Dexmedetomidina vs Remifentanil en fast track (transito rápido) durante cirugía cardiaca

Actualmente las técnicas de anestesia de tránsito rápido en cirugía cardiaca se basan en la utilización de remifentanil, sin embargo este al tener una vida media tan corta hace que sea necesaria la utilización de opioides durante el posoperatorio inmediato presentandose el riesgo de depresión ventilatoria, y complicaciones respiratorias, es por esto que la dexmedetomidina podría ser una opción bastante atractiva debida a que no produce depresión de los centros respiratorios, y disminuye el consumo de opioides en el postoperatorio hasta un 66%. Previa aprobación del comité de ética se realizó un estudio clínico controlado y aleatorizado en dos grupos de 20 pacientes, El primer grupo recibió inducción con propofol 2mg/Kg, pancuronio 0.8mg/kg, y fentanil 2mcg/kg seguido de un bolo de dexmedetomidina de 0.5mcg/kg y una infusión de 0.3 - 0.7 mcg/kg/h la cual fue suspendida al finalizar la colocación de los alambres esternales, el grupo de remifentanil recibió una inducción con propofol y pancuronio a las mismas dosis, seguido de una infusión de remifentanil de 0.1 - 0.5 mcg/kg/min suspendida al finalizar el cierre de la piel, ambos grupos recibieron analgesia con dipirona 50mg/kg, morfina 0.1mg/kg seguida de dosis de rescate de 3mg según necesidad, e infiltración de la herida quirurgica con 40cc de Bupivacaina al 0.25%. Se midio el tiempo y lugar de extubación, el consumo de medicamentos vasopresores y vasodilatadores durante la cirugiaasi como el consumo de morfina el VAS y la incidencia de nausea y vomito durante las primeras 24h posoperatorias. El 85% de los pacientes fueron extubados en salas de cirugia, sin encontrarse diferencias estadiscamente significativas entre los tiempos de extubación de ambos grupos (11.7min) para remifentanil, y (9.6min) para dexmedetomidina, en cuanto al consumo de morfina este fue significativamente menor en el grupo de dexmedetomidina 4mg vs 15mg en el grupo de remifentanil así como también lo fue la incidencia de nausea y vomito 42.9% remifentanil vs 5.2% dexmedetomidina p:0.00009. A nuestro saber este es el primer estudio clínico en la literatura en el cual se ha propuesto a la dexmedetomidina como una alternativa para técnicas anestésicas de transito rápido en cirugia cardiaca. Los resultados sugieren que es tan eficaz como el remifentanil para permitir la extubación temprana de este grupo de pacientes con una menor consumo de morfina y una menor incidencia de nauseas y vomito durante el posoperatorio. Se recomiendan la realización de estudios adicionales que permitan ratificar los resultados previamente encontrados.

Sheffield Rail Spreadsheet

This data contains the results of application of a feasibility study on rail demand. The case study of Sheffield and 100 large urban areas in the UK.

Increasing Rail's Mode Share Within The Constraints of The Existing Network

This file contains the results of application of the model (4.6) and (4.8)

Identification of resilience factors in rail engineering work

This paper discusses an ongoing project that aims at improving the potential for resilience of a system responsible for the planning of rail engineering work delivery. It focuses on the use of a human factors based approach as a way to achieve this end. In particular, the paper discusses the initial data collected by means of interviews and how this process gave way to a two fold goal: Understanding how the planning process works in reality and identifying any critical aspects of the system from a Resilience Engineering perspective. Given the nature of the process under study, information flows and communication issues have been given particular attention throughout the data collection and analysis stages. Initial data confirms that the planning process is greatly reliant on the capability of people using their knowledge and skills to communicate in a dynamic informational environment. Finally, the added value of the interviews is discussed from a human factors perspective and as a mean towards the aim of better understanding resilience in rail engineering planning.

Resilience in rail engineering work

This paper discusses an ongoing project that aims at improving the potential for resilience of a system responsible for the planning of rail engineering work delivery. This is being addressed by means of a methodology based on the observation and analysis of “real” planning activities, using resilience engineering concepts as a background. Interviews with planners have been carried out to provide an overview of the planning process and steer more in-depth investigation. Analysis of historic information and observation of planners’ main activities is underway. Given the nature of the process under study, information flows and communication issues have been given particular attention throughout the data collection and analysis stages. Initial data confirms that the planning process is greatly reliant on the capability of people using their knowledge and skills to communicate in a dynamic informational environment. Evidence was found of communication breakdowns at the boundaries of different planning levels and teams. The fact that the process is divided amongst several different areas of the organisation, often with different goals and needs, creates potential sources of conflict and tension.

Understanding safety and production risks in rail engineering planning and protection

Much of the published human factors work on risk is to do with safety and within this is concerned with prediction and analysis of human error and with human reliability assessment. Less has been published on human factors contributions to understanding and managing project, business, engineering and other forms of risk and still less jointly assessing risk to do with broad issues of ‘safety’ and broad issues of ‘production’ or ‘performance’. This paper contains a general commentary on human factors and assessment of risk of various kinds, in the context of the aims of ergonomics and concerns about being too risk averse. The paper then describes a specific project, in rail engineering, where the notion of a human factors case has been employed to analyse engineering functions and related human factors issues. A human factors issues register for potential system disturbances has been developed, prior to a human factors risk assessment, which jointly covers safety and production (engineering delivery) concerns. The paper concludes with a commentary on the potential relevance of a resilience engineering perspective to understanding rail engineering systems risk. Design, planning and management of complex systems will increasingly have to address the issue of making trade-offs between safety and production, and ergonomics should be central to this. The paper addresses the relevant issues and does so in an under-published domain – rail systems engineering work.

The Storm-Track Response to Idealized SST Perturbations in an Aquaplanet GCM

The tropospheric response to midlatitude SST anomalies has been investigated through a series of aquaplanet simulations using a high-resolution version of the Hadley Centre atmosphere model (HadAM3) under perpetual equinox conditions. Model integrations show that increases in the midlatitude SST gradient generally lead to stronger storm tracks that are shifted slightly poleward, consistent with changes in the lower-tropospheric baroclinicity. The large-scale atmospheric response is, however, highly sensitive to the position of the SST gradient anomaly relative to that of the subtropical jet in the unperturbed atmosphere. In particular, when SST gradients are increased very close to the subtropical jet, then the Hadley cell and subtropical jet is strengthened while the storm track and eddy-driven jet are shifted equatorward. Conversely, if the subtropical SST gradients are reduced and the midlatitude gradients increased, then the storm track shows a strong poleward shift and a well-separated eddy-driven jet is produced. The sign of the SST anomaly is shown to play a secondary role in determining the overall tropospheric response. These findings are used to provide a new and consistent interpretation of some previous GCM studies concerning the atmospheric response to midlatitude SST anomalies.

Storm track sensitivity to sea surface temperature resolution in a regional atmosphere model

A high resolution regional atmosphere model is used to investigate the sensitivity of the North Atlantic storm track to the spatial and temporal resolution of the sea surface temperature (SST) data used as a lower boundary condition. The model is run over an unusually large domain covering all of the North Atlantic and Europe, and is shown to produce a very good simulation of the observed storm track structure. The model is forced at the lateral boundaries with 15–20 years of data from the ERA-40 reanalysis, and at the lower boundary by SST data of differing resolution. The impacts of increasing spatial and temporal resolution are assessed separately, and in both cases increasing the resolution leads to subtle, but significant changes in the storm track. In some, but not all cases these changes act to reduce the small storm track biases seen in the model when it is forced with low-resolution SSTs. In addition there are several clear mesoscale responses to increased spatial SST resolution, with surface heat fluxes and convective precipitation increasing by 10–20% along the Gulf Stream SST gradient.

The basic ingredients of the North Atlantic storm track. Part I: land-sea contrast and orography

Understanding and predicting changes in storm tracks over longer time scales is a challenging problem, particularly in the North Atlantic. This is due in part to the complex range of forcings (land–sea contrast, orography, sea surface temperatures, etc.) that combine to produce the structure of the storm track. The impact of land–sea contrast and midlatitude orography on the North Atlantic storm track is investigated through a hierarchy of GCM simulations using idealized and “semirealistic” boundary conditions in a high-resolution version of the Hadley Centre atmosphere model (HadAM3). This framework captures the large-scale essence of features such as the North and South American continents, Eurasia, and the Rocky Mountains, enabling the results to be applied more directly to realistic modeling situations than was possible with previous idealized studies. The physical processes by which the forcing mechanisms impact the large-scale flow and the midlatitude storm tracks are discussed. The characteristics of the North American continent are found to be very important in generating the structure of the North Atlantic storm track. In particular, the southwest–northeast tilt in the upper tropospheric jet produced by southward deflection of the westerly flow incident on the Rocky Mountains leads to enhanced storm development along an axis close to that of the continent’s eastern coastline. The approximately triangular shape of North America also enables a cold pool of air to develop in the northeast, intensifying the surface temperature contrast across the eastern coastline, consistent with further enhancements of baroclinicity and storm growth along the same axis.