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1.
Anesth Analg ; 2020 Jan 31.
Artigo em Inglês | MEDLINE | ID: mdl-32022745

RESUMO

BACKGROUND: A leading cause of preventable maternal death is related to delayed response to clinical warning signs. Electronic surveillance systems may improve detection of maternal morbidity with automated notifications. This retrospective observational study evaluates the ability of an automated surveillance system and the Maternal Early Warning Criteria (MEWC) to detect severely morbid postpartum hemorrhage (sPPH) after delivery. METHODS: The electronic health records of adult obstetric patients of any gestational age delivering between April 1, 2017 and December 1, 2018 were queried to identify scheduled or unscheduled vaginal or cesarean deliveries. Deliveries complicated by sPPH were identified and defined by operative management of postpartum hemorrhage, transfusion of ≥4 units of packed red blood cells (pRBCs), ≥2 units of pRBCs and ≥2 units of fresh-frozen plasma, transfusion with >1 dose of furosemide, or transfer to the intensive care unit. The test characteristics of automated pages and the MEWC for identification of sPPH 24 hours after delivery were determined and compared using sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and their 95% confidence intervals (CIs). McNemar test was used to compare these estimates for both early warning systems. RESULTS: The average age at admission was 30.7 years (standard deviation [SD] = 5.1 years), mean gestational age 38 weeks 4 days, and cesarean delivery accounted for 30.0% of deliveries. Of 7853 deliveries, 120 (1.5%) were complicated by sPPH. The sensitivity of automated pages for sPPH within 24 hours of delivery was 60.8% (95% CI, 52.1-69.6), specificity 82.5% (95% CI, 81.7-83.4), PPV 5.1% (95% CI, 4.0-6.3), and NPV 99.3% (95% CI, 99.1-99.5). The test characteristics of the MEWC for sPPH were sensitivity 75.0% (95% CI, 67.3-82.7), specificity 66.3% (95% CI, 65.2-67.3), PPV 3.3% (95% CI, 2.7-4.0), and NPV 99.4% (95% CI, 99.2-99.6). There were 10 sPPH cases identified by automated pages, but not by the MEWC. Six of these cases were identified by a page for anemia, and 4 cases were the result of vital signs detected by the bedside monitor, but not recorded in the patient's medical record by the bedside nurse. Therefore, the combined sensitivity of the 2 systems was 83.3% (95% CI, 75.4-89.5). CONCLUSIONS: The automated system identified 10 of 120 deliveries complicated by sPPH not identified by the MEWC. Using an automated alerting system in combination with a labor and delivery unit's existing nursing-driven early warning system may improve detection of sPPH.

2.
Can J Anaesth ; 67(2): 225-234, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31529370

RESUMO

PURPOSE: Intraoperative hypoglycemia can result in devastating neurologic injury if not promptly diagnosed and treated. Few studies have defined risk factors for intraoperative hypoglycemia. The authors sought to characterize children with intraoperative hypoglycemia and determine independent risk factors. METHODS: This retrospective observational single-institution study included all patients < 18 yr of age undergoing an anesthetic from January 1 2012 to December 31 2016. The primary outcome was blood glucose < 3.3 mmol·L-1 (60 mg·dl-1). Data collected included patient characteristics, comorbidities, and intraoperative factors. A multivariable logistic regression model was used to identify independent predictors of intraoperative hypoglycemia. RESULTS: Blood glucose was measured in 7,715 of 73,592 cases with 271 (3.5%) having a glucose < 3.3 mmol·L-1 (60 mg·dl-1). Young age, weight for age < 5th percentile, developmental delay, presence of a gastric or jejunal tube, and abdominal surgery were identified as independent predictors for intraoperative hypoglycemia. Eighty percent of hypoglycemia cases occurred in children < three years of age and in children < 15 kg. CONCLUSION: Young age, weight for age < 5th percentile, developmental delay, having a gastric or jejunal tube, and abdominal surgery were independent risk factors for intraoperative hypoglycemia in children. Frequent monitoring of blood glucose and judicious isotonic dextrose administration may be warranted in these children.

3.
Anesthesiology ; 2019 11 26.
Artigo em Inglês | MEDLINE | ID: mdl-31794513

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Acute kidney injury occurs in 13% of patients undergoing major surgery and is associated with a six-fold increased risk of mortality.Single-center studies have demonstrated an association between intraoperative hypotension and acute kidney injury. WHAT THIS ARTICLE TELLS US THAT IS NEW: In a large cohort of noncardiac surgical patients, the incidence of acute kidney injury was 9%.Major factors identifying patients at risk for acute kidney injury included anemia, estimated glomerular filtration rate, elevated risk surgery, American Society of Anesthesiologists Physical Status, and expected anesthesia duration.The relationship between hypotension and acute kidney injury varied by underlying patient and procedural risk. Patients with low risk demonstrated no associated increased risk of acute kidney injury across all blood pressure ranges, whereas patients with the highest baseline risk demonstrated an association between even mild absolute intraoperative hypotension ranges and acute kidney injury. BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.

5.
A A Pract ; 12(10): 378-381, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-31091201

RESUMO

Although rare, cannot intubate and cannot oxygenate situations are challenging acute events. The development of management algorithms, standardized equipment provisions, and appropriate clinical training in the application of front-of-neck access techniques are necessary to optimize procedural success to ensure adequate oxygenation. The OxyTain algorithm is an institutionally developed protocol to manage cannot intubate and cannot oxygenate events. With proper implementation, this unique process aligning the cannula cricothyroidotomy and scalpel bougie as primary and secondary techniques, respectively, can potentially optimize procedural success. This algorithmic approach is trained routinely among our anesthesia providers, while the equipment is standardized throughout our anesthetizing locations.


Assuntos
Manuseio das Vias Aéreas/métodos , Educação Médica Continuada/métodos , Manuseio das Vias Aéreas/instrumentação , Algoritmos , Cânula , Competência Clínica , Humanos , Intubação Intratraqueal/efeitos adversos
6.
Anesthesiology ; 129(3): 615-616, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30106789
7.
BMC Anesthesiol ; 18(1): 78, 2018 06 26.
Artigo em Inglês | MEDLINE | ID: mdl-29945569

RESUMO

BACKGROUND: Maternal early warning systems reduce maternal morbidity. We developed an electronic maternal surveillance system capable of visually summarizing the labor and delivery census and identifying changes in clinical status. Automatic page alerts to clinical providers, using an algorithm developed at our institution, were incorporated in an effort to improve early detection of maternal morbidity. We report the frequency of pages generated by the system. To our knowledge, this is the first time such a system has been used in peripartum care. METHODS: Alert criteria were developed after review of maternal early warning systems, including the Maternal Early Warning Criteria (MEWC). Careful consideration was given to the frequency of pages generated by the surveillance system. MEWC notification criteria were liberalized and a paging algorithm was created that triggered paging alerts to first responders (nurses) and then managing services due to the assumption that paging all clinicians for each vital sign triggering MEWC would generate an inordinate number of pages. For preliminary analysis, to determine the effect of our automated paging algorithm on alerting frequency, the paging frequency of this system was compared to the frequency of vital signs meeting the Maternal Early Warning Criteria (MEWC). This retrospective analysis was limited to a sample of 34 patient rooms uniquely capable of storing every vital sign reported by the bedside monitor. RESULTS: Over a 91-day period, from April 1 to July 1, 2017, surveillance was conducted from 64 monitored beds, and the obstetrics service received one automated page every 2.3 h. The most common triggers for alerts were for hypertension and tachycardia. For the subset of 34 patient rooms uniquely capable of real-time recording, one vital sign met the MEWC every 9.6 to 10.3 min. Anecdotally, the system was well-received. CONCLUSIONS: This novel electronic maternal surveillance system is designed to reduce cognitive bias and improve timely clinical recognition of maternal deterioration. The automated paging algorithm developed for this software dramatically reduces paging frequency compared to paging for isolated vital sign abnormalities alone. Long-term, prospective studies will be required to determine its impact on patient outcomes.


Assuntos
Trabalho de Parto , Monitorização Fisiológica/métodos , Período Periparto , Sinais Vitais , Algoritmos , Feminino , Humanos , Gravidez , Estudos Retrospectivos
9.
BMC Anesthesiol ; 18(1): 16, 2018 02 05.
Artigo em Inglês | MEDLINE | ID: mdl-29402220

RESUMO

BACKGROUND: This paper describes the design of a multifunction alerting display for intraoperative anesthetic care. The design was inspired by the multifunction primary flight display used in modern aviation. RESULTS: The display retrieves live data from multiple sources; the physiologic monitors, the anesthesia information management system, the laboratory values and comorbidities from patient's problem summary list, medical history or history & physical. This information is integrated into a display composed of readily identifiable icons of organ systems, which are color coded to signify normal range, marginal range, abnormal range (by green, yellow, red respectively) and orange outlines for comorbidities/risk factors. There are dozens of text alerts, which can be presented as black text (informational), red text (important information) and red scrolling text (highest importance information). The alerts are derived from current standards in the literature and some involve complex calculations being conducted in the background. CONCLUSIONS: The goal of such a system is to improve the quality and safety of anesthetic care by providing enhanced situational awareness in a fashion analogous to the "glass cockpit" and its primary flight display which has improved aviation safety.


Assuntos
Anestesia/métodos , Sistemas de Apoio a Decisões Clínicas/instrumentação , Desenho de Equipamento , Monitorização Intraoperatória/instrumentação , Conscientização , Apresentação de Dados , Humanos , Software
10.
Anesthesiology ; 128(2): 272-282, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29337743

RESUMO

BACKGROUND: The authors hypothesized that a multiparameter intraoperative decision support system with real-time visualizations may improve processes of care and outcomes. METHODS: Electronic health record data were retrospectively compared over a 6-yr period across three groups: experimental cases, in which the decision support system was used for 75% or more of the case at sole discretion of the providers; parallel controls (system used 74% or less); and historical controls before system implementation. Inclusion criteria were adults under general anesthesia, advanced medical disease, case duration of 60 min or longer, and length of stay of two days or more. The process measures were avoidance of intraoperative hypotension, ventilator tidal volume greater than 10 ml/kg, and crystalloid administration (ml · kg · h). The secondary outcome measures were myocardial injury, acute kidney injury, mortality, length of hospital stay, and encounter charges. RESULTS: A total of 26,769 patients were evaluated: 7,954 experimental cases, 10,933 parallel controls, and 7,882 historical controls. Comparing experimental cases to parallel controls with propensity score adjustment, the data demonstrated the following medians, interquartile ranges, and effect sizes: hypotension 1 (0 to 5) versus 1 (0 to 5) min, P < 0.001, beta = -0.19; crystalloid administration 5.88 ml · kg · h (4.18 to 8.18) versus 6.17 (4.32 to 8.79), P < 0.001, beta = -0.03; tidal volume greater than 10 ml/kg 28% versus 37%, P < 0.001, adjusted odds ratio 0.65 (0.53 to 0.80); encounter charges $65,770 ($41,237 to $123,869) versus $69,373 ($42,101 to $132,817), P < 0.001, beta = -0.003. The secondary clinical outcome measures were not significantly affected. CONCLUSIONS: The use of an intraoperative decision support system was associated with improved process measures, but not postoperative clinical outcomes.


Assuntos
Sistemas de Apoio a Decisões Clínicas/estatística & dados numéricos , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Idoso , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
J Clin Monit Comput ; 32(4): 699-705, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28965158

RESUMO

The American Society of Anesthesiologists Standards for Basic Monitoring recommends blood pressure (BP) measurement every 5 min. Research has shown distractions or technical factors can cause prolonged measurement intervals exceeding 5 min. We investigated the relationship between prolonged non-invasive BP (NIBP) measurement interval and the incidence of hypotension, detected post-interval. Our secondary outcome was to determine independent predictors of these prolonged NIBP measurement intervals. Retrospective data were analyzed from 139,509 general anesthesia cases from our institution's Anesthesia Information Management System (AIMS). Absolute hypotension (AH) was defined a priori as a systolic BP < 80 mmHg and relative hypotension (RH) was defined as a 40% decrease in systolic BP from the preoperative baseline. Odds ratios (OR) with 95% confidence intervals and Pearson's Chi square Test reported the association of prolonged NIBP measurement intervals on hypotension detected post-NIBP measurement interval. Logistic regression models were developed to determine independent predictors of NIBP measurement intervals. The analysis revealed that NIBP measurement intervals greater than 6 and 10 min are associated with an approximately four times higher incidence of a patient transitioning into hypotension (AH/RH > 6 min OR 4.0 / 3.6; AH/RH > 10 min OR 4.3 / 3.9; p < 0.001). A key finding was that the "> 10-minute AH model" indicated that age 41-80, increased co-morbidity profile, obesity and turning (repositioning) of the operative room table were significant predictors of prolonged NIBP measurement intervals (p < 0.001). While we do not suggest NIBP measurement intervals cause hypotension, intervals greater than 6 and 10 min are associated with a fourfold increase in the propensity of an undetected transition into both RH or AH. These data support current monitoring guidelines.


Assuntos
Determinação da Pressão Arterial/métodos , Hipotensão/diagnóstico , Hipotensão/etiologia , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Monitorização Intraoperatória/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/efeitos adversos , Determinação da Pressão Arterial/normas , Feminino , Humanos , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/efeitos adversos , Monitorização Intraoperatória/normas , Estudos Retrospectivos , Fatores de Tempo , Falha de Tratamento , Adulto Jovem
12.
Anesth Analg ; 127(3): 744-752, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29256940

RESUMO

BACKGROUND: The effect of neither transfusion guidelines nor decision support tools on intraoperative transfusion has been previously evaluated. The University of Michigan introduced a transfusion guideline in 2009, and in 2011, the Department of Anesthesiology developed a transfusion decision support tool. The primary aim of this study was to assess the associations of the transfusion guideline and the optional use of the software transfusion tool with intraoperative behaviors; pretransfusion hematocrit assessment (whether or not a hematocrit was checked before each red cell unit) and restrictive red cell use (withholding transfusion unless the hematocrit was ≤21%). METHODS: This was a before-after retrospective study without a concurrent control group of patients transfused 1-3 units of red cells intraoperatively. Three phases were studied to provide data both before and after the implementation of the transfusion guideline and the intraoperative software tool. Within each phase, trends of checking hematocrits before transfusion and restrictive transfusion were charted against time. F tests were used to measure differences of slopes. The difference between means of each phase was measured using Mann-Whitney U tests. Independent associations were measured using mixed-effects multivariable logistic regression. A secondary outcome analysis was conducted for 30-day mortality, myocardial infarction, renal injury, and their combination. RESULTS: The transfusion guideline was associated with increased pretransfusion hematocrit evaluation (67.4%, standard deviation [SD] 3.9 vs 76.5%, SD 2.7; P < .001) and restrictive transfusion practice (14.0%, SD 7.4 vs 33.3%, SD 4.4; P = .001). After adjustment for confounders, the guideline phase was independently associated with increased hematocrit checking (odds ratio, 1.72; 95% confidence interval, 1.46-2.03; P < .001) and restrictive red cell transfusion (odds ratio, 2.95; 95% confidence interval, 2.46-3.54; P < .001). The software tool was not associated with either transfusion behavior. There was no significant change in the rate of renal injury (16.06%), myocardial injury (4.93%), 30-day mortality (5.47%), or a composite (21.90%). CONCLUSIONS: The introduction of a transfusion guideline was independently associated with increased intraoperative pretransfusion hematocrit assessment and restrictive transfusion. The use of a software tool did not further influence either behavior.


Assuntos
Transfusão de Eritrócitos/normas , Cuidados Intraoperatórios/normas , Guias de Prática Clínica como Assunto/normas , Software/normas , Adulto , Idoso , Transfusão de Eritrócitos/métodos , Feminino , Hematócrito/métodos , Hematócrito/normas , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos
14.
Anesthesiology ; 126(2): 249-259, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27906705

RESUMO

BACKGROUND: Assessment of need for intravascular volume resuscitation remains challenging for anesthesiologists. Dynamic waveform indices, including systolic and pulse pressure variation, are demonstrated as reliable measures of fluid responsiveness for mechanically ventilated patients. Despite widespread use, real-world reference distributions for systolic and pulse pressure variation values have not been established for euvolemic intraoperative patients. The authors sought to establish systolic and pulse pressure variation reference distributions and assess the impact of modifying factors. METHODS: The authors evaluated adult patients undergoing general anesthetics for elective noncardiac surgery. Median systolic and pulse pressure variations during a 50-min postinduction period were noted for each case. Modifying factors including body mass index, age, ventilator settings, positioning, and hemodynamic management were studied via univariate and multivariable analyses. For systolic pressure variation values, effects of data entry method (manually entered vs. automated recorded) were similarly studied. RESULTS: Among 1,791 cases, per-case median systolic and pulse pressure variation values formed nonparametric distributions. For each distribution, median values, interquartile ranges, and reference intervals (2.5th to 97.5th percentile) were, respectively, noted: these included manually entered systolic pressure variation (6.0, 5.0 to 7.0, and 3.0 to 11.0 mmHg), automated systolic pressure variation (4.7, 3.9 to 6.0, and 2.2 to 10.4 mmHg), and automated pulse pressure variation (7.0, 5.0 to 9.0, and 2.0 to 16.0%). Nonsupine positioning and preoperative ß blocker were independently associated with altered systolic and pulse pressure variations, whereas ventilator tidal volume more than 8 ml/kg ideal body weight and peak inspiratory pressure more than 16 cm H2O demonstrated independent associations for systolic pressure variation only. CONCLUSIONS: This study establishes real-world systolic and pulse pressure variation reference distributions absent in the current literature. Through a consideration of reference distributions and modifying factors, the authors' study provides further evidence for assessing intraoperative volume status and fluid management therapies.


Assuntos
Pressão Arterial/fisiologia , Índice de Massa Corporal , Procedimentos Cirúrgicos Eletivos , Posicionamento do Paciente/métodos , Respiração Artificial/métodos , Fatores Etários , Idoso , Pressão Sanguínea/fisiologia , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
15.
16.
Anesth Analg ; 122(3): 608-15, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25977993

RESUMO

BACKGROUND: Intraoperative electrocardiographic monitoring is considered a standard of care. However, there are no evidence-based algorithms for using intraoperative ST segment data to identify patients at high risk for adverse perioperative cardiac events. Therefore, we performed an exploratory study of statistical measures summarizing intraoperative ST segment values determine whether the variability of these measurements was associated with adverse postoperative events. We hypothesized that elevation, depression, and variability of ST segments captured in an anesthesia information management system are associated with postoperative serum troponin elevation. METHODS: We conducted a single-institution, retrospective study of intraoperative automated ST segment measurements from leads I, II, and III, which were recorded in the electronic anesthesia record of adult patients undergoing noncardiac surgery. The maximum, minimum, mean, and SD of ST segment values were entered into logistic regression models to find independent associations with myocardial injury, defined as an elevated serum troponin concentration during the 7 days after surgery. Performance of these models was assessed by measuring the area under the receiver operator characteristic curve. The net reclassification improvement was calculated to quantify the amount of information that the ST segment values analysis added regarding the ability to predict postoperative troponin elevation. RESULTS: Of 81,011 subjects, 4504 (5.6%) had postoperative myocardial injury. After adjusting for patient characteristics, the ST segment maximal depression (e.g., lead I: odds ratio [OR], 1.66; 95% confidence interval [CI], 1.26-2.19; P = 0.0004), maximal elevation (e.g., lead I: OR, 1.70; 95% CI, 1.34-2.17; P < 0.0001), and SD (e.g., lead I: OR, 0.16; 95% CI, 0.06-0.42; P = 0.0002) were found to have statistically significant associations with myocardial injury. Increased SD was associated with decreased risk when accounting for the maximal amount of ST segment depression and elevation and for patient characteristics. The ST segment summary statistics model had fair discrimination, with an area under the receiver operator characteristic curve of 0.71 (95% CI, 0.68-0.73). Addition of ST segment data produced a net reclassification improvement of 0.0345 (95% CI, 0.00016-0.0591; P = 0.0474). CONCLUSIONS: Analysis of automated ST segment values obtained during anesthesia may be useful for improving the prediction of postoperative troponin elevation.


Assuntos
Eletrocardiografia/estatística & dados numéricos , Monitorização Intraoperatória/estatística & dados numéricos , Troponina/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia , Automação , Cardiomiopatias/sangue , Cardiomiopatias/etiologia , Estudos de Casos e Controles , Eletrocardiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/sangue , Valor Preditivo dos Testes , Valores de Referência , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Operatórios/métodos , Resultado do Tratamento
17.
Anesthesiol Res Pract ; 2015: 623959, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25653678

RESUMO

An educational intervention was implemented at the University of Michigan starting in 2008, in which anesthesiology interns complete a dedicated month-long didactic rotation in evidence-based medicine (EBM) and research methodology. We sought to assess its utility. Scores on a validated EBM test before and after the rotation were compared and assessed for significance of improvement. A survey was also given to gauge satisfaction with the quality of the rotation and self-reported improvement in understanding of EBM topics. Fourteen consecutive interns completed the research rotation during the study period. One hundred percent completed both the pre- and postrotation test. The mean pretest score was 7.78 ± 2.46 (median = 7.5, 0-15 scale, and interquartile range 7.0-10.0) and the mean posttest score was 10.00 ± 2.35 (median = 9.5, interquartile range 8.0-12.3), which represented a statistically significant increase (P = 0.011, Wilcoxon signed-rank test). All fourteen of the residents "agreed" or "strongly agreed" that they would recommend the course to future interns and that the course increased their ability to critically review the literature. Our findings demonstrate that this can be an effective means of improving understanding of EBM topics and anesthesiology research.

18.
Eur J Anaesthesiol ; 32(5): 346-53, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25010744

RESUMO

BACKGROUND: Intraoperative awareness with explicit recall is a potentially devastating complication of surgery that has been attributed to low anaesthetic concentrations in the vast majority of cases. Past studies have proposed the determination of an adequate dose for general anaesthetics that could be used to alert providers of potentially insufficient anaesthesia. However, there have been no systematic analyses of appropriate thresholds to develop population-based alerting algorithms for preventing intraoperative awareness. OBJECTIVE: To identify a threshold for intraoperative alerting that could be applied for the prevention of awareness with explicit recall. DESIGN: Secondary analysis of a randomised controlled trial (Michigan Awareness Control Study). SETTING: Three hospitals at a tertiary care centre in the USA. PATIENTS: Unselected patients presenting for surgery under general anaesthesia. INTERVENTIONS: Alerts based on end-tidal anaesthetic concentration or bispectral index values. MAIN OUTCOME MEASURES: Using case and outcomes data from the primary study, end-tidal anaesthetic concentration and bispectral index values were analysed using Youden's index and c-statistics derived from a receiver operating characteristic curve to determine a specific alerting threshold for the prevention of awareness. RESULTS: No single population-based threshold that maximises sensitivity and specificity could be identified for the prevention of intraoperative awareness, using either anaesthetic concentration or bispectral index values. The c-statistic for anaesthetic concentration was 0.431 ±â€Š0.046, and 0.491 ±â€Š0.056 for bispectral index values. CONCLUSION: We could not derive a single population-based alerting threshold for the prevention of intraoperative awareness using either anaesthetic concentration or bispectral index values. These data indicate a need to move towards individualised alerting strategies in the prevention of intraoperative awareness. TRIAL REGISTRATION: Primary trial registration (Michigan Awareness Control Study) ClinicalTrials.gov identifier: NCT00689091.


Assuntos
Anestesia Geral/efeitos adversos , Consciência no Peroperatório/epidemiologia , Consciência no Peroperatório/prevenção & controle , Sistemas de Registro de Ordens Médicas/normas , Monitorização Intraoperatória/normas , Eletroencefalografia/métodos , Eletroencefalografia/normas , Feminino , Humanos , Consciência no Peroperatório/diagnóstico , Masculino , Michigan/epidemiologia , Monitorização Intraoperatória/métodos
19.
Anesth Analg ; 119(3): 522-32, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24722256

RESUMO

BACKGROUND: Heart failure (HF) is an important risk factor for perioperative morbidity and mortality. While these patients are at high risk for cardiac adverse events, there are few current data describing the types of noncardiac complications that occur in this population. METHODS: We performed a multicenter cohort study of patients undergoing noncardiac surgery from 2005 to 2010 as part of the American College of Surgeons National Surgical Quality Improvement Program. A HF cohort (HF that is new or worsening within 30 days of surgery) was compared with a control cohort that was matched regarding other surgical risk factors. RESULTS: Five thousand ninety-four patients with worsening preoperative HF were compared with an otherwise similar cohort of patients without worsening preoperative HF. Worsening preoperative HF was associated with increased risk of 30-day all-cause mortality (relative risk [RR] 2.08; 95% confidence interval [CI], 1.75-2.46; P < 0.001) and increased risk of morbidity (any recorded postoperative complication) (RR 1.54; 95% CI, 1.40-1.69; P < 0.001). HF patients had increased risk of developing renal failure (RR 1.85; 95% CI, 1.37-2.49; P < 0.001), need for mechanical ventilation longer than 48 hours (RR 1.81; 95% CI, 1.52-2.15; P < 0.001), pneumonia (RR 1.73; 95% CI, 1.44-2.08; P < 0.001), cardiac arrest (RR 1.69; 95% CI, 1.29-2.21; P < 0.001), unplanned intubation (RR 1.68; 95% CI, 1.41-1.99; P < 0.001), renal insufficiency (RR 1.64; 95% CI, 1.10-2.44; P = 0.014), sepsis (RR 1.43, 95% CI, 1.24-1.64; P < 0.001), and urinary tract infection (RR 1.29; 95% CI, 1.06-1.58; P = 0.011). The incidence of myocardial infarction in the sample was similar between the 2 groups (RR 1.07; 95% CI, 0.75-1.52; P = 0.719). CONCLUSIONS: Worsening preoperative HF is associated with a significant increase in postoperative morbidity and mortality when controlling for other comorbidities. Although these likely have a multifactorial etiology, patients are much more likely to suffer from respiratory, renal, and infectious complications than cardiac complications.


Assuntos
Insuficiência Cardíaca/mortalidade , Infarto do Miocárdio/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Intervalos de Confiança , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Período Pré-Operatório , Respiração Artificial , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
20.
Anesthesiology ; 119(6): 1360-9, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24071617

RESUMO

BACKGROUND: Research regarding difficult mask ventilation (DMV) combined with difficult laryngoscopy (DL) is extremely limited even though each technique serves as a rescue for one another. METHODS: Four tertiary care centers participating in the Multicenter Perioperative Outcomes Group used a consistent structured patient history and airway examination and airway outcome definition. DMV was defined as grade 3 or 4 mask ventilation, and DL was defined as grade 3 or 4 laryngoscopic view or four or more intubation attempts. The primary outcome was DMV combined with DL. Patients with the primary outcome were compared to those without the primary outcome to identify predictors of DMV combined with DL using a non-parsimonious logistic regression. RESULTS: Of 492,239 cases performed at four institutions among adult patients, 176,679 included a documented face mask ventilation and laryngoscopy attempt. Six hundred ninety-eight patients experienced the primary outcome, an overall incidence of 0.40%. One patient required an emergent cricothyrotomy, 177 were intubated using direct laryngoscopy, 284 using direct laryngoscopy with bougie introducer, 163 using videolaryngoscopy, and 73 using other techniques. Independent predictors of the primary outcome included age 46 yr or more, body mass index 30 or more, male sex, Mallampati III or IV, neck mass or radiation, limited thyromental distance, sleep apnea, presence of teeth, beard, thick neck, limited cervical spine mobility, and limited jaw protrusion (c-statistic 0.84 [95% CI, 0.82-0.87]). CONCLUSION: DMV combined with DL is an infrequent but not rare phenomenon. Most patients can be managed with the use of direct or videolaryngoscopy. An easy to use unweighted risk scale has robust discriminating capacity.


Assuntos
Máscaras Laríngeas , Laringoscopia/métodos , Respiração Artificial/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/efeitos adversos , Manuseio das Vias Aéreas/métodos , Anestesia , Interpretação Estatística de Dados , Bases de Dados Factuais , Feminino , Previsões , Humanos , Máscaras Laríngeas/efeitos adversos , Laringoscopia/efeitos adversos , Laringe/anatomia & histologia , Masculino , Pessoa de Meia-Idade , Pescoço/anatomia & histologia , Assistência Perioperatória , Respiração Artificial/efeitos adversos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
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