Anesthesiology Journal club assessment by means of semantic changes.

BACKGROUND AND OBJECTIVES: the interactive approach of a journal club has been described in the medical education literature. The aim of this investigation is to present an assessment of journal club as a tool to address the question whether residents read more and critically. METHODS: this study reports the performance of medical residents in anesthesiology from the Clinics Hospital - University of São Paulo Medical School. All medical residents were invited to answer five questions derived from discussed papers. The answer sheet consisted of an affirmative statement with a Likert type scale (totally disagree-disagree-not sure-agree-totally agree), each related to one of the chosen articles. The results were evaluated by means of item analysis - difficulty index and discrimination power. RESULTS: residents filled one hundred and seventy three evaluations in the months of December 2011 (n=51), July 2012 (n=66) and December 2012 (n=56). The first exam presented all items with straight statement, second and third exams presented mixed items. Separating "totally agree" from "agree" increased the difficulty indices, but did not improve the discrimination power. CONCLUSIONS: the use of a journal club assessment with straight and inverted statements and by means of five points scale for agreement has been shown to increase its item difficulty and discrimination power. This may reflect involvement either with the reading or the discussion during the journal meeting.

Hemodynamic impact of alveolar recruitment maneuver in patients evolving with cardiogenic shock in the immediate postoperative period of myocardial revascularization.

BACKGROUND AND OBJECTIVES: Alveolar recruitment maneuver (ARM) with pressures of 40 cmH2O in the airways is effective in the reversal of atelectasis after myocardial revascularization (MR); however, there is a lack of studies evaluating the hemodynamic impact of this maneuver in patients who evolve with cardiogenic shock after MR. The objective of this study was to test the hemodynamic tolerance to ARM in patients who develop cardiogenic shock after MR. METHODS: Ten hypoxemic patients in cardiogenic shock after MR were evaluated after admission to the ICU and hemodynamic stabilization. Ventilatory adjustments included tidal volume of 8 mL x kg(-1), PEEP 5 cmH2O, RR 12, and FiO2 0.6. Continuous pressure of 40 cmH2O was applied to the airways for 40 seconds in three cycles. Between cycles, patients were ventilated for 30 seconds, and after the last cycle, PEEP was set at 10 cmH2O. Hemodynamic measurements were obtained 1, 10, 30, and 60 minutes after ARM, and arterial and venous blood samples were drawn 10 and 60 minutes after the maneuver to determine lactate levels and blood gases. ANOVA and the Friedman test were used to analyze the data. A p of 0.05 was considered significant. RESULTS: Alveolar recruitment maneuver increased the ratio PaO2/ FiO2 from 87 to 129.5 after 10 minutes and to 120 after 60 minutes (p < 0.05) and reduced pulmonary shunting from 30% to 20% (p < 0.05). Hemodynamic changes or changes in oxygen transport immediately after or up to 60 minutes after the maneuver were not detected. CONCLUSIONS: In patients who evolved to cardiogenic shock and hypoxemia after MR, ARM improved oxygenation and was well tolerated hemodynamically.

Hypoxemia after myocardial revascularization: analysis of risk factors.

BACKGROUND AND OBJECTIVES: Severe hypoxemia is complication frequently seen in the immediate postoperative period of myocardial revascularization (MR), increasing the duration of mechanical ventilation, the incidence of pulmonary infections, hospital costs, and mortality. The objective of this study was to identify predictive factors of severe hypoxemia in patients undergoing MR. METHODS: Four-hundred and eighty-one adult patients undergoing elective MR between October 2003 and March 2004 were enrolled in this study. Severe hypoxemia was defined as PaO2/FiO2 < 150 upon admission to the ICU. The Chi-square test, Student's t or Wilcoxon test, followed by multivariate analysis and logistic regression (LR) for parameters with p < 0.25 in the univariate analysis, were used for the statistical analysis. A p > 0.2 was required to exclude the parameter from the LR model, and a p < 0.1 was considered significant. RESULTS: Time for extubation was greater in patients with severe hypoxemia (p < 0.001). Multivariate analysis identified age (p = 0.081), weight (p = 0.001), need of prolonged CBP (p = 0.033), and left ventricular dysfunction (p = 0.082) as independent predictors of severe hypoxemia. CONCLUSIONS: Older and overweighted patients, those with left ventricular dysfunction, and those who needed CPB presented an increased risk of severe hypoxemia after MR. In those patients, the use of perioperative ventilatory strategies, with elevated positive expiratory pressures and alveolar recruitment maneuver should be considered to prevent postoperative pulmonary dysfunction.

Atelectasis during anesthesia: pathophysiology and treatment.

BACKGROUND AND METHODS: The incidence of intraoperative pulmonary collapse is elevated in patients undergoing surgery under general anesthesia with muscle relaxation/paralysis. This complication is associated with worsening intraoperative gas exchange and, in some cases, the need for prolonged postoperative respiratory support. The objective of this report was to review the pathophysiological aspects of atelectasis during general anesthesia and possible therapeutic maneuvers that could prevent and treat this complication. CONTENTS: This review discusses the concepts about the incidence of intraoperative atelectasis, factors that influence their development, both mechanical and those related to mechanical ventilator settings during the surgery, diagnostic criteria, and strategies to prevent and treat this complication. CONCLUSIONS: Understanding of the mechanisms related with the development of intraoperative pulmonary collapse, as well as its treatment, can contribute to reduce the incidence of postoperative pulmonary complications, the length of recovery and hospital costs.