Acid-base disarrangement and gastric intramucosal acidosis predict outcome from major trauma.

INTRODUCTION: This prospective non-interventional study intended to assess the prognostic value of gastric intramucosal acidosis in patients with severe trauma admitted to a medical/surgical ICU. METHODS: Gastric tonometer catheters were introduced to measure air PCO2 level (Tonocap device) in forty consecutive critically ill trauma patients. Gastric intramucosal pH, air PCO2 gradient, lactate and acid-base parameters were measured at admission and at 6, 12 and 24 h thereafter. RESULTS: The median age, mean APACHE II and SOFA scores were higher in nonsurvivors than in survivors (p<0.05). There were significant differences in the PCO2 gradient between survivors and nonsurvivors at 12 and 24 hours (10+/-7 vs. 24+/-19 mmHg, 13+/-16 vs. 29+/-25 mmHg; p<0.05). Gastric intramucosal pH values were lower in nonsurvivors than in survivors, on admission and after 12 or 24 hours (p<0.05). Arterial pH and bicarbonate were lower, lactate concentration higher, and base excess more negative in nonsurvivors. Prediction of outcome (mortality and MODS) at 24 hours of ICU assessed by their ROC curves was similar (p=NS). At 24 hours, air PCO2 gradient > 18 mmHg carried a relative risk of 4.6 for death, slightly higher than a HCO3 <20 mEq/L (RR=4.29) or base excess of <-2 mmol/L (RR=3.65). CONCLUSION: Bicarbonate, base deficit, lactate, gastric intramucosal pH and PCO2 gradient discriminate survivors from nonsurvivors of major trauma. A critical air PCO2 gradient carried the greatest relative risk for death at 24 hours of ICU. Inadequate regional blood flow as detected by a critical PCO2 gradient seems to contribute to morbidity and mortality of severe trauma patients.

Acid-base disarrangement and gastric intramucosal acidosis predict outcome from major trauma / Desarranjo ácido-base e acidose gástrica intramucosal predizem desfecho de trauma grave

INTRODUCTION: This prospective non-interventional study intended to assess the prognostic value of gastric intramucosal acidosis in patients with severe trauma admitted to a medical/surgical ICU. METHODS: Gastric tonometer catheters were introduced to measure air PCO2 level (Tonocap device) in forty consecutive critically ill trauma patients. Gastric intramucosal pH, air PCO2 gradient, lactate and acid-base parameters were measured at admission and at 6, 12 and 24 h thereafter. RESULTS: The median age, mean APACHE II and SOFA scores were higher in nonsurvivors than in survivors (p<0.05). There were significant differences in the PCO2 gradient between survivors and nonsurvivors at 12 and 24 hours (10±7 vs. 24±19 mmHg, 13±16 vs. 29±25 mmHg; p<0.05). Gastric intramucosal pH values were lower in nonsurvivors than in survivors, on admission and after 12 or 24 hours (p<0.05). Arterial pH and bicarbonate were lower, lactate concentration higher, and base excess more negative in nonsurvivors. Prediction of outcome (mortality and MODS) at 24 hours of ICU assessed by their ROC curves was similar (p=NS). At 24 hours, air PCO2 gradient > 18 mmHg carried a relative risk of 4.6 for death, slightly higher than a HCO3 <20 mEq/L (RR=4.29) or base excess of <-2 mmol/L (RR=3.65). CONCLUSION: Bicarbonate, base deficit, lactate, gastric intramucosal pH and PCO2 gradient discriminate survivors from nonsurvivors of major trauma. A critical air PCO2 gradient carried the greatest relative risk for death at 24 hours of ICU. Inadequate regional blood flow as detected by a critical PCO2 gradient seems to contribute to morbidity and mortality of severe trauma patients.

INTRODUÇÃO: O objetivo deste estudo prospectivo, não-intervencionista, foi avaliar o valor prognóstico da acidose gástrica intramucosal em pacientes com trauma grave admitidos numa UTI. MÉTODOS: Cateteres tonométricos gástricos foram introduzidos para medir o nível de PCO2 aéreo em 40 pacientes traumatizados. O pH gástrico intramucosal, o gradiente de PCO2 aéreo, o lactato e os parâmetros ácido-base foram medidos na admissão e 6, 12 e 24 h após a admissão. RESULTADOS: A idade mediana, o APACHE II e os escores SOFA médios foram maiores nos não-sobreviventes que nos sobreviventes (p<0.05). Não houve diferenças significativas para o gradiente de PCO2 entre sobreviventes e não-sobreviventes após 12 e 24 horas (10±7 vs. 24±19 mmHg, 13±16 vs. 29±25 mmHg; P<0.05). Os valores de pH gástrico intramucosal foram menores nos não-sobreviventes que nos sobreviventes na admissão e após 12 ou 24 horas (P<0.05). O pH arterial e o bicarbonato foram menores, a concentração de lactato maior, o excesso de base mais negativo nos não-sobreviventes. Predição do desfecho (mortalidade e FMOS) nas 24 horas de UTI acessada pelas curvas ROC foi similar (p=NS). Nas 24 horas, um gradiente de PCO2 aéreo >18 mmHg acarretou um risco relativo de 4.6 para óbito, um pouco maior que um HCO3 <20 mEq/L (RR=4.29) ou um excesso de base <-2 mmol/L (RR=3.65). CONCLUSÃO: Bicarbonato, déficit de base, lactato, pH gástrico intramucosal e o gradiente de PCO2 discriminaram os sobreviventes dos não-sobreviventes de trauma. Um gradiente crítico de PCO2 aéreo acarretou o maior risco relativo para óbito após 24 horas de UTI. Fluxo sangüíneo regional inadequado detectado por um gradiente crítico de PCO2 parece contribuir para a morbidade e mortalidade de pacientes traumatizados graves.

Attitudes of residents and anesthesiologists toward basic sciences.

The perceived relevance of the subject matter is an essential condition for adult learning. Attitudes refer to internal states that influence learner's choices of personal action, which determine the probability of learning behaviors. Our objectives in this study were to describe and compare attitudes of residents and anesthesiologists towards the relevance of basic sciences to clinical practice. An 8-item questionnaire was given to 105 residents and 142 anesthesiologists. Data were electronically collected. Responses were graded on 5-level Likert scales. Comparisons were made between responses of residents and anesthesiologists. Although a general pattern of acknowledged relevance of basic sciences to clinical practice was observed in both groups, anesthesiologists' ratings were significantly higher than residents' ratings. Both groups emphasized in-depth formal learning of basic sciences before their clinical application, but attending anesthesiologists' scores were significantly higher than residents' scores. Residents were more favorable to a more superficial approach represented by learning general concepts than anesthesiologists, although median scores were below the center of the scale (neutral). In both groups median ratings of the role of instructors in exciting residents' curiosity through the teaching of basic sciences were located in the center of the respective scales. Both groups rated their in-training educational experiences high.

Psychometric properties of the Dundee Ready Educational Environment Measure (DREEM) applied to medical residents.

The Dundee Ready Educational Environment Measure (DREEM) is a measure of students' perceptions of the educational environment, but its performance in evaluating the educational environment in the residency setting has not yet been described. This study aimed at describing the psychometric performance of DREEM applied to medical residents. DREEM was applied to 97 residents from 12 training programs on four specialties in six institutions in three Brazilian cities. Psychometric measures included factor analysis, Cronbach's alpha coefficients, item-to-total correlations, t-test comparisons of scores between genders, institutions, specialties, and programs, correlations with the global score of the Quality of School Life Scale (concurrent validity), and test-retest reliability. Generalizability theory procedures were applied to a random subset of data. Programs (8) were the objects of measure, while institutions (6), specialties (4), raters-within-programs (40), and items-on-the-scale (50) were facets. Variance components, generalizability (G) and dependability (D) coefficients were calculated. Cronbach's alpha was 0.93. DREEM showed high discriminant and concurrent validities. Test-retest reliability was moderate. Interactions between programs, raters and items accounted for 68% of the total variance. G and D coefficients were 0.95 and 0.67, respectively. The instrument proved to be useful for relative comparisons at both resident and program level.

Problem-based learning implementation in an intensive course of anaesthesiology: a preliminary report on residents' cognitive performance and perceptions of the educational environment.

The authors describe the implementation of problem-based learning (PBL) in an introductory course to anaesthesiology (ICA) traditionally administered in teacher-centred formats. The study was performed during the 2003 and 2004 courses. Seven residents participated in ICA2003 and 5 in ICA2004. Courses covered pre- and post-anaesthesia care, airway management, pharmacology of anaesthetics, and neuraxial blocks. Lectures, demonstrations and PBL were used in ICA2003. Only PBL was used in ICA2004. ICA2003 residents' perceptions of the contribution of learning formats to solving post-tests were assessed on 100-millimetre visual analogue scales (VASs). Pre-tests, post-tests and the Dundee Ready Education Environment Measure (DREEM) measured outcomes. Pooled mean VAS scores of the perceived contribution of learning formats to the acquisition of knowledge were significantly greater for PBL (81 +/- 13.1 mm) than for lectures (71.96 +/- 16.7 mm) or practical demonstrations (74 +/- 16.9 mm). Pooled mean scores of pre-test and post-tests were 5.21 +/- 2.18 and 8.50 +/- 1.69 in ICA2003 (p < 0.05), and 5.63 +/- 1.83 and 8.98 +/- 1.13 in ICA2004 (p < 0.05), respectively. Pooled pre-test, post-test and DREEM global scores did not differ between courses. PBL may effectively address basic topics in anaesthesiology during intensive learning episodes.

A pressão arterial e a freqüência cardíaca não são bons parâmetros para avaliação do nível de ansiedade pré-operatória / Heart rate and blood pressure are not good parameters to evaluate preoperative anxiety

JUSTIFICATIVA E OBJETIVOS: Os pacientes cirúrgicos sofrem graus variados de estresse psicológico no período pré-operatório. Pacientes ansiosos podem apresentar reações psicossomáticas como hipertensão arterial e taquicardia. O objetivo deste estudo foi avaliar o nível de ansiedade pré-operatória em uma população de pacientes cirúrgicos, detectar alterações de freqüência cardíaca e pressão arterial e sua relação com idade, sexo, grau de instrução e experiência cirúrgica prévia. MÉTODO: A 145 pacientes adultos, de ambos os sexos, estado físico (ASA) I, II ou III, escolhidos aleatoriamente, perfeitamente orientados no tempo e no espaço, alfabetizados e escalados para cirurgias eletivas, foi aplicado o questionário de ansiedade pré-operatória de Amsterdã durante a consulta pré-anestésica. Foram considerados ansiosos os pacientes com escore igual ou maior que onze. Para cada paciente anotou-se o sexo, a idade, o grau de instrução, a pressão arterial sistólica (PAS) e diastólica (PAD), a freqüência cardíaca (FC), a experiência cirúrgica prévia e a história de hipertensão arterial. RESULTADOS: Sessenta e nove pacientes (47,58 por cento) apresentaram escores de ansiedade igual ou maior que onze (ansiosos), enquanto 76 pacientes (52,41 por cento) apresentaram escores menores que onze (não ansiosos). Não houve diferença significativa entre pacientes ansiosos e não ansiosos quanto à idade, PAS, PAD e FC. Entre os pacientes ansiosos, 68,12 por cento foram do sexo feminino e 31,88 por cento, do sexo masculino, p < 0,05. Os pacientes ansiosos não diferiram significativamente dos não ansiosos em relação às prevalências de experiência cirúrgica prévia, graus de instrução e história de hipertensão arterial. CONCLUSÕES: A pressão arterial e a freqüência cardíaca não refletem o nível de ansiedade pré-operatória. Pacientes do sexo feminino têm maiores probabilidades de apresentar ansiedade pré-operatória do que pacientes do sexo masculino.

The development and application of an instrument for assessing resident competence during preanesthesia consultation.

In this study, we aimed to construct, validate, and apply an instrument for assessing resident performance at outpatient preanesthesia consultation (PAC). A focus group and a Delphi panel of experts defined component items of a typical outpatient PAC, which could be used as indicators of competence. Items were incorporated in a checklist, which was further validated in a sample of consultations performed by board-certified anesthesiologists. The resulting instrument contained 37 items, grouped into five domains (physician-patient relationship, medical history, physical examination, patient education, and preanesthesia records), with high construct validity, high discriminant validity, moderate internal consistency, and high probability of inter-raters agreement. The instrument was applied to evaluate the performance of seven first-year residents at 317 consecutive PAC. Data were analyzed by constructing exponentially weighted moving average charts for domain and total scores. Statistically significant differing levels of performance could be consistently detected. Applying exponentially weighted moving average charts to the sequential analysis of the developed checklist scores can reliably assess resident performance at the devised criteria. The Preanesthesia Consultation Scoring Checklist is a potentially useful instrument for both formative and summative assessment of residents during their training in processes involved in outpatient preanesthesia evaluation.

[Heart rate and blood pressure are not good parameters to evaluate preoperative anxiety.]. / A pressão arterial e a freqüência cardíaca não são bons parâmetros para avaliação do nível de ansiedade pré-operatória.

BACKGROUND AND OBJECTIVES: Surgical patients are subject to different levels of preoperative distress. Anxious patients may present unfavorable psychophysical reactions, such as hypertension and tachycardia. This study aimed at evaluating the level of preoperative anxiety in a population of surgical patients, and at detecting heart rate and blood pressure changes and their relationship with age, gender, education and previous surgical experience. METHODS: Participated in this randomized study 145 adult patients of both genders, physical status ASA I - III, perfectly oriented in time and space, literate and scheduled for elective surgeries, to whom the Amsterdam preoperative anxiety questionnaire was applied during preanesthetic evaluation. Patients with scores > 11 were considered anxious. Age, gender, education, systolic and diastolic blood pressure, heart rate, previous surgical experience and history of hypertension were recorded. RESULTS: Sixty-nine patients (47.58%) were considered anxious, while 76 (52.41%) were considered not anxious. There were no significant differences between anxious and non-anxious patients in age, systolic and diastolic blood pressure, and heart rate. Among anxious patients 68.12% were females and 31.88% were males (p < 0.05). There were no significant differences in education, previous surgical experience and history of hypertension between anxious and non-anxious patients. CONCLUSIONS: Heart rate and blood pressure do not reflect the level of preoperative anxiety. Females are more anxious then males in the preoperative period.