Minerva anestesiologica
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Weaning from mechanical ventilation represents one of the main challenges facing ICU physicians. Difficult weaning affects about 25% of critical patients undergoing mechanical ventilation. Its duration correlates on one hand with pathophysiological aspects of the underlying disease and, on the other hand, with other factors such as the development of neuromyopathy of the critically ill patient, prolonged use of sedative-hypnotic drugs and, most of all, physicians' reluctance to identify the correct timing of therapeutic steps for weaning and subsequent extubation. ⋯ Protocols have to be used together with daily clinical evaluation of the patient and the procedure must be carried out by an ICU team of both medical and nursing staff. Attempts to wean a patient from a ventilator and extubate him should be made through a spontaneous breathing trial (SBT) with T-tube or pressure support ventilation (PSV) with pressure support of 7-8 cmH(2)O +/- PEEP =/> 4 cmH(2)O. Proper recourse to non invasive mechanical ventilation (NIMV) and an accurate timing for tracheostomy are effective tools which can be used by physicians to facilitate weaning and to improve patient outcomes.
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Coagulopathy associated with massive operative blood loss is an intricate, multicellular and multifactorial event. Massive bleeding can either be anticipated (during major surgery with high risk of bleeding) or unexpected. Management requires preoperative risk evaluation and preoperative optimization (discontinuation or modification of anticoagulant drugs, prophylactic coagulation therapy). ⋯ Therapeutic approaches include the use of blood products (red cell concentrates, platelets, plasma), coagulation factor concentrates (fibrinogen, prothrombin complex, von Willebrand factor), pharmacological agents (antifibrinolytic drugs, desmopressin), and local factors (fibrin glue). The importance of normothermia, normovolemia, and homeostasis for hemostasis must not be overlooked. The present article reviews pathomechanisms of coagulopathy in massive bleeding, as well as routine laboratory tests and viscoelastic point-of-care hemostasis monitoring as the diagnostic basis for therapeutic interventions.
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Minerva anestesiologica · Jul 2007
Comparative StudySpinal analgesia and auditory functions: a comparison of two sizes of Quincke needle.
Spinal anaesthesia may produce complications ranging from minor problems such as pain on injection, backache and urinary retention to more serious consequences such as post-dural puncture headache (PDPH), neurological complications like meningitis, cranial and peripheral nerve palsies and even cardiac arrest. Impaired auditory function is a relatively lesser-recognized complication of spinal analgesia. The objective of this study was to investigate the effects of spinal analgesia on vestibular dysfunction, using different sizes of the same type of spinal needle. ⋯ The use of a 23-gauge Quincke needle is associated with a greater reduction in the mean hearing level compared to a 26-gauge needle of the same type.
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Minerva anestesiologica · Jul 2007
Case ReportsIncident reporting in anesthesia: misidentification of propofol concentrations due to similarities in drug packaging.
We report three cases of misidentification of propofol concentrations due to similarities in drug packaging, which were identified by the incident reporting system. Incident reporting is an approach used to assess the incidence of adverse and potentially adverse events, established to manage the contributing factors and to develop appropriate strategies to prevent errors in anesthesia. Inadvertently, 2% propofol was administered instead of 1%, causing overdosage and prolonged anesthesia in two consecutive patients in the same operating room. ⋯ In our experience, incident reporting detected the recurrence of drug related errors. Therefore, a preventive strategy was put in place by eliminating 2% propofol packaging from the operating rooms. This paper highlights the need for a cultural shift in the way we collect information on incidents, and it is an example of effective improvement to prevent drug error by reducing the complexity of the system.