An analytic framework to assess organizational resilience

Background: Resilience Engineering is a paradigm for safety management that focuses on coping with complexity to achieve success, even considering several conflicting goals. Modern socio-technical systems have to be resilient to comply with the variability of everyday activities, the tight-coupled and underspecified nature of work and the nonlinear interactions among agents. At organizational level, resilience can be described as a combination of four cornerstones: monitoring, responding, learning and anticipating. Methods: Starting from these four categories, this paper aims at defining a semi-quantitative analytic framework to measure organizational resilience in complex socio-technical systems, combining the Resilience Analysis Grid (RAG) and the Analytic Hierarchy Process (AHP). Results: This paper presents an approach for defining resilience abilities of an organization, creating a structured domain-dependent framework to define a resilience profile at different levels of abstraction, to identify weaknesses and strengths of the system and thus potential actions to increase system’s adaptive capacity. An illustrative example in an anaesthesia department clarifies the outcomes of the approach. Conclusions: The outcome of the RAG, i.e. a weighted set of probing questions, can be used in different domains, as a support tool in a wider Safety-II oriented managerial action to bring safety management into the core business of the organization

Heart Rate Variability for Outcome Prediction in Intracerebral and Subarachnoid Hemorrhage: A Systematic Review

This systematic review presents clinical evidence on the association of heart rate variability with outcome prediction in intracerebral and subarachnoid hemorrhages. The literature search led to the retrieval of 19 significant studies. Outcome prediction included functional outcome, cardiovascular complications, secondary brain injury, and mortality. Various aspects of heart rate recording and analysis, based on linear time and frequency domains and a non-linear entropy approach, are reviewed. Heart rate variability was consistently associated with poor functional outcome and mortality, while controversial results were found regarding the association between heart rate variability and secondary brain injury and cardiovascular complications

Patient Positioning during Neurosurgery: A Relevant Skill for Neuroanesthesiologist in a Multidisciplinary Team Work

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Clinical Relevance of Blood Glucose Concentration and Hyperglycemia Management in Neurocritical Care Patients

AbstractIn patients admitted to a neurocritical care (NCC) unit, management of blood glucose concentration (BGC) is a challenging clinical task. Several studies have shown that episodes of hypo- and hyperglycemia and high BGC variability are associated with poor short- and long-term outcomes. Optimal BGC target-range and BGC management in NCC patients have dramatically evolved in the past decades and new insulin infusion and adequate nutrition protocols are now available. The aim of this narrative review is to report the state-of-the-art on clinical relevance on BGC and hyperglycemia management in NCC patients

Is Dexmedetomidine a Favorable Agent for Cerebral Hemodynamics

Hemodynamic stability, with special attention to arterial pressure in order to warrant an adequate cerebral perfusion, is a cornerstone of neuroanesthesia (NA) and neurocritical care (NCC) management. An abrupt elevation of arterial blood pressure can aggravate cerebral edema or induce cerebral hematoma, resulting in a prolonged NCC unit stay. On the other hand, hypotension is associated with an increased risk for cerebral ischemia that is more pronounced when autoregulation of cerebral blood flow (CBF) is impaired, and there is a compromised cerebral compliance.[1,2] However, NCC encompasses subgroups of patients such as traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), and intracerebral hemorrhage ones in whom there is the unique need to maintain supranormal blood pressure values with a view to ensure adequate cerebral perfusion and to optimize outcome.[1,2,3] Moreover, any derangement of cerebrovascular hemodynamics may contribute to intracranial pressure (ICP) elevation with concomitant cerebral perfusion pressure (CPP) deterioration, which can further exacerbate ischemic damage.[3] Thus, the ideal sedative agent in NA and NCC setting should have minimal impact on hemodynamics. Dexmedetomidine (Dex), a highly selective a2-adrenoreceptor agonist, is emerging as a potentially attractive adjunct in the neurosurgical practice due to its pharmacology promise benefits.[4] Nonetheless, the appealing performance of Dex is tempered by the reported unfavorable hemodynamic sequelae, consisting of bradycardia, hypotension, and hypertension, an effect being more apparent with rapid infusion.[2,3] Of utmost interest in populations with intracranial pathology is also the impact of Dex on CBF and metabolism (cerebral metabolic rate of oxygen [CMRO2]) coupling. Existing evidence supports a dose-dependent decline in both global and regional CBF after Dex administration, which cannot be solely addressed to its impact on systemic hemodynamic performance.[2,3,4] This is thought to be via direct vasoconstriction of the cerebral vasculature and indirectly via effects on the intrinsic neural pathways modulating vascular effects, being almost 30% at clinically relevant Dex concentrations.[4,5,6] Serial transcranial Doppler (TCD) exams in healthy volunteers confirm previous findings in animal models showing a strong linear relationship between middle cerebral artery (MCA) flow velocity (FV) and Dex infusion.[7] The concomitant elevation of pulsatility index (PI) indicates vasoconstriction of the cerebral vasculature as the most profound underlying mechanism.[7] The authors of the present study used TCD imaging to test the effects of the loading dose of Dex 1 mcg/kg over 10 min on cerebral hemodynamic in patients without any co-morbidity scheduled to undergo lumbar discectomy.[8] A notable decline of mean FV in MCA and an augmentation of PI and cerebral vascular resistance index were recorded.[8] It seems that the clinical impact of CBF deterioration is directed by the clinical circumstances. The use of Dex might be useful adjunct in clinical situations when an increase in CBF could be detrimental such as vasogenic cerebral edema (i.e., TBI, large brain tumors). Nevertheless, Dex infusion is questionable in patients with SAH and acute stroke, since the associate drop in arterial pressure could worsen the coexisting increase in circulating catecholamines and massive sympathetic outflow. Furthermore, the magnitude of cerebral hemodynamic alterations induced by Dex sedation can possibly be modified by confounding factors such as vasomotor reactivity to carbon dioxide (CO2 )-challenge, adequacy of cerebral autoregulation, and background anesthetic regimens administration.[5] In the current study, any possible influence of intraoperative confounding factors was eliminated by maintaining stable systemic hemodynamics, end-tidal CO2 tension, and oxygenation status.[8] A possible triggering mechanism for CBF deterioration could be a CMRO2 reduction. Nonetheless, evidence from experimental studies shows that CMRO2 remains unaffected by the use of Dex; no relevant data from human studies exist.[4] Despite the reported neuroprotective effects of Dex in models of ischemic brain injury, the aforementioned clinical features raise concerns that reduction of CBF in the face of an unaltered reduction of CMRO2, potentially limits adequate cerebral oxygenation of brain tissue at risk for ischemic injury. The last key element of cerebral hemodynamics is ICP, as the elevated ICP promotes CBF deterioration, thus leading to a potential global or regional cerebral ischemia. In the present study, the estimated CPP presented a significant deterioration, mainly attributed to the concomitant elevation of zero flow pressure. The authors explained this finding under the light of cerebral vascular resistance elevation. The extremely limited clinical data, however, have failed to confirm a notable alteration of ICP during Dex administration, so the clinical relevance of these effects is uncertain at the present time.[5,6] It should be underlined that a2-agonists are more potent vasoconstrictors on the venous than on the arteriolar side of the cerebral vasculature.[5] Because the venous compartment comprises most of the cerebral blood volume, a2-agonists could presumably decrease ICP without greatly increasing arteriolar cerebrovascular resistance. Much of the knowledge accumulated on the impact of Dex upon cerebral hemodynamics is derived by limited quality evidence, mainly supported by experimental data and observational clinical trials with variable methodological quality, nonconsistent design, and selected target population with no significant comorbidities and intracranial pathology; this was also the case in this study.[7,8,9] Thus, an in-depth assessment of the impact of Dex on cerebral vasomotor reserve and adequacy of substrates supply in different clinical scenarios based on markers obtained from reliable and objective tools, is warranted.[7] Albeit, the accuracy of TCD is limited by the intrinsic technical limitations, operator dependency, and assumptions made regarding vessel diameter, it seems that it can serve as a valid tool to monitor at the bedside the evolution of CBF alterations and possibly cerebral autoregulation performance and ICP estimation in patients presenting with cerebral pathology.[7,9] In conclusion, available clinical evidence on the use of Dex in neurosurgical and NCC is limited, and no definite conclusion can be drawn until more rigorously designated trials to elucidate the effect of Dex administration in different dose regimens as a sole sedative agent or as adjunct to other sedatives on systemic and cerebral hemodynamics, brain metabolism and its impact on short- and long-term outcomes in various neurosurgical populations. According to the available evidence, there are possible warnings about the safety of Dex in intracranial pathology due to associated hemodynamic effects that might ultimately lead to suboptimal cerebral perfusion

Ventilation Targets for Patients Undergoing Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review

Mechanical thrombectomy (MT) has become a standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Recent evidence suggests that general anesthesia (GA) and mechanical ventilation do not lead to inferior neurologic outcomes if compared to non-GA. However, the guidelines lack specific recommendations for ventilation targets during MT under GA. This systematic review aims to identify ventilation strategies correlating with better neurological outcomes in AIS patients undergoing MT, particularly focusing on oxygenation and carbon dioxide (CO2) targets. A systematic search of multiple databases was conducted to identify human studies reporting the correlation between ventilation strategies and neurological outcomes in MT for AIS. Eligible studies included clinical trials, observational studies, and case–control studies. Out of 157 studies assessed, 11 met the inclusion criteria. Five studies investigated oxygenation targets, while six studies explored CO2 targets. The published studies highlighted the controversial role of supplemental normobaric oxygen therapy and its potential association with worse outcomes. Regarding CO2 targets, the studies identified a potential association between end tidal CO2 levels and functional outcomes, with hypocapnia being unfavorable. This systematic review demonstrates that the current available evidence still lacks strength to suggest specific ventilation targets, but it highlights the potential risks of hyperoxia and hypocapnia in this specific cohort of patients

Impact and Implementation of Simulation-Based Training for Safety

Patient safety is an issue of imminent concern in the high-risk field of medicine, and systematic changes that alter the way medical professionals approach patient care are needed. Simulation-based training (SBT) is an exemplary solution for addressing the dynamic medical environment of today. Grounded in methodologies developed by the aviation industry, SBT exceeds traditional didactic and apprenticeship models in terms of speed of learning, amount of information retained, and capability for deliberate practice. SBT remains an option in many medical schools and continuing medical education curriculums (CMEs), though its use in training has been shown to improve clinical practice. Future simulation-based anesthesiology training research needs to develop methods for measuring both the degree to which training translates into increased practitioner competency and the effect of training on safety improvements for patients

Sedation During Neurocritical Care

AbstractSedation is an essential therapeutic strategy in the care of neurocritical patients. Intravenous sedative agents are the most widely used, with promising alternatives (dexmedetomidine, ketamine, and volatile agents) to propofol and midazolam arising. Studies designed to evaluate superiority and avoid biases are required. A neurological awakening test is safe in most patients. Potential risks and benefits of limiting deep sedation and daily interruption of sedation in these patients remain unclear. The aim of this review was to report recent clinical evidence on sedation in this subgroup of patients, focusing on its effects on clinical prognosis

Postoperative delirium in kidney transplant patients

Delirium, also known as acute brain failure, is a medical condition characterized by recent onset of confusion, fluctuating awareness, disorganized thought, with memory and attention impairment. Post-operative delirium (POD) generally arises 1 to 3 days after surgery, in 25-37% of the hospitalized patients and in > 65% of those admitted to intensive care unit [1]

Slack in the infrastructure of intensive care units : resilience management in the postpandemic era

Background Although slack is an asset to resilient hospitals, it is usually explicitly discussed only in terms of the quantity and quality of beds and staff. This paper expands this view by addressing slack in four infrastructures of intensive care units (ICUs) (physical space, electricity supply, oxygen supply, and air treatment) during the COVID pandemic. Methods The study occurred in a leading private hospital in Brazil, aiming at the identification of slack in four units originally designed as ICUs and two units adapted as ICUs. Data collection was based on 12 interviews with healthcare professionals, documents, and comparison between infrastructures and regulatory requirements. Results Twenty-seven instantiations of slack were identified, with several indications that the adapted ICUs did not provide infrastructure conditions as good as the designed ones. Findings gave rise to five propositions addressing: relationships intra and inter infrastructures; the need for adapted ICUs that match as closely as possible the designed ICUs; the consideration of both clinical and engineering perspectives in design; and the need for the revision of some requirements of the Brazilian regulations. Conclusions Results are relevant to both the designers of the infrastructures and to the designers of clinical activities as these must take place in fit-for-purpose workspaces. Top management might also benefit as they are the ultimate responsible for decision-making on whether or not to invest in slack. The pandemic dramatically demonstrated the value of investing in slack resources, creating momentum for this discussion in health services