This editorial discusses the potential long-term consequences of anesthetic management that extend beyond the immediate perioperative period. It notes that while preventable anesthetic mortality has declined greatly, all-cause postoperative mortality remains high at around 5-10%. The editorial then examines evidence that some intraoperative decisions can influence long-term outcomes like surgical site infections, cancer recurrence, and cardiovascular events. Specifically, it discusses how hypothermia increases infection risk, and how regional anesthesia may help preserve the immune system and reduce cancer metastasis. The editorial concludes by highlighting several other recent editorials in Anesthesiology that also explored long-term outcomes.
This document summarizes research on acute lung injury (ALI) and outcomes after thoracic surgery. It finds that while operative mortality has remained stable, ALI is now the leading cause of death following surgery. Risk factors for developing ALI include preexisting lung dysfunction, extended resection, injurious ventilation, and fluid overload. The pathogenesis of ALI is thought to involve a "multiple hit" sequence triggering inflammation and increased permeability of the alveolar-capillary barrier. Protective lung ventilation strategies using low tidal volumes and PEEP may help prevent ALI by reducing ventilator-induced lung injury.
The document summarizes the activities of the Rotary Club of Makati Greenbelt. It discusses upcoming events like a raffle draw and medical mission. It also recaps a recent fundraiser event at the Manila Polo Club that the club supported. An officer profile is provided for PP Alfredo "Al" Joaquin who has long been involved with the club. The newsletter closes with reminders about upcoming activities in October through December, including a tree planting event, Christmas feeding project, and fellowship gathering.
This study analyzed equipment-related problems that occurred during 83,154 anesthetics over 5 years at a university hospital in Norway. The researchers found that the frequency of equipment problems was low, occurring in 0.05% of regional anesthetics and 0.23% of general anesthetics. One-third of problems involved the anesthesia machine. In a quarter of cases, human error contributed to the problem. No patients died or suffered lasting harm from equipment problems. The researchers concluded that the rate of equipment issues was low and mostly minor in severity. Aside from improving equipment check procedures, no new strategies were needed to reduce problems further.
Madagascar. Scalin up micro-irrigation. Andriamanalina Raharinjatovo Fenomanantsoa, Project coordinator, Agriculturalists and Veterinaries without Frontiers. Furthering water cooperation in rural areas. Making it happen! International Annual UN-Water Zaragoza Conference 2012/2013. Preparing for the 2013 International Year. Water Cooperation: Making it Happen! 8-10 January 2013
Definitive Consulting is an executive search firm that provides clients in professional services sectors with exclusive access to top talent. The firm focuses on building long-term relationships and takes a strategic advisory approach to identifying candidates that are the best fit for both the client's needs and the individual's career goals. Definitive Consulting aims to deliver competitive advantage for its clients through its niche market expertise and targeted recruitment approach.
The document provides information about Rotary Club Makati Greenbelt's activities in October 2009. It discusses the club hosting the 3rd leg of the Governor's Cup golf tournament. It also describes the club distributing relief goods to areas affected by typhoons. Additionally, it announces upcoming club meetings and events, such as a medical-dental mission, tree planting, and Christmas activities. The newsletter aims to keep members informed and engaged in service.
The document summarizes Rotary's objectives and provides updates from the Rotary Club of Makati Greenbelt. It discusses Rotary's goal of encouraging fellowship, high ethical standards, and international understanding. It also describes the club's relief efforts after Typhoon Ondoy, including donating supplies and distributing them in Taguig. The club co-hosted a district conference and participated in medical missions with a sister club.
The document summarizes the implementation of a crew resource management (CRM) training program at York Hospital to improve communication and teamwork in operating rooms (ORs) and enhance patient safety. The hospital developed a four-module CRM curriculum taught to over 530 OR staff members over two years. Observational studies found briefings and debriefings increased from 67% and 42% utilization before training to 100% and 87% utilization after training, suggesting improved adoption of CRM techniques. While no formal statistical analysis was conducted, patient safety culture survey scores improved slightly after implementation. The program demonstrated that a community hospital can successfully develop and adopt a customized CRM program to foster a culture of safety.
This document summarizes research on acute lung injury (ALI) and outcomes after thoracic surgery. It finds that while operative mortality has remained stable, ALI is now the leading cause of death following surgery. Risk factors for developing ALI include preexisting lung dysfunction, extended resection, injurious ventilation, and fluid overload. The pathogenesis of ALI is thought to involve a "multiple hit" sequence triggering inflammation and increased permeability of the alveolar-capillary barrier. Protective lung ventilation strategies using low tidal volumes and PEEP may help prevent ALI by reducing ventilator-induced lung injury.
The document summarizes the activities of the Rotary Club of Makati Greenbelt. It discusses upcoming events like a raffle draw and medical mission. It also recaps a recent fundraiser event at the Manila Polo Club that the club supported. An officer profile is provided for PP Alfredo "Al" Joaquin who has long been involved with the club. The newsletter closes with reminders about upcoming activities in October through December, including a tree planting event, Christmas feeding project, and fellowship gathering.
This study analyzed equipment-related problems that occurred during 83,154 anesthetics over 5 years at a university hospital in Norway. The researchers found that the frequency of equipment problems was low, occurring in 0.05% of regional anesthetics and 0.23% of general anesthetics. One-third of problems involved the anesthesia machine. In a quarter of cases, human error contributed to the problem. No patients died or suffered lasting harm from equipment problems. The researchers concluded that the rate of equipment issues was low and mostly minor in severity. Aside from improving equipment check procedures, no new strategies were needed to reduce problems further.
Madagascar. Scalin up micro-irrigation. Andriamanalina Raharinjatovo Fenomanantsoa, Project coordinator, Agriculturalists and Veterinaries without Frontiers. Furthering water cooperation in rural areas. Making it happen! International Annual UN-Water Zaragoza Conference 2012/2013. Preparing for the 2013 International Year. Water Cooperation: Making it Happen! 8-10 January 2013
Definitive Consulting is an executive search firm that provides clients in professional services sectors with exclusive access to top talent. The firm focuses on building long-term relationships and takes a strategic advisory approach to identifying candidates that are the best fit for both the client's needs and the individual's career goals. Definitive Consulting aims to deliver competitive advantage for its clients through its niche market expertise and targeted recruitment approach.
The document provides information about Rotary Club Makati Greenbelt's activities in October 2009. It discusses the club hosting the 3rd leg of the Governor's Cup golf tournament. It also describes the club distributing relief goods to areas affected by typhoons. Additionally, it announces upcoming club meetings and events, such as a medical-dental mission, tree planting, and Christmas activities. The newsletter aims to keep members informed and engaged in service.
The document summarizes Rotary's objectives and provides updates from the Rotary Club of Makati Greenbelt. It discusses Rotary's goal of encouraging fellowship, high ethical standards, and international understanding. It also describes the club's relief efforts after Typhoon Ondoy, including donating supplies and distributing them in Taguig. The club co-hosted a district conference and participated in medical missions with a sister club.
The document summarizes the implementation of a crew resource management (CRM) training program at York Hospital to improve communication and teamwork in operating rooms (ORs) and enhance patient safety. The hospital developed a four-module CRM curriculum taught to over 530 OR staff members over two years. Observational studies found briefings and debriefings increased from 67% and 42% utilization before training to 100% and 87% utilization after training, suggesting improved adoption of CRM techniques. While no formal statistical analysis was conducted, patient safety culture survey scores improved slightly after implementation. The program demonstrated that a community hospital can successfully develop and adopt a customized CRM program to foster a culture of safety.
This document summarizes research on chronic post-surgical pain (CPSP) over the past 10 years. It finds that CPSP is a significant problem affecting large numbers of patients. While studies of CPSP have improved, definition and measurement issues remain. Recent research has focused on risk factors in hopes of prevention. Severe acute post-operative pain emerges as an influential risk factor. Further research is still needed to better understand mechanisms and improve treatment of CPSP.
This document discusses factors that can influence the risk of postoperative infection and the role of anaesthetists in prevention. It notes that surgical site infections occur in 5-20% of surgeries and outlines several strategies anaesthetists can employ, including proper administration of antibiotic prophylaxis before incision, maintaining normothermia, and using maximal sterile barriers for invasive procedures like central line insertion. The timing of antibiotic prophylaxis is particularly important to reduce infection risk.
Radiotherapy for painful bone metastasesbigsky_2009
This document discusses radiotherapy treatment options for painful bone metastases. It summarizes that pain from bone metastases is commonly treated successfully with local external beam irradiation. There is controversy around whether single dose treatments requiring one visit or fractionated courses requiring multiple visits are more effective. While many radiotherapists still use fractionated regimens, the evidence shows that single fractions are as effective in relieving pain from bone metastases. For widespread bone metastases, hemibody irradiation should be considered to avoid repeated local treatments, though it is more toxic.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
This document provides an introduction to local anesthesia. It discusses that dentists, not doctors, were responsible for discovering anesthesia due to their motivation to alleviate pain from dental procedures. The first two people to introduce anesthesia were dentists - Horace Wells with nitrous oxide in 1844 and William Morton with ether. Local anesthesia works by preventing the generation and conduction of nerve impulses, setting up a chemical roadblock between the source of pain and the brain. The document then discusses the mechanism of action, factors affecting local anesthetics, and uses and contraindications of local anesthesia.
The document discusses the potential anti-inflammatory benefits of low-dose radiation for various benign diseases and conditions. While radiation is commonly used to treat such conditions in other countries, its use for non-cancerous illnesses is more limited in the United States. Several studies have found radiation effective in reducing pain and inflammation in joints and tissues for issues like arthritis, tendinitis and preventing excessive bone growth after hip surgery. However, more research is still needed to better understand optimal doses and mechanisms of action before widespread use for inflammation in the US.
This document summarizes an application brief about using micro-ultrasound to study cancer angiogenesis. It discusses how micro-ultrasound allows researchers to non-invasively visualize 3D tumor volume, neoangiogenesis, and blood perfusion over time in small animal models. This helps researchers better understand cancer development and anti-angiogenic therapies. VisualSonics' micro-ultrasound systems provide high resolution real-time imaging of tumor growth and vascularity to help reduce the number of animals needed for research.
Tumor angiogenesis is currently one of the key focal points in biomedical research. It is based upon the hypothesis laid out by Judah Folkman in 1971 that neovasculature is needed to support the growth and metastasis of tumors, and thus anti-angiogenic treatment might be an effective way to cure cancer. Genentech’s anti-VEGF-A drug Avastin a great demonstration of this concept, generating more than $2.7 billion of sales in 2008.
Physiotherapy modalities like low-level laser therapy, ultraviolet light therapy, and ultrasound can help promote wound healing in conditions like pressure sores, diabetic foot ulcers, and infected wounds. A study found that a single 180-second exposure of ultraviolet C light significantly reduced bacteria levels in chronic wounds contaminated with MRSA. Ultraviolet light may increase wound healing by stimulating fibroblast fibronectin production and collagen lattice contraction. Ultrasound can also accelerate wound healing through its effects on inflammation, cell permeability, and stimulation of fibroblasts.
Gabapentin reduced acute pain after mastectomy and decreased the incidence of chronic pain in two studies. A single dose of gabapentin was ineffective for reducing thoracotomy pain when an epidural was also used. Regional anesthesia and intravenous lidocaine reduced chronic pain incidence after mastectomy or thoracotomy in several studies. Ketamine and intercostal cryoanalgesia did not reduce chronic pain. Total intravenous anesthesia may reduce post-thoracotomy pain in one study.
This document summarizes evidence and opportunities for preventing surgical site infections. It discusses how endogenous colonization and various patient, procedure, and surgical team factors can increase infection risk. Effective prevention strategies include: (1) reducing patient endogenous colonization through decolonization protocols and proper preoperative care; (2) appropriate use of antibiotic prophylaxis during surgery; and (3) maintaining proper asepsis through careful surgical technique and strict adherence to infection control measures by the surgical team. While some strategies like supplemental oxygen or certain wound dressings have less clear evidence, implementing a bundle of the most effective practices can significantly reduce surgical site infection rates.
Rationale for use of antibiotics after periodontal surgery Vidya Vishnu
1) The document discusses the rationale for use of antibiotics after periodontal surgery. While some studies support their use to reduce pain and swelling and improve healing, other studies found no benefit when surgery was performed under strict aseptic conditions.
2) The prevalence of postoperative infections after periodontal surgery is low (<1-4.4%) even without antibiotics. Strict aseptic protocols during surgery are important to prevent infections.
3) More recent studies and reviews have found no clear benefit to routine use of antibiotics after surgery to prevent infection alone. They may be indicated if infection is already present or for medical reasons.
Peripheral venous catheters (PVCs) are commonly used to deliver intravenous therapy, but are associated with complications like infection and phlebitis. It is estimated that one in three hospital patients have a PVC inserted at any given time. Careful observation and monitoring of PVC sites, along with strict hygiene practices during insertion and maintenance, are essential to minimize risks and quickly identify any complications. PVCs should be removed as soon as they are no longer clinically necessary to reduce health risks.
This document summarizes a study comparing outcomes of general versus spinal anesthesia for total hip arthroplasty. The study found higher odds of adverse events, such as prolonged ventilation and unplanned intubation, with general anesthesia. While many studies have found improved outcomes with spinal anesthesia, it remains underutilized. The interpretation of such database studies is limited as they cannot prove causality. A large prospective randomized trial would be needed to definitively compare the techniques.
Anesthetic risk, quality improvement and liability●๋•αηкιтα madan
This document discusses anesthesia risk and mortality. It provides estimates from various studies that anesthesia-related mortality rates range from less than 1 per 10,000 anesthetics to 1 per 1,560 anesthetics historically. Common complications discussed include nerve injuries, awareness during general anesthesia, eye/dental injuries, and postoperative cognitive dysfunction in elderly patients. Risk management strategies to minimize liability like adherence to standards of care, vigilance, documentation, and informed consent are also outlined.
ERECTILE RESTORATION: SURGICAL Peri-operative management and guidelinesEsther García Rojo
1. Penile prosthesis implantation can effectively treat both penile deformity and erectile dysfunction from Peyronie's disease, with high success and satisfaction rates. However, prosthesis infections remain a concern.
2. Risk of infection can be reduced through proper patient selection and preparation, use of antibiotic-coated devices, adherence to surgical protocols like restricted OR traffic and appropriate skin preparation and draping, and post-operative wound care measures. Perioperative antibiotics are also recommended.
3. While no method can completely prevent infection, these evidence-based practices aim to lower the risk to less than 1%, avoiding severe consequences of prosthesis removal and re-implantation that can result from device infections
This document reviews modern control strategies for regulating propofol anesthesia administration during surgery. It begins by discussing the workflow of anesthesia, including induction, maintenance, and emergence phases. It then describes the compartmental pharmacokinetic and pharmacodynamic models used to represent how propofol is metabolized and its effects. The rest of the document reviews different control schemes that have been applied, including linear control initially and later more sophisticated nonlinear schemes like sliding mode control and model predictive control. It assesses the performance of these closed-loop control systems and concludes that sliding mode control is better able to handle nonlinearities and maintain an optimal hypnosis level.
Fast track surgery aims to accelerate patient recovery through a coordinated approach involving preoperative education, optimized anesthesia and pain management, and aggressive postoperative rehabilitation including early feeding and mobilization. The goal is to shorten hospital stays, reduce complications, and speed recovery times for elective surgeries. Key elements of fast track surgery programs include preoperative patient education, regional anesthesia when possible, measures to reduce surgical stress, multimodal approaches to controlling nausea, vomiting and ileus, adequate postoperative pain management, early removal of tubes and catheters when evidence-based, encouragement of early feeding and mobilization, and detailed discharge planning. Reported results show that fast track surgery can result in shorter hospital stays and comparable or reduced complication rates compared to traditional
1) A study showed that the choice of anesthesiologist affects outcomes in cardiac surgery, with patients of low-performing anesthesiologists having twice the rate of death or complications compared to patients of high-performing anesthesiologists.
2) While some view anesthesiologists as interchangeable, the results demonstrate that individual anesthesiologists can significantly impact outcomes.
3) Additional studies discussed in the document examine how better understanding differences in provider performance and standardizing best practices can help improve outcomes for all patients.
O documento discute a sepse, uma condição médica grave causada por infecção, que afeta milhões de pessoas a cada ano e causa muitas mortes potencialmente evitáveis. A visão para 2020 é reduzir a incidência de sepse em 20% através de melhores estratégias de prevenção e tratamento, e aumentar a sobrevida de pacientes com sepse para acima de 80% em todo o mundo.
O documento discute a sepse, uma condição médica grave causada por infecção, que afeta milhões de pessoas a cada ano e causa muitas mortes potencialmente evitáveis. A visão para 2020 é reduzir a incidência de sepse em 20% através de estratégias de prevenção e tratamento melhorado, e aumentar a sobrevida de pacientes com sepse para acima de 80% em todo o mundo.
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This document summarizes research on chronic post-surgical pain (CPSP) over the past 10 years. It finds that CPSP is a significant problem affecting large numbers of patients. While studies of CPSP have improved, definition and measurement issues remain. Recent research has focused on risk factors in hopes of prevention. Severe acute post-operative pain emerges as an influential risk factor. Further research is still needed to better understand mechanisms and improve treatment of CPSP.
This document discusses factors that can influence the risk of postoperative infection and the role of anaesthetists in prevention. It notes that surgical site infections occur in 5-20% of surgeries and outlines several strategies anaesthetists can employ, including proper administration of antibiotic prophylaxis before incision, maintaining normothermia, and using maximal sterile barriers for invasive procedures like central line insertion. The timing of antibiotic prophylaxis is particularly important to reduce infection risk.
Radiotherapy for painful bone metastasesbigsky_2009
This document discusses radiotherapy treatment options for painful bone metastases. It summarizes that pain from bone metastases is commonly treated successfully with local external beam irradiation. There is controversy around whether single dose treatments requiring one visit or fractionated courses requiring multiple visits are more effective. While many radiotherapists still use fractionated regimens, the evidence shows that single fractions are as effective in relieving pain from bone metastases. For widespread bone metastases, hemibody irradiation should be considered to avoid repeated local treatments, though it is more toxic.
This document summarizes an article about volunteer surgeons providing care to wounded soldiers in Iraq and Afghanistan. It discusses the senior visiting surgeon program established by the American College of Surgeons that allows surgeons to volunteer their time. The volunteer rotation described involved caring for patients at Landstuhl Regional Medical Center in Germany as part of the complex medical evacuation process bringing wounded soldiers from war zones to the United States for further treatment and recovery.
This document provides an introduction to local anesthesia. It discusses that dentists, not doctors, were responsible for discovering anesthesia due to their motivation to alleviate pain from dental procedures. The first two people to introduce anesthesia were dentists - Horace Wells with nitrous oxide in 1844 and William Morton with ether. Local anesthesia works by preventing the generation and conduction of nerve impulses, setting up a chemical roadblock between the source of pain and the brain. The document then discusses the mechanism of action, factors affecting local anesthetics, and uses and contraindications of local anesthesia.
The document discusses the potential anti-inflammatory benefits of low-dose radiation for various benign diseases and conditions. While radiation is commonly used to treat such conditions in other countries, its use for non-cancerous illnesses is more limited in the United States. Several studies have found radiation effective in reducing pain and inflammation in joints and tissues for issues like arthritis, tendinitis and preventing excessive bone growth after hip surgery. However, more research is still needed to better understand optimal doses and mechanisms of action before widespread use for inflammation in the US.
This document summarizes an application brief about using micro-ultrasound to study cancer angiogenesis. It discusses how micro-ultrasound allows researchers to non-invasively visualize 3D tumor volume, neoangiogenesis, and blood perfusion over time in small animal models. This helps researchers better understand cancer development and anti-angiogenic therapies. VisualSonics' micro-ultrasound systems provide high resolution real-time imaging of tumor growth and vascularity to help reduce the number of animals needed for research.
Tumor angiogenesis is currently one of the key focal points in biomedical research. It is based upon the hypothesis laid out by Judah Folkman in 1971 that neovasculature is needed to support the growth and metastasis of tumors, and thus anti-angiogenic treatment might be an effective way to cure cancer. Genentech’s anti-VEGF-A drug Avastin a great demonstration of this concept, generating more than $2.7 billion of sales in 2008.
Physiotherapy modalities like low-level laser therapy, ultraviolet light therapy, and ultrasound can help promote wound healing in conditions like pressure sores, diabetic foot ulcers, and infected wounds. A study found that a single 180-second exposure of ultraviolet C light significantly reduced bacteria levels in chronic wounds contaminated with MRSA. Ultraviolet light may increase wound healing by stimulating fibroblast fibronectin production and collagen lattice contraction. Ultrasound can also accelerate wound healing through its effects on inflammation, cell permeability, and stimulation of fibroblasts.
Gabapentin reduced acute pain after mastectomy and decreased the incidence of chronic pain in two studies. A single dose of gabapentin was ineffective for reducing thoracotomy pain when an epidural was also used. Regional anesthesia and intravenous lidocaine reduced chronic pain incidence after mastectomy or thoracotomy in several studies. Ketamine and intercostal cryoanalgesia did not reduce chronic pain. Total intravenous anesthesia may reduce post-thoracotomy pain in one study.
This document summarizes evidence and opportunities for preventing surgical site infections. It discusses how endogenous colonization and various patient, procedure, and surgical team factors can increase infection risk. Effective prevention strategies include: (1) reducing patient endogenous colonization through decolonization protocols and proper preoperative care; (2) appropriate use of antibiotic prophylaxis during surgery; and (3) maintaining proper asepsis through careful surgical technique and strict adherence to infection control measures by the surgical team. While some strategies like supplemental oxygen or certain wound dressings have less clear evidence, implementing a bundle of the most effective practices can significantly reduce surgical site infection rates.
Rationale for use of antibiotics after periodontal surgery Vidya Vishnu
1) The document discusses the rationale for use of antibiotics after periodontal surgery. While some studies support their use to reduce pain and swelling and improve healing, other studies found no benefit when surgery was performed under strict aseptic conditions.
2) The prevalence of postoperative infections after periodontal surgery is low (<1-4.4%) even without antibiotics. Strict aseptic protocols during surgery are important to prevent infections.
3) More recent studies and reviews have found no clear benefit to routine use of antibiotics after surgery to prevent infection alone. They may be indicated if infection is already present or for medical reasons.
Peripheral venous catheters (PVCs) are commonly used to deliver intravenous therapy, but are associated with complications like infection and phlebitis. It is estimated that one in three hospital patients have a PVC inserted at any given time. Careful observation and monitoring of PVC sites, along with strict hygiene practices during insertion and maintenance, are essential to minimize risks and quickly identify any complications. PVCs should be removed as soon as they are no longer clinically necessary to reduce health risks.
This document summarizes a study comparing outcomes of general versus spinal anesthesia for total hip arthroplasty. The study found higher odds of adverse events, such as prolonged ventilation and unplanned intubation, with general anesthesia. While many studies have found improved outcomes with spinal anesthesia, it remains underutilized. The interpretation of such database studies is limited as they cannot prove causality. A large prospective randomized trial would be needed to definitively compare the techniques.
Anesthetic risk, quality improvement and liability●๋•αηкιтα madan
This document discusses anesthesia risk and mortality. It provides estimates from various studies that anesthesia-related mortality rates range from less than 1 per 10,000 anesthetics to 1 per 1,560 anesthetics historically. Common complications discussed include nerve injuries, awareness during general anesthesia, eye/dental injuries, and postoperative cognitive dysfunction in elderly patients. Risk management strategies to minimize liability like adherence to standards of care, vigilance, documentation, and informed consent are also outlined.
ERECTILE RESTORATION: SURGICAL Peri-operative management and guidelinesEsther García Rojo
1. Penile prosthesis implantation can effectively treat both penile deformity and erectile dysfunction from Peyronie's disease, with high success and satisfaction rates. However, prosthesis infections remain a concern.
2. Risk of infection can be reduced through proper patient selection and preparation, use of antibiotic-coated devices, adherence to surgical protocols like restricted OR traffic and appropriate skin preparation and draping, and post-operative wound care measures. Perioperative antibiotics are also recommended.
3. While no method can completely prevent infection, these evidence-based practices aim to lower the risk to less than 1%, avoiding severe consequences of prosthesis removal and re-implantation that can result from device infections
This document reviews modern control strategies for regulating propofol anesthesia administration during surgery. It begins by discussing the workflow of anesthesia, including induction, maintenance, and emergence phases. It then describes the compartmental pharmacokinetic and pharmacodynamic models used to represent how propofol is metabolized and its effects. The rest of the document reviews different control schemes that have been applied, including linear control initially and later more sophisticated nonlinear schemes like sliding mode control and model predictive control. It assesses the performance of these closed-loop control systems and concludes that sliding mode control is better able to handle nonlinearities and maintain an optimal hypnosis level.
Fast track surgery aims to accelerate patient recovery through a coordinated approach involving preoperative education, optimized anesthesia and pain management, and aggressive postoperative rehabilitation including early feeding and mobilization. The goal is to shorten hospital stays, reduce complications, and speed recovery times for elective surgeries. Key elements of fast track surgery programs include preoperative patient education, regional anesthesia when possible, measures to reduce surgical stress, multimodal approaches to controlling nausea, vomiting and ileus, adequate postoperative pain management, early removal of tubes and catheters when evidence-based, encouragement of early feeding and mobilization, and detailed discharge planning. Reported results show that fast track surgery can result in shorter hospital stays and comparable or reduced complication rates compared to traditional
1) A study showed that the choice of anesthesiologist affects outcomes in cardiac surgery, with patients of low-performing anesthesiologists having twice the rate of death or complications compared to patients of high-performing anesthesiologists.
2) While some view anesthesiologists as interchangeable, the results demonstrate that individual anesthesiologists can significantly impact outcomes.
3) Additional studies discussed in the document examine how better understanding differences in provider performance and standardizing best practices can help improve outcomes for all patients.
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O documento discute a sepse, uma condição médica grave causada por infecção, que afeta milhões de pessoas a cada ano e causa muitas mortes potencialmente evitáveis. A visão para 2020 é reduzir a incidência de sepse em 20% através de melhores estratégias de prevenção e tratamento, e aumentar a sobrevida de pacientes com sepse para acima de 80% em todo o mundo.
O documento discute a sepse, uma condição médica grave causada por infecção, que afeta milhões de pessoas a cada ano e causa muitas mortes potencialmente evitáveis. A visão para 2020 é reduzir a incidência de sepse em 20% através de estratégias de prevenção e tratamento melhorado, e aumentar a sobrevida de pacientes com sepse para acima de 80% em todo o mundo.
1) O boletim apresenta o primeiro boletim de farmacovigilância da Anvisa, que tem como objetivo fornecer feedback sobre medidas regulatórias e orientar profissionais de saúde sobre vigilância de medicamentos.
2) A farmacovigilância monitora efeitos adversos de medicamentos após registro para prevenir problemas à saúde, sendo importante devido a reações que só ocorrem com uso em larga escala.
3) O boletim destaca a importância da notificação correta de eventos adversos, já que muitas not
A Agência Nacional de Vigilância Sanitária abre consulta pública para padronizar as cores das embalagens de Soluções Parenterais de Pequeno Volume de acordo com sua classe terapêutica. O documento propõe cores específicas para identificar anestésicos, analgésicos, relaxantes musculares e outros medicamentos. As empresas terão 180 dias para adequar as embalagens e a ANVISA consolidará as contribuições recebidas.
O evento será promovido pela Central Prática no dia 23 de setembro, das 9h às 17h55, no auditório da instituição, em São Paulo na Rua Frei Caneca, 159.
O curso de extensão discute dilemas éticos e jurídicos relacionados à biomedicina e biotecnologia em 40 horas aos sábados entre setembro e novembro de 2011. O curso é destinado a médicos, advogados, psicólogos e enfermeiros e abordará temas como reprodução humana, genética, doação de órgãos e terminalidade da vida.
The study prospectively evaluated a predefined algorithm for managing unanticipated difficult airways in anesthetized patients. Over an 18-month period, the algorithm was followed for 100 difficult airway cases out of 11,257 intubations. The algorithm recommended using a gum elastic bougie for the first attempt and Intubating Laryngeal Mask Airway for the second attempt if needed. Adherence to the algorithm was high, with successful ventilation and oxygenation achieved in nearly all cases using these airway devices. The algorithm proved effective for managing most unexpected difficult airway scenarios.
This study assessed factors that influence physicians' decisions about transporting critically ill patients between hospitals. A survey was sent to intensive care physicians in the Netherlands asking them to rate the transportability of patients described in 16 clinical scenarios varying 8 factors. Conjoint analysis showed that the type of escort personnel and transport facilities had the greatest negative impact on preferences for transportability, while factors reflecting patient severity had less influence. Physicians were more likely to approve transport if specialized intensive care staff and a fully equipped mobile ICU were available. Patient age, arrhythmias, and the reason for transport did not significantly affect decisions.
Em homenagem ao Dia Internacional
da Mulher (celebrado em 8 de
março) e ao ano em que o Brasil tem
pela primeira vez na sua história uma
presidente mulher – Dilma Roussef,
a Revista DOC conversou com presidentes
de cinco grandes sociedades
brasileiras – Cardiologia; Ginecologia
e Obstetrícia; Neurologia; Anestesiologia;
e Geriatria e Gerontologia,
além de duas médicas referências
em suas áreas de atuação.
Este documento discute a reposição volêmica durante procedimentos anestésicos. Ele fornece diretrizes sobre como avaliar a necessidade de reposição volêmica clinicamente e por meio de monitorização, reconhecendo que a avaliação precisa pode ser desafiadora. A reposição volêmica é importante para manter a estabilidade hemodinâmica e perfusão adequada dos tecidos durante o procedimento cirúrgico.
This document reviews strategies to improve surgical outcomes through multimodal perioperative care approaches. It finds that newer perioperative care approaches have reduced both morbidity and mortality in surgical patients. Specifically, it discusses how regional anesthesia, minimally invasive surgery, intraoperative normothermia, and accelerated rehabilitation programs can reduce stress responses and complications after surgery. The major challenge is developing standardized "fast track" surgical programs using multimodal interventions to achieve pain-free and risk-free perioperative courses.
A carta descreve a campanha da Sociedade de Anestesiologia do Estado de São Paulo para valorizar o trabalho dos médicos anestesistas no sistema público e nos planos de saúde, que inclui uma paralisação em 21 de outubro para chamar atenção para os baixos salários e honorários, assim como as más condições de trabalho.
Este documento resume as principais alterações nas Diretrizes da American Heart Association (AHA) de 2010 para Ressuscitação Cardiopulmonar (RCP) e Atendimento Cardiovascular de Emergência (ACE), concentrando-se em (1) enfatizar a importância de compressões torácicas de alta qualidade, (2) alterar a sequência de suporte básico de vida de A-B-C para C-A-B, iniciando com compressões torácicas, e (3) destacar a importância dos cuidados pós-parada cardí
1) O documento discute métodos para prevenir aspiração pulmonar do conteúdo gástrico durante procedimentos cirúrgicos, incluindo o controle do volume e pH do conteúdo gástrico, redução do refluxo gastroesofágico e proteção das vias aéreas.
2) Recomendações atuais sugerem períodos menores de jejum pré-operatório, principalmente para líquidos, para melhor conforto dos pacientes sem aumentar riscos.
3) A intubação traqueal após indução
The document summarizes 61 incidents and 23 near misses reported to the Safe Anaesthesia Liaison Group between August 11, 2009 and February 26, 2010. It analyzes the incidents by theme, with the most common themes being infrastructure issues (20 incidents), medical device/equipment issues (19 incidents), and implementation of care issues (19 incidents). It provides examples for each theme and concludes by emphasizing the importance of continued incident reporting to improve patient safety.
The document provides guidelines for the perioperative management of patients with obstructive sleep apnea (OSA). It defines OSA and discusses its prevalence. The guidelines were developed through a rigorous process including a literature review and input from experts. The guidelines aim to improve perioperative care and reduce risks for patients with OSA undergoing procedures. Recommendations are made regarding preoperative assessment and risk stratification of patients, as well as postoperative monitoring and care.
The medication safety project had two aims: 1) to identify areas of exposure to risk and make recommendations to enhance medication safety, and 2) to inform the development of a medication safety checklist specific to operating rooms. An interdisciplinary team conducted a review of medication use in operating rooms and related areas. They observed environments where medications were prescribed, stored, prepared, dispensed and administered. The team made recommendations in areas like improving documentation of patient medication histories, reducing abbreviations, enhancing pharmacist support, and standardizing medication storage, labeling and carts. Many of the recommendations have been implemented.
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These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
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1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
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Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
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2. 2 EDITORIAL VIEWS
Surgical Site Infection is surgery per se, which releases tumor cells into circu-
lation,18 depresses cell-mediated immunity including
Arguably, the first convincing evidence for long-term cytotoxic T-cell and natural killer cell functions,20 re-
outcomes related to anesthetic management dates to duces circulating concentrations of tumor-related antian-
1996, which saw publication of two key articles in the giogenic factors, increases concentrations of proangio-
New England Journal of Medicine. One, from Mangano genic factors such as vascular endothelial growth
et al., linked perioperative -blocker administration to factor,21 and releases growth factors that promote
myocardial infarction and mortality7 (more about this local and distant growth of malignant tissue.19 The
topic below). The other, from Kurz et al., showed that
second factor is that volatile anesthesia per se impairs
mild hypothermia triples the risk of surgical wound
neutrophil, macrophage, dendritic-cell, T-cell, and nat-
infection8 even though surgical site infections become
ural killer-cell immune functions.22 The third factor is
clinically apparent 1– 4 weeks after surgery. The link
opioids that inhibit both cellular and humoral immune
between hypothermia and infection was subsequently
function.22 Furthermore, morphine is proangiogenic and
confirmed by an additional randomized trial.9 The risk
of surgical wound infection also appears to be mod- promotes tumor growth.23 Consequently, nonopioid anal-
erated by supplemental oxygen, even when supple- gesia helps preserve natural killer cell function in animals
mental oxygen is only provided during surgery and 2 and humans and reduces metastatic spread of cancer in
or 6 hr thereafter.10,11 rodents.24
There is thus considerable evidence that wound infec- Regional anesthesia and analgesia attenuate or prevent
tions, despite becoming clinically apparent weeks after each of these adverse effects. For example, regional
surgery, are established during and immediately after sur- anesthesia largely prevents the neuroendocrine stress
gery. All surgical wounds become contaminated; surgical response to surgery by blocking afferent neural transmis-
sterility is only relative! Whether contamination progresses sion from reaching the central nervous system and by
to a clinical infection is determined by the adequacy of host blocking descending efferent activation of the sympa-
defenses during a decisive period lasting some hours after thetic nervous system.25 Consequently, natural killer-cell
contamination. In the case of bacteria causing surgical function is better preserved with regional anesthesia and
wound infections, the most important host defense is oxi- metastatic load to the lungs is reduced in a rat model of
dative killing by neutrophils.12 This process requires mo- breast cancer metastasis.20
lecular oxygen13 and is a function of tissue (as opposed to When regional and general anesthetics are combined,
arterial) oxygen partial pressure over the entire physiologic the amount of general anesthetic required is much re-
range. Interventions that increase tissue oxygen during the duced, as is presumably immune suppression. Further-
decisive period, such as maintaining normothermia14 and more, regional analgesia provides superb pain relief,
providing supplemental oxygen,10 reduce progression of essentially obviating the need for postoperative opioids,
contamination to clinical infection. and the consequent adverse effects on immune function
It is likely that infection risk is similarly diminished by and of tumor growth.22,25 Regional analgesia also re-
other factors that support tissue oxygenation,15 including duces release of endogenous opioids.26
adequate sympathetic block16 and good control of surgical
Available data thus suggest that regional anesthesia and
pain.17 The potential benefit of these and other interven-
analgesia help preserve effective defenses against tumor
tions have yet to be determined in large- scale outcome
progression by attenuating the surgical stress response,
studies, but they remain under active investigation.
by reducing general anesthesia requirements, and by
sparing postoperative opioids.27 Animal studies are con-
sistent with this theory, showing that regional anesthesia
Regional Analgesia and Cancer Recurrence and optimum postoperative analgesia independently re-
An additional long-term outcome to consider is cancer. duce the metastatic burden in animals inoculated with
Although not widely appreciated, tumor surgery is usu- breast adenocarcinoma cells.28 Available human data,
ally associated with release of tumor cells into the lym- although extremely limited, are also consistent with this
phatic and blood streams; furthermore, a large fraction theory. For example, paravertebral anesthesia and anal-
of patients already harbor micrometastases and scattered gesia for breast cancer surgery is associated with an
tumor cells at the time of surgery.18 Whether this min- approximately four-fold reduced risk of recurrence or
imal residual disease results in clinical metastases de- metastasis.29 Similarly, epidural analgesia for radical pros-
pends largely on the balance between antimetastatic tate surgery is associated with a 60% reduction in recur-
immune activity and the tumor’s ability to seed, prolif- rence risk.30 Major prospective trials of paravertebral anal-
erate, and attract new blood vessels.19 gesia for breast cancer surgery (NCT00418457)31 and
At least three perioperative factors shift the balance epidural analgesia for colon cancer are in progress
toward progression of minimal residual disease. The first (NCT00684229).
Anesthesiology, V 111, No 1, Jul 2009
3. EDITORIAL VIEWS 3
Recent and Future Editorials Exploring 3. Kohn KT, Corrigan JM, Donaldson M: To err is human: Building a safer
health system. Washington, DC, Academy Press, 1999
Long-term Outcomes 4. Arbous MS, Meursing AE, van Kleef JW, de Lange JJ, Spoormans HH, Touw
P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on
Additional proven or potential long-term outcomes of severe morbidity and mortality. ANESTHESIOLOGY 2005; 102:257–68; quiz 491–2
5. Lagasse RS: Innocent prattle. ANESTHESIOLOGY 2009; 110:698–9
perioperative management have already been addressed 6. Monk TG, Saini V, Weldon BC, Sigl JC: Anesthetic management and one-year
in recent ANESTHESIOLOGY editorials. For example, an edi- mortality after noncardiac surgery. Anesth Analg 2005; 100:4–10
7. Mangano DT, Layug EL, Wallace A, Tateo I: Effect of atenolol on mortality
torial in the December issue by Spahn et al. highlights and cardiovascular morbidity after noncardiac surgery. Multicenter Study of
the dangers of red cell transfusions, especially noninfec- Perioperative Ischemia Research Group. N Engl J Med 1996; 335:1713–20
8. Kurz A, Sessler DI, Lenhardt RA: Study of wound infections and temperature
tious complications, which are the major risk.32 Editori- group: Perioperative normothermia to reduce the incidence of surgical-wound
als in the February (Fahy et al.33 and Nunnally and infection and shorten hospitalization. N Engl J Med 1996; 334:1209–15
9. Melling AC, Ali B, Scott EM, Leaper DJ: Effects of preoperative warming on
O’Conner34) and March (Lanier and Pasternak35) issues the incidence of wound infection after clean surgery: A randomised controlled
discuss the risks and benefits of tight glycemic control. trial. Lancet 2001; 358:876–80
10. Greif R, Akca O, Horn E-P, Kurz A, Sessler DI: Outcomes Research™
¸
Also in March, Kehlet and Bundgaard-Nielsen discuss Group: Supplemental perioperative oxygen to reduce the incidence of surgical
long-term consequences of perioperative fluid manage- wound infection. N Engl J Med 2000; 342:161–7
11. Belda FJ, Aguilera L, Garcia de la Asuncion J, Alberti J, Vicente R, Ferrandiz
ment.36 An editorial by Maze focused on postoperative L, Rodriguez R, Company R, Sessler DI, Aguilar G, Botello SG, Orti R: Supple-
cognitive dysfunction.37 And finally, April editorials by mental perioperative oxygen and the risk of surgical wound infection: A random-
ized controlled trial. JAMA 2005; 294:2035–42
Patel and Sun38 and by Perouansky and Hemmings39 12. Benhaim P, Hunt TK: Natural resistance to infection: Leukocyte functions.
dealt with volatile anesthetic toxicity in newborns. J Burn Care Rehabil 1992; 13:287–92
13. Jonsson K, Hunt TK, Mathes SJ: Oxygen as an isolated variable influences
This is the first of four editorials to address additional resistance to infection. Ann Surg 1988; 208:783–7
potential long-term consequences of anesthetic manage- 14. Sheffield CW, Sessler DI, Hopf HW, Schroeder M, Moayeri A, Hunt TK,
West JM: Centrally and locally mediated thermoregulatory responses alter sub-
ment. The next will be by Philip Devereaux, M.D., Ph.D., cutaneous oxygen tension. Wound Rep Reg 1997; 4:339–45
from the Department of Clinical Epidemiology and Bio- 15. Hopf HW, Hunt TK, West JM, Blomquist P, Goodson WH 3rd, Jensen JA,
Jonsson K, Paty PB, Rabkin JM, Upton RA, von Smitten K, Whitney JD: Wound
statistics and Medicine, McMaster University in West tissue oxygen tension predicts the risk of wound infection in surgical patients.
Hamilton, Ontario, Canada, who will present the evi- Arch Surg 1997; 132:997–1004
16. Kabon B, Fleischmann E, Treschan T, Taguchi A, Kapral S, Kurz A:
dence linking -blocker administration and sympatholy- Thoracic epidural anesthesia increases tissue oxygenation during major abdom-
sis with perioperative myocardial infarction, stroke, and inal surgery. Anesth Analg 2003; 97:1812–7
mortality. Devereaux was the principal investigator on 17. Akca O, Melischek M, Scheck T, Hellwagner K, Arkilic C, Kurz A, Kapral
¸ ¸
S, Heinz T, Lackner FX, Sessler DI: Postoperative pain and subcutaneous oxygen
the recent POISE trial, which is by far the largest ran- tension. Lancet 1999; 354:41–2
domized trial of perioperative -blocker use.40 Marc De 18. Denis MG, Lipart C, Leborgne J, LeHur PA, Galmiche JP, Denis M, Ruud E,
Truchaud A, Lustenberger P: Detection of disseminated tumor cells in peripheral
Kock, M.D., Ph.D., Department of Anesthesiology, Uni- blood of colorectal cancer patients. Int J Cancer 1997; 74:540–4
versite Catholique de Louvain, St. Luc Hospital, Brussels, 19. Shakhar G, Ben-Eliyahu S: Potential prophylactic measures against postop-
erative immunosuppression: Could they reduce recurrence rates in oncological
Belgium, who has published extensively on the topic, patients? Ann Surg Oncol 2003; 10:972–92
will then discuss persistent incision pain. Finally, 20. Bar-Yosef S, Melamed R, Page GG, Shakhar G, Shakhar K, Ben-Eliyahu S:
Attenuation of the tumor-promoting effect of surgery by spinal blockade in rats.
Alexander Hannenberg, M.D., of the Department of An- ANESTHESIOLOGY 2001; 94:1066–73
esthesiology, Newton-Wellesley Hospital, Tufts Univer- 21. Antoni MH, Lutgendorf SK, Cole SW, Dhabhar FS, Sephton SE, McDonald
PG, Stefanek M, Sood AK: The influence of bio-behavioural factors on tumour
sity School of Medicine, Newton, Massachusetts, and biology: Pathways and mechanisms. Nat Rev Cancer 2006; 6:240–8
Mark Warner, M.D., of the Department of Anesthesiol- 22. Sacerdote P, Bianchi M, Gaspani L, Manfredi B, Maucione A, Terno G, Am-
matuna M, Panerai AE: The effects of tramadol and morphine on immune responses
ogy, Mayo Clinic, Rochester, Minnesota, will discuss and pain after surgery in cancer patients. Anesth Analg 2000; 90:1411–4
how the new Anesthesia Quality Institute and Mainte- 23. Gupta K, Kshirsagar S, Chang L, Schwartz R, Law PY, Yee D, Hebbel RP:
Morphine stimulates angiogenesis by activating proangiogenic and survival-pro-
nance of Certification in Anesthesiology may improve moting signaling and promotes breast tumor growth. Cancer Res 2002; 62:
long-term anesthetic outcomes. As leaders of these initi- 4491–8
24. Ben-Eliyahu S, Page GG, Yirmiya R, Shakhar G: Evidence that stress and
atives, they are well positioned to put them into surgical interventions promote tumor development by suppressing natural killer
perspective. cell activity. Int J Cancer 1999; 80:880–8
25. O’Riain SC, Buggy DJ, Kerin MJ, Watson RW, Moriarty DC: Inhibition of
Finally, I am delighted to announce that long-terms out- the stress response to breast cancer surgery by regional anesthesia and analgesia
comes will be the topic of the 2010 ANESTHESIOLOGY Journal does not affect vascular endothelial growth factor and prostaglandin E2. Anesth
Analg 2005; 100:244–9
Symposium. We look forward to an in-depth exploration of 26. Chae BK, Lee HW, Sun K, Choi YH, Kim HM: The effect of combined
this exciting new dimension of anesthesia. epidural and light general anesthesia on stress hormones in open heart surgery
patients. Surg Today 1998; 28:727–31
Daniel I. Sessler M.D. Department of Outcomes Research, The 27. Sessler DI: Does regional analgesia reduce the risk of cancer recurrence? A
Cleveland Clinic, Cleveland, Ohio. DS@OR.org hypothesis. Eur J Cancer Prev 2008; 17:269–72
28. Page GG, Blakely WP, Ben-Eliyahu S: Evidence that postoperative pain is a
mediator of the tumor-promoting effects of surgery in rats. Pain 2001; 90:191–9
29. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI: Can anes-
References thetic technique for primary breast cancer surgery affect recurrence or metasta-
sis? ANESTHESIOLOGY 2006; 4:660–4
1. Lienhart A, Auroy Y, Pequignot F, Benhamou D, Warszawski J, Bovet M, 30. Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy DJ:
Jougla E: Survey of anesthesia-related mortality in France. ANESTHESIOLOGY 2006; Anesthetic technique for radical prostatectomy surgery affects cancer recur-
105:1087–97 rence: A retrospective analysis. ANESTHESIOLOGY 2008; 109:180–7
2. Li G, Warner M, Lang BH, Huang L, Sun LS: Epidemiology of anesthesia- 31. Sessler DI, Ben-Eliyahu S, Mascha EJ, Parat MO, Buggy DJ: Can regional
related mortality in the United States, 1999 –2005. ANESTHESIOLOGY 2009; 110: analgesia reduce the risk of recurrence after breast cancer? Methodology of a
759–65 multicenter randomized trial. Contemp Clin Trials 2008; 29:517–26
Anesthesiology, V 111, No 1, Jul 2009