RESUMO
BACKGROUND: Despite multiple reminders, education sessions, and multidisciplinary team involvement, adherence to an evidence-based mechanical ventilation weaning protocol had been less than 1% in a general systems intensive care unit since implementation. OBJECTIVE: To assess the effectiveness of using an implementation program, the Model for Accelerating Improvement, to improve adherence and clinical outcomes after restarting a mechanical ventilation weaning protocol in an adult general systems intensive care unit. METHODS: A prospective comparative design, before and after implementation of the Model for Accelerating Improvement, was used with a consecutive sample of 129 patients and 112 multidisciplinary team members. Clinical outcomes were rate of unsuccessful extubations, rate of ventilator-associated pneumonia, and duration of mechanical ventilation; practice outcomes were staff's understanding of the mechanical ventilation weaning protocol, perceptions of the practice safety climate, and adherence to the weaning protocol. RESULTS: After the intervention, the rate of unsuccessful extubations decreased, and staff's understanding of and adherence to the weaning protocol increased significantly. The rate of ventilator-associated pneumonia, duration of mechanical ventilation, and staff's perceptions of the practice safety climate did not change significantly. CONCLUSION: Implementing the Model for Accelerating Improvement improved understanding of and adherence to protocol-directed weaning and reduced the rate of unsuccessful extubations.
Assuntos
Protocolos Clínicos , Cuidados Críticos/normas , Fidelidade a Diretrizes , Unidades de Terapia Intensiva/normas , Desmame do Respirador , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Alberta , Feminino , Grupos Focais , Humanos , Capacitação em Serviço , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Gestão da Qualidade TotalRESUMO
We present a single patient with a successful breast reconstruction using the peri-iliac fat pad as a free flap based on the deep circumflex iliac artery and vein. Although the follow-up is short, in this patient the donor site has been acceptable, and we believe that this flap will have a place in the selection of donor sites for autogenous tissue breast reconstruction.
Assuntos
Tecido Adiposo/transplante , Neoplasias da Mama/cirurgia , Carcinoma Intraductal não Infiltrante/cirurgia , Mamoplastia/métodos , Retalhos Cirúrgicos/métodos , Feminino , Seguimentos , Quadril , Humanos , Mastectomia Radical Modificada , Pessoa de Meia-Idade , Pinturas , Resultado do TratamentoRESUMO
Venous congestion in the intraoperative and postoperative period can be a problem with some transverse rectus abdominis musculocutaneous flaps. We evolved a technique to allow us the ability to bleed the congested flap in a controlled manner both intra- and postoperatively. Arteriotomy cannulae are placed within the lumens of the deep inferior epigastric artery (DIEA) and vein (DIEV) and they are brought out on the lateral aspect of the reconstructed breast. We believe that intermittent venous bleeding from the DIEV allows a congested flap time to improve venous outflow and adapt to the new reversed blood circulation. When laser Doppler flow meter is simultaneously used as a monitor, bleeding from the DIEV or DIEA can improve balance between arterial and venous pressure in the flap.