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2.
Curr Opin Anaesthesiol ; 32(3): 263-267, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30985339

RESUMO

PURPOSE OF REVIEW: As the application of a test dose after epidural catheter insertion in obstetrics has recurrently been associated with serious adverse events affecting both maternal and foetal outcomes, the question whether to test or not remains a controversial issue. RECENT FINDINGS: Present guidelines do not provide clear recommendations in this regard and several recent surveys indicate a heterogeneity in clinical routine. SUMMARY: Physiological alterations during pregnancy and labour restrict the use and also the validity of traditional test agents. Epinephrine is not appropriate to detect a vascular insertion in labour and the application of a local anaesthetic test dose may lead to dose-dependent fatal consequences should the catheter be intrathecal, due to an increased sensitivity in parturients. Given the current practice of opioid-amended-low-concentration epidurals, the waiving of a test dose results at worst in a failed epidural, a stark contrast to the potentially severe to fatal complications of a 'traditional' test dose. Hence, an originally preventive measure providing potentially more harm than the consequences of the situation aimed to prevent, should not be recommended. A simple fractionated administration of the initial analgesic dose seems reasonable though.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Anestésicos Locais/administração & dosagem , Cateterismo/métodos , Epinefrina/administração & dosagem , Analgesia Epidural/efeitos adversos , Analgesia Epidural/instrumentação , Analgesia Epidural/normas , Analgesia Obstétrica/efeitos adversos , Analgesia Obstétrica/instrumentação , Analgesia Obstétrica/normas , Anestésicos Locais/efeitos adversos , Cateterismo/efeitos adversos , Cateterismo/instrumentação , Cateterismo/normas , Cateteres/efeitos adversos , Relação Dose-Resposta a Droga , Espaço Epidural , Epinefrina/efeitos adversos , Feminino , Humanos , Injeções Epidurais/efeitos adversos , Injeções Epidurais/instrumentação , Injeções Epidurais/métodos , Injeções Epidurais/normas , Guias de Prática Clínica como Assunto , Gravidez
3.
Ann Vasc Surg ; 59: 158-166, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31009720

RESUMO

BACKGROUND: Almost 80% of patients with end-stage renal disease (ESRD) initiate dialysis via a central venous catheter (CVC). CVCs are associated with multiple complications and a high cost of care. The purpose of our project is to determine the impact of early cannulation arteriovenous grafts (ECAVGs) on quality of care and costs. METHODS: The dialysis access modality, complications, secondary interventions, hospital outcomes, and detailed costs were tracked for 397 sequential patients who underwent access creation between July 2014 and October 2018. Complications were grouped into deep vein thrombosis, line infections, sepsis, pneumothorax, and other. Secondary interventions included angioplasty, angioplasty and stent grafting, thrombectomy, surgical revision, and explantation. Hospital outcomes included length of stay, inpatient mortality, 30-day readmission, and discharge disposition. Costs included supplies, medications, laboratory tests, labor, and other direct costs. All variables were measured at the time of the index procedure, 30 days, 90 days, 180 days, 270 days, 1 year, 18 months, and 2 years. RESULTS: There were 131 patients who underwent arteriovenous fistula (AVF) and 266 who received ECAVG for dialysis access. The total cost of care per patient was $17,523 for AVF and $5,894 for ECAVG at 1 year (P < 0.01). Primary-assisted patency for AVF was 49.3% versus 81.4% for ECAVG (P = 0.027), and secondary-assisted patency for AVF was 63.8% versus 85.4% for ECAVG at 1 year (P = 0.011). There was a survival advantage for ECAVGs at 1 year (78.6% for AVF vs 85.0% for ECAVG, P = 0.034). Patients who received ECAVG had fewer CVC days (2.3% vs 19.1% for AVF, P < 0.001), fewer complications (1.6% vs. 21.5% for AVF, P < 0.001), and fewer secondary interventions (17.0% vs 52.5% for AVF, P < 0.001). CONCLUSIONS: This is the first study on patients with ESRD to report detailed outcomes and cost analysis as it relates to AVF versus ECAVG. ECAVGs have an advantage over AVFs due to lower overall cost and better clinical outcomes at 1 year. Implementation of an urgent start dialysis access program centered around ECAVGs may help achieve the national goal of better health care at a lower cost for patients with ESRD.


Assuntos
Derivação Arteriovenosa Cirúrgica , Cateterismo , Falência Renal Crônica/terapia , Diálise Renal , Enxerto Vascular , Derivação Arteriovenosa Cirúrgica/efeitos adversos , Derivação Arteriovenosa Cirúrgica/economia , Derivação Arteriovenosa Cirúrgica/mortalidade , Derivação Arteriovenosa Cirúrgica/normas , Cateterismo/efeitos adversos , Cateterismo/economia , Cateterismo/mortalidade , Cateterismo/normas , Redução de Custos , Análise Custo-Benefício , Feminino , Oclusão de Enxerto Vascular/economia , Oclusão de Enxerto Vascular/terapia , Custos de Cuidados de Saúde , Mortalidade Hospitalar , Hospitalização , Humanos , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/economia , Falência Renal Crônica/mortalidade , Masculino , Pessoa de Meia-Idade , /normas , Indicadores de Qualidade em Assistência à Saúde , Diálise Renal/efeitos adversos , Diálise Renal/economia , Diálise Renal/mortalidade , Diálise Renal/normas , Retratamento , Fatores de Tempo , Resultado do Tratamento , Enxerto Vascular/efeitos adversos , Enxerto Vascular/economia , Enxerto Vascular/mortalidade , Enxerto Vascular/normas
4.
Mil Med ; 184(Suppl 1): 326-328, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30901409

RESUMO

With damage control surgery and resuscitation teams, the military is bringing surgical as well as intensive care far forward to areas where mass casualty events are an ever-present threat. One procedure that the team is required to be proficient in is arterial line insertion and transducing. To our knowledge, there are no previously described field arterial line simulation models. We present an arterial line insertion and transducer simulator created using medium resistance Thera-band tubing, saline, Coban, and a SAM splint. Ten deployed members of a damage control surgical team received 30 minutes of instruction on how to properly insert an arterial line and how to set up the transducer equipment. All participants were able to show proficiency in radial artery line insertion and transducer setup despite 8 of the 10 participants having never inserted or setup an arterial line. We describe, to our knowledge, the first arterial line insertion and transducing model utilizing only items found in the deployed environment. This model can be easily made and utilized to train medical personnel of all skill levels to augment the capabilities of medical units in areas where mass casualty events are likely.


Assuntos
Cateterismo/métodos , Simulação de Paciente , Ressuscitação/educação , Dispositivos de Acesso Vascular/normas , Cateterismo/normas , Competência Clínica/normas , Humanos , Medicina Militar/educação
5.
Rev Gaucha Enferm ; 40(spe): e20180232, 2019 Jan 10.
Artigo em Português, Inglês | MEDLINE | ID: mdl-30652807

RESUMO

OBJECTIVE: To describe the process of implanting the surgical safety checklist in a catheterization laboratory (CL). METHOD: Descriptive case report study about the safety strategies developed in the last six years in a university hospital in the southern region of Brazil. RESULTS: The six international patient safety goals (IPSG) were incorporated into the care practice in accordance with the hospital's Joint Comission International (JCI) accreditation program, through a continuous process of educational nature. The checklist was adapted considering the characteristics of the unit and the procedures performed. CONCLUSION: The implementation of the checklist provided the promotion of patient safety, greater staff integration, advances in communication among professionals and the recording of in-room care information.


Assuntos
Cateterismo/normas , Lista de Checagem , Hospitais Universitários , Segurança do Paciente , Cateterismo/métodos , Formulários como Assunto , Humanos , Procedimentos Cirúrgicos Operatórios/normas
6.
J Cardiothorac Vasc Anesth ; 33(4): 993-1000, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30149982

RESUMO

OBJECTIVE: Cerebrospinal fluid drainage catheter-related complications can be reduced by following strict guidelines during their introduction, maintenance, and removal. The authors therefore aimed to determine whether simulation-based learning would improve senior anesthesiology residents' patient care performance during the insertion and management of these catheters compared to interactive problem-based learning (PBL) using the Anaesthetists' Non-Technical Skills global rating scale (ANTS). DESIGN: Prospective randomized trial. SETTING: Vascular or hybrid operating rooms in a large academic tertiary care center. PARTICIPANTS: Senior anesthesia (categorical anesthesia-3) residents rotating through the vascular rotation at the Cleveland Clinic main campus in the period between December 2014 and June 2017. INTERVENTION: Simulation-based learning versus PBL. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the composite score (ANTS global rating scale) achieved by participating residents as evaluated by their supervising anesthesiologists. Out of 28 residents who completed the study, N = 13 were randomized to simulation-based learning and N = 15 residents to the PBL approach. The median (first quartile, third quartile) composite score was 16 (14, 16) and 16 (13, 16) for the simulation-based learning and PBL groups, respectively. There was no significant difference in staff evaluation of the 2 study groups (p = 0.48) with an estimated odds (95% confidence interval) of getting a better staff evaluation score of 1.9 (0.3-10.6) times higher comparing simulation versus traditional training groups. CONCLUSION: Compared to interactive PBL, simulation-based learning does not result in a statistically significant improvement in anesthesia resident performance during insertion and management of cerebrospinal fluid drainage catheters.


Assuntos
Centros Médicos Acadêmicos/métodos , Anestesiologia/métodos , Cateterismo/métodos , Internato e Residência/métodos , Aprendizagem Baseada em Problemas/métodos , Treinamento por Simulação/métodos , Centros Médicos Acadêmicos/normas , Anestesiologia/educação , Anestesiologia/normas , Cateterismo/normas , Vazamento de Líquido Cefalorraquidiano/prevenção & controle , Competência Clínica/normas , Avaliação Educacional/métodos , Avaliação Educacional/normas , Feminino , Humanos , Internato e Residência/normas , Masculino , Aprendizagem Baseada em Problemas/normas , Estudos Prospectivos , Treinamento por Simulação/normas
7.
Am J Respir Crit Care Med ; 199(11): 1368-1376, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30576221

RESUMO

Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation. Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation). Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed. Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/FiO2 had a greater weight than respiratory rate. Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).


Assuntos
Gasometria , Cateterismo/normas , Técnicas e Procedimentos Diagnósticos/normas , Oxigenação por Membrana Extracorpórea/normas , Oxigenoterapia/normas , Pneumonia/terapia , Taxa Respiratória , Idoso , Estudos de Coortes , Confiabilidade dos Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/normas , Guias de Prática Clínica como Assunto , Estudos Prospectivos
8.
Rev. gaúch. enferm ; 40(spe): e20180232, 2019. graf
Artigo em Português | LILACS | ID: biblio-978509

RESUMO

Resumo OBJETIVO Descrever o processo de implantação da lista de verificação de segurança cirúrgica em laboratório de cateterismo (LC). MÉTODO Estudo descritivo do tipo relato de experiência das estratégias de segurança desenvolvidas nos últimos seis anos em hospital universitário da região Sul do Brasil. RESULTADOS Foram incorporadas na prática assistencial as seis metas internacionais de segurança do paciente (MISP) em consonância com o programa de acreditação hospitalar pela Joint Comission International (JCI), por meio de um processo contínuo com caráter educativo. A lista de verificação foi adaptada considerando as características da unidade e os procedimentos realizados. CONCLUSÕES A implantação da lista de verificação proporcionou a promoção da segurança do paciente, maior integração da equipe, avanços na comunicação entre os profissionais e no registro das informações da assistência em sala.


Resumen OBJETIVO Describir el proceso de implantación de la lista de verificación de seguridad quirúrgica en un laboratorio de cateterismo (LC). MÉTODO Estudio descriptivo del tipo relato de experiencia sobre las estrategias de seguridad desarrolladas en los últimos seis años en un hospital universitario de la región Sur de Brasil. RESULTADOS Se incorporaron en la práctica asistencial las seis metas internacionales de seguridad del paciente (MISP) en consonancia con el programa de acreditación hospitalaria por la Joint Comission International (JCI), a través de un proceso continuo con carácter educativo. La lista de verificación fue adaptada considerando las características de la unidad y los procedimientos realizados. Conclusión: La implantación de la lista de verificación proporcionó la promoción de la seguridad del paciente, una mayor integración del equipo, avances en la comunicación entre los profesionales y en el registro de las informaciones de la asistencia en sala.


Abstract OBJECTIVE To describe the process of implanting the surgical safety checklist in a catheterization laboratory (CL). METHOD Descriptive case report study about the safety strategies developed in the last six years in a university hospital in the southern region of Brazil. RESULTS The six international patient safety goals (IPSG) were incorporated into the care practice in accordance with the hospital's Joint Comission International (JCI) accreditation program, through a continuous process of educational nature. The checklist was adapted considering the characteristics of the unit and the procedures performed. CONCLUSION The implementation of the checklist provided the promotion of patient safety, greater staff integration, advances in communication among professionals and the recording of in-room care information.


Assuntos
Humanos , Universidades , Cateterismo/normas , Lista de Checagem , Segurança do Paciente , Procedimentos Cirúrgicos Operatórios/normas , Cateterismo/métodos
9.
GMS J Med Educ ; 35(4): Doc48, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30539073

RESUMO

Background: Chest tube insertion is a standard intervention for management of various injuries of the thorax. Efficient clinical training of this and similar bed-side procedures is equally demanded and improvable. Here, we propose a nouveau means of assessment and feedback using an Objective Structured Assessment of Technical Skills (OSATS) tool. The modified OSATS for chest drain insertion is evaluated in a pilot trial focusing on chest drain insertion. Methods: Participants in the pilot trial were medical students (3rd-6th year of studies, n=9), junior residents (1st-3rd post-graduate year, n=12), senior residents (4th-6th post-graduate year, n=14), and attending surgeons (n=6) from Heidelberg University. Chest drain insertions on a cadaveric porcine model were rated by experts with the modified OSATS score. Participants' performances were videotaped and subsequently rated by two remote experts (video rating). Primary aim was to assess criterion validity of the OSATS to distinguish experience levels. Results: Kruskal-Wallis test showed significant differences between means of scores between four groups stratified by previous experience in chest tube insertion (level 0: 22.1±3.2 vs. level 1: 26.8±2.8 vs. level 2: 35.4±2.2 vs. level 3: 41.0±2.0; p=0.002; p1,3=0.049, p0,3=0.005). However, if groups were stratified by formal professional level, no statistically significant distinction could be made using OSATS. Hence, the OSATS tool showed criterion validity for differentiation between experience levels. Conclusion: In the pilot study, the modified OSATS for chest tube insertion was apt to standardize expert rating and could be used to measure skill and to depict different experience levels. The OSATS will help facilitate training and assessment of chest drain insertion and could therefore improve surgical training for trauma situations. According to our data, the OSATS might be integrated into modern curricula.


Assuntos
Cateterismo/normas , Tubos Torácicos/estatística & dados numéricos , Avaliação Educacional/normas , Cateterismo/instrumentação , Cateterismo/métodos , Competência Clínica/normas , Competência Clínica/estatística & dados numéricos , Educação de Graduação em Medicina/métodos , Educação de Graduação em Medicina/estatística & dados numéricos , Avaliação Educacional/métodos , Alemanha , Humanos , Projetos Piloto , Estatísticas não Paramétricas , Estudantes de Medicina/estatística & dados numéricos
10.
AACN Adv Crit Care ; 29(4): 432-441, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30523014

RESUMO

Recurrent pleural effusion is a symptom of several end-stage diseases and is associated with limited life expectancy. Patients with this condition have disabling symptoms resulting in reduced quality of life and often receive inconsistent treatment due to delayed recognition of pleural effusion, repeat procedures, and lengthy hospitalizations. Placement of a tunneled pleural catheter allows the patient to manage his or her symptoms at home, yet this treatment remains underused because of provider misconceptions and unfamiliarity with the intervention. This article provides an overview of the indications for placement of a tunneled pleural catheter, possible complications, and management strategies, and introduces evidence-based clinical decision support tools to enhance provider knowledge. In addition, the article describes the implementation and evaluation of a performance improvement initiative on the use of tunneled pleural catheters in a multifaceted health care system.


Assuntos
Cateterismo/normas , Cuidados Críticos/normas , Drenagem/normas , Insuficiência Cardíaca/complicações , Derrame Pleural/terapia , Pleurodese/normas , Guias de Prática Clínica como Assunto , Cateterismo/métodos , Cuidados Críticos/métodos , Drenagem/métodos , Humanos , Derrame Pleural/etiologia , Pleurodese/métodos , Recidiva
11.
BMC Med Educ ; 18(1): 257, 2018 Nov 12.
Artigo em Inglês | MEDLINE | ID: mdl-30419869

RESUMO

BACKGROUND: Recent studies have shown that clinical tasks only represent a small percentage in the scope of final-year medical students' activities and often lack sufficient supervision. It appears that final-year medical students are frequently deployed to perform "routine tasks" and show deficits in the performance of more complex activities. This study aimed to evaluate final-year students' clinical performance in multiple impromptu clinical scenarios using video-based assessment. METHODS: We assessed final-year medical students' clinical performance in a prospective, descriptive, clinical follow-up study with 24 final-year medical students during their Internal Medicine rotation. Participating students were videotaped while practicing history taking, physical examination, IV cannulation, and case presentation at the beginning and end of their rotation. Clinical performance was rated by two independent, blinded video assessors using binary checklists, activity specific rating scales and a five-point global rating scale for clinical competence. RESULTS: Students' performance, assessed by the global rating scale for clinical competence, improved significantly during their rotation. However, their task performance was not rated as sufficient for independent practice in most cases. Analysis of average scores revealed that overall performance levels differed significantly, whereby average performance was better for less complex and more frequently performed activities. CONCLUSIONS: We were able to show that students' performance levels differ significantly depending on the frequency and complexity of activities. Hence, to ensure adequate job preparedness for clinical practice, students need sufficiently supervised and comprehensive on-ward medical training.


Assuntos
Competência Clínica/normas , Educação de Pós-Graduação em Medicina , Medicina Interna/educação , Estudantes de Medicina , Gravação em Vídeo , Adulto , Cateterismo/normas , Lista de Checagem , Avaliação Educacional , Feminino , Seguimentos , Feedback Formativo , Humanos , Medicina Interna/normas , Masculino , Anamnese/normas , Exame Físico/normas , Relações Médico-Paciente , Estudos Prospectivos , Adulto Jovem
12.
Endoscopy ; 50(11): 1116-1127, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30340220

RESUMO

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology present a short list of key performance measures for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP). We recommend that endoscopy services across Europe adopt the following seven key and one minor performance measures for EUS and ERCP, for measurement and evaluation in daily practice at center and endoscopist level: 1: Adequate antibiotic prophylaxis before ERCP (key performance measure, at least 90 %); 2: Antibiotic prophylaxis before EUS-guided puncture of cystic lesions (key performance measure, at least 95 %); 3: Bile duct cannulation rate (key performance measure, at least 90 %); 4: Tissue sampling during EUS (key performance measure, at least 85 %); 5: Appropriate stent placement in patients with biliary obstruction below the hilum (key performance measure, at least 95 %); 6: Bile duct stone extraction (key performance measure, at least 90 %); 7: Post-ERCP pancreatitis (key performance measure, less than 10 %). 8: Adequate documentation of EUS landmarks (minor performance measure, at least 90 %).This present list of quality performance measures for ERCP and EUS recommended by ESGE should not be considered to be exhaustive: it might be extended in future to address further clinical and scientific issues.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/normas , Endossonografia/normas , Indicadores de Qualidade em Assistência à Saúde , Antibioticoprofilaxia/normas , Biópsia/normas , Cateterismo/normas , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Ducto Colédoco , Cálculos Biliares/terapia , Humanos , Pancreatite/etiologia , Melhoria de Qualidade , Stents/normas
13.
Artigo em Alemão | MEDLINE | ID: mdl-29945286

RESUMO

This guideline was presented in 2016 due to the need for an up to date evidence-based guidance focusing on patient safety. In addition to safety-related aspects of catheter insertion or removal, organisational issues and structured training concepts were discussed. The guideline was created based on the review of current literature as well as expert opinion. The article summarizes and discusses the most important recommendations and the reader is provided with practical advice for catheter insertion or removal with the intention to improve the safety of the patients.


Assuntos
Cateterismo/normas , Dispositivos de Acesso Vascular , Anestesiologia/normas , Infecções Relacionadas a Cateter/prevenção & controle , Cateterismo/efeitos adversos , Cateterismo Venoso Central/normas , Cateterismo Periférico/normas , Guias como Assunto , Humanos , Infusões Intraósseas , Irlanda , Segurança do Paciente , Reino Unido , Dispositivos de Acesso Vascular/efeitos adversos
15.
Aliment Pharmacol Ther ; 48(3): 347-357, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29920726

RESUMO

BACKGROUND: Fibrotic stricture is a common complication of Crohn's disease (CD) affecting approximately half of all patients. No specific anti-fibrotic therapies are available; however, several therapies are currently under evaluation. Drug development for the indication of stricturing CD is hampered by a lack of standardised definitions, diagnostic modalities, clinical trial eligibility criteria, endpoints and treatment targets in stricturing CD. AIM: To standardise definitions, diagnosis and treatment targets for anti-fibrotic stricture therapies in Chron's disease. METHODS: An interdisciplinary expert panel consisting of 15 gastroenterologists and radiologists was assembled. Using modified RAND/University of California Los Angeles appropriateness methodology, 109 candidate items derived from systematic review and expert opinion focusing on small intestinal strictures were anonymously rated as inappropriate, uncertain or appropriate. Survey results were discussed as a group before a second and third round of voting. RESULTS: Fibrotic strictures are defined by the combination of luminal narrowing, wall thickening and pre-stenotic dilation. Definitions of anastomotic (at site of prior intestinal resection with anastomosis) and naïve small bowel strictures were similar; however, there was uncertainty regarding wall thickness in anastomotic strictures. Magnetic resonance imaging is considered the optimal technique to define fibrotic strictures and assess response to therapy. Symptomatic strictures are defined by abdominal distension, cramping, dietary restrictions, nausea, vomiting, abdominal pain and post-prandial abdominal pain. Need for intervention (endoscopic balloon dilation or surgery) within 24-48 weeks is considered the appropriate endpoint in pharmacological trials. CONCLUSIONS: Consensus criteria for diagnosis and response to therapy in stricturing Crohn's disease should inform both clinical practice and trial design.


Assuntos
Consenso , Doença de Crohn/terapia , Prova Pericial , Obstrução Intestinal/diagnóstico , Obstrução Intestinal/terapia , Guias de Prática Clínica como Assunto/normas , Cateterismo/métodos , Cateterismo/normas , Ensaios Clínicos como Assunto/normas , Ensaios Clínicos como Assunto/estatística & dados numéricos , Colo/patologia , Colo/cirurgia , Constrição Patológica/diagnóstico , Constrição Patológica/etiologia , Constrição Patológica/terapia , Doença de Crohn/complicações , Doença de Crohn/diagnóstico , Dilatação/métodos , Dilatação/normas , Endoscopia , Fibrose/diagnóstico , Fibrose/etiologia , Fibrose/terapia , Humanos , Obstrução Intestinal/classificação , Obstrução Intestinal/etiologia , Intestino Delgado/patologia , Intestino Delgado/cirurgia , Padrões de Referência
16.
Brachytherapy ; 17(4): 726-731, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29779953

RESUMO

PURPOSE: Nasobiliary high-dose-rate (HDR) brachytherapy has emerged as an effective tool to boost the radiation dose for patients with unresectable perihilar cholangiocarcinoma. This work describes a quality assurance (QA) tool for measuring the HDR afterloader's performance, including the transit dose, when the source wire travels through a tortuous nasobiliary catheter path. METHODS AND MATERIALS: The nasobiliary QA device was designed to mimic the anatomical path of a nasobiliary catheter, including the nasal, stomach, duodenum, and bile duct loops. Two of these loops, the duodenum and bile duct loops, have adjustable radii of curvature, resulting in the ability to maximize stress on the source wire in transit. The device was used to measure the performance over time for the HDR afterloader and the differences between intraluminal catheter lots. An upper limit on the transit dose was also measured using radiochromic film and compared with a simple theoretical model. RESULTS: The QA device was capable of detecting performance variations among nasobiliary catheter lots and following radioactive source replacement. The transit dose from a nasobiliary treatment increased by up to one order of magnitude when the source wire encountered higher than normal friction. Three distinct travel speeds of the source wire were observed: 5.2, 17.4, and 54.7 cm/s. The maximum transit dose was 0.3 Gy at a radial distance of 5 mm from a 40.3 kU 192Ir source. CONCLUSIONS: The source wire encounters substantially greater friction when it navigates through the nasobiliary brachytherapy catheter. A QA tool that mimics the nasal, stomach, duodenum, and bile duct loops may be used to evaluate transit dose and the afterloader's performance over time.


Assuntos
Neoplasias dos Ductos Biliares/radioterapia , Braquiterapia/instrumentação , Cateterismo/instrumentação , Cateteres/normas , Colangiocarcinoma/radioterapia , Radioisótopos de Irídio/uso terapêutico , Ductos Biliares , Braquiterapia/normas , Cateterismo/normas , Desenho de Equipamento , Humanos , Nariz , Dosagem Radioterapêutica
17.
Arch Dis Child ; 103(10): 952-956, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29618485

RESUMO

OBJECTIVE: We investigated whether ultrasound guidance was advantageous over the anatomical landmark technique when performed by inexperienced paediatricians. DESIGN: Randomised controlled trial. SETTING: A paediatric intensive care unit of a teaching hospital. PATIENTS: 80 children (aged 28 days to <14 years). INTERVENTIONS: Internal jugular vein cannulation with ultrasound guidance in real time or the anatomical landmark technique. MAIN OUTCOME MEASURES: Success rate, success rate on the first attempt, success rate within three attempts, puncture time, number of attempts required for success and occurrence of complications. RESULTS: We found a higher success rate in the ultrasound guidance than in the control group (95% vs 61%, respectively; p<0.001; relative risk (RR)=0.64, 95% CI (CI) 0.50 to 0.83). Success on the first attempt was seen in 95% and 34% of venous punctures in the US guidance and control groups, respectively (p<0.001; RR=0.35, 95% CI 0.23 to 0.54). Fewer than three attempts were required to achieve success in 95% of patients in the US guidance group but only 44% in the control group (p<0.001; RR=0.46, 95% CI 0.32 to 0.66). Haematomas, inadvertent arterial punctures, the number of attempts and the puncture time were all significantly lower in the ultrasound guidance than in the control group (p<0.015 for all). CONCLUSIONS: Critically ill children may benefit from the ultrasound guidance for internal jugular cannulation, even when the procedure is performed by operators with limited experience. TRIAL REGISTRATION NUMBER: RBR-4t35tk.


Assuntos
Cateterismo , Veias Jugulares/cirurgia , Complicações Pós-Operatórias , Ultrassonografia de Intervenção/métodos , Adolescente , Cateterismo/efeitos adversos , Cateterismo/métodos , Cateterismo/normas , Criança , Pré-Escolar , Competência Clínica , Feminino , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Pediatras/normas , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia
18.
World Neurosurg ; 114: e1290-e1296, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29626681

RESUMO

BACKGROUND: External ventricular drainage (EVD) catheter placement is one of the most commonly performed neurosurgical procedures. The study's objective was to compare a computed tomography (CT) bolt scan-guided approach for the placement of EVDs with conventional landmark-based insertion. METHODS: In this retrospective case-control study, we analyzed patients undergoing bolt-kit EVD catheter placement, either CT-guided or landmark-based, between 2013 and 2016. The CT bolt scan-guided approach was based on a dose-reduced CT scan after bolt fixation with immediate image reconstruction along the axis of the bolt to evaluate the putative insertion axis. If needed, angulation of the bolt was corrected and the procedure repeated before the catheter was inserted. Primary endpoint was the accuracy of insertion. Secondary endpoints were the overall number of attempts, duration of intervention, complication rates, and cumulative radiation dose. RESULTS: In total, 34 patients were included in the final analysis. In the group undergoing CT-guided placement, the average ventricle width was significantly smaller (P = 0.04) and average midline shift significantly more pronounced (P = 0.01). CT-guided placement resulted in correct positioning of the catheter in the ipsilateral frontal horn in all 100% of the cases compared with landmark-guided insertion (63%; P = 0.01). Application of the CT-guided approach increased the number of total CT scans (3.6 ± 1.9) and the overall radiation dose (3.34 ± 1.61 mSv) compared with the freehand insertion group (1.84 ± 2.0 mSv and 1.55 ± 1.66 mSv). No differences were found for the other secondary outcome parameters. CONCLUSIONS: CT-guided bolt-kit EVD catheter placement is feasible and accurate in the most difficult cases.


Assuntos
Drenagem/normas , Serviços Médicos de Emergência/normas , Monitorização Neurofisiológica Intraoperatória/normas , Tomografia Computadorizada por Raios X/normas , Ventriculostomia/normas , Adulto , Idoso , Estudos de Casos e Controles , Cateterismo/métodos , Cateterismo/normas , Drenagem/métodos , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Monitorização Neurofisiológica Intraoperatória/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos , Ventriculostomia/métodos
19.
Appl Nurs Res ; 40: 76-79, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29579503

RESUMO

AIM: To evaluate the effect of daily PIV-based phlebotomy using the PIVO device on PIVC dwell times and replacement rates, as well as the reliability of blood sample collection, and patient response to this method of blood collection. BACKGROUND: Blood draws which are also known as phlebotomy for laboratory analyses are one of the most common experiences for hospitalized patients. When performed by venipuncture, they are often associated with pain and anxiety for patients. Most hospitals avoid phlebotomy from peripheral IV catheters due to sample hemolysis, sample dilution by fluids in PIVC line or infused medications, PIVC dislodgement or infiltration, and increased rates of phlebitis. METHODS: A prospective, randomized- controlled study of 160 GI surgery patients was enrolled. Patients were randomized to either control evaluation of PIVC dwell or to receive daily PIVO blood collections in addition to evaluation of PIVC dwell. RESULTS: Daily PIVO blood collections did not negatively affect PIVC dwell or replacement rates. Overall 81% of blood collection attempts were successful and the likelihood of success was strongly associated with PIVC condition. Patients reported 0.7/10 pain for PIVO blood collection on a 0-10 pain scale and a 9.1/10 preference for PIVO on a 0 (strongly prefer needle) to 10 (strongly prefer PIVO) preference scale. Results suggest that use of a PIV based blood collection was a reliable and valid approach and was superior to routine phlebotomy in self-reported responses from patients.


Assuntos
Coleta de Amostras Sanguíneas/normas , Cateterismo/normas , Satisfação do Paciente , Flebotomia/normas , Guias de Prática Clínica como Assunto , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Tempo , Adulto Jovem
20.
J Clin Neurosci ; 51: 91-99, 2018 May.
Artigo em Inglês | MEDLINE | ID: mdl-29483004

RESUMO

The aim of this study was to describe our experience in the treatment of various pathological conditions of the cranial and spinal blood vessels and hypervascularized lesions using dual lumen balloon catheters. Twenty-five patients were treated with endovascular techniques: two with vasospasm of cerebral blood vessels caused by subarachnoid hemorrhage, one with a hypervascularized metastasis in the vertebral body, two with spinal dural fistula, four with cerebral dural fistula, three with cerebral arteriovenous malformations, and 13 with aneurysms. The dual lumen balloon catheters were used for remodeling of the coil mesh, injection of various liquid embolic agents, particles and nimodipine, for the prevention of reflux and deployment of coils and stents. The diameter of catheterized blood vessels varied from 0.7 mm to 4 mm. Two complications occurred: perforation of an aneurysm in one case and gluing of the tip of balloon catheter by embolic material in another case. All other interventions were uneventful, and therapeutic goals were achieved in all cases except in the case with gluing of the tip of balloon catheter. The balloons effectively prevented reflux regardless of the type of the embolic material and diameter of blood vessel. The results of our study show that dual lumen balloon catheters allow complex interventions in the narrow cerebral and spinal blood vessels where the safe use of two single lumen catheters is either limited or impossible.


Assuntos
Angioplastia com Balão/métodos , Fístula Arteriovenosa/diagnóstico por imagem , Cateteres/normas , Aneurisma Intracraniano/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Adulto , Angioplastia com Balão/instrumentação , Angioplastia com Balão/normas , Fístula Arteriovenosa/terapia , Cateterismo/instrumentação , Cateterismo/métodos , Cateterismo/normas , Cateteres/estatística & dados numéricos , Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Embolização Terapêutica/normas , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Humanos , Aneurisma Intracraniano/terapia , Malformações Arteriovenosas Intracranianas/terapia , Pessoa de Meia-Idade , Stents , Resultado do Tratamento
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