Audio/visual recording of doctors in hospitals: Guideline from the Association of Anaesthetists.

Guidelines are presented that summarise the legal position regarding the audio/visual recording of doctors and others in hospitals. In general, there are few, if any, legal grounds for refusing a request by patients to record procedures and/or discussions with clinicians, although some staff may feel uncomfortable being recorded. Trusts and others are advised to draw up local policies and ensure staff and patients are adequately informed.

Validation of cardiac output studies from the Mostcare compared to a pulmonary artery catheter in septic patients.

BACKGROUND: The Mostcare monitor is a non-invasive cardiac output monitor. It has been well validated in cardiac surgical patients but there is limited evidence on its use in patients with severe sepsis and septic shock. METHODS: The study included the first 22 consecutive patients with severe sepsis and septic shock in whom the floatation of a pulmonary artery catheter was deemed necessary to guide clinical management. Cardiac output measurements including cardiac output, cardiac index and stroke volume were simultaneously calculated and recorded from a thermodilution pulmonary artery catheter and from the Mostcare monitor respectively. The two methods of measuring cardiac output were compared by Bland-Altman statistics and linear regression analysis. A percentage error of less than 30% was defined as acceptable for this study. RESULTS: Bland-Altman analysis for cardiac output showed a Bias of 0.31 L.min-1, precision (=SD) of 1.97 L.min-1 and a percentage error of 62.54%. For Cardiac Index the bias was 0.21 L.min-1.m-2, precision of 1.10 L.min-1.m-2 and a percentage error of 64%. For stroke volume the bias was 5 mL, precision of 24.46 mL and percentage error of 70.21%. Linear regression produced a correlation coefficient r2 for cardiac output, cardiac index, and stroke volume, of 0.403, 0.306, and 0.3 respectively. CONCLUSION: Compared to thermodilution cardiac output, cardiac output studies obtained from the Mostcare monitor have an unacceptably high error rate. The Mostcare monitor demonstrated to be an unreliable monitoring device to measure cardiac output in patients with severe sepsis and septic shock on an intensive care unit.

The relationship between hospital volume and mortality following mechanical ventilation in the Intensive Care Unit.

BACKGROUND: A number of recent studies in North America and Europe have investigated the relationship between hospital volume and outcomes following mechanical ventilation in an Intensive Care Unit (ICU). All of these studies have revealed an association between worse outcomes and smaller-volume hospitals. This relationship has not been investigated recently in the UK. METHODS: A retrospective cohort study was performed using data from the Birmingham and Black Country Critical Care Network database. Adult patients who received mechanical ventilation for more than 24 hours from the period from April 1, 1996, to March 31, 2006, were included in the study. The odds ratio for death in the ICU was calculated in relation to the hospital's volume of ventilation. Estimates accounted for clustering within hospitals and were adjusted for patient demographics (sex, age), APACHE II score, year of ventilation, length of ICU stay and urgency status. RESULTS: A total of 17132 adult patient episodes were included in the analysis. The adjusted odds ratio for death in the ICU following mechanical ventilation for more than 24 hours was 1.11 (95% confidence interval: 0.91 to 1.35; P=0.297). CONCLUSION: There is no relationship between hospital volume and mortality following mechanical ventilation in the ICU. Further larger prospective studies are needed to confirm this apparent lack of a relationship between hospital volume and mortality following mechanical ventilation in ICUs in a network of hospitals in the UK.

The High-Risk Surgical Patient: Current Management Strategies to Reduce Morbidity and Mortality from Organ Dysfunction in Surgical Intensive Care.

A number of patients undergoing major surgery have an associated high morbidity leading to a long stay in the intensive care unit. This group of patients can be regarded as high risk, as their mortality rate is in the region of 20 to 30%. The high-risk patient is likely to have at least one of the characteristics listed in Table 1. Perioperative cardiac morbidity remains the leading cause of postoperative mortality. Although we can now support patients through the early phase of shock, trauma or other life-threatening illness, some will go on to develop progressive failure of one or more vital organs. In this article, we review some of the current processes of care that may improve outcomes in these surgical patients, as improving patient outcome is the purpose of medical care.

The high-risk surgical patient: current management strategies to reduce morbidity and mortality from organ dysfunction in surgical intensive care.

A number of patients undergoing major surgery have an associated high morbidity leading to a long stay in the intensive care unit. This group of patients can be regarded as high risk, as their mortality rate is in the region of 20 to 30%. The high-risk patient is likely to have at least one of the characteristics listed in Table 1. Perioperative cardiac morbidity remains the leading cause of postoperative mortality. Although we can now support patients through the early phase of shock, trauma or other life-threatening illness, some will go on to develop progressive failure of one or more vital organs. In this article, we review some of the current processes of care that may improve outcomes in these surgical patients, as improving patient outcome is the purpose of medical care.

Comparison of intra-articular fentanyl and intra-articular bupivacaine for post-operative pain relief after knee arthroscopy.

A randomized double-blinded study consisting of 107 patients was conducted to compare the effect on post-operative pain relief of intra-articular fentanyl and intra-articular bupivacaine after knee arthroscopy. The results showed that intra-articular bupivacaine produced superior analgesia in the immediate post-operative period. At 2 h post-operatively, the intra-articular bupivacaine group had a mean pain score of 2.0 (standard deviation 2.1, P < 0.05) compared with the intra-articular fentanyl group which had a mean pain score of 3.2 (standard deviation 2.3, P < 0.05). After 2 h post-operatively, intra-articular bupivacaine and intra-articular fentanyl had a similar effect on pain scores. The mean pain score 18 h post-operatively was 2.7 for the intra-articular bupivacaine group (standard deviation 2.2, P value 0.6) compared with the intra-articular fentanyl group which had a mean pain score of 2.8 (standard deviation 1.9, P value 0.6).

Comparison of the structure of human intervertebral discs in the cervical, thoracic and lumbar regions of the spine.

Posterior and anterior heights, cross-sectional area and shape were measured for all the intervertebral discs in four spines from elderly human cadavers. Disc height was a minimum at the T4-5 level; thoracic discs were less wedge-shaped than those in the cervical and lumbar regions. Cross-sectional area increased from the cranial to caudal extremity; at the L5-S1 level the nucleus pulposus occupied a high proportion of this area. Cervical discs tended to have an elliptical cross-sectional shape, thoracic discs were more circular and lumbar discs tended to have an elliptical cross-section which was flattened or re-entrant posteriorly. This shape distribution was quantified by defining a shape index which had a maximum value of 1 for a circular cross-section. Orientations of the reinforcing fibres in the outer lamellae of the anterior annulus fibrosus were measured from 27 discs by X-ray diffraction. For these measurements, C3-4, T7-8 and L2-3 were chosen as representative of cervical, thoracic and lumbar discs. The fibre tilt, with respect to the axis of the spine, was significantly less in the cervical discs (at 65 degrees) than in the thoracic and lumbar discs (about 70 degrees). These findings are interpreted in relation to differing functional requirements and possible mechanisms of failure in the cervical, thoracic and lumbar regions of the spine in the light of current knowledge on the biomechanics of the intervertebral disc.