Teleanesthesia? Transcontinental Anesthesia

From Medgadget:

Just two weeks after we reported on teleanesthesia in the form of remotely performed nerve blocks, the first report of transcontinental anesthesia comes in. On August 30, anesthesiologists of McGill-McGill University Health Centre in Montreal, kept watch over a patient in Pisa, Italy undergoing thyroid gland surgery.

Hypokalemia during the cooling phase of therapeutic hypothermia and its impact on arrhythmogenesis

From Resuscitation:

Mild to moderate therapeutic hypothermia (TH) has been shown to improve survival and neurological outcome in patients resuscitated from out-of-hospital cardiac arrest (OHCA) with ventricular fibrillation (VF) as the presenting rhythm. This approach entails the management of physiological variables which fall outside the realm of conventional critical cardiac care. Management of serum potassium fluxes remains pivotal in the avoidance of lethal ventricular arrhythmia.

Methods:  We retrospectively analyzed potassium variability with TH and performed correlative analysis of QT intervals and the incidence of ventricular arrhythmia.

Results:  We enrolled 94 sequential patients with OHCA, and serum potassium was followed intensively. The average initial potassium value was 3.9±0.7mmoll−1 and decreased to a nadir of 3.2±0.7mmoll−1 at 10h after initiation of cooling (p<0.001). Eleven patients developed sustained polymorphic ventricular tachycardia (PVT) with eight of these occurring during the cooling phase. The corrected QT interval prolonged in relation to the development of hypothermia (p<0.001). Hypokalemia was significantly associated with the development of PVT (p=0.002), with this arrhythmia being most likely to develop in patients with serum potassium values of less than 2.5mmoll−1 (p=0.002). Rebound hyperkalemia did not reach concerning levels (maximum 4.26±0.8mmoll−1 at 40h) and was not associated with the occurrence of ventricular arrhythmia. Furthermore, repletion of serum potassium did not correlate with the development of ventricular arrhythmia.

Conclusions:  Therapeutic hypothermia is associated with a significant decline in serum potassium during cooling. Hypothermic core temperatures do not appear to protect against ventricular arrhythmia in the context of severe hypokalemia and cautious supplementation to maintain potassium at 3.0mmoll−1 appears to be both safe and effective.

Barriers to Adoption of Evidence-Based Prehospital Airway Management Practices in California

From Prehospital Emergency Care:

Objective. To describe current prehospital airway management practices for adults and children and barriers to adoption of evidence-based airway management practices in California.

Methods. We surveyed local medical directors of California’s 31 emergency medical services (EMS) agencies regarding prehospital airway management, including provider scope of practice, continuous quality improvement practices, and perceptions regarding barriers to the implementation of evidence-based airway management practices. The survey instrument was a Web-based, closed-response form  that medical directors could access by an e-mailed link provided by investigators. Medical directors were contacted by phone, mail, and e-mail to request their participation in the Web-based survey.

Results. Twenty-five of 31 (81%) EMS medical directors completed the survey. Five medical directors completed surveys for two agencies over which they had responsibility. All responding medical directors employ bag-mask ventilation (BMV), airway adjuncts, and adult endotracheal intubation (ETI), which are procedures widely accepted in EMS practice. Rapid-sequence intubation (RSI), which has been shown to cause harm in certain patient subgroups, was not employed by any of the respondents. Prehospital pediatric ETI, which has been shown not to provide any benefit over BMV, was employed by 22 of 25 (88%) medical directors. Thirteen of 23 (57%) respondents identified “more evidence is needed” or “these results do not apply to my EMS system” as the top reasons to continue the practice of prehospital pediatric ETI.

Conclusions. The results of our study suggest that in areas of EMS where robust evidence exists, medical directors (100%) will discontinue or not adopt skills that potentially harm patients, such as RSI, but are unlikely (12%) to discontinue procedures that show no benefit to patients (such as pediatric ETI). Barriers to adoption of evidence-based practice include difficulty in generalizing results of studies across diverse EMS systems and perceived lack of evidence that the procedure should be abandoned.

Urgent Care, Retail Clinics Offer Alternatives to ER Visits

From BusinessWeek:

An estimated 17 percent of all patients who visit U.S. hospital emergency departments could be treated at urgent care centers or retail medical clinics instead, a move that would save $4.4 billion a year in health care costs, a new U.S. study suggests.

Fractures and lacerations, strains and minor infections are among the conditions that can be treated safely outside of hospitals, according to a RAND Corporation study published in the September issue of the journal Health Affairs. RAND is a nonprofit research organization.

The researchers noted that retail medical clinics and urgent care centers are open in the evenings and on weekends, and allow for walk-in appointments. Previous studies have found that these facilities are much cheaper than an emergency department visit.

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