[The current situation and trends in the clinical treatment of shock].

Shock is defined as hypoperfusion of tissues and/or organs. The initial focus of resuscitation following shock is on establishing an open airway and ensuring adequate ventilation and circulation. Causes of shock can be recognized quickly via clinical manifestations. A professional physical examination and observation of response to therapy can result in early diagnosis of the causes of unstable vital signs. Identification of shock symptoms in order to administer appropriate treatment quickly is key to saving patient lives, because "time is tissue". In all shock cases, treatments begin with an evaluation, resuscitation and immediate treatment of life-threatening symptoms. Patients may experience more than one kind of shock simultaneously, which further complicates their assessment and treatment. The critical care of shock should be done thoroughly and systematically in order to assess and manage patients so as to avoid dysfunctions in one organ damaging others. During emergency and critical management of shock patients, once a certain stage of assessment is completed, further evaluation is necessary to assess condition improvement. If improvement is confirmed, maintenance therapy may be considered. If improvement is not confirmed, it should be considered whether treatment is inadequate or misfocused, or whether the patient's response is atypically poor. In addition to timely resuscitation and ICU care, there are specific effective treatments for each type of shock. Such must be administered in accordance with guidelines, standard protocols and goal-oriented approaches. Trends in shock management currently focus on integrating guidelines, standard protocols and goal-oriented approaches into a "treatment bundle", which facilitates the implementation of clinical medical care and completes specific goals within a specified time limit to reduce the risk of multiple organ failure and death due to shock.

Analysis of anesthesia-controlled operating room time after propofol-based total intravenous anesthesia compared with desflurane anesthesia in functional endoscopic sinus surgery.

Anesthesia technique may contribute to the improvement of operation room (OR) efficiency by reducing anesthesia-controlled time. We compared the difference between propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia (DES) for functional endoscopic sinus surgery (FESS) undergoing general anesthesiaWe performed a retrospective study using data collected in our hospital to compare the anesthesia-controlled time of FESS using either TIVA via target-controlled infusion with propofol/fentanyl or DES/fentanyl-based anesthesia between January 2010 and December 2011. The various time intervals (surgical time, anesthesia time, extubation time, total OR stay time, post anesthesia care unit [PACU] stay time) and the percentage of prolonged extubation were compared between the 2 anesthetic techniques.We included data from 717 patients, with 305 patients receiving TIVA and 412 patients receiving DES. An emergence time >15 minutes is defined as prolonged extubation. The extubation time was faster (8.8 [3.5] vs. 9.6 [4.0] minutes; P = .03), and the percentage of prolonged extubation was lower (7.5% vs. 13.6%, risk difference 6.1%, P < .001) in the TIVA group than in the DES group. However, there was no significant difference between ACT, total OR stay time, and PACU stay time.In our hospital, propofol-based TIVA by target-controlled infusion provide faster emergence and lower chance of prolonged extubation compared with DES anesthesia in FESS. However, the reduction in extubation time may not improve OR efficiency.

Survey of 11-year anesthesia-related mortality and analysis of its associated factors in Taiwan.

OBJECTIVE: In developed countries, the societies of anesthesiologists have published reports of anesthesia quality. However, there are still no publications on anesthesia quality in Taiwan, even though the Taiwan Society of Anesthesiologists (TSA) was founded in 1956. This study was designed to evaluate the quality of anesthesia in Taiwan using databases maintained by the TSA and the Bureau of National Health Insurance-Taiwan (BNHI-T). METHODS: The TSA published annual reports in 1995-1998 and 2002-2008 (with a 3-year interval), which included a survey on anesthesia-related mortality and morbidity, the manpower and composition of anesthesia teams, and the causes of anesthesia-related complications. Since 2002, the BNHI-T has collaborated with the National Health Research Institute-Taiwan to establish a database of health care service. To understand anesthesia quality in Taiwan, we collected data from the annual TSA surveys and the BNHI-T, and analyzed trends in anesthesia-related mortality, causes of anesthesia complications, and relative manpower composition. RESULTS: The rate of anesthesia-related mortality was 11.9 deaths/100,000 cases. More than 50% of all anesthesia-related complications were preventable. About 1500 anesthetic procedures were performed annually by each anesthesiologist in Taiwan. The ratio of anesthesiologists to nurse anesthetists was 1:3-5. CONCLUSION: Anesthesia-related mortality was about 10-fold higher in Taiwan than in the United States, Japan and the United Kingdom. Mortality related to quality of anesthesia in Taiwan must be reduced. To achieve this target, we have recommended the following six approaches: (1) decrease the workload of anesthesiologists; (2) increase reimbursement by the BNHI-T for anesthesia; (3) improve the training quality of anesthetist residents; (4) strengthen the quality of board examinations; (5) improve the training quality of nurse anesthetists; and (6) standardize monitoring procedures and equipment. Only once these measures are introduced, in combination with effective quality assurance and subjective improvement systems, can we expect an improvement in the quality of anesthesia in Taiwan.