Administración de dosis equivocada de fenilefrina en Reanimación. Caso del trimestre

A real clinical case reported to SENSAR is presented. A patient admitted to the surgical intensive care unit following a lung resection, suffered arterial hypotension. The nurse was asked to give the patient 1 mL of phenylephrine. A few seconds afterwards, the patient experienced a hypertensive crisis, which resolved spontaneously without damage. Thereafter, the nurse was interviewed and a dosing error was identified: she had mistakenly given the patient 1 mg of phenylephrine (1 mL) instead of 100 mcg (1 mL of the standard dilution, 1 mg in 10 mL).The incident analysis revealed latent factors (event triggers) due to the lack of protocols and standard operating procedures, communication errors among team members (physician-nurse), suboptimal training, and underdeveloped safety culture.In order to preempt similar incidents in the future, the following actions were implemented in the surgical intensive care unit: a protocol for bolus and short lived infusions (< 30 min) was developed and to close the communication gap through the adoption of communication techniques. The protocol was designed by physicians and nurses to standardize the administration of drugs with high potential for errors. To close the communication gap, repeated checks about saying and understanding was proposed («closed loop»). Labeling syringes with the drug dilution was also recommended.     

基于2D电阻抗成像的位置误差和相对数量指数的后处理方法

本文提出了一种基于2D电阻抗成像的位置误差和相对数量指数的后处理方法,用于多种电导率分布的确定、组织成分的识别以及位置信息的确定。此外,还介绍了一种基于现有两种重建算法的混合正则化算法,并将三种重建算法重建的结果进行了比较。结果证明,这种后处理方法可以提高2D电阻抗成像的位置精度和空间分辨率,使得电阻抗成像适用于临床检查和过程监测。     

质量控制检测在血液净化设备预防性维护中的作用探讨

本文对血液净化设备的常见故障进行分类讨论,并通过分析其质控数据,发现质控数据的偏移量和设备故障发生率之间存在相关性。血液净化设备发生流量故障时,设备质控数据在300 mL/min及500 mL/min两检测点存在较大偏移;发生电导率故障时,设备质控数据在13.5 ms/cm及14.5 ms/cm两检测点存在较大偏移。因此,可根据血液净化设备质控数据的偏移情况,有针对性的对设备进行预防性维修,从而减少设备故障发生率,提高设备安全水平。     

Theta oscillatory dynamics of inhibitory control,error processing,and post-error adjustments: Neural underpinnings and alcohol-induced dysregulation in social drinkers

Background

Alcohol intoxication impairs inhibitory control, resulting in disinhibited, impulsive behavior. The anterior cingulate cortex (ACC) plays an essential role in a range of executive functions and is sensitive to the effects of alcohol, which contributes to the top-down cognitive dysregulation. This study used a multimodal approach to examine the acute effects of alcohol on the neural underpinnings of inhibitory control, inhibition failures, and neurobehavioral optimization as reflected in trial-to-trial dynamics of post-error adjustments.

Methods

Adult social drinkers served as their own controls by participating in the Go/NoGo task during acute alcohol and placebo conditions in a multi-session, counterbalanced design. Distributed source modeling of the magnetoencephalographic signal was combined with structural magnetic resonance imaging to characterize the spatio-temporal dynamics of inhibitory control in the time-frequency domain.

Results

Successful response inhibition (NoGo) elicited right-lateralized event-related theta power (4 to 7 Hz). Errors elicited a short-latency increase in theta power in the dorsal (dACC), followed by activity in the rostral (rACC), which may underlie an affective “oh, no!” orienting response to errors. Error-related theta in the dACC was associated with subsequent activity of the motor areas on the first post-error trial, suggesting the occurrence of post-error output adjustments. Importantly, a gradual increase of the dACC theta across post-error trials closely tracked improvements in accuracy under placebo, which may reflect cognitive control engagement to optimize response accuracy. In contrast, alcohol increased NoGo commission errors, dysregulated theta during correct NoGo withholding, and abolished the post-error theta enhancement of cognitive control.

Conclusions

Confirming the sensitivity of frontal theta to inhibitory control and error monitoring, the results support functional and temporal dissociation along the dorso-rostral axis of the ACC and the deleterious effects of alcohol on the frontal circuitry subserving top-down regulation. Over time, alcohol-induced disinhibition may give rise to compulsive drinking and contribute to alcohol misuse.     

Effects of Pulsatile Subcutaneous Injections of Insulin Lispro on Plasma Insulin Concentration Levels

Background

Most insulin pumps used for the treatment of diabetes perform subcutaneous insulin injections by pulses. The purpose of this work is to analyze the effects of pulsatile injections of modern insulins on plasma insulin levels compared with a continuous insulin infusion.

Method

We simulate pulsatile implementations of a basal rate profile over a day on a type 1 diabetes mellitus patient using insulin lispro. Pulse periods were varied between 1 and 60 min, and random pump errors were included, modeled as white noise, 1/f noise, or 1/f² noise with relative standard deviations up to 10% of the pump output.

Results

Oscillations in plasma insulin caused by the pulsatile injections were not significant with respect to the global variations for pulse periods below 15 min. This cutoff period was found to be robust to random pump errors with standard deviations up to 10% of the pump output and hence solely determined by the insulin kinetics. Additionally, we showed that the pulse period achieving the best implementation of a continuous profile is an increasing function of the error variance for a given type of noise.

Conclusions

Our findings support that continuous insulin infusion can be implemented by a pulsatile injection of insulin as infrequent as a pulse every 15 min without significant effects on plasma insulin levels. If clinically confirmed, this result would have important consequences on the design and in silico testing of automated insulin treatment strategies, as increased delivery intervals imply higher accuracy of insulin delivery and facilitated implementations of closed-loop control algorithms.     

Out-of-Hospital Pediatric Patient Safety Events: Results of the CSI Chart Review

Objective: Studies of adult hospital patients have identified medical errors as a significant cause of morbidity and mortality. Little is known about the frequency and nature of pediatric patient safety events in the out-of-hospital setting. We sought to quantify pediatric patient safety events in EMS and identify patient, call, and care characteristics associated with potentially severe events. Methods: As part of the Children's Safety Initiative -EMS, expert panels independently reviewed charts of pediatric critical ambulance transports in a metropolitan area over a three-year period. Regression models were used to identify factors associated with increased risk of potentially severe safety events. Patient safety events were categorized as: Unintended injury; Near miss; Suboptimal action; Error; or Management complication (“UNSEMs”) and their severity and potential preventability were assessed. Results: Overall, 265 of 378 (70.1%) unique charts contained at least one UNSEM, including 146 (32.8%) errors and 199 (44.7%) suboptimal actions. Sixty-one UNSEMs were categorized as potentially severe (23.3% of UNSEMs) and nearly half (45.3%) were rated entirely preventable. Two factors were associated with heightened risk for a severe UNSEM: (1) age 29 days to 11 months (OR 3.3, 95% CI 1.25-8.68); (2) cases requiring resuscitation (OR 3.1, 95% CI 1.16-8.28). Severe UNSEMs were disproportionately higher among cardiopulmonary arrests (8.5% of cases, 34.4% of severe UNSEMs). Conclusions: During high-risk out-of-hospital care of pediatric patients, safety events are common, potentially severe, and largely preventable. Infants and those requiring resuscitation are important areas of focus to reduce out-of-hospital pediatric patient safety events.