Impact of a phosphorylcholine-coated cardiac bypass circuit on blood loss and platelet function: a prospective, randomized study.

Platelet dysfunction due to cardiopulmonary bypass (CPB) surgery increases the risk of bleeding. This study analyzed the effect of a phosphorylcholine (PC)-coated CPB circuit on blood loss, transfusion needs, and platelet function. We performed a prospective, randomized study at Strasbourg University Hospital, which included 40 adults undergoing coronary artery bypass graft surgery (CABG) (n = 20) or mitral valve repair (n = 20) using CPB. Patients were randomized either to PC-coated CPB or uncoated CPB (10 CABG patients and 10 mitral valve repair patients in each group). Blood loss and transfusion needs were evaluated intra- and postoperatively. Markers of platelet activation and thrombin generation were measured at anesthesia induction, at the beginning and end of CPB, on skin closure, and on days 0, 1, and 5. Comparisons were made by Student's t test or covariance analysis (significance threshold p < or = .05). Blood loss was significantly lower in the PC group during the first 6 postoperative hours (171 +/- 102 vs. 285 +/- 193 mL, p = .024), at the threshold of significance from 6-24 hours (p = .052), and similar in both groups after 24 hours. During CPB, platelet count decreased by 48% in both groups. There was no difference in markers of platelet activation, thrombin generation, or transfusion needs between the two groups. Norepinephrine use was more frequent in the control group (63% vs. 33%) but not significantly. PC-coating of the CPB surface reduced early postoperative bleeding, especially in CABG patients, but had no significant effect on platelet function because of large interindividual variations that prevented the establishment of a causal relationship.

Impact of training periods in the emergency department on the motivation of health care students to learn.

OBJECTIVES: Motivation is one of the most important factors for learning and achievement. The perceived value of the task, perceptions of self-efficacy and beliefs about control of learning are the main determinants of motivation. They are highly influenced by the individual's personal history and especially by significant past experiences. We assessed the impact of training periods in the emergency department on the motivation of health care students to learn in the field of emergency medicine. METHODS: A survey was conducted in 2008 with 112 undergraduate medical students and 201 undergraduate nursing students attending an emergency medicine academic programme. At the beginning of the course, the students completed an anonymous 26-item questionnaire to assess their motivational orientations. RESULTS: Perceived task value was higher for students who had previously attended a training period in the emergency department (P = 0.002). Perceived self-efficacy was depressed when the respondent had been confronted with negative outcome events (P < 0.001). Control of learning beliefs was affected negatively in students who had attended a training period in the emergency department (P < 0.001). CONCLUSIONS: Motivation is a major contributor to the success of learning. Training periods in the emergency department can have positive and negative impacts on the learning motivation of medical and nursing students in the field of emergency medicine. Ideally, and in terms of increasing motivation, health care students should gain experiential learning in the emergency department before attending a corresponding academic course. During this period, tutors should provide appropriate supervision and feedback in order to support self-efficacy perception and learning control beliefs.

Using baseline data to address the lack of hospital beds during mass-casualty incidents.

The management of victims during mass-casualty incidents (MCIs) is improving. In many countries, physicians and paramedics are well-trained to manage these incidents. A problem that has been encountered during MCIs is the lack of adequate numbers of hospital beds to accommodate the injured. In Europe, hospitals are crowded. One solution for the lack of beds is the creation of baseline data systems that could be consulted by medical personnel in all European countries. A MCI never has occurred in northeastern Europe, but such an event remains a possibility. This paper describes how the use of SAGEC 67, a free-access, information database concerning the availability of beds should help the participating countries, initially France, Germany, and Switzerland, respond to a MCI by dispatching each patient to an appropriate hospital and informing their families and physicians using their own language. Baseline data for more than 20 countries, and for hospitals, especially those in Germany, Switzerland, and France, were collected. Information about the number of beds and their availability hour-by-hour was included. In the case of MCIs, the baseline data program is opened and automatically connects to all of the countries. In case of a necessary hospital evacuation, the required beds immediately are occupied in one of these three countries. Questions and conversations among medical staff or family members can be accomplished between hospitals through computer, secured-line chatting that automatically translates into appropriate language. During the patient evacuation phase of a MCI, respondents acknowledged that a combination of local, state, and private resources and international cooperation eventually would be needed to meet the demand. Patient evacuation is optimized through the use of SAGEC 67, a free baseline database.

Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia.

BACKGROUND: Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid. METHODS: In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day. RESULTS: Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups. CONCLUSION: After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Effects of subtenon anesthesia combined with general anesthesia on perioperative analgesic requirements in pediatric strabismus surgery.

BACKGROUND AND OBJECTIVES: Pediatric strabismus surgery leads to undesirable intraoperative and postoperative side effects that include pain, postoperative nausea and vomiting (PONV), and oculocardiac reflex (OCR). We hypothesized that subtenon anesthesia performed before the start of surgery and combined with general intravenous anesthesia would reduce these adverse effects. METHODS: Forty children (2.5 to 6 years of age, ASA status I to II) were prospectively randomized to receive either subtenon bupivacaine 0.5% or a saline injection before the beginning of surgery in a double-blind manner. Perioperative analgesic requirements, pain scores (CHEOPS scale), hemodynamics, and incidence of OCR and PONV were compared. RESULTS: Postoperative pain scores were lower (P < .001) at removal of the laryngeal mask and 30 minutes later in the bupivacaine group. Intraoperative and postoperative analgesic requirements were significantly reduced in this group (P < .01). The incidence of OCR and PONV were also significantly decreased (P < .01). Intraoperative values of blood pressure were significantly higher in the saline group at 20 minutes (P < .02). CONCLUSION: We conclude that preoperative subtenon bupivacaine 0.5% compared with a saline injection contributed to reduction of perioperative pain and undesirable side effects in pediatric strabismus surgery performed under general anesthesia.

Does thoracic epidural analgesia improve outcome after lung transplantation?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether the use of preoperative or early postoperative thoracic epidural analgesia (TEA) is effective in improving outcomes--reducing duration of mechanical ventilation, intensive care unit (ICU) length of stay and respiratory complications--in patients undergoing lung transplantation (LTx). Of the 42 papers found using a report search, five presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, four out of the five retrieved studies clearly supported the use of TEA as the cornerstone of a multi-faceted strategy for improving outcomes after LTx. Indeed, the interest and benefit was shown not only in terms of duration of mechanical ventilation, but also in reducing the ICU length of stay and the number of respiratory complications. Hence, current evidence suggests TEA to be safe and effective in alleviating postoperative pain and in improving patient recovery, thus enhancing the choice of available medical care and bettering outcome after LTx. However, given the low level of evidence of published studies, prospective trials are warranted to confirm those encouraging results.

Gender stereotypes: an explanation to the underrepresentation of women in emergency medicine.

OBJECTIVES: Women are underrepresented in emergency medicine (EM) residency programs in comparison with many other specialties. The reasons for this are unclear. One hypothesis is that negative gender stereotypes about EM careers might exist among female medical students. In the field of education, negative gender stereotypes are known to lead to career avoidance, because they tend to decrease self-efficacy perception. The aims of this study were to assess the prevalence of negative gender stereotypes about EM practice among medical students and to measure the effects of these stereotypes on females' self-efficacy perception toward EM learning. METHODS: A survey was conducted of the 255 third-year medical students from three medical schools who attended a mandatory EM academic program in France. They completed an anonymous questionnaire exploring their gender stereotypes about EM practice and their self-efficacy perception toward EM learning. RESULTS: Gender stereotypes are common among medical students, especially in women. Self-efficacy perception is negatively correlated to female students' belief that EM careers are better suited for men (p < 0.05). CONCLUSIONS: Negative gender stereotypes among female medical students may lead to EM career avoidance, because of the decrease in their self-efficacy perception toward EM learning.

Efficacy and safety of remifentanil in coronary artery bypass graft surgery: a randomized, double-blind dose comparison study.

OBJECTIVES: To compare the efficacy and safety of 3 doses of remifentanil as part of a total intravenous anesthesia technique with low-dose propofol in patients undergoing coronary artery bypass graft (CABG) surgery. DESIGN: Multicenter, multinational, double-blind, randomized, dose comparison study. SETTING: Nine hospitals in 5 countries. PARTICIPANTS: One hundred forty-one patients undergoing first-time elective CABG surgery. INTERVENTIONS: Patients were premedicated with a short-acting oral benzodiazepine up to 2 h before surgery and randomized to receive continuous infusions of remifentanil 1.0 microg/kg/min (n = 45), 1.5 microg/kg/min (n = 44), or 2.0 microg/kg/min (n = 43), in combination with propofol 3 mg/kg/h. Nine patients received remifentanil 1.0 microg/kg/min on an open-label basis. Three different induction sequences (IS) were used. In IS 1 (n = 31), induction was started with remifentanil infusion followed 5 minutes later by propofol 0.5 mg/kg bolus and infusion at 3 mg/kg/h. Further bolus doses of propofol (10 mg) were given if loss of consciousness (LOC) was not attained after 5 minutes; pancuronium, 0.04 to 0.1 mg/kg, was administered at LOC. In IS 2 (n = 68), a priming dose of pancuronium, 0.015 mg/kg, was administered just before starting remifentanil. In IS 3 (n = 42), bolus doses of propofol, 10 mg every 10 seconds, were given until LOC, followed by pancuronium, 0.04 to 0.1 mg/kg, and the remifentanil and propofol infusions were started. MEASUREMENTS AND MAIN RESULTS: There were no significant differences among the remifentanil dose groups with regard to the primary outcome measure, responses to sternotomy/sternal spread/maximal sternal spread. Responses to these stimuli were recorded in 11%, 11%, and 14% of patients in the remifentanil 1.0, 1.5, and 2.0 microg/kg/min dose groups, respectively. Similarly, there were no significant differences in the responses to other surgical stimuli. There was a high incidence of muscle rigidity when remifentanil was used to induce anesthesia. CONCLUSIONS: All 3 remifentanil dose regimens provided profound suppression of responses to surgical stimuli in the majority of patients. There was no apparent advantage in starting the remifentanil infusion rate above 1.0 microg/kg/min. Remifentanil is not suitable for use as a sole induction agent.