Anaesthesia and intensive care
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Anaesth Intensive Care · Jul 2012
The impact of clinical protocols in the management of severe sepsis: a prospective cohort study.
This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. ⋯ In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.
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Anaesth Intensive Care · Jul 2012
Cerebrospinal fluid volume and nerve root vulnerability during lumbar puncture or spinal anaesthesia at different vertebral levels.
Cerebrospinal fluid (CSF) and nerve root volumes within the lumbosacral dural sac were estimated at various vertebral levels, in an attempt to determine any possible relevance to the incidence of nerve root trauma during lumbar puncture or spinal anaesthesia. Magnetic resonance images from seven patients were studied. Volumes were calculated by semi-automatic threshold segmentation combined with manual editing of each slice. ⋯ Vulnerability to nerve root damage was expressed as the Vulnerability Index (%), being defined as the ratio of root volume to dural sac volume (CSF volume + root volume). The value ranged between 7 and 14% at L5, increasing rostrally to 30 to 43% at T12. Caution is obviously required in high punctures to avoid contact with the conus medullaris, but the cauda equina is also vulnerable to contact with more caudal punctures and had a Vulnerability Index of about 25% at L4, that increased rostrally.
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Anaesth Intensive Care · Jul 2012
Audit of cardiac pathology detection using a criteria-based perioperative echocardiography service.
Transthoracic echocardiography is often used to screen patients prior to non-cardiac surgery to detect conditions associated with perioperative haemodynamic compromise and to stratify risk. However, anaesthetists' use of echocardiography is quite variable. A consortium led by the American College of Cardiology Foundation has developed appropriate use criteria for echocardiography. ⋯ The most common indications were poor exercise tolerance (27.4%), ischaemic heart disease (20.9%) and cardiac murmurs (16.3%). Over 26% of patients studied had significant cardiac pathology (i.e. moderate or severe echocardiographic findings), most importantly moderate or severe aortic stenosis (8.6%), poor left ventricular function (7.1%), a regional wall motion abnormality (4.3%) or moderate or severe mitral regurgitation (4.1%). Using appropriate use criteria to guide ordering transthoracic echocardiography studies led to a high detection rate of clinically important cardiac pathology in our perioperative service.
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Anaesth Intensive Care · Jul 2012
Comparative StudyA comparison of pulse contour wave analysis and ultrasonic cardiac output monitoring in the critically ill.
Cardiac output (CO) is a key determinant of major organ blood flow and solute delivery to drug eliminating organs. As such, CO assessment is a key covariate in understanding altered drug handling in the critically ill. Newer minimally-invasive devices are providing unique platforms for such an application, although comparison data are currently lacking. ⋯ In 54 patients a second paired assessment was obtained at three hours. A weak, although significant correlation (r=0.377, P=0.005) was observed suggesting that gross trends over time were similar. In conclusion, our findings demonstrate poor agreement between these techniques suggesting that these devices are not simply interchangeable when assessing CO in a research or clinical setting.
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Anaesth Intensive Care · Jul 2012
Gabapentin in the treatment of post-dural puncture headache: a case series.
Gabapentin has been reported to be useful in the management of epilepsy, neuropathic pain and post-dural puncture headache. Seventeen obstetric cases are presented in which gabapentin was used either as a primary therapy for the management of severe headache following a diagnosed dural puncture or as an analgesic adjunct in patients with dural puncture headache unresponsive to epidural blood patch. ⋯ In nine patients we observed an excellent result with reduction of headache severity within 24 hours. Gabapentin appears potentially beneficial in the management of patients with post-dural puncture headaches.