Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 90
Filtrar
1.
J Cardiothorac Vasc Anesth ; 36(8 Pt B): 2983-2990, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35351397

RESUMO

OBJECTIVES: Accurate preoperative transfusion risk stratification may serve to better manage older patients undergoing cardiac surgery. Therefore, the aim of the present study was to externally validate the existing Association of Cardiothoracic Anesthetists perioperative risk of blood transfusion (ACTA-PORT) score in a population ≥70 years of age scheduled for cardiac surgery. Furthermore, the study authors investigated the additional prognostic value of individual frailty variables to this transfusion risk score. DESIGN: A retrospective analysis. SETTING: At a tertiary-care hospital. PARTICIPANTS: Five hundred seven patients aged ≥70 years undergoing elective cardiac surgery from July 2015 to August 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the administration of a perioperative blood transfusion. Frailty domains were assessed in a preanesthesia geriatric assessment, and a priori selection of biomarkers derived from blood was determined. The original ACTA-PORT score resulted in a c-statistic of 0.78 (95% confidence interval 0.74-0.82), with moderate calibration in predicting perioperative allogeneic transfusion in older patients undergoing cardiac surgery. Model updating, using the closed testing procedure, resulted in model revision with a higher discriminatory performance (c-statistic of 0.83, 95% confidence interval 0.79-0.86) and corrected calibration slope. Iron deficiency, impaired nutritional status, and physical impairment were associated with perioperative transfusions. The addition of individual frailty variables to the updated ACTA-PORT model did not result in improved predictive performance. CONCLUSIONS: External validation of the original ACTA-PORT score showed good discrimination and moderate calibration in older patients at risk of frailty undergoing cardiac surgery. Updating the original ACTA-PORT improved the predictive performance. Careful evaluation of additional frailty domains did not add prognostic value to the ACTA-PORT score.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Fragilidade , Idoso , Transfusão de Sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Fragilidade/diagnóstico , Humanos , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
2.
Anesthesiology ; 136(2): 279-292, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34851425

RESUMO

BACKGROUND: Numerous pharmacokinetic models have been published aiming at more accurate and safer dosing of dexmedetomidine. The vast majority of the developed models underpredict the measured plasma concentrations with respect to the target concentration, especially at plasma concentrations higher than those used in the original studies. The aim of this article was to develop a dexmedetomidine pharmacokinetic model in healthy adults emphasizing linear versus nonlinear kinetics. METHODS: The data of two previously published clinical trials with stepwise increasing dexmedetomidine target-controlled infusion were pooled to build a pharmacokinetic model using the NONMEM software package (ICON Development Solutions, USA). Data from 48 healthy subjects, included in a stratified manner, were utilized to build the model. RESULTS: A three-compartment mamillary model with nonlinear elimination from the central compartment was superior to a model assuming linear pharmacokinetics. Covariates included in the final model were age, sex, and total body weight. Cardiac output did not explain between-subject or within-subject variability in dexmedetomidine clearance. The results of a simulation study based on the final model showed that at concentrations up to 2 ng · ml-1, the predicted dexmedetomidine plasma concentrations were similar between the currently available Hannivoort model assuming linear pharmacokinetics and the nonlinear model developed in this study. At higher simulated plasma concentrations, exposure increased nonlinearly with target concentration due to the decreasing dexmedetomidine clearance with increasing plasma concentrations. Simulations also show that currently approved dosing regimens in the intensive care unit may potentially lead to higher-than-expected dexmedetomidine plasma concentrations. CONCLUSIONS: This study developed a nonlinear three-compartment pharmacokinetic model that accurately described dexmedetomidine plasma concentrations. Dexmedetomidine may be safely administered up to target-controlled infusion targets under 2 ng · ml-1 using the Hannivoort model, which assumed linear pharmacokinetics. Consideration should be taken during long-term administration and during an initial loading dose when following the dosing strategies of the current guidelines.


Assuntos
Dexmedetomidina/administração & dosagem , Dexmedetomidina/sangue , Sistemas de Liberação de Medicamentos/métodos , Taxa de Depuração Metabólica/efeitos dos fármacos , Modelos Biológicos , Dinâmica não Linear , Adolescente , Adulto , Idoso , Analgésicos não Narcóticos/administração & dosagem , Analgésicos não Narcóticos/sangue , Relação Dose-Resposta a Droga , Feminino , Humanos , Infusões Intravenosas , Modelos Lineares , Masculino , Taxa de Depuração Metabólica/fisiologia , Pessoa de Meia-Idade , Adulto Jovem
3.
Shock ; 57(2): 161-167, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34238904

RESUMO

OBJECTIVE: To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients. DESIGN AND SETTING: This is a post hoc analysis of a prospective multicenter cohort study. PATIENTS: Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded. ENDPOINTS: The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 µmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30. RESULTS: Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655). CONCLUSIONS: Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.


Assuntos
Hiperbilirrubinemia/complicações , Sepse/complicações , Adulto , Estudos de Coortes , Estado Terminal , Feminino , Humanos , Hiperbilirrubinemia/epidemiologia , Incidência , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prognóstico , Estudos Prospectivos , Sepse/epidemiologia , Sepse/fisiopatologia
4.
Crit Care ; 25(1): 280, 2021 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-34353348

RESUMO

The respiratory system reacts instantaneously to intrinsic and extrinsic inputs. This adaptability results in significant fluctuations in breathing parameters, such as respiratory rate, tidal volume, and inspiratory flow profiles. Breathing variability is influenced by several conditions, including sleep, various pulmonary diseases, hypoxia, and anxiety disorders. Recent studies have suggested that weaning failure during mechanical ventilation may be predicted by low respiratory variability. This review describes methods for quantifying breathing variability, summarises the conditions and comorbidities that affect breathing variability, and discusses the potential implications of breathing variability for anaesthesia and intensive care.


Assuntos
Anestesiologia/tendências , Cuidados Críticos/tendências , Mecânica Respiratória/fisiologia , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/normas , Anestesiologia/métodos , Cuidados Críticos/métodos , Humanos , Respiração Artificial/métodos , Estudos de Tempo e Movimento
5.
Clin Appl Thromb Hemost ; 27: 10760296211016541, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34013768

RESUMO

Postoperative coagulopathic bleeding is common in cardiac surgery and is associated with increased morbidity and mortality. Ideally, real-time information on in-vivo coagulation should be available. However, up to now it is unclear which perioperative coagulation parameters can be used best to accurately identify patients at increased risk of bleeding. The present study analyzed the associations of perioperative fibrinogen concentrations and whole blood viscoelastic tests with postoperative bleeding in 89 patients undergoing combined cardiac surgery procedures. Postoperative bleeding was recorded until 24 hours after surgery. Regression analyses were performed to establish associations between blood loss and coagulation parameters after cardiopulmonary bypass including a prediction model with known confounding factors for bleeding. Coagulation tests show large changes over the perioperative course with the strongest coagulopathic deviations from baseline after cardiopulmonary bypass. After adjustment for multiple confounders, viscoelastic clot strength instead of fibrinogen concentration showed a similar performance for 24 hour blood loss and a better performance for 6 hour blood loss. This makes intraoperative viscoelastic testing a useful tool to strengthen early clinical decision-making with the potential to reduce perioperative blood transfusions.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Fibrinogênio/metabolismo , Hemorragia/etiologia , Tromboelastografia/métodos , Idoso , Feminino , Humanos , Masculino
6.
Prehosp Emerg Care ; 25(5): 644-655, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32960672

RESUMO

OBJECTIVE: A thorough understanding of the epidemiology, patient characteristics, trauma mechanisms, and current outcomes among patients with severe traumatic brain injury (TBI) is important as it may inform potential strategies to improve prehospital emergency care. The aim of this study is to describe the prehospital epidemiology, characteristics and outcome of (suspected) severe TBI in the Netherlands. METHODS: The BRAIN-PROTECT study is a prospective observational study on prehospital management of patients with severe TBI in the Netherlands. The study population comprised all consecutive patients with clinical suspicion of TBI and a prehospital GCS score ≤ 8, who were managed by one of the 4 Helicopter Emergency Medical Services (HEMS). Patients were followed-up in 9 trauma centers until 1 year after injury. Planned sub-analyses were performed for patients with "confirmed" and "isolated" TBI. RESULTS: Data from 2,589 patients, of whom 2,117 (81.8%) were transferred to a participating trauma center, were analyzed. The incidence rate of prehospitally suspected and confirmed severe TBI were 3.2 (95% CI: 3.1;3.4) and 2.7 (95% CI: 2.5;2.8) per 100,000 inhabitants per year, respectively. Median patient age was 46 years, 58.4% were involved in traffic crashes, of which 37.4% were bicycle related. 47.6% presented with an initial GCS of 3. The median time from HEMS dispatch to hospital arrival was 54 minutes. The overall 30-day mortality was 39.0% (95% CI: 36.8;41.2). CONCLUSION: This article summarizes the prehospital epidemiology, characteristics and outcome of severe TBI in the Netherlands, and highlights areas in which primary prevention and prehospital care can be improved.


Assuntos
Resgate Aéreo , Lesões Encefálicas Traumáticas , Serviços Médicos de Emergência , Encéfalo , Lesões Encefálicas Traumáticas/epidemiologia , Lesões Encefálicas Traumáticas/terapia , Escala de Coma de Glasgow , Humanos , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Estudos Retrospectivos
7.
Burns ; 47(1): 127-132, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33082023

RESUMO

BACKGROUND: Hemostasis during burn surgery is difficult to achieve, and high blood loss commonly occurs. Bleeding control measures are limited, and many patients require allogeneic blood transfusions. Cell salvage is a well-known method used to reduce transfusions. However, its evidence in burns is limited. Therefore, this study aimed to examine the feasibility of cell salvage during burn surgery. STUDY DESIGN AND METHODS: A prospective, observational study was conducted with 16 patients (20 measurements) scheduled for major burn surgery. Blood was recovered by washing saturated gauze pads with heparinized saline, which was then processed using the Cell Saver. Erythrocyte concentrate quality was analyzed by measuring hemoglobin, hematocrit, potassium, and free hemoglobin concentration. Microbial contamination was assessed based on cultures at every step of the process. Differences in blood samples were tested using the Student's t-test. RESULTS: The red blood cell mass recovered was 29 ± 11% of the mass lost. Patients' preoperative hemoglobin and hematocrit levels were 10.5 ± 1.8 g/dL and 0.33 ± 0.05 L/L, respectively. The erythrocyte concentrate showed hemoglobin and hematocrit levels of 13.2 ± 3.9 g/dL and 0.40 ± 0.11 L/L thus showing a concentration effect. The potassium level was lower in the erythrocyte concentrate (2.5 ± 1.5 vs. 4.1 ± 0.4 mmol/L, p < 0.05). The free hemoglobin level was low (0.16 ± 0.21 µmol/L). All cultures of the erythrocyte concentrate showed bacterial growth compared to 21% of wound cultures. CONCLUSION: Recovering erythrocytes during burn excisional surgery using cell salvage is possible. Despite strict sterile handling, erythrocyte concentrates of all patients showed bacterial contamination. The consequence of this contamination remains unclear and should be investigated in future studies.


Assuntos
Perda Sanguínea Cirúrgica/fisiopatologia , Corpo Celular/patologia , Reparo do DNA/fisiologia , Eritrócitos/microbiologia , Terapia de Salvação/métodos , Adulto , Idoso , Transfusão de Sangue , Eritrócitos/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
8.
JAMA Neurol ; 78(3): 338-345, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33284310

RESUMO

Importance: The development and expansion of intracranial hematoma are associated with adverse outcomes. Use of tranexamic acid might limit intracranial hematoma formation, but its association with outcomes of severe traumatic brain injury (TBI) is unclear. Objective: To assess whether prehospital administration of tranexamic acid is associated with mortality and functional outcomes in a group of patients with severe TBI. Design, Setting, and Participants: This multicenter cohort study is an analysis of prospectively collected observational data from the Brain Injury: Prehospital Registry of Outcome, Treatments and Epidemiology of Cerebral Trauma (BRAIN-PROTECT) study in the Netherlands. Patients treated for suspected severe TBI by the Dutch Helicopter Emergency Medical Services between February 2012 and December 2017 were included. Patients were followed up for 1 year after inclusion. Data were analyzed from January 10, 2020, to September 10, 2020. Exposures: Administration of tranexamic acid during prehospital treatment. Main Outcomes and Measures: The primary outcome was 30-day mortality. Secondary outcomes included mortality at 1 year, functional neurological recovery at discharge (measured by Glasgow Outcome Scale), and length of hospital stay. Data were also collected on demographic factors, preinjury medical condition, injury characteristics, operational characteristics, and prehospital vital parameters. Results: A total of 1827 patients were analyzed, of whom 1283 (70%) were male individuals and the median (interquartile range) age was 45 (23-65) years. In the unadjusted analysis, higher 30-day mortality was observed in patients who received prehospital tranexamic acid (odds ratio [OR], 1.34; 95% CI, 1.16-1.55; P < .001), compared with patients who did not receive prehospital tranexamic acid. After adjustment for confounders, no association between prehospital administration of tranexamic acid and mortality was found across the entire cohort of patients. However, a substantial increase in the odds of 30-day mortality persisted in patients with severe isolated TBI who received prehospital tranexamic acid (OR, 4.49; 95% CI, 1.57-12.87; P = .005) and after multiple imputations (OR, 2.05; 95% CI, 1.22-3.45; P = .007). Conclusions and Relevance: This study found that prehospital tranexamic acid administration was associated with increased mortality in patients with isolated severe TBI, suggesting the judicious use of the drug when no evidence for extracranial hemorrhage is present.


Assuntos
Lesões Encefálicas Traumáticas/tratamento farmacológico , Lesões Encefálicas Traumáticas/mortalidade , Serviços Médicos de Emergência/tendências , Índice de Gravidade de Doença , Ácido Tranexâmico/administração & dosagem , Ácido Tranexâmico/efeitos adversos , Adulto , Idoso , Antifibrinolíticos/administração & dosagem , Antifibrinolíticos/efeitos adversos , Lesões Encefálicas Traumáticas/diagnóstico , Estudos de Coortes , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
10.
Transfus Med ; 30(2): 86-105, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32080942

RESUMO

OBJECTIVES: The primary aim of this scoping review is to describe the current use of pre-hospital transfusion of red blood cells (PHTRBC) and to evaluate criteria used to initiate PHTRBC. The effects on patients' outcomes will be reviewed in Part 2. BACKGROUND: Haemorrhage is a preventable cause of death in trauma patients, and transfusion of red blood cells is increasingly used by Emergency Medical Services (EMS) for damage control resuscitation. However, there are no guidelines and little consensus on when to initiate PHTRBC. METHODS: PubMed and Web of Science were searched through January 2019; 71 articles were included. RESULTS: Transfusion triggers vary widely and involve vital signs, clinical signs of poor tissue perfusion, point of care measurements and pre-hospital ultrasound imaging. In particular, hypotension (most often defined as systolic blood pressure ≤ 90 mmHg), tachycardia (most often defined as heart rate ≥ 120/min), clinical signs of poor perfusion (eg, prolonged capillary refill time or changes in mental status) and injury type (ie, penetrating wounds) are common pre-hospital transfusion triggers. CONCLUSIONS: PHTRBC is increasingly used by Emergency Medical Services, but guidelines on when to initiate transfusion are lacking. We identified the most commonly used transfusion criteria, and these findings may provide the basis for consensus-based pre-hospital transfusion protocols.


Assuntos
Transfusão de Sangue , Serviços Médicos de Emergência , Hemorragia/terapia , Ressuscitação , Humanos
11.
Transfus Med ; 30(2): 106-133, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31903684

RESUMO

The primary aim of this systematic review is to describe the effects of prehospital transfusion of red blood cells (PHTRBC) on patient outcomes. Damage control resuscitation attempts to prevent death through haemorrhage in trauma patients. In this context, transfusion of red blood cells is increasingly used by emergency medical services (EMS). However, evidence on the effects on outcomes is scarce. PubMed and Web of Science were searched through January 2019; 55 articles were included. No randomised controlled studies were identified. While several observational studies suggest an increased survival after PHTRBC, consistent evidence for beneficial effects of PHTRBC on survival was not found. PHTRBC appears to improve haemodynamic parameters, but there is no evidence that shock on arrival to hospital is averted, nor of an association with trauma induced coagulopathy or with length of stay in hospitals or intensive care units. In conclusion, PHTRBC is increasingly used by EMS, but there is no strong evidence for effects of PHTRBC on mortality. Further research with study designs that allow causal inferences is required for more conclusive evidence. The combination of PHTRBC with plasma, as well as the use of individualised transfusion criteria, may potentially show more benefits and should be thoroughly investigated in the future. The review was registered at Prospero (CRD42018084658).


Assuntos
Serviços Médicos de Emergência , Transfusão de Eritrócitos , Hemorragia/terapia , Ressuscitação , Humanos
12.
Curr Opin Anaesthesiol ; 32(6): 762-763, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31634156
13.
Curr Opin Anaesthesiol ; 32(6): 783-791, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31464698

RESUMO

PURPOSE OF REVIEW: The topic of perioperative hyperoxia remains controversial, with valid arguments on both the 'pro' and 'con' side. On the 'pro' side, the prevention of surgical site infections was a strong argument, leading to the recommendation of the use of hyperoxia in the guidelines of the Center for Disease Control and the WHO. On the 'con' side, the pathophysiology of hyperoxia has increasingly been acknowledged, in particular the pulmonary side effects and aggravation of ischaemia/reperfusion injuries. RECENT FINDINGS: Some 'pro' articles leading to the Center for Disease Control and WHO guidelines advocating perioperative hyperoxia have been retracted, and the recommendations were downgraded from 'strong' to 'conditional'. At the same time, evidence that supports a tailored, more restrictive use of oxygen, for example, in patients with myocardial infarction or following cardiac arrest, is accumulating. SUMMARY: The change in recommendation exemplifies that despite much work performed on the field of hyperoxia recently, evidence on either side of the argument remains weak. Outcome-based research is needed for reaching a definite recommendation.


Assuntos
Oxigênio/administração & dosagem , Humanos , Hiperóxia , Oxigênio/análise , Período Perioperatório , Medição de Risco
14.
Air Med J ; 38(3): 209-211, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31122589

RESUMO

Hemorrhaging is the leading cause of preventable death after trauma. In our helicopter emergency medical service (HEMS), we introduced a bundle of 3 hemostatic adjuncts: 1) tourniquet, 2) hemostatic chitosan-based wound packings, and 3) tranexamic acid (TXA). The real-life frequency of applying these adjuncts in HEMS remains unclear. Therefore, we analyzed our electronic HEMS database regarding the use of these hemostatic adjuncts. We analyzed all subsequent dispatches of our HEMS "Lifeliner 1" within a searchable digital database (01.02.2013-22.05.2018). This HEMS operates 24/7, servicing ∼4.5 million inhabitants of the Netherlands. During the 75-month study period, we registered 15,759 dispatches, of which 8,658 were canceled, and 7,101 included on-site patient care, including 4,928 (69.4%) trauma cases. In total, we recorded 78 tourniquet applications (1.1% of patients), 104 hemostatic wound packings (1.5% of patients), and 1,379 cases with prehospital TXA administration (19.4% of patients). This difference in the use of hemostatics has several contributors, including a possible lack of awareness for tourniquets and procoagulant wound packing, a high proportion of blunt trauma with internal bleeding not accessible to tourniquet or wound packing, and a liberal use of TXA (eg, in patients with unproven hemorrhage). Besides creating awareness for those hemostatic adjuncts, the practical implications of our findings need further evaluation in future studies.


Assuntos
Resgate Aéreo , Hemorragia/terapia , Adulto , Resgate Aéreo/estatística & dados numéricos , Antifibrinolíticos/uso terapêutico , Bandagens , Serviços Médicos de Emergência/métodos , Feminino , Técnicas Hemostáticas , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Torniquetes , Ferimentos e Lesões/terapia , Adulto Jovem
15.
BMC Emerg Med ; 19(1): 12, 2019 01 23.
Artigo em Inglês | MEDLINE | ID: mdl-30674276

RESUMO

BACKGROUND: Creating a patent airway by cricothyrotomy is the ultimate maneuver to allow oxygenation (and ventilation) of the patient. Given the rarity of airway management catastrophes necessitating cricothyrotomy, sufficiently sized prospective randomized trials are difficult to perform. Our Helicopter Emergency Medical Service (HEMS) documents all cases electronically, allowing a retrospective analysis of a larger database for all cases of prehospital cricothyrotomy. METHODS: We analyzed all 19,382 dispatches of our HEMS 'Lifeliner 1', since set-up of a searchable digital database. This HEMS operates 24/7, covering ~ 4.5 million inhabitants of The Netherlands. The potential cases were searched and cross-checked in two independent databases. RESULTS: We recorded n = 18 cases of prehospital cricothyrotomy. In all 18 cases, less invasive airway techniques, e.g., supraglottic devices, were attempted before cricothyrotomy. With exception of 2 cases, at least one attempt of orotracheal intubation had been performed before cricothyrotomy. Out of the 18 cases, 4 were performed by puncture-based technique (Melker), the remaining 14 cases by surgical technique. Indications for cricothyrotomy were diverse, dividable into 9 trauma cases and 9 medical cases. The procedure was successful in all but one case (17/18, i.e., 94%; with a 95% confidence interval of 72.7-99.9%). Outcome was such that 6/18 patients arrived at the hospital alive. Long term outcome was poor, with only 2/18 patients discharged from hospital alive. CONCLUSIONS: Cricothyrotomy remains, although rare, a regularly occurring requirement in (H)EMS. Our finding of a convincingly high success rate of 94% in trained hands encourages training and a timely performance of cricothyrotomy.


Assuntos
Resgate Aéreo/estatística & dados numéricos , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/estatística & dados numéricos , Obstrução das Vias Respiratórias/cirurgia , Adolescente , Adulto , Humanos , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
16.
J Patient Saf ; 15(3): 224-229, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-29112022

RESUMO

OBJECTIVES: Inadequate patient handovers are associated with the occurrence of medical errors. The objective of the present study was to explore the structure and quality of handovers in the acute medical assessment unit. METHODS: A prospective observational study was conducted in an academic hospital in the Netherlands. Handover structure was observed by ordering handover information according to the elements of the Situation, Background, Assessment, Recommendation, and Read back (SBAR-R) handover tool. Handover quality was measured by means of a questionnaire, i.e., the rating tool for handover quality, and by assessing situation awareness of the degree to which professionals after a handover agreed on the complexity of the patient's care needs. RESULTS: A total of 71 handovers were observed. In most handovers, different elements of the SBAR-R were used frequently (median, 7.5 elements; range, 2.0-15.0). On the quality of handovers, 109 respondents (44.1%) completed the questionnaire. On a 0-to-100 scale, median scores on information transfer were 67.9 (interquartile range [IQR],17.9), 75.0 (IQR, 25.0) on shared understanding, and 75.0 (IQR, 16.7) on working atmosphere. Agreement in situation awareness was 70.0%. CONCLUSIONS: Handovers in the acute medical assessment unit were poorly structured; however, the perceived quality of handovers was substantial. Implementing the SBAR-R may be an effective strategy to improve handover practice and situation awareness, although further study to its applicability in acute medical assessment units is necessary.


Assuntos
Transferência da Responsabilidade pelo Paciente/normas , Qualidade da Assistência à Saúde/normas , Comparação Transcultural , Feminino , Humanos , Masculino , Estudos Prospectivos
17.
Curr Opin Anaesthesiol ; 31(6): 732-738, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30169340

RESUMO

PURPOSE OF REVIEW: Early warnings scores are designed to detect clinical deterioration and promote intervention at the earliest possible moment. Although the ultimate effects on patient outcomes are unclear, early warning scores are now legally mandated in several countries. Here, we review the performance of early warning scores in surgical and perioperative populations. RECENT FINDINGS: Early warning scores can be used to screen for postoperative deterioration and surgical complications. We describe a framework to evaluate the balance between missed events and warning signals that are not followed by an adverse event (nonevents). In large surgical cohort studies, the missed event rates ranged between 19 and 69% and the nonevent rates ranged between 72 and 99% for 'optimal' threshold early warning sores. Recent investigations have shown that there may be a substantial discrepancy between the theoretical benefits shown in validation studies and the practical clinical implementation of early warning scores, which may partly explain the absence of measurable benefit from these systems. SUMMARY: Early warning scores may facilitate protocolized escalation of care for patients at risk of adverse events and can be used in surgical and postoperative patients, but high nonevent rates and practical implementation problems can restrict their usefulness.


Assuntos
Diagnóstico Precoce , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Humanos , Procedimentos Cirúrgicos Operatórios/efeitos adversos
19.
Curr Opin Anaesthesiol ; 31(6): 716-722, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30095483

RESUMO

PURPOSE OF REVIEW: This narrative review summarizes recent insights into the role of remote monitoring of vital signs in the postoperative period in surgical wards. RECENT FINDINGS: Despite recent improvements in the safety of anesthesia and surgical procedures, postoperative complication rates are still unacceptably high. This is partly attributable to the intermittent provision of personal care to patients by nurses and ward physicians. Continuous remote monitoring of vital functions in the early postoperative period may reduce these complication rates. There are several medical-grade remote monitoring platforms available that integrate a biosensor signal with electronic patient records, enabling automated prediction or notification of patient deterioration. Most available platforms have technical limitations with respect to the accuracy of respiratory rate measurements. Of note, although the implementation of automated notifications of patient deterioration is associated with a reduced activation of acute response teams, the involvement of ward physicians in the early diagnosis and treatment of subtle changes in vital functions is increased. SUMMARY: Remote monitoring of vital signs in the surgical ward may contribute to prevention of severe complications and reduction in failure-to-rescue rates, although evidence for this association is still lacking. Anesthesiologists should contribute their knowledge and skills with respect to perioperative abnormalities in vital functions to improve patient safety during the postoperative period.


Assuntos
Anestesia/métodos , Monitorização Fisiológica/métodos , Cuidados Pós-Operatórios/métodos , Telemedicina/métodos , Sinais Vitais , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia
20.
Clin Case Rep ; 6(8): 1521-1524, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30147896

RESUMO

Clamshell thoracotomy (CST) may be indicated and life-saving in carefully selected cases of blunt trauma. As such, the current clinical stance of general contraindication of CST in blunt trauma should be reviewed and criteria developed to accommodate select cases, considering the diversity of injuries resulting from blunt trauma.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...