RESUMO
BACKGROUND: Evidence is lacking regarding the efficacy of Optiflow transnasal humidified rapid-insufflation ventilator exchange (THRIVE™) in obese patients. We compared the impact of this technique at 70 L min-1 with 4 L min-1 oxygen via nasal prongs on safe apnoea times of paralysed obese patients. METHODS: We randomised adults with a BMI >35 kg m-2 undergoing elective bariatric surgery. While apnoeic and paralysed, Group T received 70 L min-1 oxygen via Optiflow THRIVE™. Group N received nasal prong oxygen at 4 L min-1. The primary outcome was time to SpO2 ≤95% while apnoeic, with a 360 s cut-off. This was analysed by applying a time-to-event analysis. RESULTS: Forty-two patients were included. The median (inter-quartile range) BMI was 44.8 kg m-2 (40.0-50.0) in Group T and 42.0 kg m-2 (39.3-45.1) in Group N. Median (inter-quartile range) time to SpO2 ≤95% in Group T was 356 (165 to ≥360) s and in Group N, 210 (160-270) s. Using a survival analysis framework, median time-to-event in Group T was 356 s (95% confidence interval 165 s-upper limit not defined) and 210 s (95% confidence interval 160-242 s) (P=0.049) in Group N. CONCLUSIONS: Compared with oxygen delivered via nasal prongs at 4 L min-1, oxygen delivery via Optiflow THRIVE™ at a flow rate of 70 L min-1 can prolong safe apnoea time, however, the results are statistically inconclusive. Optiflow THRIVE™ did decrease the rate of reduction in Pao2 during apnoea. CLINICAL TRIAL REGISTRATION: ANZCTR 12618000445279.
Assuntos
Apneia/metabolismo , Cirurgia Bariátrica/métodos , Obesidade/cirurgia , Oxigenoterapia/métodos , Adulto , Feminino , Humanos , Insuflação/métodos , Masculino , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Oxigênio/metabolismo , Paralisia/fisiopatologia , Troca Gasosa Pulmonar , Fatores de TempoRESUMO
BACKGROUND: Rotational thromboelastometry (ROTEM® ) is a point-of-care test of coagulation. ROTEM® -defined hypercoagulability has been identified in pregnant women and in non-pregnant patients with diabetes mellitus. Pregnancy is known to be a hypercoagulable state, but the influence of gestational diabetes mellitus (GDM) on coagulation is unknown. AIM: The aim of this study was to assess the combined effect of pregnancy and GDM on coagulation using ROTEM® and to compare this to healthy pregnant women presenting for elective caesarean delivery. MATERIALS AND METHODS: Ethics approval was granted for recruitment of women presenting for elective caesarean delivery. Women with pre-existing conditions affecting coagulation were excluded. Group N included health pregnant women at term and Group G included pregnant women at term with GDM. Data regarding GDM management and glycaemic control were collected. Poor glycaemic control was defined by markers of accelerated fetal growth and elevated fasting or postprandial blood glucose levels. The ROTEM® parameters (extrinsically activated thromboelastometric test (EXTEM) / fibrin polymerisation test (FIBTEM) amplitude at five minutes, coagulation time, maximum clot firmness and clot formation time) were compared between the two groups using Student's t-test. RESULTS: There were 75 women in Group N and 21 women in Group G. Mean age and median body mass index values were comparable for both groups. There were no statistical differences found between the EXTEM and FIBTEM parameters analysed for the two groups. CONCLUSIONS: There was no association between GDM and increased hypercoagulability as demonstrated by ROTEM® parameters in healthy pregnant women presenting for elective caesarean delivery at term.
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Diabetes Gestacional , Trombofilia , Coagulação Sanguínea , Testes de Coagulação Sanguínea , Diabetes Gestacional/diagnóstico , Feminino , Humanos , Gravidez , Tromboelastografia , Trombofilia/diagnósticoRESUMO
BACKGROUND: Measuring blood pressure in patients with obesity is challenging. The ClearSight™ finger cuff (FC) uses the vascular unloading technique to provide continuous non-invasive blood pressure measurements. We aimed to test the agreement of the FC with invasive radial arterial monitoring (INV) in patients with obesity. METHODS: Participants had a body mass index (BMI) ≥45 kg/m2 and underwent laparoscopic bariatric surgery. FC and INV measurements were obtained simultaneously every 5 min on each patient, following induction of anesthesia. Agreement over time was assessed using modified Bland-Altman plots and error grid analysis permitted clinical interpretation of the results. Four-quadrant plots allowed assessment of concordance in blood pressure changes. RESULTS: The 30 participants had a median (IQR) BMI of 50.2 kg/m2 (IQR 48.3-55.3). The observed bias (SD, 95% limits of agreement) for systolic blood pressure (SBP) was 14.3 mmHg (14.1, -13.4 - 42.0), 5.2 mmHg (10.9, -16.0 - 26.5) for mean arterial pressure (MAP) and 2.6 mmHg (10.8, -18.6 - 23.8) for diastolic blood pressure (DBP). Error grid analysis showed that the proportion of readings in risk zones A-E were 90.8, 6.5, 2.7, 0 and 0% for SBP and 91.4, 4.3, 4.3, 0 and 0% for MAP, respectively. Discordance occurred in ≤8% of pairs for consecutive change in SBP, MAP and DBP. CONCLUSIONS: The vascular unloading technique was not adequately in agreement with radial arterial monitoring. Evaluation in a larger sample is required before recommending this technique for intraoperative monitoring of patients with BMI ≥45 kg/m2.
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Determinação da Pressão Arterial/instrumentação , Determinação da Pressão Arterial/métodos , Monitorização Intraoperatória/instrumentação , Monitorização Intraoperatória/métodos , Obesidade/cirurgia , Artéria Radial/fisiologia , Adulto , Idoso , Cirurgia Bariátrica , Pressão Sanguínea/fisiologia , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/fisiopatologia , Estudos Prospectivos , Reprodutibilidade dos Testes , Adulto JovemRESUMO
BACKGROUND: Rotational thromboelastometry (ROTEM® ) is a point-of-care coagulation test which has been used to demonstrate hypercoagulability in pregnant populations and obese populations. AIM: The aim of this study was to assess the combined effect of pregnancy and obesity on coagulation using ROTEM® in healthy pregnant women of varying body mass indices (BMIs) presenting for elective caesarean delivery. MATERIALS AND METHODS: Ethics approval was granted for recruitment of women presenting for elective caesarean delivery. Women with any condition affecting coagulation were excluded. The ROTEM® parameters of extrinsically activated thromboelastometric test / fibrin polymerisation test (EXTEM/FIBTEM) amplitude at five minutes (A5), coagulation time (CT), maximum clot firmness (MCF) and clot formation time (CFT) were compared between three different groups: normal weight, overweight and obese women. RESULTS: One hundred and eighty-five women presenting for elective caesarean delivery met inclusion criteria and were divided into three groups; normal weight (BMI < 25 kg/m2 , n = 86), overweight (BMI 25-29.9 kg/m2 , n = 54) and obese (BMI ≥ 30 kg/m2 , n = 45). They had a mean (SD) age of 32.7 ± 5.0 years and the median (interquartile range) BMI of 21.9 kg/m2 (20.5-23.0), 27.0 kg/m2 (26.0-28.5), 36.0 kg/m2 (32.2-41.8) for the normal weight, overweight and obese groups respectively. Forty-one (22.2%) women were nulliparous. Across the three groups for FIBTEM A5 (P = 0.018), FIBTEM MCF (P = 0.032), FIBTEM CFT (P = 0.047) and EXTEM MCF (P = 0.015) there was evidence of increasing coagulability with increasing BMI. However, following Bonferroni correction, this was no longer significant. CONCLUSIONS: There is no association between BMI and ROTEM® parameters in pregnant women presenting for elective caesarean delivery at term.
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Coagulação Sanguínea , Tromboelastografia , Adulto , Testes de Coagulação Sanguínea , Feminino , Humanos , Obesidade/complicações , Gravidez , Terceiro Trimestre da GravidezRESUMO
The laryngeal mask airways supreme (LMA-Supreme™) and protector (LMA-Protector™) are generally placed blindly, often resulting in a less than optimal position and vision-guided placement has been recommended. This prospective, randomized controlled study compared the efficacy of airway seal by measuring the oropharyngeal leak pressure in 100 surgical patients who underwent a variety of non-thoracic surgery under general anaesthesia, suitable with a supraglottic airway device. Patients were allocated to either the LMA-Supreme (n = 50) or LMA-Protector (n = 50) group. All insertions were performed under vision of a videolaryngoscope using an 'insert-detect-correct-as-you-go' technique with standardized corrective measures. Our primary endpoint, mean oropharyngeal leak pressure, was significantly higher in the LMA-Protector (31.7 ± 2.9 cm H2O) compared to the LMA-Supreme (27.7 ± 3.5 cm H2O) group (mean difference 4.0 cm H2O, 95% confidence interval (CI) 2.7-5.3 cm H2O, p < 0.001) after achieving a near-optimal fibreoptic position in the LMA-Protector (94%) and LMA-Supreme (96%) groups. No statistically significant differences were shown for secondary outcomes of alignment, number of insertion attempts and malpositions, and final anatomical position as scored by fibreoptic evaluation. Corrective manoeuvres were required in virtually all patients to obtain a correct anatomically positioned LMA. Position outcomes of the two devices were similar except for the proportion of procedures with folds in the proximal cuff (90% LMA-Supreme vs. 2% LMA-Protector, p < 0.001), the need for intracuff pressure adjustments (80% LMA-Supreme vs. 48% LMA-Protector, p = 0.001) and size correction (18% LMA-Supreme vs. 4% LMA-Protector, p = 0.025). In conclusion, a higher oropharyngeal leak pressure can be achieved with LMA-Protector compared to LMA-Supreme with optimal anatomical position when insertion is vision-guided.
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Manuseio das Vias Aéreas/instrumentação , Máscaras Laríngeas , Adulto , Anestesia Geral , Desenho de Equipamento , Feminino , Tecnologia de Fibra Óptica , Humanos , Laringoscópios , Masculino , Pessoa de Meia-Idade , Pressão , Estudos ProspectivosRESUMO
Healthcare waste is a rampant issue in Australian hospitals. The operating room (OR) contributes disproportionately to total hospital waste. There has been considerable research in the literature concentrating on strategies to improve OR and hospital waste accumulation, in an attempt to provide guidance and direction on how to reduce the healthcare ecological footprint. We reviewed the literature for leading greening initiatives currently utilised in the OR in Australia and internationally. This narrative literature review focuses on the trend of OR greening initiatives over the last 25 years, comparing different innovative approaches, the successes and setbacks, and the financial implications of initiatives. A variety of measures that hospital management, surgeons, anaesthetists, nurses and other healthcare personnel can take to reduce the ecological footprint of their healthcare facility are outlined. Greening initiatives include reducing, recycling, reusing, rethinking and researching, as well as novel technology and smarter architectural design. We also evaluated the barriers to improving waste management, which include lack of leadership, misconceptions among staff, and an overall resistance to change. In conclusion, in a world where greenhouse gas emissions cause unprecedented climate change and landfill space is finite, it is incumbent upon hospitals to help reduce the environmental impact of their facility. Reducing pollution and greenhouse gas emissions would moderate the incidence of human disease, save money for the healthcare system and society as a whole, and contribute to a safer and healthier world we all would like to live in.
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Eliminação de Resíduos , Gerenciamento de Resíduos , Austrália , Efeito Estufa , Humanos , Salas Cirúrgicas , Reciclagem , Instalações de Eliminação de ResíduosRESUMO
Sustainability interventions were implemented at the Royal Brisbane and Women's Hospital (RBWH) following identification of inhaled anaesthetic gases as a target for reducing medical carbon emissions. This quality improvement study assessed and evaluated the impact of sustainability interventions on the environmental and financial cost of inhaled anaesthetic gas use in order to guide future initiatives and research in reducing carbon emissions from healthcare practice.Ethical exemption was granted from the RBWH Research Ethics Committee (EX/2021/QRBW/76078). Usage (bottles) and expenditure for desflurane and sevoflurane from January 2016 to December 2021 were obtained. Global warming potential and carbon dioxide equivalent (CO2e) were used to report environmental impact of volatile agents. Methods to estimate this were performed in Excel based on Campbell and Pierce methodology. An Environmental Protection Agency greenhouse gas equivalency calculator was used to convert CO2e to equivalent petrol carbon emissions and kilometres travelled by a typical passenger vehicle.The total number of bottles of sevoflurane and desflurane purchased between January 2016 and December 2021 decreased by 34.76% from 1991 to 1299. The number of desflurane bottles purchased decreased by 95.63% from 800 to 35 bottles. The number of sevoflurane bottles purchased increased by 6.13% from 1191 bottles to 1264 bottles. This was achieved by implementing quality improvement interventions such as staff education of desflurane-sparing practices, distribution of posters and progressive removal of desflurane from operating theatres. Total carbon emission from volatile anaesthetics equalled 2326 tonnes CO2e. Combined desflurane and sevoflurane emissions decreased by 87.88%. In 2016, desflurane made up 92.39% of the annual CO2e, which steadily decreased to 33.36% in 2021. Combined sevoflurane and desflurane usage costs decreased by 58.33%.Substantial reductions in carbon emissions from volatile anaesthetics demonstrate the significant degree to which environmentally sustainable practices have been implemented. Applying desflurane-sparing practice can heavily limit anaesthetic drug expenditure and contribution to environmental waste. This is important given the global health sector's challenge to optimise patient outcomes in the face of global climate change crisis.
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Anestesia , Anestésicos Inalatórios , Gases de Efeito Estufa , Isoflurano , Éteres Metílicos , Desflurano , Feminino , Humanos , Sevoflurano , Estados UnidosRESUMO
A perioperative patient blood management (PBM) educational intervention was implemented for first year postgraduate doctors (interns) at the Royal Brisbane and Women's Hospital (RBWH) following identification of a perioperative PBM training requirement. This quality improvement activity evaluated the effectiveness of this educational intervention in improving intern knowledge of perioperative PBM principles.A 15-question perioperative PBM focused multiple choice questionnaire developed from information attained from comprehensive, evidence and consensus-based guidelines regarding PBM practice was distributed to interns immediately before a compulsory perioperative PBM educational intervention and then again 5 weeks later. The perioperative PBM educational intervention was delivered every 10 weeks (five interventions in total) to a different group of interns each time. Statistical analysis determined significance between mean questionnaire score before and after the intervention.The mean pre-intervention score for correctly answered questions was 7/15 (SD 2.73) and mean post-intervention score was 9/15 (SD 2.99) (p=0.02). Categorisation of questions into core domains of perioperative PBM demonstrated intern scores for correctly answered questions improved in all domains following the educational intervention.Perioperative PBM education delivered through a dedicated intervention aimed to improve knowledge is associated with objective evidence of educational benefits for interns at RBWH. It is an effective strategy to enact PBM governance and bestow clinical guideline knowledge. This is important given the global health sector's challenge to improve patient outcomes despite increasingly restricted funding and pressure on doctors to devote more time to service and less to teaching.
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Competência Clínica , Melhoria de Qualidade , Transfusão de Sangue , Feminino , HumanosRESUMO
Background: Increasing evidence indicates a role for Epstein-Barr virus (EBV) in the pathogenesis of multiple sclerosis (MS). EBV-infected autoreactive B cells might accumulate in the central nervous system because of defective cytotoxic CD8+ T cell immunity. We have previously reported results of a phase I clinical trial of autologous EBV-specific T cell therapy in MS 6 months after treatment. Objective: To investigate longer-term outcomes in MS patients who received autologous EBV-specific T cell therapy. Methods: We assessed participants 2 and 3 years after completion of T cell therapy. Results: We collected data from all 10 treated participants at year 2 and from 9 participants at year 3. No serious treatment-related adverse events were observed. Four participants had at least some sustained clinical improvement at year 2, including reduced fatigue in three participants, and reduced Expanded Disability Status Scale score in two participants. Three participants experienced a sustained improvement in at least some symptoms at year 3. More sustained improvement was associated with higher EBV-specific CD8+ T cell reactivity in the administered T cell product. Conclusion: Autologous EBV-specific T cell therapy is well-tolerated, and some degree of clinical improvement can be sustained for up to 3 years after treatment.
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Neoplasias Abdominais/cirurgia , Anestésicos/administração & dosagem , Procedimentos Cirúrgicos do Sistema Biliar/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Fígado/cirurgia , Feocromocitoma/cirurgia , Neoplasias Abdominais/diagnóstico , Adulto , Sistema Biliar/patologia , Gerenciamento Clínico , Humanos , Fígado/patologia , Masculino , Feocromocitoma/diagnósticoRESUMO
Allogeneic blood transfusion (ABT) is associated with transfusion-related immune modulation (TRIM) and subsequent poorer patient outcomes including perioperative infection, multiple organ failure, and mortality. The precise mechanism(s) underlying TRIM remain largely unknown. During intraoperative cell salvage (ICS) a patient's own (autologous) blood is collected, anticoagulated, processed, and reinfused. One impediment to understanding the influence of the immune system on transfusion-related adverse outcomes has been the inability to characterize immune profile changes induced by blood transfusion, including ICS. Dendritic cells and monocytes play a central role in regulation of immune responses, and dysfunction may contribute to adverse outcomes. During a prospective observational study (n = 19), an in vitro model was used to assess dendritic cell and monocyte immune responses and the overall immune response following ABT or ICS exposure. Exposure to both ABT and ICS suppressed dendritic cell and monocyte function. This suppression was, however, significantly less marked following ICS. ICS presented an improved immune competence. This assessment of immune competence through the study of intracellular cytokine production, co-stimulatory and adhesion molecules expressed on dendritic cells and monocytes, and modulation of the overall leukocyte response may predict a reduction of adverse outcomes ( i.e., infection) following ICS.
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Transfusão de Sangue/métodos , Humanos , Imunidade/fisiologia , Monócitos/fisiologia , Estudos ProspectivosRESUMO
Generally, ORs produce approximately one-fifth to one-third of all waste in a hospital. Before our quality improvement project was performed in our tertiary care facility, all OR waste was disposed of as clinical waste. Disposal of clinical waste is more costly than disposal of general waste. Therefore, accurately segregating waste can have significant financial incentives. Our quality improvement project involved the implementation of processes that segregated general waste in the OR from clinical waste and translated to an almost 60% reduction of waste disposal costs for OR waste. Further, we implemented a recycling program that reclaimed a portion of the general waste. In total, our efforts reduced the amount of clinical waste produced by the OR by 82%, and the amount of total OR waste was reduced by more than 50%.