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Signa Vitae

Journal of Intensive Care and Emergency Medicine

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Comparison of sevoflurane and propofol anaesthetic regimes in respect to the release of troponin I and cystatin C in off-pump myocardial revascularisation: a randomised controlled trial

Abstract

Objective. Sevoflurane has been used in cardiac surgery because of its protective effects on the myocardium from ischaemic injury. We wanted to test the hypothesis that sevoflurane has beneficial effects on the heart and kidneys in comparison to propofol.

Methods. We conducted a randomised controlled study, with balanced randomization blocked by sex. The participants were 62 patients undergoing off-pump myocardial revascularization (44 men and 18 women), who did not have a myocardial infarction less than 24 hours before the start of the operation and who had normal serum values of troponin I preoperatively. The surgery and the measurements were conducted according to the same protocol for both groups. Propofol was used for the induction of anaesthesia in both groups; anaesthesia was continued with either propofol or sevoflurane. Troponin I and cystatin C plasma concentrations were determined in eight consecutive blood samples, starting before induction of anaesthesia and ending 48 hours after admission to the intensive care unit (ICU). The data were log-transformed and analysed using analysis of variance.

Results. We observed a clear and highly statistically significant effect of time for troponin I (p<0.001) without statistically significant differences between the groups (either main or interaction effects). For the majority of patients, the measurements rose quickly upon reperfusion and reached a peak 12 hours after admission to the ICU, descending approximately back to the reperfusion level 48 hours after admission to the ICU. Similar inferences were reached for cystatin C, for which the time-course was approximately bath-shaped.

Conclusion. We observed no clear superiority of either sevoflurane or propofol anaesthetic regime in off-pump myocardial revascularisation.

Key words: anaesthetic regime, cardioprotection, kidney function, heart surgery

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The effect of posture modification during continuous one-handed chest compression: A pilot study using in-hospital pediatric cardiac arrest simulation

Abstract

Background. We modified the posture of the one-handed chest compression (MOHCC) as follows: first, the axis of the rescuer’s compression hand was adjusted to the lower half of the patient’s sternum; second, the opposite hand was wrapped around the elbow joint of the rescuer’s compression arm. This study evaluated the effect of the MOHCC on the mean chest compression depth (MCD) over time.

Methods. Thirty medical doctors conducted 2 min of continuous MOHCC without ventilation using the in-hospital pediatric arrest model (70-cm-high bed, 25-cm-high stepstool, a pediatric manikin and a cardiopulmonary resuscitation (CPR) meter). The MCD and mean chest compression rate (MCR) were measured at 30 s intervals using the Q-CPR review software.

Results. The MCD changed significantly over time (0–30 s, 41.9–44.7 mm; 30–60 s, 40.4–43.6 mm; 60–90 s, 39.2–42.8 mm; 90–120 s, 38.6–42.3 mm; [95% CI], P=0.002). However, it did not decrease significantly between 60–90 s and 90–120 s (P=0.173). The total decrease in MCD was 2.9 mm over a 2 min period. The MCR did not change significantly over time (0–30 s, 108.6–118.9 /min; 30–60 s, 107.9–119.1 /min; 60–90 s, 107.7–119.3 /min; 90–120 s, 107.4–119.0 /min; P=0.800).

Conclusions. Although the MCD changed significantly over a 2 min period, it did not decrease significantly after 90 s during performance of MOHCC. The MOHCC might be considered when the one-handed chest compression (OHCC) is selected as a chest compression method for cardiac arrest in small children.

Key words: cardiopulmonary resuscitation, cardiac arrest, child, fatigue

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Effects of bed height on the performance of endotracheal intubation and bag mask ventilation

Abstract

Objectives. This study was performed to evaluate whether different bed heights affect the performance of airway procedures.

Methods. Thirty three medical doctors performed endotracheal intubation (EI) and bag mask ventilation (BMV) using three different bed heights; knee height, mid-thigh height, and anterior superior iliac spine (ASIS) height. For EI, performance was assessed based on intubation time, intubation success, and damage to teeth. For BMV, performance was assessed based on tidal volume, ventilation rate, peak pressure, minute ventilation, and airway opening. In addition, three numeric rating scales (NRS; 1 to 10) were used to assess the level of difficulty for each procedure and the doctors’ self-confidence. NRS scoring was based on posture (comfortable to uncomfortable), handling (easy to hard), and visual field (good to bad).

Results. No significant differences in performance were observed for EI or BMV at the three different bed heights. However, all of the NRS scores were significantly different among the different bed heights (P<0.001), and were poorest for the knee height beds: knee height (EI: posture 5.8~7.3, handling 4.3~5.7, visual field 3.9~5.5; BMV: posture 7.1~8.0, handling 5.9~7.2, 95% CI), mid-thigh height (EI: posture 2.9~4.0, handling 2.9~4.0, visual field 2.7~3.8; BMV: posture 2.4~3.2, handling 2.3~3.5) and ASIS height (EI: posture 2.2~3.5, handling 2.6~3.8, visual field 2.1~3.4; BMV: posture 2.9~4.4, handling 4.7~6.1).

Conclusions. Although the participants reported that the knee height beds were the least comfortable, hardest to handle, and made seeing the vocal cord difficult, these caveats did not affect their performance during airway procedures.

Key words: endotracheal intubation, positive pressure ventilation, bed, cardiopulmonary resuscitation

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Improving Emergency Department Capacity Efficiency

Abstract

Objective. The demand for emergency services has risen dramatically around the world. Many Emergency Departments (EDs) have signs of low capacity efficiency (which we define as the rate at which a production facility with limited resources can convert input into output); insufficient resources (staffing, equipment, facilities), inefficient ways to use them, or both. Our purpose was to investigate how to improve ED capacity efficiency through layout planning and present some novel ideas of ED bottlenecks.

Methods. We adopted an industrial engineering perspective to one Finnish ED as a case example. In contrary to a simple case report we used more generalizable methods and demand-supply chain analysis to improve capacity efficiency.

Results. This study resulted in concrete and generalizable improvements of capacity efficiency concerning both ED premises and staffing. The former includes designing patient locations, organizing beds, improving space usage and optimizing an ED layout. The latter identified the demand for different specialties and optimal allocation of nursing staff.

Conclusion. We present a rather unique combination of ways to enhance ED functionality by using methods of industrial engineering.

Key words: capacity efficiency, emergency department, operations management, healthcare

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Rescuer fatigue does not correlate to energy expenditure during simulated basic life support

Abstract

It is known that providing basic life support (BLS) may be limited by the physical capabilities of rescuers. The other factor that may affect BLS quality is its energy expenditure. Therefore, we decided to compare the energy expenditure of standard BLS with a compression-ventilation ratio of 30:2 (S-BLS) and compression-only BLS (CO-BLS) and assess the sensation of fatigue and perceived exertion associated with these activities.

Methods. We conducted a simulation study on 10 healthy volunteers using a resuscitation manikin. Participants were randomly assigned to start with CO-BLS or with S-BLS, in accordance with recent guidelines. Later, every individual provided the other type of BLS. BLS was terminated in the event of exhaustion, impossibility to retain high-quality BLS or after 30 minutes of BLS. Energy expenditure was expressed as relative oxygen consumption (VO2/kg) and area under the curve of all VO2/kg measurements during each BLS procedure indexed to one minute (AUCVO2/kg min). All participants completed a survey to assess perceived intensity of exertion by Borg, and sensation of general fatigue by visual analogue scale.

Results. Maximal VO2/kg (23.16±3.94 vs. 20.17±2.14 ml/kg/min, p=0.049) and AUCVO2/kg min (18.90±3.13 vs. 15.91±2.07 ml/min3; p=0.021) during S-BLS were significantly higher compared to CO-BLS. Conversely, a more intense rate of perceived exertion (16.6±2.0 vs. 13.8±1.2, p=0.001) and sensation of general fatigue (86.5±10.8 vs. 75.0±14.3, p=0.058) were associated with CO-BLS. Neither sensation of general fatigue, nor perceived exertion correlated with energy expenditure.

Conclusions. Energy expenditure of S-BLS was higher than of CO-BLS in our study, while sensation of fatigue and perceived exertion reflected the opposite association.

Key words: basic life support, energy expenditure, general fatigue

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