Activities of a medical emergency team twenty years after its introduction

INTRODUCTION

We describe and quantify the wide range of activities that a mature Medical Emergency Team can progressively perform.

METHODS

The activities performed by a Medical Emergency Team 20 years after its introduction were prospectively collected during 105 consecutive days.

RESULTS

The main activity was focused on the follow-up visits to previously treated critically ill patients (mean 7.5 visits/die in working days, 5.1 in the others). A large amount of other scheduled or unscheduled activities (like sedation or analgesia for diagnostic procedures, central venous line placement, phone consultation regarding critical care aspects of treatments) were performed: on average, 7.3 side-activities/die in working days and 5.2 in the others. First consultations in patients not previously seen were on average 3.1/die on working days, 2.4 in the others. Cardiac arrest accounted for 27 (9%) of first time visits.

CONCLUSIONS

A Medical Emergency Team can progressively perform many kinds of activities. An evaluation limited to the reduction of in-hospital cardiac arrests or a too early assessment may underestimate its beneficial effects on the Hospital complexity.

Dilatative percutaneous tracheostomy during double antiplatelet therapy: two consecutive cases

This article reports two cases of dilatative percutaneous tracheostomy performed on patients treated with double antiplatelet therapy. Both patients had cardiac arrest following myocardial infarction. After primary angioplasty with stent placement, a double antiplatelet therapy was started. Due to poor neurological outcome, dilatative percutaneous tracheostomy was performed on both patients. Antiplatelet therapy was not discontinued because of the unacceptable risk of stent thrombosis. No immediate or late hemorrhagic complications occurred. In our experience, dilatative percutaneous tracheostomy during double antiplatelet therapy can be safely performed in selected patients without other risk factors.

Benefits and costs of methadone treatment: results from a lifetime simulation model

Several studies have examined the benefits and costs of drug treatment; however, they have typically focused on the benefits and costs of a single treatment episode. Although beneficial for certain analyses, the results are limited because they implicitly treat drug abuse as an acute problem that can be treated in one episode. We developed a Monte Carlo simulation model that incorporates the chronic nature of drug abuse. Our model represents the progression of individuals from the general population aged 18-60 with respect to their heroin use, treatment for heroin use, criminal behavior, employment, and health care use. We also present three model scenarios representing an increase in the probability of going to treatment, an increase in the treatment length of stay, and a scenario in which drug treatment is not available to evaluate how changes in treatment parameters affect model results. We find that the benefit-cost ratio of treatment from our lifetime model (37.72) exceeds the benefit-cost ratio from a static model (4.86). The model provides a rich characterization of the dynamics of heroin use and captures the notion of heroin use as a chronic recurring condition. Similar models can be developed for other chronic diseases, such as diabetes, mental illness, or cardiovascular disease.

Prilocaine or mepivacaine for combined sciatic-femoral nerve block in patients receiving elective knee arthroscopy

AIM

The aim of this study was to evaluate the onset time of surgical block, recovery of motor function and duration of post-operative analgesia of combined sciatic-femoral nerve block performed with either mepivacaine or prilocaine.

METHODS

With Ethical Committee approval and written informed consent, 30 ASA physical status I-II patients, undergoing elective arthroscopic knee surgery, received a combined sciatic-femoral nerve block with 30 ml of either 2% mepivacaine (n=15) or 1% prilocaine (n=15). An independent observer recorded the onset time of sensory and motor blocks, the need for intraoperative analgesia supplementation, recovery of motor function, and first request of post-operative pain medication.

RESULTS

Onset time of nerve block required 15+/-5 min with prilocaine and 12+/-7 min with mepivacaine (p=0.33). No patient required general anesthesia to complete surgery; 3 patients receiving prilocaine (20%) and 2 patients receiving mepivacaine (13%) required 0.1 mg fentanyl intravenously to complete surgery (p=0.99). Recovery of motor function and first request of post-operative pain medication occurred after 238+/-36 min and 259+/-31 min with prilocaine, and 220+/-48 min and 248+/-47 min with mepivacaine (p=0.257 and p=0.43, respectively). Patient satisfaction was good in all studied patients.

CONCLUSION

Prilocaine 1% provides adequate sensory and motor block for arthroscopic knee surgery, with a clinical profile similar to that produced by 2% mepivacaine, and may be a good option for surgical procedures of intermediate duration and not associated with severe postoperative pain.

Low perioperative mortality for cardiac surgery in octogenarians

AIM

The number of cardiac operations in octogenarians is steadily increasing. A review of personal 4 years' experience is made in order to identify which variables are associated to a poor prognosis in this high risk population.

METHODS

Perioperative variables and short-term outcome of 109 consecutive octogenarians were prospectively collected in a database. Data were analysed with descriptive statistics. Univariate and multivariate analyses were performed to identify preoperative risk factors for prolonged mechanical ventilation and ICU stay.

RESULTS

The 109 octogenarians represented 1.8% of the 4 940 cardiac operations performed at our University Teaching Hospital in the period January 1998-June 2001: 94 patients had comorbidities (86%); 46 underwent valve surgery (42%), 38 had coronary artery bypass grafting surgery (36%), and combined procedures or aortic arch replacement were performed in 25 patients (22%). Two patients died (1.8%). Postoperative complications included: myocardial infarction (10 patients, 9%), stroke (6 patients, 5%), renal replacement therapy (1 patient, 1%). Sixty nine patients (63%) had an uneventful perioperative period (63%). On a multivariate analysis, cardiopulmonary bypass (CPB) time was associated with prolonged intubation and ICU stay; mitral pathology predicted prolonged intubation while previous cardiac surgery was associated with prolonged ICU stay.

CONCLUSION

The 109 octogenarians studied had an excellent course in the immediate postoperative period. Therefore, on the basis of personal experience cardiac surgery could be safely performed in octogenarians.

Beating-heart coronary artery bypass graft surgery at San Raffaele Hospital: four years of experience

OBJECTIVE

To review the database of 1,902 consecutive patients who underwent coronary artery bypass graft (CABG) surgery in the period 1998 through 2001 at this institution, and to compare the preoperative status, anesthetic management, and postoperative outcome of 364 patients with the beating-heart technique with 1,538 patients who underwent the operation on cardiopulmonary bypass.

DESIGN

Observational study.

SETTING

University hospital.

PARTICIPANTS

Consecutive patients (n = 1,902) who underwent CABG surgery in the period 1998 through 2001.

MEASUREMENTS AND MAIN RESULTS

Comparison (chi-square test) of the preoperative status shows that surgeons' choice for the beating-heart technique was based on the presence of severe preoperative comorbidities: renal impairment (p < 0.0001), chronic obstructive pulmonary disease (p < 0.04), and low ejection fraction (p < 0.0001). On a multivariate analysis, the beating-heart technique was associated with reduced transfusion needs and duration of mechanical ventilation.

CONCLUSION

Beating-heart surgery is gaining popularity as a safe method for myocardial revascularization. Excellent results have been achieved with this technique in this center.