Experiencia con el uso de rocuronio en la intubación orotraqueal en una unidad de soporte vital avanzada móvil (USVA) / No disponible

Objetivo: Valorar la seguridad, eficacia y condicionesde la intubación orotraqueal (IOT) delbloqueante neuromuscular (BNM) no despolarizanterocuronio (R) durante la secuencia rápidade intubación (SRI) en el medio extrahospitalario,así como las posibles alteraciones hemodinámicasy la necesidad de utilizar otros BNM tras la dosisde inducción con R.Material y método: Se realizó un estudio prospectivodesde marzo de 2005 a octubre de 2007,según un protocolo de IOT con R (dosis: 0,6mg/kg) en el ámbito extrahospitalario en unaunidad de soporte vital avanzado móvil (USVA).Se analizaron: sexo, edad, motivo de IOT, condicionesde IOT mediante la clasificación deCormack-Lehane (C-L) y de Krieg (K), parámetroshemodinámicas: presión arterial media(PAM) y frecuencia cardiaca (FC) y saturaciónperiférica de oxígeno (SpO2), antes de la IOT y al1, 2 y 5 minutos, el uso de otro tipo de BNM yposibles complicaciones.Fueron motivo de exclusión: edad < 14 años,PCR y lesión cervical o maxilofacial. Resultados: Se recogieron un total de 50 pacientes,38 varones (12 mujeres), edad media 45 ± 24años, motivo de IOT: neurológico (GCS < 9) 39pacientes, cardiológico 4 y respiratorio 7 pacientes.Las condiciones de IOT según la clasificación de K:grado I (cuello y cuerdas relajadas, no tose) 36pacientes, grado II (igual pero tose) 12 pacientes,grado III (cuerdas aproximadas) un paciente ygrado IV (imposible la IOT): un paciente y según laclasificación de C-L: grado I (se visualiza la glotis):29, grado II (se visualiza la comisura posterior): 18pacientes, grado III (sólo se visualiza la epiglotis):2 pacientes y grado IV ( no se visualiza la epiglotis):1 paciente...(AU)

Aim: To evaluate the safety, efficacy and conditions for orotracheal intubation (OTI) of nondepolarizingneuromuscular blocker (NMB)rocuronium (R) for rapid sequence intubation (RSI) in the extrahospitalary environment, as well as the possibility of haemodynamic alterationsand the need for using other NMB after the induction dose with R. Methods: Aprospective and retrospective studywas carried out from March 2005 to October 2007, according to the OIT protocol with R (dose 0.6 mg/kg) in the out-of-hospital environment in themobile Advanced Life Support Units (ALSU). The following parameters were evaluated before and at minute 1, 2 and 5 after OTI: age, sex, OTI indication,OTI conditions according to Cormack-Lehane (C-L) classification and Krieg (K) scale, haemodynamic parameters: Mean Arterial Pressure (MAP),Heart Rate (HR), and arterial oxygen saturation (SatO2). The need for other type of NMB and the possible complications were also analysed.Cardiac arrest, neck or maxillofacial injury and patients < 14 years old were excluded. Results: 50 patients: 38 males (12 women) were included. Mean age was 45 ± 24 years old, OTI indications: neurological (GCS < 9) 39 patients,cardiological in 4 and respiratory in 7 patients. The conditions for OTI, according to K scale: grade I (good relaxation, vocal cords open, no coughing) in 36 patients, grade II ( same as grade I, with coughing) in 12 patients, grade III ( vocal cordsmoving) 1 patient and grade IV (epiglotis cannot be seen) in 1 patient and according to C-L: grade I (most of the glotis is seen): 29 patients; grade II(only posterior position of the glottis can be seen): 18 patients; grade III (only the epiglottis can be seen): 2 patients; grade IV (neither epiglottis nor glottis can be seen): 1 patient...(AU)

Patients as partners in clinical research: a proposal for applying quality improvement methods to patient care.

OBJECTIVES: The authors show the potential value of using statistical process control (SPC) methods to measure change in health status for patients with chronic conditions. Examples will be used to compare the strengths and weaknesses of these methods to randomized clinical trials (RCTs). METHODS: Run charts, control charts, and regression models are used to explain variations in patients' hypertension and diabetes. RESULTS: Significant improvements are shown in the examples given using the Western Electric rules. CONCLUSIONS: These SPC methods can be used for self-management of chronic conditions. They provide a new set of tools for measuring health care outcomes.

Continuous quality improvement and knowledge for improvement applied to asthma care.

BACKGROUND: Two key ideas in the practice of continuous quality improvement (CQI) in health care are knowledge for improvement as distinguished from professional knowledge in improving the end results of patient care and the failure of the bad apple theory to explain variation in outcomes. METHODS: As part of their eight-week primary care clerkship, medical students at Case Western Reserve University (Cleveland, Ohio) are assigned to more than 20 sites in the greater Cleveland area where they observe and report on the cost and outcome of care for a patient with asthma. (An earlier article presented run charts and fishbone diagrams based on these reports.) In continuing this project, as described in this article, students report on the frequency of causes of variation in costs and outcomes of care. RESULTS: Students are asked to cite the one factor they believe had the most important effect on the cost and clinical outcome of the asthma patient they studied. For cost variation ranked by frequency, disease severity and site of care are reported most frequently, each accounting for 18% of responses. The most frequently reported cause of outcome variation was disease severity. No correlation was found between cost and outcome; higher costs do not produce healthier patients nor are they associated with greater outcome severity. For the nine most frequently used sites of care, the one-way analysis of means for costs shows that average costs for eight of nine sites are well within the expected range. Only one site (G) falls outside the upper boundary. Bringing this one "bad apple" site into conformity would have very little effect on overall costs. The one-way analysis of standard deviations shows that there may be only one case in the site that explains the bad apple outlier. CONCLUSION: Although more than one half of the causes of asthma variation reported in this study fall outside traditional professional knowledge, most of the content of health professions education still falls within the professional realm. Real improvement will require combining traditional professional knowledge with knowledge for improvement.