European journal of anaesthesiology. Supplement
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Eur J Anaesthesiol Suppl · Jan 1993
Randomized Controlled Trial Comparative Study Clinical TrialHaemodynamic effects and comparison of enoximone, dobutamine and dopamine following mitral valve surgery.
Mitral valve surgery may be complicated by a post-operative low output state requiring inotropic support, and a wide variety of factors may influence the choice of agents used to treat this condition. The authors have examined and compared the haemodynamic effects of the highly specific phosphodiesterase inhibitor enoximone, and the adrenergic agents dobutamine and dopamine in patients undergoing mitral valve surgery. Enoximone, 0.5 mg kg-1 bolus, followed by a continuous infusion of 5 micrograms kg-1 min-1, was compared against dobutamine, 7 micrograms kg-1 min-1, and dopamine, 5 micrograms kg-1 min-1, with the protocol allowing for an increase in the infusion rate by a factor of two if clinical and haemodynamic measurements indicated. ⋯ Three of the 25 patients receiving dobutamine were withdrawn from the study because of inadequate haemodynamic response, while the remaining 22 patients demonstrated significant increases in heart rate, cardiac index and stroke index, with a reduction in systemic vascular resistance. Nine of the 25 patients receiving dopamine failed to respond adequately, while the remaining 16 demonstrated an increase in heart rate and cardiac index but with little change in stroke index and a modest reduction in systemic vascular resistance. Enoximone has been shown to be a highly effective first-line inotrope in patients following mitral valve surgery with significant advantages over dobutamine and dopamine.
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Eur J Anaesthesiol Suppl · Jan 1993
ReviewRisk assessment in the formulation of anaesthesia safety standards.
Risk assessment involves identifying hazards and then estimating their chance of occurrence and their severity. Risk management involves the cost-effective reduction of risk to levels perceived to be acceptable to society; risk levels set by experts may not be accepted, as perceived risk is strongly influenced by the nature of the adverse outcome and the context in which it was incurred. An understanding of the psychology of risk perception may lessen the negative impact of disasters and may better prepare the victims and their relatives. ⋯ These constituted one to two thirds of all incidents during anaesthesia, and account for most causes of brain damage that are dealt with by medical insurance companies. The size of the settlements provides evidence that these are viewed as very serious problems. Minimum standards were formulated with this information in mind; in recommending a sequence for equipment purchases great emphasis was placed on preventing the patient from breathing hypoxic gas mixtures, and on continuous monitoring of the adequacy of the airway, ventilation, the circulation and tissue oxygenation.
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In the future we may anticipate continued efforts to define standards addressing anaesthesia equipment, organization, and the qualification of personnel. Many standards will be revised and/or expanded, as experience with these standards accumulates. In addition to these external standards, we foresee efforts to seek consensus among clinicians on the definition of appropriate clinical patterns. In the long run, these efforts to define practice guidelines may lead to re-assessment of what and how we teach newcomers to anaesthesia, and how to assess the quality of anaesthesia care.
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The International Task Force on Anaesthesia Safety was formed in 1989 to institute a new international effort to improve anaesthesia safety worldwide. Membership was by invitation to individuals with strong credentials in the anaesthesia safety movement in their own countries. ⋯ Consultation from a variety of individuals and groups not represented on the Task Force was actively sought. In June 1992, the World Federation of Societies of Anaesthesiologists adopted the Task Force's international standards document and commended it to its 98 member societies worldwide.
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Recent advances have reduced the risks of anaesthesia to a virtually immeasurable level. However, if the specialty wishes to continue to foster support, it will require active promotion of the benefits, not hazards, of our practice. The few published surveys of the image of the anaesthetist show that the public poorly understands either our background training or education, or the responsibility we bear in their care. ⋯ It is certain that we cannot tolerate the sensationalized tragedies resulting from anaesthetic neglect in bygone years; we must effectively discipline ourselves if standards are not being met. We should lose no opportunity to become involved outside the operating room, whether in pre-admission clinics, pain management, obstetrics, critical care, or by becoming actively involved as full members of the medical staff. Doing so will further our professional image in the eyes of other physicians and, ultimately, the public we seek to influence.