Romanian journal of anaesthesia and intensive care最新文献

Anaphylaxis is life-threatening and should be addressed urgently. Its treatment is not without side effects and an accurate diagnosis must be made to prevent potential harm by the wrongful use of medication. A 46-year-old woman with hypertension treated with angiotensin converting enzyme inhibitor (ACEI) presented to the emergency department with non-pitting oedema of the face and limbs. A hasty diagnosis of anaphylaxis was made and intravenous adrenaline administered. The patient developed a myocardial infarction caused by coronary artery spasm that required invasive intervention. The initial clinical picture was resolved when the ACEI was discontinued unmasking a case of ACEI-induced angioedema. The correct differentiation of these two apparently similar clinical entities is of utmost importance in the management of emergency department patients.

Background: There is some evidence that anaesthetists often perform neuraxial blocks at a higher lumbar interspace than intended. It may be questioned whether parturients are at greater risk for neurological damage when the dura is perforated at a more cephalad interspace than L2-L3.

Methods: Thirty-six patients scheduled for elective Caesarean delivery under CSE anaesthesia were selected for study. Using a B-D Durasafe Adjustable needle combination, the skin-to-epidural distance and the width of the epidural space were measured and matched with 36 female patients undergoing the same anaesthetic technique for orthopaedic procedures.

Results: Pregnant patients had a higher bodyweight (77 vs. 67 kg, p = 0.007) than those scheduled for orthopaedic surgery. The skin-to-epidural distance was similar in both groups (5.3 vs. 5.1 cm, p = 0.3). The width of the epidural space was 1.1 mm larger in parturients (8.2 vs. 7.1 mm, p = 0.04). More patients in this group had tip-to-tip distances exceeding 10 mm (25 vs. 12%).

Conclusion: The greater epidural space or tip-to-tip distance between the epidural and spinal needle points in term parturients results in a lower margin of safety with respect to the distance from the dura to spinal cord or conus medullaris. Puncturing the correct interspace is, therefore, of crucial importance in pregnant patients.

Background: Minimally invasive hemodynamic monitoring is still controversial among the methods used to assess the hemodynamic profile of the septic shock patient. The aim of this study was to test the level of agreement between two different devices.

Methods: We collected 385 data entries during 12-hour intervals from four critically ill patients with septic shock and high doses of vasoactive therapy using two minimally invasive methods at the same time: Vigileo™ device which uses the pulse contour principle, and EV1000™ monitoring platform which uses the transpulmonary thermodilution principle. The studied parameters were Stroke Volume (SV), Cardiac Output (CO) and Mean Arterial Pressure (MAP). We tested the agreement by performing the visual examination of data patterns using graphs and studying the bias, limits of agreement and creating Bland-Altman plots. For assessing the systematic, proportional and random differences, we computed a Passing-Bablock regression with the CUSUM test for linearity.

Results: The one sample t-Test for the differences between the two methods against the null value was statistically significant for the studied parameters (p < 0.0001). The Bland-Altman analysis found no agreement between the data obtained using the two techniques, with calculated error percent as high as 88.28% for SV, 82.02% for CO and 42.06% for MAP. The Passing-Bablock regression analysis tested positive for systematic differences, but this could not be accounted for.

Conclusion: We found no agreement between data obtained from the studied devices; therefore, these cannot be used interchangeably for critically ill septic shock patients on high doses of vasoactive substances.

Background: Operating room time is a limited, expensive commodity in acute hospitals. Strategies aimed at reduction of non-operative time improve operating room throughput and capacity. We conducted a prospective study to evaluate and augment operating room throughput and capacity using context-specific work practice changes.

Methods: Following institutional and ethical approval, an interdisciplinary group designed and introduced a series of work practice changes specific to a stand-alone soft tissue trauma theatre, comprising modifications to patient processing, staff behaviours and additional anaesthesiologist hours. Time intervals relating to each patient were measured during a 16 week period before and after implementing work practice changes. The primary outcome measure was non-operative time, with daily caseload and cancellations amongst secondary outcome measures.

Results: 251 procedures were included over 58 working days (8 to 17 Monday to Friday). Non-operative time [55.6 (31.1) vs 52.3 (9.8) minutes, p = 0.48], daily caseload [4 [1-9] vs 4 [2-7], p = 0.56], and the number of daily cancellations [3 [0-11] vs 5 [0-8], p = 0.38], did not differ between baseline and study phases. Regional anaesthesia for upper limb surgery increased during the study phase [26/59 (44.0%) vs 10/63 (15.9%), p = 0.014] with resultant decrease in mean duration of recovery room stay [20.7 (17.7) vs 30 (20.5) minutes, p = 0.0001] and increased recovery room bypass [26/116 (22.4%) vs 6/135 (4.4%), p = 0.0002]. Avoidable delays accounted for 124.8 (72.2) minutes of theatre time lost each day.

Conclusion: In conclusion, additional attending anaesthesiologist hours combined with work practice changes did not impact on measures of theatre throughput and capacity. The study identified important variables that contribute to avoidable delays, and points the way for future research.

The new approach of a patient-centred, appropriate and timely care that was at the heart of the Institute of Medicine (IOM) initiative is changing the face of the healthcare industry in general and, in particular, of anesthesiology as a speciality. The drivers of this change are better quality and decreased healthcare costs, since despite a large expenditure for healthcare, the quality of care has not changed tremendously. Metrics have been identified, derived from the cybernetic model first described by the quality "parent". Donabedian and each of those metrics have both advantages as well as disadvantages. Ultimately the outcome measures are the ones that CMS will hold hospitals accountable for financially as well as from a safety standpoint. The culture of safety and quality as well as methodologies to improve that culture will shape the future of quality of care and improve outcomes and patient satisfaction.

Background and aims: Methods of simulation training and quality assessment during obstetric emergencies are still ambiguous. The aim of this study was to evaluate the effectiveness of anaesthesiologists' simulation training for emergency situations in obstetrics.

Methods: We conducted a prospective, descriptive, and comparative study to evaluate the anaesthesiologists' simulation training effectiveness during obstetrical emergencies. Data of 109 obstetrical anaesthesiologists trained over two years for invasive procedures and cardiopulmonary resuscitation, high-fidelity scenarios and medical personnel teamwork included were analyzed. We used the two-sided t-test (p < 0.05 considered significant).

Results: We noted during the fifth training sessions, the anaesthesiologists had a significant manipulation time decrease for all skills compared to the ones assessed during their first training session (p < 0.01). The 100-grade scale scores for all invasive techniques significantly improved during the anaesthesiologists' training (p < 0.01). Cardiopulmonary resuscitation effectiveness and team work also improved significantly during the fifth session (p < 0.01).

Conclusions: As a result of simulation training, significant improvement of speed and quality indicators, for invasive techniques in obstetrical emergency states treatment, was noted. For the fifth training sessions, there was a decrease in the practical skills execution time. The overall effectiveness and teamwork quality for cardiopulmonary resuscitation showed significant improvement.