JAMA : the journal of the American Medical Association
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Cardiac arrests due solely to anesthesia were studied in a large university hospital over a 15-year period. There were 27 cardiac arrests among 163,240 anesthetics given, for a 15-year incidence of 1.7 per 10,000 anesthetics. Fourteen of these patients (0.9 per 10,000) subsequently died. ⋯ Hemodynamic instability in very ill patients was an association in 22%. Specific errors in anesthetic management could be identified in 75%. Progressive bradycardia preceding the arrest was observed in all but one case.
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Randomized Controlled Trial Comparative Study Clinical Trial
Thermodilution cardiac output measurement. Effects of the respiratory cycle on its reproducibility.
Thermodilution cardiac output measurements are commonly employed in the management of critically ill patients. Serial measurements often show significant variation, and poor reproducibility limits their clinical utility. ⋯ Saline injections initiated at peak-inspiration or end-exhalation resulted in cardiac output measurements with much smaller standard deviations than those seen with random injections. Thermodilution cardiac output measurements performed at random times in the respiratory cycle should be avoided, and we recommend initiating these measurements at end-exhalation.
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We studied the use of do-not-resuscitate (DNR) orders at three teaching hospitals that did not have official protocols for such orders to see whether their use meets the goals (decision making before a crisis and promoting patient autonomy) that have been identified for such orders. We found that 20% of all patients had or were being considered for DNR orders, that the patient and/or family was usually involved (83%) in the decision not to resuscitate, but rarely involved (25%) in decisions to resuscitate, or in cases of no decision, that a wide range of care was provided to patients with a DNR status, and that partial resuscitative efforts would be employed in some cases. Our main conclusion in light of our findings is that DNR orders are currently not fulfilling their major goals. We offer six proposals for improving future DNR protocols.