RESUMO
BACKGROUND: We analysed the clinical practice of anaesthesia associates in the UK, as reported to the 7th National Audit Project of the Royal College of Anaesthetists, and compared these with medically qualified anaesthetists. METHODS: We included data from our baseline survey, activity survey and case registry as with other reports from the project. RESULTS: Among 197 departments of anaesthesia, 52 (26%) employed anaesthesia associates. Of 10,009 responding anaesthesia care providers, 71 (< 1%) were anaesthesia associates, of whom 33 (47%) reporting working nights or weekends (compared with 97% of medically qualified anaesthetists in training and > 90% of consultants). Anaesthesia associates reported less training and confidence in managing peri-operative cardiac arrest and its aftermath compared with medically qualified anaesthetists. Anaesthesia associates were less directly involved in the management and the aftermath of peri-operative cardiac arrest than medically qualified anaesthetists, and the psychological impacts on professional and personal life appeared to be less. Among 24,172 cases, anaesthesia associates attended 432 (2%) and were the senior anaesthesia care provider in 63 (< 1%), with indirect supervision in 27 (43%). Anaesthesia associates worked predominantly in a small number of surgical specialties during weekdays and working daytime hours. Complication rates were low in cases managed by anaesthesia associates, likely reflecting case mix. However, activity and registry case mix data show anaesthesia associates do manage high-risk cases (patients who are older, comorbid, obese and frail) with the potential for serious complications. Registry cases included higher risk cases with respect to the clinical setting and patient factors. CONCLUSION: Anaesthesia associates work in enhanced roles, relative to the scope of practice at qualification agreed by organisations. Recent changes mean the Royal College of Anaesthetists and Association of Anaesthetists do not currently support an enhanced scope of practice.
RESUMO
BACKGROUND: The 7th National Audit Project of the Royal College of Anaesthetists studied peri-operative cardiac arrest because of existing knowledge gaps in this important topic. This applies in particular to cardiology patients receiving anaesthetic care, because numbers, types and complexity of minimally invasive interventional procedures requiring planned and unplanned anaesthesia in the cardiac intervention suite is increasing. METHODS: We analysed collected data to determine the epidemiology, clinical features, management and outcomes of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures. RESULTS: There were 54 reports of peri-operative cardiac arrest in adult patients receiving anaesthetic care for cardiology procedures, accounting for 54/881 (6.1%) of all reports to NAP7. The estimated incidence (95%CI) of cardiac arrests in this group was 1/450 or 0.22 (0.17-0.29)%. These patients were older than other adult patients in the NAP7 population, with a notably high proportion of patients of Asian ethnicity when compared with the remaining NAP7 cohort (9/54, 17% vs. 35/709, 5%). Rates of extracorporeal membrane oxygenation cardiopulmonary resuscitation were low (3/53, 6%). A common theme was that of logistical issues and teamworking, with reporters commenting on the difficulties of remote and/or unfamiliar locations and communication issues between specialties, on occasion resulting in poor teamworking and a lack of focus. The NAP7 panel review identified several other common themes which included: cardiogenic shock; late involvement of anaesthesia in the case; and transcatheter aortic valve implantation. CONCLUSION: Cardiology procedures requiring anaesthesia care account for < 1% of anaesthesia activity but generate 6% of all peri-operative cardiac arrests. The incidence of cardiac arrest was disproportionately high in cardiological procedures requiring anaesthetic care. The nature of the cardiac arrest reports to NAP7 indicate that logistical and human factors in multidisciplinary teams in the cardiac intervention suite merit addressing to improve care.
RESUMO
BACKGROUND: Few existing resuscitation guidelines include specific reference to intra-operative cardiac arrest, but its optimal treatment is likely to require some adaptation of standard protocols. METHODS: We analysed data from the 7th National Audit Project of the Royal College of Anaesthetists to determine the incidence and outcome from intra-operative cardiac arrest and to summarise the advanced life support interventions reported as being used by anaesthetists. RESULTS: In the baseline survey, > 50% of anaesthetists responded that they would start chest compressions when the non-invasive systolic pressure was < 40-50 mmHg. Of the 881 registry patients, 548 were adult patients (aged > 18 years) having non-obstetric procedures under the care of an anaesthetist, and who had arrested during anaesthesia (from induction to emergence). Sustained return of spontaneous circulation was achieved in 425 (78%) patients and 338 (62%) were alive at the time of reporting. In the 365 patients with pulseless electrical activity or bradycardia, adrenaline was given as a 1 mg bolus in 237 (65%). A precordial thump was used in 14 (3%) patients, and although this was associated with return of spontaneous circulation at the next rhythm check in almost three-quarters of patients, in only one of these was the initial rhythm shockable. Calcium (gluconate or chloride) and 8.4% sodium bicarbonate were given to 51 (9%) and 25 (5%) patients, but there were specific indications for these treatments in less than half of the patients. A thrombolytic drug was given to 5 (1%) patients, and extracorporeal cardiopulmonary resuscitation was used in 9 (2%) of which eight occurred during cardiac procedures. CONCLUSIONS: The specific characteristics of intra-operative cardiac arrest imply that its optimal treatment requires modifications to standard advanced life support guidelines.
Assuntos
Parada Cardíaca , Humanos , Parada Cardíaca/terapia , Parada Cardíaca/epidemiologia , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Adulto , Complicações Intraoperatórias/epidemiologia , Auditoria Médica , Suporte Vital Cardíaco Avançado , Reanimação Cardiopulmonar/métodos , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: Acute diverticulitis (AD) is a common cause of presentation to emergency surgical services. Follow-up with endoluminal investigation to exclude colorectal cancer (CRC) remains controversial. Guidelines are increasingly moving to a more restrictive follow-up based on severity of disease and age. The purpose of this observational study was to assess the prevalence of CRC in AD patients and the impact of follow-up on endoscopy services. METHODS: Patients admitted with a diagnosis of AD over a 2-year period were reviewed. The proportion of patients undergoing endoscopic follow-up and the CRC detection rate were recorded. The potential impact of a more conservative approach to follow-up was evaluated. RESULTS: There were 484 patients with AD presenting 546 times (M:F = 198:286; median age = 63 years). 80% of admissions were aged 50 or older. There were 43 emergency interventions in 39 patients (10 percutaneous drain; 33 surgery). The remainder were managed conservatively. 28 patients (5.1%) underwent colonic resection with cancer found in one specimen (3.6%). 287 patients underwent endoluminal follow-up with cancer diagnosed in 3 cases (1.0%). There was no significant difference in the prevalence of CRC between patients requiring emergency surgery and those managed conservatively, or between patients with complicated versus uncomplicated diverticulitis. CONCLUSION: CRC masquerading as acute diverticulitis is rare. The incidence of neoplasia both at endoscopic follow-up and in patients requiring emergency intervention is low. Conservative follow-up strategies appear safe, but their effectiveness in reducing the burden on endoscopy services may be limited by current age-based recommendations. Restricting follow-up to those with complicated AD would reduce the number of patients requiring endoluminal investigation by 70%.
Assuntos
Neoplasias Colorretais , Doença Diverticular do Colo , Diverticulite , Humanos , Pessoa de Meia-Idade , Seguimentos , Doença Diverticular do Colo/complicações , Doença Diverticular do Colo/diagnóstico , Doença Diverticular do Colo/epidemiologia , Colonoscopia/efeitos adversos , Diverticulite/complicações , Neoplasias Colorretais/diagnóstico , Doença Aguda , Estudos RetrospectivosRESUMO
OBJECTIVE: To determine if oesophago-gastro-duodenoscopy (OGD) generates increased levels of aerosol in conscious patients and identify the source events. DESIGN: A prospective, environmental aerosol monitoring study, undertaken in an ultraclean environment, on patients undergoing OGD. Sampling was performed 20 cm away from the patient's mouth using an optical particle sizer. Aerosol levels during OGD were compared with tidal breathing and voluntary coughs within subject. RESULTS: Patients undergoing bariatric surgical assessment were recruited (mean body mass index 44 and mean age 40 years, n=15). A low background particle concentration in theatres (3 L-1) enabled detection of aerosol generation by tidal breathing (mean particle concentration 118 L-1). Aerosol recording during OGD showed an average particle number concentration of 595 L-1 with a wide range (3-4320 L-1). Bioaerosol-generating events, namely, coughing or burping, were common. Coughing was evoked in 60% of the endoscopies, with a greater peak concentration and a greater total number of sampled particles than the patient's reference voluntary coughs (11 710 vs 2320 L-1 and 780 vs 191 particles, n=9 and p=0.008). Endoscopies with coughs generated a higher level of aerosol than tidal breathing, whereas those without coughs were not different to the background. Burps also generated increased aerosol concentration, similar to those recorded during voluntary coughs. The insertion and removal of the endoscope were not aerosol generating unless a cough was triggered. CONCLUSION: Coughing evoked during OGD is the main source of the increased aerosol levels, and therefore, OGD should be regarded as a procedure with high risk of producing respiratory aerosols. OGD should be conducted with airborne personal protective equipment and appropriate precautions in those patients who are at risk of having COVID-19 or other respiratory pathogens.
Assuntos
COVID-19 , Tosse , Endoscopia Gastrointestinal/efeitos adversos , Adulto , Aerossóis , Tosse/etiologia , Duodenoscopia , Esofagoscopia , Gastroscopia , Humanos , Tamanho da Partícula , Estudos ProspectivosRESUMO
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de-labelling service for their patients. It is intended to supplement the BSACI 2015 guideline "Management of allergy to penicillin and other beta-lactams" and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta-lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non-allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.
Assuntos
Hipersensibilidade a Drogas , Penicilinas , Adulto , Antibacterianos/efeitos adversos , Criança , Hipersensibilidade a Drogas/diagnóstico , Hipersensibilidade a Drogas/epidemiologia , Hipersensibilidade a Drogas/terapia , Hospitais , Humanos , Penicilinas/efeitos adversos , beta-Lactamas/efeitos adversosRESUMO
Recent evidence, highlighted in this editorial, creates a strong argument for universal use of videolaryngoscopy in anaesthesia to improve efficiency and safety of tracheal intubation. In a recent study published in the British Journal of Anaesthesia, the authors implemented widespread (66%) use of videolaryngoscopy as first choice in one hospital and compared this with a control hospital, in which this was not implemented. Increased videolaryngoscopy use was associated with a significant fall in the rate of difficult airways, use of airway rescue techniques, and operator-reported difficulty, whilst in the control hospitals no such changes were seen. Locations outside the operating theatre might also benefit from universal laryngoscopy, but the evidence base is less robust, most notably in pre-hospital emergency medicine. The extent to which variation in results in different locations is attributable to different patient factors or organisational and operator factors is considered.
Assuntos
Anestesiologia , Laringoscópios , Humanos , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Salas CirúrgicasRESUMO
BACKGROUND: Tracheal intubation is a commonly performed procedure that can be associated with complications and result in patient harm. Videolaryngoscopy (VL) may decrease this risk as compared with Macintosh direct laryngoscopy (DL). This review evaluates the risk and benefit profile of VL compared with DL in adults. METHODS: We searched MEDLINE, Embase, CENTRAL, and Web of Science on February 27, 2021. We included RCTs comparing VL with DL in patients undergoing tracheal intubation in any setting. We separately compared outcomes according to VL design: Macintosh-style, hyperangulated, and channelled. RESULTS: A total of 222 RCTs (with 26 149 participants) were included. Most studies had unclear risk of bias in at least one domain, and all were at high risk of performance and detection bias. We found that videolaryngoscopes of any design likely reduce rates of failed intubation (Macintosh-style: risk ratio [RR]=0.41; 95% confidence interval [CI], 0.26-0.65; hyperangulated: RR=0.51; 95% CI, 0.34-0.76; channelled: RR=0.43, 95% CI, 0.30-0.61; moderate-certainty evidence) with increased rates of successful intubation on first attempt and better glottic views across patient groups and settings. Hyperangulated designs are likely favourable in terms of reducing the rate of oesophageal intubation, and result in improved rates of successful intubation in individuals presenting with difficult airway features (P=0.03). We also present other patient-oriented outcomes. CONCLUSIONS: In this systematic review and meta-analysis of trials of adults undergoing tracheal intubation, VL was associated with fewer failed attempts and complications such as hypoxaemia, whereas glottic views were improved. SYSTEMATIC REVIEW REGISTRATION: This article is based on a Cochrane Review published in the Cochrane Database of Systematic Reviews (CDSR) 2022, Issue 4, DOI: 10.1002/14651858.CD011136.pub3 (see www.cochranelibrary.com for information). Cochrane Reviews are regularly updated as new evidence emerges and in response to feedback, and the CDSR should be consulted for the most recent version of the review.
Assuntos
Laringoscópios , Laringoscopia , Adulto , Esôfago , Glote , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Laringoscopia/métodosRESUMO
BACKGROUND: Tracheal intubation is a common procedure performed to secure the airway in adults undergoing surgery or those who are critically ill. Intubation is sometimes associated with difficulties and complications that may result in patient harm. While it is traditionally achieved by performing direct laryngoscopy, the past three decades have seen the advent of rigid indirect videolaryngoscopes (VLs). A mounting body of evidence comparing the two approaches to tracheal intubation has been acquired over this period of time. This is an update of a Cochrane Review first published in 2016. OBJECTIVES: To assess whether use of different designs of VLs in adults requiring tracheal intubation reduces the failure rate compared with direct laryngoscopy, and assess the benefits and risks of these devices in selected population groups, users and settings. SEARCH METHODS: We searched MEDLINE, Embase, CENTRAL and Web of Science on 27 February 2021. We also searched clinical trials databases, conference proceedings and conducted forward and backward citation searches. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and quasi-RCTs with adults undergoing laryngoscopy performed with either a VL or a Macintosh direct laryngoscope (DL) in any clinical setting. We included parallel and cross-over study designs. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We collected data for the following outcomes: failed intubation, hypoxaemia, successful first attempt at tracheal intubation, oesophageal intubation, dental trauma, Cormack-Lehane grade, and time for tracheal intubation. MAIN RESULTS: We included 222 studies (219 RCTs, three quasi-RCTs) with 26,149 participants undergoing tracheal intubation. Most studies recruited adults undergoing elective surgery requiring tracheal intubation. Twenty-one studies recruited participants with a known or predicted difficult airway, and an additional 25 studies simulated a difficult airway. Twenty-one studies were conducted outside the operating theatre environment; of these, six were in the prehospital setting, seven in the emergency department and eight in the intensive care unit. We report here the findings of the three main comparisons according to videolaryngoscopy device type. We downgraded the certainty of the outcomes for imprecision, study limitations (e.g. high or unclear risks of bias), inconsistency when we noted substantial levels of statistical heterogeneity and publication bias. Macintosh-style videolaryngoscopy versus direct laryngoscopy (61 studies, 9883 participants) We found moderate-certainty evidence that a Macintosh-style VL probably reduces rates of failed intubation (risk ratio (RR) 0.41, 95% confidence interval (CI) 0.26 to 0.65; 41 studies, 4615 participants) and hypoxaemia (RR 0.72, 95% CI 0.52 to 0.99; 16 studies, 2127 participants). These devices may also increase rates of success on the first intubation attempt (RR 1.05, 95% CI 1.02 to 1.09; 42 studies, 7311 participants; low-certainty evidence) and probably improve glottic view when assessed as Cormack-Lehane grade 3 and 4 (RR 0.38, 95% CI 0.29 to 0.48; 38 studies, 4368 participants; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.51, 95% CI 0.22 to 1.21; 14 studies, 2404 participants) but this finding was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of this evidence was very low (RR 0.68, 95% CI 0.16 to 2.89; 18 studies, 2297 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 96%). Hyperangulated videolaryngoscopy versus direct laryngoscopy (96 studies, 11,438 participants) We found moderate-certainty evidence that hyperangulated VLs probably reduce rates of failed intubation (RR 0.51, 95% CI 0.34 to 0.76; 63 studies, 7146 participants) and oesophageal intubation (RR 0.39, 95% CI 0.18 to 0.81; 14 studies, 1968 participants). In subgroup analysis, we noted that hyperangulated VLs were more likely to reduce failed intubation when used on known or predicted difficult airways (RR 0.29, 95% CI 0.17 to 0.48; P = 0.03 for subgroup differences; 15 studies, 1520 participants). We also found that these devices may increase rates of success on the first intubation attempt (RR 1.03, 95% CI 1.00 to 1.05; 66 studies, 8086 participants; low-certainty evidence) and the glottic view is probably also improved (RR 0.15, 95% CI 0.10 to 0.24; 54 studies, 6058 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). However, we found low-certainty evidence of little or no clear difference in rates of hypoxaemia (RR 0.49, 95% CI 0.22 to 1.11; 15 studies, 1691 participants), and the findings for dental trauma were unclear because the certainty of this evidence was very low (RR 0.51, 95% CI 0.16 to 1.59; 30 studies, 3497 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 99%). Channelled videolaryngoscopy versus direct laryngoscopy (73 studies, 7165 participants) We found moderate-certainty evidence that channelled VLs probably reduce rates of failed intubation (RR 0.43, 95% CI 0.30 to 0.61; 53 studies, 5367 participants) and hypoxaemia (RR 0.25, 95% CI 0.12 to 0.50; 15 studies, 1966 participants). They may also increase rates of success on the first intubation attempt (RR 1.10, 95% CI 1.05 to 1.15; 47 studies, 5210 participants; very low-certainty evidence) and probably improve glottic view (RR 0.14, 95% CI 0.09 to 0.21; 40 studies, 3955 participants; data for Cormack-Lehane grade 3/4 views; moderate-certainty evidence). We found little or no clear difference in rates of oesophageal intubation (RR 0.54, 95% CI 0.17 to 1.75; 16 studies, 1756 participants) but this was supported by low-certainty evidence. We were unsure of the findings for dental trauma because the certainty of the evidence was very low (RR 0.52, 95% CI 0.13 to 2.12; 29 studies, 2375 participants). We were not able to pool data for time required for tracheal intubation owing to considerable heterogeneity (I2 = 98%). AUTHORS' CONCLUSIONS: VLs of all designs likely reduce rates of failed intubation and result in higher rates of successful intubation on the first attempt with improved glottic views. Macintosh-style and channelled VLs likely reduce rates of hypoxaemic events, while hyperangulated VLs probably reduce rates of oesophageal intubation. We conclude that videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.
Assuntos
Laringoscópios , Laringoscopia , Adulto , Estado Terminal , Humanos , Intubação Intratraqueal , Laringoscopia/métodosRESUMO
Tracheal intubation is among the most frequently performed manoeuvres in the critical care setting, and can be life-saving in critical illness, though also associated with serious adverse events such as oesophageal intubation or tracheal tube obstruction, displacement, or disconnection from the ventilator. A key finding of the 4th National Audit Project (NAP4) was identification of waveform capnography as the single intervention with the highest potential for reducing morbidity and mortality during tracheal intubation and maintenance of an artificial airway. In the INTUBE study, penetration of capnography into ICUs was low, and was not in use in 70% of the episodes of oesophageal intubation. To reduce harm and avoidable death, there is a need for a global initiative to increase access to and use of capnography in ICUs.
Assuntos
Capnografia/métodos , Cuidados Críticos/métodos , Intubação Intratraqueal/métodos , Obstrução das Vias Respiratórias/etiologia , Obstrução das Vias Respiratórias/prevenção & controle , Acessibilidade aos Serviços de Saúde , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversosRESUMO
Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.
Assuntos
Betacoronavirus , Infecções por Coronavirus/terapia , Intubação Intratraqueal/métodos , Equipamento de Proteção Individual , Pneumonia Viral/terapia , Idoso , COVID-19 , China , Infecções por Coronavirus/complicações , Infecções por Coronavirus/prevenção & controle , Feminino , Humanos , Hipotensão/etiologia , Hipóxia/etiologia , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/complicações , Pneumonia Viral/prevenção & controle , Pneumotórax/etiologia , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , SARS-CoV-2RESUMO
Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.
RESUMO
BACKGROUND: Clinical indicators are powerful tools to quantify the safety and quality of patient care. Their validity is often unclear and definitions extremely heterogeneous. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid clinical outcome indicators for use in perioperative clinical trials. METHODS: We identified clinical indicators via a systematic review of the anaesthesia and perioperative medicine literature (PubMed/OVID, EMBASE, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 54 clinician-researchers worldwide. Indicators were first shortlisted and the most suitable definitions for evaluation of quality and safety interventions determined. Indicators were then assessed for validity, reliability, feasibility, and clarity. RESULTS: We identified 167 clinical outcome indicators. Participation in the three Delphi rounds was 100% (n=13), 68% (n=54), and 85% (n= 6), respectively. A final list of eight outcome indicators was generated: surgical site infection at 30 days, stroke within 30 days of surgery, death within 30 days of coronary artery bypass grafting, death within 30 days of surgery, admission to the intensive care unit within 14 days of surgery, readmission to hospital within 30 days of surgery, and length of hospital stay (with or without in-hospital mortality). They were rated by the majority of experts as valid, reliable, easy to use, and clearly defined. CONCLUSIONS: These clinical indicators can be confidently used as endpoints in clinical trials measuring quality, safety, and improvement in perioperative care. REGISTRATION: PROSPERO 2016 CRD42016042102 (http://www.crd.york.ac.uk/PROSPERO/display_record.php? ID=CRD42016042102).
Assuntos
Consenso , Avaliação de Resultados em Cuidados de Saúde/normas , Segurança do Paciente/normas , Assistência Perioperatória/normas , Qualidade da Assistência à Saúde/normas , Ensaios Clínicos como Assunto , Humanos , Padrões de Referência , Reprodutibilidade dos TestesRESUMO
OBJECTIVE: To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP). DESIGN: Systematic review with best evidence synthesis. DATA SOURCES: The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched. ELIGIBILITY CRITERIA: Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement. RESULTS: Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12-26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes. CONCLUSION: Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections. TRIAL REGISTRATION NUMBER: PROSPERO CRD42016033161.