strengths, and protocols) of 0.22% (95% confidence interval, 0.07%-0.38%) and R2 > 0.995 relative to the known PDFF at each site, field strength, and protocol, with a slope between 0.96 and 1.02 and an intercept between -0.56% and 1.13%. ANCOVA did not reveal effects of field strength (P = 0.36) or protocol (P = 0.19). There was a significant effect of vendor (F = 25.13, P = 1.07 × 10-10 ) with a bias of -0.37% (Philips) and -1.22% (Siemens) relative to GE Healthcare. The overall ICC was 0.999. CONCLUSION: CSE-based fat quantification is accurate and reproducible across sites, vendors, field strengths, and protocols. Magn Reson Med 77:1516-1524, 2017. © 2016 International Society for Magnetic Resonance in Medicine.
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Tejido Adiposo/diagnóstico por imagen , Agua Corporal/diagnóstico por imagen , Imagen por Resonancia Magnética/instrumentación , Fantasmas de Imagen , Diseño de Equipo , Análisis de Falla de Equipo , Protones , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
BACKGROUND: Preoperative ordering of blood products has been an area of optimization due to considerable variability among physicians; overpreparation can lead to extra costs and underpreparation of blood can potentially compromise patient safety. STUDY DESIGN AND METHODS: We examined the potential cost savings of extending the storage interval of a presurgical type-and-screen sample from 7 to 14 days, thereby reducing the need for a new specimen on the day of surgery. RESULTS: Sensitivity analysis showed annual cost savings for our institution to be an estimated $38,770 ($22,420-$73,120). CONCLUSION: These results are even more robust when incorporating the additional potential savings from improved operating room efficiency.
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Transfusión Sanguínea/economía , Ahorro de Costo/métodos , Cuidados Preoperatorios/métodos , Almacenamiento de Sangre/métodos , Conservación de la Sangre/economía , Análisis Costo-Beneficio , Humanos , Cuidados Preoperatorios/economía , Factores de TiempoRESUMEN
PURPOSE OF REVIEW: There is ongoing controversy surrounding the use of glucose monitoring in the perioperative setting. It is an important aspect of patient care, but the best way to go about monitoring this parameter is still up for debate. This article will review previously established data and new developments in this field. RECENT FINDINGS: Several different methods exist to measure blood glucose levels in the perioperative setting, including central laboratory devices, blood gas analyzers, and point-of-care devices. However, it has been recommended that point-of-care devices not be used on 'critically ill' patients, which throws into question the common use of these devices perioperatively. Recently, the Centers for Medicare and Medicaid placed a moratorium on this recommendation, and these devices continue to be a staple in the perioperative setting, but there are other methods of glucose monitoring that can be employed. SUMMARY: The monitoring of blood glucose levels in the perioperative patient remains an important part of patient care; however, debate still exist on how best to reliably measure blood glucose levels in the most effective manner.
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Glucemia/metabolismo , Atención Perioperativa/métodos , Enfermedad Crítica , Humanos , Hiperglucemia/sangre , Hiperglucemia/terapia , Hipoglucemia/sangre , Hipoglucemia/terapia , Complicaciones Intraoperatorias/sangre , Complicaciones Intraoperatorias/terapia , Monitoreo Intraoperatorio , Monitoreo Fisiológico , Sistemas de Atención de PuntoRESUMEN
OBJECTIVE: This special article will review the history of blood glucose meter hospital use and current issues surrounding their use in this patient population. STUDY SELECTION: Secondary to accuracy concerns that have been known, but likely underappreciated for many years, the U.S. Food and Drug Administration and Centers for Medicare and Medicaid Services are moving toward eliminating current blood glucose meters for use with critically ill patients. DATA SOURCES: Recent guidance from the U.S. Food and Drug Administration and Centers for Medicare and Medicaid Services along with several recent publications will be used as the primary data sources. DATA EXTRACTION: U.S. Food and Drug Administration, Centers for Medicare and Medicaid Services communications combined with recent interpretation of this guidance were used to provide this overview. DATA SYNTHESIS: Centers for Medicare and Medicaid Services have issued a temporary moratorium on the prohibition of the use of blood glucose meters in the critically ill. They have not given a deadline for the moratorium or solicited comments. CONCLUSIONS: Physicians who care for critically ill patients need to be cognizant of the accuracy and interference limitations of blood glucose meters and aware of the current regulatory situation.
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Glucemia/análisis , Enfermedad Crítica , Hospitales , Sistemas de Atención de Punto/normas , Centers for Medicare and Medicaid Services, U.S. , Humanos , Factores de Tiempo , Estados Unidos , United States Food and Drug AdministrationRESUMEN
Modern clinical research commonly uses complex designs with multiple related outcomes, including repeated-measures designs. While multiple comparison corrections and effect size calculations are needed to more accurately assess an intervention's significance and impact, understanding the limitations of these methods in the case of dependency and correlation is important. In this review, we outline methods for multiple comparison corrections and effect size calculations and considerations in cases of correlation and summarize relevant simulation studies to illustrate these concepts.
Asunto(s)
Investigación Biomédica/estadística & datos numéricos , Algoritmos , Simulación por Computador , Humanos , Proyectos de Investigación , Tamaño de la MuestraAsunto(s)
Anestesiólogos , Exámenes Obligatorios , Errores Médicos/prevención & control , Inhabilitación Médica , Detección de Abuso de Sustancias , Trastornos Relacionados con Sustancias/prevención & control , Anestesiólogos/economía , Análisis Costo-Beneficio , Humanos , Exámenes Obligatorios/economía , Errores Médicos/economía , Seguridad del Paciente , Inhabilitación Médica/economía , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Uso Recreativo de Drogas , Reproducibilidad de los Resultados , Detección de Abuso de Sustancias/economía , Trastornos Relacionados con Sustancias/diagnóstico , Trastornos Relacionados con Sustancias/economíaRESUMEN
Artifacts are frequently encountered during echocardiographic examinations. An understanding of the physics and underlying assumptions of ultrasound processing involved with image generation is important for accurate interpretation of 2D grayscale, spectral Doppler, color flow Doppler, and 3D artifacts and their clinical implications.
Asunto(s)
Artefactos , Ecocardiografía/estadística & datos numéricos , Ecocardiografía/métodos , Ecocardiografía Tetradimensional , Humanos , Física , UltrasonidoRESUMEN
BACKGROUND: Contamination of a central venous catheter may occur through use of conventional open-lumen stopcock devices (COLDs), or disinfectable, needleless, closed connectors (DNCCs). We investigated the effectiveness of a new universal IV access cleaning device (Site-Scrub) compared with 70% isopropyl alcohol prep pads for sanitizing COLDs or DNCCs inoculated with common catheter-associated pathogens. METHODS: Site-Scrub was compared with 70% alcohol prep pads for sanitizing contaminated female Luer lock COLD or DNCC filled with sterile saline or propofol and 2 common bacterial central venous catheter contaminants (Staphylococcus epidermidis or Pseudomonas aeruginosa). Devices were contaminated using a glove touch (COLD and DNCC) or syringe tip (COLD). The primary end point of the study was colony-forming units (CFU) after 24 hours. RESULTS: The use of glove touch contamination, the contaminants, S epidermidis and P aeruginosa, produced CFU in saline-filled COLDs treated with the Site-Scrub, but not in those treated with alcohol pads (P < 0.001). Similar results were observed with propofol-filled COLDs (P < 0.001). For DNCCs filled with saline or propofol, both alcohol and Site-Scrub effectively reduced CFU growth compared with contaminated controls (P < 0.001). When COLDs were contaminated by treated syringe tips, there was no significant evidence of reduction in CFU growth by using either alcohol pads or Site-Scrub compared with contaminated controls. CONCLUSIONS: These data suggest that when the inner surface of the COLD is contaminated, both alcohol pads and Site-Scrub were not significantly effective in decontaminating the COLD. When the COLD rim is contaminated, however, alcohol pads outperform Site-Scrub. DNCCs were uniformly decontaminated with either treatment. Future work should focus on better access systems because current COLDs are difficult to decontaminate.
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2-Propanol/química , Cateterismo Venoso Central/efectos adversos , Catéteres de Permanencia/efectos adversos , Desinfección/instrumentación , Contaminación de Equipos/prevención & control , Cateterismo Venoso Central/instrumentación , Infección Hospitalaria/prevención & control , Descontaminación/instrumentación , Humanos , Pseudomonas aeruginosa/aislamiento & purificación , Staphylococcus epidermidis/aislamiento & purificación , Células Madre , Factores de TiempoRESUMEN
STUDY OBJECTIVE: In 2018, the American Society of Anesthesiologists stated that student registered nurse anesthetists (SRNAs) "are not yet fully qualified anesthesia personnel." It remains unclear, however, whether postprocedural outcomes are affected by SRNAs providing anesthesia care under the medical direction of anesthesiologists, as compared with medically directed anesthesiology fellows or residents, or certified registered nurse anesthetists (CRNAs). We therefore aimed to examine whether medically directed SRNAs serving as in-room anesthesia providers impact surgical outcomes. DESIGN: Retrospective, matched-cohort analysis. SETTING: Adult patients (≥18 years old) undergoing inpatient surgery between 2000 and 2017 at a tertiary academic medical center. PATIENTS: 15,365 patients exclusively cared for by medically directed SRNAs were matched to 15,365 cared for by medically directed CRNAs, anesthesiology residents, and/or fellows. INTERVENTIONS: None. MEASUREMENTS: The primary composite outcome was postoperative occurrence of in-hospital mortality and six categories of major morbidities (infectious, bleeding, serious cardiac, gastrointestinal, respiratory, and urinary complications). In-hospital mortality was analyzed as the secondary outcome. MAIN RESULTS: In all, 30,730 cases were matched using propensity score matching to control for potential confounding. The primary outcome was identified in 2295 (7.5%) cases (7.5% with exclusive medically directed SRNAs vs 7.4% with medically directed CRNAs, residents and/or fellows; relative risk, 1.02; 95% CI, 0.94-1.11). Thus, our effort to determine noninferiority (10% difference in relative risk) with other providers was inconclusive (P = .07). However, the medically directed SRNA group (0.8% [118]) was found to be noninferior (P < .001) to the matched group (1.0% [156]) on in-hospital mortality (relative risk, 0.75; 95% CI, 0.59-0.96). CONCLUSIONS: Among 30,730 patients undergoing inpatient surgery at a single hospital, findings were inconclusive regarding whether exclusive medically directed SRNAs as in-room providers were noninferior to other providers. The use of medically directed SRNAs under this staffing model should be subject to further review. Clinical Trial and Registry URL: Not applicable.
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Anestesia , Anestesiología , Adulto , Humanos , Adolescente , Estudios Retrospectivos , Anestesiólogos , Enfermeras Anestesistas , Recursos HumanosRESUMEN
Evaluating the accuracy of medical devices has traditionally been a blend of statistical analyses, at times without contextualizing the clinical application. There have been a number of recent publications on the accuracy of a continuous noninvasive hemoglobin measurement device, the Masimo Radical-7 Pulse Co-oximeter, focusing on the traditional statistical metrics of bias and precision. In this review, which contains material presented at the Innovations and Applications of Monitoring Perfusion, Oxygenation, and Ventilation (IAMPOV) Symposium at Yale University in 2012, we critically investigated these metrics as applied to the new technology, exploring what is required of a noninvasive hemoglobin monitor and whether the conventional statistics adequately answer our questions about clinical accuracy. We discuss the glucose error grid, well known in the glucose monitoring literature, and describe an analogous version for hemoglobin monitoring. This hemoglobin error grid can be used to evaluate the required clinical accuracy (±g/dL) of a hemoglobin measurement device to provide more conclusive evidence on whether to transfuse an individual patient. The important decision to transfuse a patient usually requires both an accurate hemoglobin measurement and a physiologic reason to elect transfusion. It is our opinion that the published accuracy data of the Masimo Radical-7 is not good enough to make the transfusion decision.