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1.
Br J Anaesth ; 123(6): 887-897, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31591019

RESUMO

BACKGROUND: An unintended consequence of medical technologies is loss of personal interactions and humanism between patients and their healthcare providers, leading to depersonalisation of medicine. As humanism is not integrated as part of formal postgraduate anaesthesiology education curricula, our goal was to design, introduce, and evaluate a comprehensive humanism curriculum into anaesthesiology training. METHODS: Subject-matter experts developed and delivered the humanism curriculum, which included interactive workshops, simulation sessions, formal feedback, and patient immersion experience. The effectiveness of the programme was evaluated using pre- and post-curriculum assessments in first-year postgraduate trainee doctors (residents). RESULTS: The anaesthesiology residents reported high satisfaction scores. Pre-/post-Jefferson Scale of Patient Perceptions of Physician Empathy showed an increase in empathy ratings with a median improvement of 12 points (range; P=0.013). After training, patients rated the residents as more empathetic (31 [4] vs 22 [5]; P<0.001; 95% confidence interval [CI]: 7-12) and professional (47 [3] vs 35 [8]; P<0.001; 95% CI: 9-16). Patient overall satisfaction with their anaesthesia provider improved after training (51 [6] vs 37 [10]; P<0.001; 95% CI: 10-18). Patients rated their anxiety lower in the post-training period compared with pretraining (1.8 [2.3] vs 3.6 [1.6]; P=0.001; 95% CI: 0.8-2.9). Patient-reported pain scores decreased after training (2.3 [2.5] vs 3.8 [2.1]; P=0.010; 95% CI: 0.4-2.8). CONCLUSIONS: Implementation of a humanism curriculum during postgraduate anaesthesiology training was well accepted, and can result in increased physician empathy and professionalism. This may improve patient pain, anxiety, and overall satisfaction with perioperative care.


Assuntos
Anestesiologia/educação , Competência Clínica/estatística & dados numéricos , Currículo , Humanismo , Internato e Residência , Satisfação do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesiologia/métodos , Atitude do Pessoal de Saúde , Empatia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudantes de Medicina/psicologia , Adulto Jovem
2.
JPEN J Parenter Enteral Nutr ; 43(1): 81-87, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29846011

RESUMO

BACKGROUND: Malnutrition influences clinical outcomes. Although various screening tools are available to assess nutrition status, their use in the intensive care unit (ICU) has not been rigorously studied. Our goal was to compare the Nutrition Risk in Critically Ill (NUTRIC) to the Nutritional Risk Screening (NRS) 2002 in terms of their associations with macronutrient deficit in ICU patients. METHODS: We performed a retrospective analysis to investigate the relationship between NUTRIC vs NRS 2002 and macronutrient deficit (protein and calories) in critically ill patients. We performed linear regression analyses, controlling for age, sex, race, body mass index, and ICU length of stay. We then dichotomized our primary exposures and outcomes to perform logistic regression analyses, controlling for the same covariates. RESULTS: The analytic cohort included 312 adults. Mean NUTRIC and NRS 2002 scores were 4 ± 2 and 4 ± 1, respectively. Linear regression demonstrated that each increment in NUTRIC score was associated with a 49 g higher protein deficit (ß = 48.70: 95% confidence interval [CI] 29.23-68.17) and a 752 kcal higher caloric deficit (ß = 751.95; 95% CI 447.80-1056.09). Logistic regression demonstrated that NUTRIC scores >4 had over twice the odds of protein deficits ≥300 g (odds ratio [OR] 2.35; 95% CI 1.43-3.85) and caloric deficits ≥6000 kcal (OR 2.73; 95% CI 1.66-4.50) compared with NUTRIC scores ≤4. We did not observe an association of NRS 2002 scores with macronutrient deficit. CONCLUSION: Our data suggest that NUTRIC is superior to NRS 2002 for assessing malnutrition risk in ICU patients. Randomized, controlled studies are needed to determine whether nutrition interventions, stratified by NUTRIC score, can improve patient outcomes.

3.
Nutr Clin Pract ; 34(4): 572-580, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30294930

RESUMO

BACKGROUND: Vitamin D status is associated with length of stay (LOS) and discharge destination in critically ill patients. To further understand this relationship, we investigated whether admission 25-hydroxyvitaminD (25OHD) levels are associated with discharge functional status in the intensive care unit (ICU). METHODS: In this retrospective study, data from 2 surgical ICUs at a large teaching hospital were analyzed. 25OHD levels were measured within 24 hours of ICU admission and Functional Status Score for the ICU (FSS-ICU) was calculated within 24 hours of ICU discharge for all patients. To investigate the association of vitamin D status with FSS-ICU, we constructed linear and logistic regression models, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU LOS, and cumulative protein or caloric deficit during ICU admission. RESULTS: Mean 25OHD level and FSS-ICU was 19 (SD 8) ng/mL and 17 (SD 4), respectively, in the analytic cohort (n = 300). Each unit increase in 25OHD level was associated with a 0.2 increment in FSS-ICU (ß = .20; 95% CI 0.14-0.25). Patients with 25OHD levels <20 ng/mL had >3-fold risk of low FSS-ICU (<17) compared with patients with 25OHD >20 ng/mL (OR 3.45; 95% CI 1.96-6.08). CONCLUSIONS: Our results suggest that vitamin D status at admission is associated with discharge FSS-ICU in critically ill surgical patients. Future studies are needed to validate our results, to build upon our findings, and to determine whether optimizing 25OHD levels can improve functional status and other important clinical outcomes in ICU patients.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Estado Nutricional , Admissão do Paciente/estatística & dados numéricos , Alta do Paciente/estatística & dados numéricos , Vitamina D/análogos & derivados , Idoso , Feminino , Humanos , Tempo de Internação , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Desempenho Físico Funcional , Estudos Prospectivos , Estudos Retrospectivos , Vitamina D/análise
4.
Nutr Clin Pract ; 34(1): 142-147, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30101993

RESUMO

BACKGROUND: Hospital-acquired pressure injuries (HAPIs) typically develop following critical illness due to immobility and suboptimal perfusion. Vitamin D helps to maintain epithelial cell integrity, particularly at barrier sites such as skin. It is unclear whether vitamin D status is a modifiable risk factor for HAPIs in critically ill patients. Our goal was to investigate the relationship between admission 25-hydroxyvitamin D (25OHD) levels with the development of HAPIs in surgical intensive care unit (ICU) patients. METHODS: We performed a retrospective cohort study of patients admitted to surgical ICUs at a major teaching hospital in Boston, Massachusetts. To investigate the association of 25OHD levels with subsequent development of HAPIs, we performed logistic regression analyses, controlling for body mass index, Nutrition Risk in the Critically Ill score, ICU length of stay, and cumulative ICU caloric or protein deficit. RESULTS: A total of 402 patients comprised our analytic cohort. Each unit increment in 25OHD was associated with 11% decreased odds of HAPIs (odds ratio [OR] 0.89; 95% CI 0.840.95). When vitamin D status was dichotomized, patients with 25OHD <20 ng/mL were >2 times as likely to develop HAPIs (OR 2.51; 95% CI 1.065.97) compared with patients with 25OHD >20 ng/mL. CONCLUSION: In our cohort of critically ill surgical patients, vitamin D status at ICU admission was linked to subsequent development of HAPIs. Randomized, controlled trials are needed to assess whether optimizing 25OHD levels in the ICU can reduce the incidence of HAPIs and improve other clinically relevant outcomes in critically ill patients.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Estado Terminal/epidemiologia , Estado Nutricional/fisiologia , Lesão por Pressão , Vitamina D/sangue , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Lesão por Pressão/sangue , Lesão por Pressão/epidemiologia , Estudos Retrospectivos
5.
Nutr Clin Pract ; 34(3): 400-405, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30207404

RESUMO

BACKGROUND: The Patient- And Nutrition-Derived Outcome Risk Assessment (PANDORA) was recently validated for predicting mortality in hospitalized patients; however, its utility in the intensive care unit (ICU) remains unknown. METHODS: We investigated whether PANDORA is associated with 30, 90, and 180 day mortality in critically ill surgical patients by performing logistic regressions, controlling for age, sex, race, body mass index, macronutrient deficit, and length of stay. The area under the receiver operating characteristic curves (AUC) of PANDORA vs Acute Physiology and Chronic Health Evaluation (APACHE) II scores for mortality at each time point were also compared. RESULTS: 312 patients comprised the analytic cohort. PANDORA was associated with mortality at 30 (OR 1.08; 95% CI 1.04-1.13; P < .001), 90 (OR 1.09; 95% CI 1.03-1.12; P < .001), and 180 days (OR 1.10; 95% CI 1.06-1.15; P < .001). PANDORA and APACHE II were comparable for mortality prediction at 30 (AUC: 0.69, 95% CI 0.62-0.76 vs 0.74, 95% CI 0.67-0.81; P = .29), 90 (AUC: 0.71, 95% CI 0.63-0.77 vs 0.74, 95% CI 0.67-0.80; P = .52), and 180 days (AUC: 0.73, 95% CI 0.67-0.79 vs 0.75, 95% CI 0.69-0.81; P = .66). CONCLUSION: In surgical ICU patients, PANDORA was associated with mortality and was comparable with APACHE II for mortality prediction at 30, 90, and 180 days after initiation of care. Prospective studies are needed to assess whether nutrition support, stratified by PANDORA scores, can improve outcomes in surgical ICU patients.


Assuntos
Estado Terminal/mortalidade , Estado Nutricional , Cuidados Pós-Operatórios , APACHE , Adulto , Idoso , Feminino , Hospitalização , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Terapia Nutricional/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença
6.
JPEN J Parenter Enteral Nutr ; 41(6): 986-992, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-26838527

RESUMO

BACKGROUND: Deranged serum phosphate (Phos) levels are associated with anemia in hospitalized patients, but their relevance to critical illness is unclear. Therefore, our goal was to investigate whether abnormal Phos on admission to the surgical intensive care unit (ICU) is associated with anemia. MATERIALS AND METHODS: We performed a retrospective analysis of data from an ongoing study of nutrition in critical illness. Serum Phos and hemoglobin levels were obtained at ICU admission. Normal Phos was defined as 2.5-4.0 mg/dL. To investigate the association between Phos and anemia, we performed logistic regression analyses, while controlling for age, sex, race, body mass index, Nutrition Risk Screening score, Deyo-Charlson Comorbidity Index, creatinine, mean corpuscular volume, and serum albumin. RESULTS: In total, 510 patients comprised the analytic cohort; 62% were anemic, 30% had Phos >4.0 mg/dL, and 14% had levels <2.5 mg/dL. Logistic regression analysis demonstrated each unit increment in Phos was associated with a 25% higher likelihood of anemia (odds ratio [OR], 1.25; 95% confidence interval [CI], 1.04-1.50). Moreover, patients with Phos >4.0 mg/dL had a 68% higher likelihood of anemia compared with those with normal levels (OR, 1.68; 95% CI, 1.02-2.80). Patients with Phos <2.5 mg/dL were not more likely to be anemic compared with those with normal levels. CONCLUSION: Surgical ICU patients with admission Phos >4.0 mg/dL are more likely to be anemic compared with those with normal levels. Our findings support the need for studies to determine whether globally maintaining optimal Phos reduces the likelihood of anemia and whether ideal Phos during acute care hospitalization influences clinical outcomes.


Assuntos
Anemia/sangue , Estado Terminal , Fosfatos/sangue , Procedimentos Cirúrgicos Operatórios , Adulto , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Estudos Transversais , Feminino , Hemoglobinas/metabolismo , Hospitalização , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Estado Nutricional , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco
7.
J Crit Care ; 34: 7-11, 2016 08.
Artigo em Inglês | MEDLINE | ID: mdl-27288601

RESUMO

PURPOSE: Recent evidence suggests that red cell distribution width (RDW) is associated with mortality in mixed cohorts of critically ill patients. Our goal was to investigate whether elevated RDW at initiation of critical care in the intensive care unit (ICU) is associated with 90-day mortality in surgical patients. METHODS: We performed a retrospective, single-center cohort study. Normal RDW was defined as 11.5%-14.5%. To investigate the association of admission RDW with 90-day mortality, we performed a logistic regression analysis, controlling for age, sex, race, body mass index, Nutrition Risk Screening 2002 score, Acute Physiology and Chronic Health Evaluation II score, hospital length of stay, as well as levels of creatinine, albumin, and mean corpuscular volume. RESULTS: 500 patients comprised the analytic cohort; 47% patients had elevated RDW and overall 90-day mortality was 28%. Logistic regression analysis demonstrated that patients with elevated RDW had a greater than two-fold increased odds of mortality (OR 2.28: 95%CI 1.20-4.33) compared to patients with normal RDW. CONCLUSIONS: Elevated RDW at initiation of care is associated with increased odds of 90-day mortality in surgical ICU patients. These data support the need for prospective studies to determine whether RDW can improve risk stratification in surgical ICU patients.


Assuntos
Estado Terminal/mortalidade , Índices de Eritrócitos/fisiologia , APACHE , Adolescente , Adulto , Idoso , Boston , Estudos de Coortes , Cuidados Críticos , Estado Terminal/terapia , Feminino , Hospitalização , Hospitais Universitários , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Adulto Jovem
8.
West J Emerg Med ; 16(6): 907-12, 2015 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-26594288

RESUMO

INTRODUCTION: Traditional Advanced Cardiac Life Support (ACLS) courses are evaluated using written multiple-choice tests. High-fidelity simulation is a widely used adjunct to didactic content, and has been used in many specialties as a training resource as well as an evaluative tool. There are no data to our knowledge that compare simulation examination scores with written test scores for ACLS courses. OBJECTIVE: To compare and correlate a novel high-fidelity simulation-based evaluation with traditional written testing for senior medical students in an ACLS course. METHODS: We performed a prospective cohort study to determine the correlation between simulation-based evaluation and traditional written testing in a medical school simulation center. Students were tested on a standard acute coronary syndrome/ventricular fibrillation cardiac arrest scenario. Our primary outcome measure was correlation of exam results for 19 volunteer fourth-year medical students after a 32-hour ACLS-based Resuscitation Boot Camp course. Our secondary outcome was comparison of simulation-based vs. written outcome scores. RESULTS: The composite average score on the written evaluation was substantially higher (93.6%) than the simulation performance score (81.3%, absolute difference 12.3%, 95% CI [10.6-14.0%], p<0.00005). We found a statistically significant moderate correlation between simulation scenario test performance and traditional written testing (Pearson r=0.48, p=0.04), validating the new evaluation method. CONCLUSION: Simulation-based ACLS evaluation methods correlate with traditional written testing and demonstrate resuscitation knowledge and skills. Simulation may be a more discriminating and challenging testing method, as students scored higher on written evaluation methods compared to simulation.


Assuntos
Suporte Vital Cardíaco Avançado/educação , Educação de Graduação em Medicina/métodos , Avaliação Educacional/métodos , Treinamento por Simulação , California , Feminino , Humanos , Modelos Lineares , Masculino , Variações Dependentes do Observador , Estudos Prospectivos
9.
Anesthesiology ; 123(3): 670-82, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26181338

RESUMO

BACKGROUND: The perioperative surgical home model highlights the need for trainees to include modalities that are focused on the entire perioperative experience. The focus of this study was to design, introduce, and evaluate the integration of a whole-body point-of-care (POC) ultrasound curriculum (Focused periOperative Risk Evaluation Sonography Involving Gastroabdominal Hemodynamic and Transthoracic ultrasound) into residency training. METHODS: For 2 yr, anesthesiology residents (n = 42) received lectures using a model/simulation design and half were also randomly assigned to receive pathology assessment training. Posttraining performance was assessed through Kirkpatrick levels 1 to 4 outcomes based on the resident satisfaction surveys, multiple-choice tests, pathologic image evaluation, human model testing, and assessment of clinical impact via review of clinical examination data. RESULTS: Evaluation of the curriculum demonstrated high satisfaction scores (n = 30), improved content test scores (n = 37) for all tested categories (48 ± 16 to 69 ± 17%, P < 0.002), and improvement on human model examinations. Residents randomized to receive pathology training (n = 18) also showed higher scores compared with those who did not (n = 19) (9.1 ± 2.5 vs. 17.4 ± 3.1, P < 0.05). Clinical examinations performed in the organization after the study (n = 224) showed that POC ultrasound affected clinical management at a rate of 76% and detected new pathology at a rate of 31%. CONCLUSIONS: Results suggest that a whole-body POC ultrasound curriculum can be effectively taught to anesthesiology residents and that this training may provide clinical benefit. These results should be evaluated within the context of the perioperative surgical home.


Assuntos
Anestesiologia/educação , Competência Clínica , Internato e Residência , Assistência Perioperatória/educação , Sistemas Automatizados de Assistência Junto ao Leito , Ultrassonografia , Anestesiologia/normas , Competência Clínica/normas , Currículo/normas , Humanos , Internato e Residência/normas , Assistência Perioperatória/normas , Sistemas Automatizados de Assistência Junto ao Leito/normas , Estudos Prospectivos , Distribuição Aleatória , Ultrassonografia/normas
10.
Crit Care ; 19: 94, 2015 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-25888403

RESUMO

INTRODUCTION: Goal-directed fluid therapy strategies have been shown to benefit moderate- to high-risk surgery patients. Despite this, these strategies are often not implemented. The aim of this study was to assess a closed-loop fluid administration system in a surgical cohort and compare the results with those for matched patients who received manual management. Our hypothesis was that the patients receiving closed-loop assistance would spend more time in a preload-independent state, defined as percentage of case time with stroke volume variation less than or equal to 12%. METHODS: Patients eligible for the study were all those over 18 years of age scheduled for hepatobiliary, pancreatic or splenic surgery and expected to receive intravascular arterial blood pressure monitoring as part of their anesthetic care. The closed-loop resuscitation target was selected by the primary anesthesia team, and the system was responsible for implementation of goal-directed fluid therapy during surgery. Following completion of enrollment, each study patient was matched to a non-closed-loop assisted case performed during the same time period using a propensity match to reduce bias. RESULTS: A total of 40 patients were enrolled, 5 were ultimately excluded and 25 matched pairs were selected from among the remaining 35 patients within the predefined caliper distance. There was no significant difference in fluid administration between groups. The closed-loop group spent a significantly higher portion of case time in a preload-independent state (95 ± 6% of case time versus 87 ± 14%, P =0.008). There was no difference in case mean or final stroke volume index (45 ± 10 versus 43 ± 9 and 45 ± 11 versus 42 ± 11, respectively) or mean arterial pressure (79 ± 8 versus 83 ± 9). Case end heart rate was significantly lower in the closed-loop assisted group (77 ± 10 versus 88 ± 13, P =0.003). CONCLUSION: In this case-control study with propensity matching, clinician use of closed-loop assistance resulted in a greater portion of case time spent in a preload-independent state throughout surgery compared with manual delivery of goal-directed fluid therapy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02020863. Registered 19 December 2013.


Assuntos
Abdome/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Hidratação/métodos , Idoso , Anestesia Geral , Perda Sanguínea Cirúrgica/prevenção & controle , Débito Cardíaco/fisiologia , Estudos de Casos e Controles , Procedimentos Cirúrgicos do Sistema Digestório/normas , Estudos de Viabilidade , Feminino , Hidratação/instrumentação , Fidelidade a Diretrizes , Frequência Cardíaca/fisiologia , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Pontuação de Propensão , Ressuscitação , Volume Sistólico/fisiologia
12.
J Clin Anesth ; 26(6): 443-54, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25195059

RESUMO

STUDY OBJECTIVE: To expose residents to two methods of education for point-of-care ultrasound, a traditional didactic lecture and a model/simulation-based lecture, which focus on concepts of cardiopulmonary function, volume status, and evaluation of severe thoracic/abdominal injuries; and to assess which method is more effective. DESIGN: Single-center, prospective, blinded trial. SETTING: University hospital. SUBJECTS: Anesthesiology residents who were assigned to an educational day during the two-month research study period. MEASUREMENTS: Residents were allocated to two groups to receive either a 90-minute, one-on-one didactic lecture or a 90-minute lecture in a simulation center, during which they practiced on a human model and simulation mannequin (normal pathology). Data points included a pre-lecture multiple-choice test, post-lecture multiple-choice test, and post-lecture, human model-based examination. Post-lecture tests were performed within three weeks of the lecture. An experienced sonographer who was blinded to the education modality graded the model-based skill assessment examinations. Participants completed a follow-up survey to assess the perceptions of the quality of their instruction between the two groups. MAIN RESULTS: 20 residents completed the study. No differences were noted between the two groups in pre-lecture test scores (P = 0.97), but significantly higher scores for the model/simulation group occurred on both the post-lecture multiple choice (P = 0.038) and post-lecture model (P = 0.041) examinations. Follow-up resident surveys showed significantly higher scores in the model/simulation group regarding overall interest in perioperative ultrasound (P = 0.047) as well understanding of the physiologic concepts (P = 0.021). CONCLUSIONS: A model/simulation-based based lecture series may be more effective in teaching the skills needed to perform a point-of-care ultrasound examination to anesthesiology residents.


Assuntos
Anestesiologia/educação , Educação de Pós-Graduação em Medicina/métodos , Assistência Perioperatória/normas , Ultrassonografia de Intervenção/normas , California , Competência Clínica , Currículo , Humanos , Internato e Residência , Manequins , Simulação de Paciente , Sistemas Automatizados de Assistência Junto ao Leito/normas , Método Simples-Cego , Ensino/métodos
13.
Teach Learn Med ; 26(3): 266-73, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25010238

RESUMO

BACKGROUND: Medical student training and experience in cardiac arrest situations is limited. Traditional Advanced Cardiac Life Support (ACLS) teaching methods are largely unrealistic with rare personal experience as team leader. Yet Postgraduate Year 1 residents may perform this role shortly after graduation. PURPOSES: We expanded our ACLS teaching to a "Resuscitation Boot Camp" where we taught 2010 ACLS to 19 pregraduation students in didactic (12 hours) and experiential (8 hours) format. METHODS: Immediately before the course, we recorded students performing an acute coronary syndrome/ventricular fibrillation (VF) scenario. As a final test, we recorded the same scenario for each student. Primary outcomes were time to cardiopulmonary resuscitation (CPR) and defibrillation (DF). Secondary measures were total scenario score, dangerous actions, proportion of students voicing "ventricular fibrillation," 12-lead ST-elevation myocardial infarction (STEMI) interpretation, and care necessary for return of spontaneous circulation (ROSC). Two expert ACLS instructors scored both performances on a 121-point scale, with each student serving as their own control. We used t tests and McNemar tests for paired data with statistical significance at p<.05. RESULTS: Before instruction, average time from arrest to CPR was 112 seconds and to first DF 3.01 minutes. Students scored 45±9/121 points and 9/19 (49%) performed dangerous actions. After instruction, time to CPR was 12 seconds (p=004) and to first DF 1.53 minutes (p=.03). Time to DF was delayed as students showed mastery of bag-valve-mask ventilation before DF. After instruction, students scored 97±4/121 points (p<.0001) with no dangerous actions. Before training, only 4 of 19 (21%) students performed both CPR and DF within 2 minutes, and 3 of these had ROSC. After training, 14 of 19 (74%) achieved CPR+DF≤2 minutes (p=.002), and all had ROSC. Before training, 5 of 19 (26%) students said "VF" and 4 of 19 obtained an ECG, but none identified STEMI. After training, corresponding performance was 13 of 19 "VF" (68%, p=021) and 100% ECG and STEMI identification (p<.05). CONCLUSIONS: This course significantly improved knowledge and psychomotor skills. Critical actions required for resuscitation were much more common after training. ACLS training including high-fidelity simulation decreases time to CPR and DF and improves performance during resuscitation.


Assuntos
Suporte Vital Cardíaco Avançado/educação , Educação de Graduação em Medicina/métodos , Cardiopatias/terapia , Adulto , Reanimação Cardiopulmonar/educação , Competência Clínica , Currículo , Avaliação Educacional , Cardioversão Elétrica , Feminino , Humanos , Masculino , Manequins , Desempenho Psicomotor
14.
Anesthesiology ; 120(5): 1080-97, 2014 May.
Artigo em Inglês | MEDLINE | ID: mdl-24637618

RESUMO

BACKGROUND: Continuous noninvasive arterial pressure monitoring devices are available for bedside use, but the accuracy and precision of these devices have not been evaluated in a systematic review and meta-analysis. METHODS: The authors performed a systematic review and meta-analysis of studies comparing continuous noninvasive arterial pressure monitoring with invasive arterial pressure monitoring. Random-effects pooled bias and SD of bias for systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure were calculated. Continuous noninvasive arterial pressure monitoring was considered acceptable if pooled estimates of bias and SD were not greater than 5 and 8 mmHg, respectively, as recommended by the Association for the Advancement of Medical Instrumentation. RESULTS: Twenty-eight studies (919 patients) were included. The overall random-effect pooled bias and SD were -1.6 ± 12.2 mmHg (95% limits of agreement -25.5 to 22.2 mmHg) for systolic arterial pressure, 5.3 ± 8.3 mmHg (-11.0 to 21.6 mmHg) for diastolic arterial pressure, and 3.2 ± 8.4 mmHg (-13.4 to 19.7 mmHg) for mean arterial pressure. In 14 studies focusing on currently commercially available devices, bias and SD were -1.8 ± 12.4 mmHg (-26.2 to 22.5 mmHg) for systolic arterial pressure, 6.0 ± 8.6 mmHg (-10.9 to 22.9 mmHg) for diastolic arterial pressure, and 3.9 ± 8.7 mmHg (-13.1 to 21.0 mmHg) for mean arterial pressure. CONCLUSIONS: The results from this meta-analysis found that inaccuracy and imprecision of continuous noninvasive arterial pressure monitoring devices are larger than what was defined as acceptable. This may have implications for clinical situations where continuous noninvasive arterial pressure is being used for patient care decisions.


Assuntos
Pressão Arterial/fisiologia , Monitorização Ambulatorial da Pressão Arterial/normas , Monitores de Pressão Arterial/normas , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Monitorização Ambulatorial da Pressão Arterial/métodos , Humanos
15.
Anesth Analg ; 117(5): 1119-29, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23835453

RESUMO

BACKGROUND: Closed-loop systems have been designed to assist practitioners in maintaining stability of various physiologic variables in the clinical setting. In this context, we recently performed in silico testing of a novel closed-loop fluid management system that is designed for cardiac output and pulse pressure variation monitoring and optimization. The goal of the present study was to assess the effectiveness of this newly developed system in optimizing hemodynamic variables in an in vivo surgical setting. METHODS: Sixteen Yorkshire pigs underwent a 2-phase hemorrhage protocol and were resuscitated by either the Learning Intravenous Resuscitator closed-loop system or an anesthesiologist. Median hemodynamic values and variation of hemodynamics were compared between groups. RESULTS: Cardiac index (in liters per minute per square meter) and stroke volume index (in milliliters per square meter) were higher in the closed-loop group compared with the anesthesiologist group over the protocol (3.7 [3.4-4.1] vs 3.5 [3.2-3.9]; 95% Wald confidence interval, -0.5 to -0.23; P < 0.0005 and 40 [34-45] vs 36 [31-38]; 95% Wald confidence interval, -5.9 to -3.1; P < 0.0005, respectively). There was no significant difference in total fluid administration between the closed-loop and anesthesiologist groups (3685 [3230-4418] vs 3253 [2735-3926] mL; 95% confidence interval, -1651 to 431; P = 0.28). Closed-loop group animals also had lower coefficients of variance of cardiac index and stroke volume index during the protocol (11% [10%-16%] vs 22% [18%-23%]; confidence interval, 0.8%-12.3%; P = 0.02 and 11% [8%-16%] vs 17% [13%-21%]; confidence interval, 0.2%-11.4%; P = 0.04, respectively). CONCLUSION: This in vivo study building on previous simulation work demonstrates that the closed-loop fluid management system used in this experiment can perform fluid resuscitation during mild and severe hemorrhages and is able to maintain high cardiac output and stroke volume while reducing hemodynamic variability.


Assuntos
Anestesiologia/instrumentação , Anestesiologia/métodos , Hidratação/métodos , Ressuscitação/métodos , Algoritmos , Animais , Pressão Sanguínea , Débito Cardíaco , Retroalimentação , Hemodinâmica , Hemorragia/prevenção & controle , Hemorragia/terapia , Monitorização Intraoperatória/métodos , Distribuição Aleatória , Volume Sistólico/fisiologia , Suínos
16.
J Cardiothorac Vasc Anesth ; 26(5): 933-9, 2012 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-22795172

RESUMO

OBJECTIVE: The authors compared the performance of a group of anesthesia providers to closed-loop (Learning Intravenous Resuscitator [LIR]) management in a simulated hemorrhage scenario using cardiac output monitoring. DESIGN: A prospective cohort study. SETTING: In silico simulation. PARTICIPANTS: University hospital anesthesiologists and the LIR closed-loop fluid administration system. INTERVENTIONS: Using a patient simulator, a 90-minute simulated hemorrhage protocol was run, which included a 1,200-mL blood loss over 30 minutes. Twenty practicing anesthesiology providers were asked to manage this scenario by providing fluids and vasopressor medication at their discretion. The simulation program was also run 20 times with the LIR closed-loop algorithm managing fluids and an additional 20 times with no intervention. MEASUREMENTS AND MAIN RESULTS: Simulated patient weight, height, heart rate, mean arterial pressure, and cardiac output (CO) were similar at baseline. The mean stroke volume, the mean arterial pressure, CO, and the final CO were higher in the closed-loop group than in the practitioners group, and the coefficient of variance was lower. The closed-loop group received slightly more fluid (2.1 v 1.9 L, p < 0.05) than the anesthesiologist group. CONCLUSIONS: Despite the roughly similar volumes of fluid given, the closed-loop maintained more stable hemodynamics than the practitioners primarily because the fluid was given earlier in the protocol and CO optimized before the hemorrhage began, whereas practitioners tended to resuscitate well but only after significant hemodynamic change indicated the need. Overall, these data support the potential usefulness of this closed-loop algorithm in clinical settings in which dynamic predictors are not available or applicable.


Assuntos
Anestesia com Circuito Fechado/métodos , Anestesiologia/métodos , Pressão Arterial/fisiologia , Frequência Cardíaca/fisiologia , Cuidados Intraoperatórios/métodos , Volume Sistólico/fisiologia , Anestesia com Circuito Fechado/normas , Anestesiologia/normas , Estudos de Coortes , Humanos , Cuidados Intraoperatórios/normas , Complicações Intraoperatórias/prevenção & controle , Médicos , Hemorragia Pós-Operatória/prevenção & controle , Estudos Prospectivos
17.
J Clin Monit Comput ; 26(3): 191-6, 2012 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-22491961

RESUMO

Pulse pressure variation (PPV) can be monitored several ways, but according to recent survey data it is most often visually estimated ("eyeballed") by practitioners. It is not known how accurate visual estimation of PPV is, or whether eyeballing of PPV in goal-directed fluid therapy studies may limit the ability to blind the control group to PPV value. The goal of this study was to test the accuracy of visual estimation of PPV. Using a simulator program designed by the authors that runs on a PC, 20 residents and 19 attendings were shown five arterial pressure waveforms each with different PPV values (range 1-30 %) moving at one of three sweep speeds (6.25, 12.5, or 25 mm/s) and asked to determine the PPV. There was a weak but significant relationship between true PPV and eyeball PPV (r (2) = 0.22; p < 0.01). The agreement between true PPV and eyeball PPV was 3.3 ± 8.7 %. The mean percent error was 122 %. The rate of correct response group classification was 65 %. Mean percent error was higher the faster the waveform sweep speed (130 % at 25 mm/s vs. 117 % at 6.25 mm/s), and correct responsiveness classification lower (58 % at 25 mm/s vs. 69 % at 6.25 mm/s). The results from this study show that eyeballing the arterial pressure waveform in order to evaluate pulse pressure variation is not accurate.


Assuntos
Pressão Sanguínea , Simulação por Computador , Monitorização Fisiológica/estatística & dados numéricos , Adulto , Análise de Variância , Feminino , Hidratação , Humanos , Masculino , Variações Dependentes do Observador , Distribuição Aleatória , Software
18.
J Urol ; 187(4): 1385-91, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-22341287

RESUMO

PURPOSE: Simulation based team training provides an opportunity to develop interdisciplinary communication skills and address potential medical errors in a high fidelity, low stakes environment. We evaluated the implementation of a novel simulation based team training scenario and assessed the technical and nontechnical performance of urology and anesthesiology residents. MATERIALS AND METHODS: Urology residents were randomly paired with anesthesiology residents to participate in a simulation based team training scenario involving the management of 2 scripted critical events during laparoscopic radical nephrectomy, including the vasovagal response to pneumoperitoneum and renal vein injury during hilar dissection. A novel kidney surgical model and a high fidelity mannequin simulator were used for the simulation. A debriefing session followed each simulation based team training scenario. Assessments of technical and nontechnical performance were made using task specific checklists and global rating scales. RESULTS: A total of 16 residents participated, of whom 94% rated the simulation based team training scenario as useful for communication skill training. Also, 88% of urology residents believed that the kidney surgical model was useful for technical skill training. Urology resident training level correlated with technical performance (p=0.004) and blood loss during renal vein injury management (p=0.022) but not with nontechnical performance. Anesthesia resident training level correlated with nontechnical performance (p=0.036). Urology residents consistently rated themselves higher on nontechnical performance than did faculty (p=0.033). Anesthesia residents did not differ in the self-assessment of nontechnical performance compared to faculty assessments. CONCLUSIONS: Residents rated the simulation based team training scenario as useful for interdisciplinary communication skill training. Urology resident training level correlated with technical performance but not with nontechnical performance. Urology residents consistently overestimated their nontechnical performance.


Assuntos
Anestesiologia/educação , Competência Clínica , Comunicação Interdisciplinar , Internato e Residência , Laparoscopia/efeitos adversos , Laparoscopia/educação , Equipe de Assistência ao Paciente/normas , Urologia/educação , Simulação de Paciente , Complicações Pós-Operatórias/prevenção & controle
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