The perception of shared medical decision making of expert and lay people: Effects of observing a movie clip depicting a medical consultation.

OBJECTIVE: To test for differences between experts and lay people in assessment of the degree to which a doctor engaged in a shared decision making (SDM) with a patient using the OPTION scale and a movie clip as stimulus material. METHODS: A segment of the movie 'Wit', depicting the communication of the diagnosis and the therapy proposed of a cancer, was shown to (a) university students with no knowledge about doctor-patient communication; (b) nurses working in medicine departments; (c) advanced medical students; (d) hospital physicians. The participants were asked to complete the OPTION scale which measures the extent to which physicians involve patients in medical decisions. An analysis of variance was used to compare OPTION scores across the four groups and to compare males and females. RESULTS: Being female [F((1,190))=11.9; p<.001] and being familiar with medical issues [F((3,190))=11.09; p<.001] were both significantly associated with a negative evaluations of the doctor's ability to involve the patient in the SDM. CONCLUSION: Lay people and males (including male experts), are less demanding regarding SDM abilities. PRACTICE IMPLICATIONS: A more systematic use of videos and the OPTION scale as validated outcome measure could be helpful educational strategy for the teaching of SDM

Long-Term COVID: Case Report and Methodological Proposals for Return to Work

Almost two years after the beginning of the SARS-CoV-2 pandemic, the knowledge of which in the infectious and therapeutic spheres is constantly evolving, attention paid to the medicolegal aspects linked to this emergency phenomenon has mainly focused on the liability implications falling on healthcare personnel. With regard to the medicolegal assessment of the outcomes of COVID-19 illness, although it is a procedure that is commonly used, and although references in the assessment tables in force have been adhered to, a specific assessment protocol has not been standardized that takes into account, from an objective point of view, the degree of severity of the long-term residual outcomes and their impact on the social and working lives of subjects. This shortcoming appears to be attributable to the immediate need to categorize the results of COVID-19, but, in our opinion, it deserves an in-depth study and protocols to enable evaluation committees to draw up an assessment as precisely as possible and that is free of gaps, which could be the subject of legal disputes. The aim of the present work, in light of a worldwide problem, is to arrive at specific and univocal evaluation criteria for COVID-19 disease outcomes, applicable in different operational contexts of reemployment

Anesthesiology residents induction month: a pilot study showing an effective and safe way to train novice residents through simulation

The transition of new residents from medical school to the post-graduate clinical environment remains challenging. We hypothesized that an introductory simulation course could improve new residents' performance in anesthesiology

Tidal volume challenge to predict fluid responsiveness in the operating room: A prospective trial on neurosurgical patients undergoing protective ventilation

Pulse pressure variation (PPV) and stroke volume variation (SVV) do not predict fluid responsiveness when using a protective ventilation strategy: the use of functional haemodynamic tests can be useful to overcome this limitation

Assessment of Fluid Responsiveness in Prone Neurosurgical Patients Undergoing Protective Ventilation: Role of Dynamic Indices, Tidal Volume Challenge, and End-Expiratory Occlusion Test

In patients in the prone position, the reliability of pulse pressure variation and stroke volume variation (PPV and SVV) and the use of functional hemodynamic tests to predict fluid responsiveness have not previously been established. Perioperatively, in this setting, optimizing fluid management can be challenging, and fluid overload is associated with both intraoperative and postoperative complications. We designed this study to assess the sensitivity and specificity of baseline PPV and SVV, the tidal volume (VT) challenge (VTC) and the end-expiratory occlusion test (EEOT) in predicting fluid responsiveness during elective spinal surgery

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Background: Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low Vt, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery. Methods: This single-centre, pilot randomized clinical trial was conducted at the University Hospital “Maggiore della Carità” (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6–8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality. Results: A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups. Conclusions: LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements. Trial registration: registered on the Australian New Zealand Clinical Trial Registry (www.anzctr.org.au), registration number ACTRN12615000707561

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

none14sinoneLonghini, Federico; Pasin, Laura; Montagnini, Claudia; Konrad, Petra; Bruni, Andrea; Garofalo, Eugenio; Murabito, Paolo; Pelaia, Corrado; Rondi, Valentina; Dellapiazza, Fabrizio; Cammarota, Gianmaria; Vaschetto, Rosanna; Schultz, Marcus J.; Navalesi, PaoloLonghini, Federico; Pasin, Laura; Montagnini, Claudia; Konrad, Petra; Bruni, Andrea; Garofalo, Eugenio; Murabito, Paolo; Pelaia, Corrado; Rondi, Valentina; Dellapiazza, Fabrizio; Cammarota, Gianmaria; Vaschetto, Rosanna; Schultz, Marcus J.; Navalesi, Paol

Perioperative Management Of Children With Neuromuscular Disorders Based On A Common Protocol: A Prospective, National Study In Italy

BACKGROUND: Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared peri-operative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).METHOD: We conducted a multicenter, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.RESULTS: We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 [2-14] days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher ICU admission rate and longer hospital LOS.CONCLUSION: Diseases severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs

Perioperative management of children with neuromuscular disorders based on a common protocol: A prospective, national study in Italy

BACKGROUND: Children with neuromuscular diseases (NMDs) often display respiratory muscle weakness which increases the risk of postoperative pulmonary complications (PPCs) after general anaesthesia. Non-invasive ventilation (NIV) associated with mechanical insufflation-exsufflation (MI-E) can reduce the incidence and severity of PPCs. The aim of this study was to report our experience with a shared peri-operative protocol that consists in using NIV combined with MI-E to improve the postoperative outcome of NMD children (IT-NEUMA-Ped).METHOD: We conducted a multicenter, observational study on 167 consecutive paediatric patients with NMDs undergoing anaesthesia from December 2015 to December 2018 in a network of 13 Italian hospitals.RESULTS: We found that 89% of the 167 children (mean age 8 years old) were at high risk of PPCs, due to the presence of at least one respiratory risk factor. In particular, 51% of them had preoperative ventilatory support dependence. Only 14 (8%) patients developed PPCs and only two patients needed tracheostomy. Average hospital length of stay (LOS) was 6 [2-14] days. The study population was stratified according to preoperative respiratory devices dependency and invasiveness of the procedure. Patients with preoperative ventilatory support dependence showed significantly higher ICU admission rate and longer hospital LOS.CONCLUSION: Diseases severity seems to be more related to the outcome of this population than invasiveness of procedures. NIV combined with MI-E can help in preventing and resolve PPCs

Pharmacodynamic analysis of a fluid challenge with 4 ml kg-1 over 10 or 20 min: a multicenter cross-over randomized clinical trial.

A number of studies performed in the operating room evaluated the hemodynamic effects of the fluid challenge (FC), solely considering the effect before and after the infusion. Few studies have investigated the pharmacodynamic effect of the FC on hemodynamic flow and pressure variables. We designed this trial aiming at describing the pharmacodynamic profile of two different FC infusion times, of a fixed dose of 4 ml kg-1. Forty-nine elective neurosurgical patients received two consecutive FCs of 4 ml kg-1 of crystalloids in 10 (FC10) or 20 (FC20) minutes, in a random order. Fluid responsiveness was defined as stroke volume index increase ≥ 10%. We assessed the net area under the curve (AUC), the maximal percentage difference from baseline (dmax), time when the dmax was observed (tmax), change from baseline at 1-min (d1) and 5-min (d5) after FC end. After FC10 and FC20, 25 (51%) and 14 (29%) of 49 patients were classified as fluid responders (p = 0.001). With the exception of the AUCs of SAP and MAP, the AUCs of all the considered hemodynamic variables were comparable. The dmax and the tmax were overall comparable. In both groups, the hemodynamic effects on flow variables were dissipated within 5 min after FC end. The infusion time of FC administration affects fluid responsiveness, being higher for FC10 as compared to FC20. The effect on flow variables of either FCs fades 5 min after the end of infusion