Anaesthesia and intensive care
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Anaesth Intensive Care · Nov 2012
Randomized Controlled Trial Comparative StudyFifteen-hour day shifts have little effect on the performance of taskwork by anaesthesia trainees during uncomplicated clinical simulation.
Shiftwork and work-hour limits for junior doctors are now well established in hospital work patterns. In order to ensure that trainees have adequate exposure to daytime elective surgical procedures, there is a tendency to have long shifts that include an after-hours component. However, long shifts can cause performance decrement due to time-on-task fatigue. ⋯ In both conditions, there was failure to meet current guidelines for preoperative evaluation or machine check, and when fatigued there was a 'trend' (P=0.06) to a reduction in the number of items in the machine check. With increase in time awake, there was an increase in time taken for explanation to the patient, an increase in mean duration of explanation to the patient, more time looking at the intravenous line or fluids when multi-tasking but less time adjusting the intravenous fluid. These effects are minor during routine uncomplicated induction of anaesthesia, but further investigation is needed to examine fatigue effects during non-routine circumstances.
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Anaesth Intensive Care · Nov 2012
Comparative StudyA prospective, observational study comparing postoperative residual curarisation and early adverse respiratory events in patients reversed with neostigmine or sugammadex or after apparent spontaneous recovery.
Six years ago, a study performed in our department reported that the incidence of postoperative residual curarisation (PORC) was 39%. The reassessment of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice is relevant now that sugammadex has become available. The incidence of PORC, defined by a train-of-four (TOF) <90%, was evaluated at post-anaesthesia care unit (PACU) arrival in patients whose neuromuscular block had been reversed with neostigmine or sugammadex and those in whom reversal was felt unnecessary (adequate spontaneous recovery). ⋯ Body mass index was the only independent predictor of SpO(2) <90% during the stay in the PACU. These findings indicate that in recent years, the incidence of PORC, defined by a TOF <90%, has dramatically decreased in our institution. The differences in PORC were not statistically significant between patients who received sugammadex for reversal and patients with spontaneous recovery or neostigmine reversal.
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Anaesth Intensive Care · Nov 2012
Randomized Controlled Trial Comparative StudyEffects of a 1:1 inspiratory to expiratory ratio on respiratory mechanics and oxygenation during one-lung ventilation in the lateral decubitus position.
Prolonged inspiratory to expiratory (I:E) ratio ventilation may have both positive and negative effects on respiratory mechanics and oxygenation during one-lung ventilation (OLV), but definitive information is currently lacking. We therefore compared the effects of volume-controlled ventilation with I:E ratios of 1:1 and 1:2 on respiratory mechanics and oxygenation during OLV. Fifty-six patients undergoing thoracoscopic lobectomy were randomly assigned volume-controlled ventilation with an I:E ratio of 1:1 (group 1:1, n=28) or 1:2 (group 1:2, n=28) during OLV. ⋯ There were no significant differences in PaO2 during OLV between the two groups (OLV30, P=0.856; OLV60, P=0.473). In summary, volume-controlled ventilation with an I:E ratio of 1:1 reduced peak and plateau airway pressures improved dynamic compliance and efficiency of alveolar ventilation, but it did not improve arterial oxygenation in a substantial manner. Furthermore, the associated increase in mean airway pressure might have reduced cardiac output, resulting in a lower central venous oxygen saturation.
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Anaesth Intensive Care · Nov 2012
Patterns of patient-ventilator asynchrony as predictors of prolonged mechanical ventilation.
Patient-ventilator asynchrony has been associated with adverse outcomes. The largest body of investigation has focused on ineffective ventilator triggering. Nevertheless, the effect of other patterns of asynchrony on patient outcomes is unknown. ⋯ AUC for the dish-out index was 0.88±0.09. AUC for overshoot, delay termination and composite indexes were 0.55±0.12, 0.62±0.12 and 0.70±0.10 respectively. Dish-out index is the best predictor of prolonged mechanical ventilation, compared with other patterns of patient-ventilator asynchrony.
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Anaesth Intensive Care · Nov 2012
Uptake of guidelines in the management of patients taking anticoagulants and antiplatelet agents presenting for elective surgery.
Management guidelines for patients on antithrombotic agents presenting for surgery have long been disseminated. Clinical practice, however, does not always follow published guidelines in a timely manner, despite their dissemination. This project is an audit of the management of patients on anticoagulants or antiplatelet agents presenting for elective surgery in a large metropolitan teaching hospital. ⋯ Data was collected for the 102 patients who fulfilled the inclusion criteria: 55.4% of decisions by surgeons and 51.4% of decisions by anaesthetists made in this study matched guidelines; 31.4% of decisions made by anaesthetists were fully compliant with guidelines; 20% of anaesthetic decisions were unintentionally compliant and 48.6% of anaesthetic decisions were noncompliant. A variety of reasons were cited for decisions made without the use of guidelines such as other clinical imperatives, lack of guideline awareness and a belief that it is not the role of the anaesthetist to manage perioperative antithrombotic therapy, amongst others. It is evident from this audit that compliance with guidelines remains an area where there is an opportunity for further practice improvement.