Fatiga del reanimador y calidad de las compresiones torácicas en niños con y sin vía aérea asegurada

Introducción: La calidad de las compresiones torácicas tiene importancia durante la reanimación pediátrica y se ve afectada por diversos factores como la fatiga del reanimador, esta puede verse condicionada por las características de las compresiones establecidas según la presencia o ausencia de un dispositivo avanzado en la vía aérea determinando la interrupción continuidad de las mismas. En este estudio se realizó una simulación clínica, evaluando la presencia de fatiga del reanimador frente a pacientes con y sin dispositivo avanzado de la vía aérea. Metodología: Se incluyeron 12 participantes, quienes realizaron compresiones torácicas a un simulador clínico, tanto para el caso de la maniobra 1 correspondiente a ciclos interrumpidos con el fin de proporcionar ventilaciones, como para el caso de la maniobra 2 en la que la actividad fue continua. Se midieron calidad de compresiones, VO2 max y fatiga mediante escala de Borg RPE 6-20. Resultados: La calidad de las compresiones disminuyó en ambos grupos después del minuto 2 y más rápidamente cuando fueron ininterrumpidas. La fatiga se incrementó cuando las compresiones fueron continuas. Discusión: Se evidencia una relación directamente proporcional del aumento de la fatiga en relación al tiempo de reanimación e inversamente proporcional entre la calidad de las compresiones y la sensación de cansancio, en especial después del minuto 2. Un tiempo de 2 minutos podría ser el tiempo ideal para lograr compresiones de calidad y para realizar el reemplazo de la persona que realiza las compresiones.

Incidencia y factores asociados a infecciones bacterianas en el primer mes postrasplante hepático en la Fundación Cardioinfantil

Introducción: El trasplante hepático ortotópico es la colocación de un nuevo hígado en la misma ubicación del explantado. El objetivo es prolongar la duración y la calidad de vida en pacientes con enfermedades hepáticas terminales. Sin embargo, las infecciones bacterianas son una complicación en los pacientes receptores del trasplante, comprometiendo el éxito del procedimiento. El objetivo fue determinar los factores asociados a infecciones bacterianas en el primer mes tras realizada la intervención y describir las características demográficas de esa población. De 332 trasplantes realizados, que 262 cumplieron criterios para el análisis. Métodos: Se realizó un estudio observacional analítico de casos y controles anidado en una cohorte, en mayores de 18 años, receptores de trasplante hepático primario, de la FCI-IC de 2005 a 2014; excluyendo trasplante combinado hígado riñón, retrasplantes o fallecidos por causa diferente a la infecciosa durante el primer mes. Resultados: Se encontró que la ventilación mecánica por más de 1 día, el catéter venoso central mayor de 3 días son los principales factores de riesgo para infecciones bacterianas. La albúmina mayor de 2,6gr/dl se asoció a menor infección. Los agentes etiológicos predominantes fueron gérmenes gram negativos como E. coli, K. pneumonia y E. cloacae. Mientras que bacteremia, infección urinaria y peritonitis fueron las infecciones más frecuentes. La incidencia de infección bacteriana en esta población fue 24%. Discusión: Se recomienda por tanto extubación antes de 24 horas, uso de catéter central menor de 3 días y limitar el uso del catéter vesical.

Anestesia regional y periférica guiada por ultrasonido en el paciente critico

El presente trabajo es un capítulo de libro titulado “Anestesia Regional y Periférica Guiada por Ultrasonido en el Paciente Crítico” que será incluido en la última edición del libro “Manual de Ultrasonido en Terapia Intensiva y Emergencias” cuyo editor es el Doctor José de Jesús Rincón Salas y que será publicado por la Editorial Prado de México para distribución latinoamericana desde dicho país. Por solicitud del editor y teniendo en cuenta el enfoque del libro, el presente trabajo está dirigido a estudiantes de formación, médicos graduados y especialistas en las áreas de cuidado intensivo, anestesiología, dolor, medicina interna y medicina de urgencias. Tiene como propósito empapar de conocimientos necesarios y prácticos en anestesia regional a personas que usualmente no han tenido contacto con la anestesia regional, pues desafortunadamente sólo en los últimos años ha sido posible que la anestesia regional haya comenzado a salir de las salas de cirugía, ámbito donde ha estado confinada tradicionalmente. El lenguaje utilizado es sencillo y el capítulo ha sido escrito para que sea fácil de leer y consultar, dejando así mensajes muy claros sobre la utilidad, viabilidad e implicaciones que tiene el uso de anestesia regional guiada por ultrasonido en cuidado intensivo. Los autores esperamos que de esta manera, el presente capítulo permita continuar superando los obstáculos que se interponen entre los invaluables beneficios de la anestesia regional y los pacientes de cuidado intensivo que necesitan de ella.

Wind-tunnel modelling of dispersion from a scalar area source in urban-like roughness

A wind-tunnel study was conducted to investigate ventilation of scalars from urban-like geometries at neighbourhood scale by exploring two different geometries a uniform height roughness and a non-uniform height roughness, both with an equal plan and frontal density of λ p = λ f = 25%. In both configurations a sub-unit of the idealized urban surface was coated with a thin layer of naphthalene to represent area sources. The naphthalene sublimation method was used to measure directly total area-averaged transport of scalars out of the complex geometries. At the same time, naphthalene vapour concentrations controlled by the turbulent fluxes were detected using a fast Flame Ionisation Detection (FID) technique. This paper describes the novel use of a naphthalene coated surface as an area source in dispersion studies. Particular emphasis was also given to testing whether the concentration measurements were independent of Reynolds number. For low wind speeds, transfer from the naphthalene surface is determined by a combination of forced and natural convection. Compared with a propane point source release, a 25% higher free stream velocity was needed for the naphthalene area source to yield Reynolds-number-independent concentration fields. Ventilation transfer coefficients w T /U derived from the naphthalene sublimation method showed that, whilst there was enhanced vertical momentum exchange due to obstacle height variability, advection was reduced and dispersion from the source area was not enhanced. Thus, the height variability of a canopy is an important parameter when generalising urban dispersion. Fine resolution concentration measurements in the canopy showed the effect of height variability on dispersion at street scale. Rapid vertical transport in the wake of individual high-rise obstacles was found to generate elevated point-like sources. A Gaussian plume model was used to analyse differences in the downstream plumes. Intensified lateral and vertical plume spread and plume dilution with height was found for the non-uniform height roughness

Mechanisms of ocean heat uptake in a coupled climate model and the implications for tracer based predictions of ocean heat uptake

The distribution of tracers in the ocean is often taken as an indication of the ventilation pathways for oceanic water masses. It has been suggested that under anthropogenic forcing heat will be taken up into the interior of the ocean along isopycnal ventilation pathways. This notion is investigated by examining distributions of potential temperature and a passive anomaly temperature tracer in a coupled climate experiment where CO2 is increased at a rate of 2% per year. We show that interior temperature changes cannot be explained solely by passive tracer transport along isopycnals. Heat uptake is strongly affected by changes in circulation and has a substantial diapycnal component.

Synoptic controls on boundary-layer characteristics

We report the characteristics of the three-dimensional, time evolving, atmospheric boundary layer that develops beneath an idealised, dry, baroclinic weather system. The boundary-layer structure is forced by thermal advection associated with the weather system. Large positive heat fluxes behind the cold front drive a vigorous convective boundary layer, whereas moderate negative heat fluxes in the warm sector between the cold and warm fronts generate shallow, stably stratified or neutral boundary layers. The forcing of the boundary-layer structure is quantified by forming an Eulerian mass budget integrated over the depth of the boundary layer. The mass budget indicates that tropospheric air is entrained into the boundary layer both in the vicinity of the high-pressure centre, and behind the cold front. It is then transported horizontally within the boundary layer and converges towards the cyclone's warm sector, whence it is ventilated out into the troposphere. This cycling of air is likely to be important for the ventilation of pollution out of the boundary layer, and for the transformation of the properties of large-scale air masses.

Constraining a North Atlantic Ocean general circulation model with chlorofluorocarbon observations

Measurements of anthropogenic tracers such as chlorofluorocarbons and tritium must be quantitatively combined with ocean general circulation models as a component of systematic model development. The authors have developed and tested an inverse method, using a Green's function, to constrain general circulation models with transient tracer data. Using this method chlorofluorocarbon-11 and -12 (CFC-11 and -12) observations are combined with a North Atlantic configuration of the Miami Isopycnic Coordinate Ocean Model with 4/3 degrees resolution. Systematic differences can be seen between the observed CFC concentrations and prior CFC fields simulated by the model. These differences are reduced by the inversion, which determines the optimal gas transfer across the air-sea interface, accounting for uncertainties in the tracer observations. After including the effects of unresolved variability in the CFC fields, the model is found to be inconsistent with the observations because the model/data misfit slightly exceeds the error estimates. By excluding observations in waters ventilated north of the Greenland-Scotland ridge (sigma (0) < 27.82 kg m(-3); shallower than about 2000 m), the fit is improved, indicating that the Nordic overflows are poorly represented in the model. Some systematic differences in the model/data residuals remain and are related, in part, to excessively deep model ventilation near Rockall and deficient ventilation in the main thermocline of the eastern subtropical gyre. Nevertheless, there do not appear to be gross errors in the basin-scale model circulation. Analysis of the CFC inventory using the constrained model suggests that the North Atlantic Ocean shallower than about 2000 m was near 20% saturated in the mid-1990s. Overall, this basin is a sink to 22% of the total atmosphere-to-ocean CFC-11 flux-twice the global average value. The average water mass formation rates over the CFC transient are 7.0 and 6.0 Sv (Sv = 10(6) m(3) s(-1)) for subtropical mode water and subpolar mode water, respectively.

The Acute Care Undergraduate TEaching (ACUTE) initiative: consensus development of core competencies in acute care for undergraduates in the United Kingdom

Background: The care of the acutely ill patient in hospital is often sub-optimal. Poor recognition of critical illness combined with a lack of knowledge, failure to appreciate the clinical urgency of a situation, a lack of supervision, failure to seek advice and poor communication have been identified as contributory factors. At present the training of medical students in these important skills is fragmented. The aim of this study was to use consensus techniques to identify the core competencies in the care of acutely ill or arrested adult patients that medical students should possess at the point of graduation. Design: Healthcare professionals were invited to contribute suggestions for competencies to a website as part of a modified Delphi survey. The competency proposals were grouped into themes and rated by a nominal group comprised of physicians, nurses and students from the UK. The nominal group rated the importance of each competency using a 5-point Likert scale. Results: A total of 359 healthcare professionals contributed 2,629 competency suggestions during the Delphi survey. These were reduced to 88 representative themes covering: airway and oxygenation; breathing and ventilation; circulation; confusion and coma; drugs, therapeutics and protocols; clinical examination; monitoring and investigations; team-working, organisation and communication; patient and societal needs; trauma; equipment; pre-hospital care; infection and inflammation. The nominal group identified 71 essential and 16 optional competencies which students should possess at the point of graduation. Conclusions: We propose these competencies form a core set for undergraduate training in resuscitation and acute care.

Work performance, productivity and indoor air

Temperature, relative humidity, and air quality all affect the sensory system via thermo receptors in the skin and the olfactory system. Air quality is mainly defined by the contaminants in the air. However, the most persistent memory of any space is often its odor. Strong, emotional, and past experiences are awakened by the olfactory sense. Odors can also influence cognitive processes that affect creative task performance, as well as personal memories and moods. Besides nitrogen and oxygen, the air contains particles and many chemicals that affect the efficiency of the oxygenation process in the blood, and ultimately the air breathed affects thinking and concentration. It is important to show clients the value of spending more capital on high-quality buildings that promote good ventilation. The process of achieving indoor-air quality is a continual one throughout the design, construction, commissioning, and facilities management processes. This paper reviews the evidence.

Failure of a control strategy for a hybrid air-conditioning and wind catchers/towers system at Bluewater shopping malls in Kent

Purpose – To evaluate the control strategy for a hybrid natural ventilation wind catchers and air-conditioning system and to assess the contribution of wind catchers to indoor air environments and energy savings if any. Design/methodology/approach – Most of the modeling techniques for assessing wind catchers performance are theoretical. Post-occupancy evaluation studies of buildings will provide an insight into the operation of these building components and help to inform facilities managers. A case study for POE was presented in this paper. Findings – The monitoring of the summer and winter month operations showed that the indoor air quality parameters were kept within the design target range. The design control strategy failed to record data regarding the operation, opening time and position of wind catchers system. Though the implemented control strategy was working effectively in monitoring the operation of mechanical ventilation systems, i.e. AHU, did not integrate the wind catchers with the mechanical ventilation system. Research limitations/implications – Owing to short-falls in the control strategy implemented in this project, it was found difficult to quantify and verify the contribution of the wind catchers to the internal conditions and, hence, energy savings. Practical implications – Controlling the operation of the wind catchers via the AHU will lead to isolation of the wind catchers in the event of malfunctioning of the AHU. Wind catchers will contribute to the ventilation of space, particularly in the summer months. Originality/value – This paper demonstrates the value of POE as indispensable tool for FM professionals. It further provides insight into the application of natural ventilation systems in building for healthier indoor environments at lower energy cost. The design of the control strategy for natural ventilation and air-conditioning should be considered at the design stage involving the FM personnel.

Performance evaluation of wall mounted convector for pre-heating naturally ventilated spaces

This paper presents the results of performance monitoring under real winter weather conditions, controlled laboratory testing and computational fluid dynamics (CFD) analysis of a wall mounted ventilation air inlet heat convector. For real winter weather monitoring, the wall-mounted convector was installed in a laboratory room of the Engineering Building of the School of Construction Management and Engineering. Air and hot water temperatures and air speeds were measured at the entrance to the convector and in the room. The hot water temperature was controlled at 40, 60 and 80 °C. The monitoring results were later used as boundary conditions for a CFD simulation to investigate the air movement in the room. Controlled laboratory testing was conducted in laboratories at the University of Reading, UK and at Wetterstad Consultancy, Sweden. The results of the performance investigation showed that the system contributed greatly to the room heating, particularly at a water temperature of 80 °C. Also adequate fresh air was supplied to the room. Such a system is able to provide an energy efficient method of eliminating problems associated with cold winter draughts.

Condensation and moisture transport in cold roofs: effect of roof underlay

Cold pitched roofs, with their form of construction situating insulation on a horizontal ceiling, are intrinsically vulnerable to condensation. This study reports the results derived from using a simulation package (Heat, Air and Moisture modelling tool, or HAM-Tools) to investigate the risk of condensation in cold pitched roofs in housing fitted with a vapour-permeable underlay (VPU) of known characteristics. In order to visualize the effect of the VPUs on moisture transfer, several scenarios were modelled, and compared with the results from a conventional bituminous felt with high resistance (200 MNs/g, Sd = 40 m). The results indicate that ventilation is essential in the roof to reduce condensation. However, a sensitivity analysis proved that reducing the overall tightness of the ceiling and using lower-resistance VPUs would help in controlling condensation formation in the roof. To a large extent, the proposed characteristic performance of the VPU as predicted by manufacturers and some researchers may only be realistic if gaps in the ceiling are sealed completely during construction, which may be practically difficult given current construction practice.

Lessons learnt about water use, harvesting, recycling and drainage

This Information Paper is the third in a four-part series that looks at the lessons learnt from the BRE Innovation Park concerning compliance with the Code for Sustainable Homes published in November 2006. It focuses on water use, harvesting, recycling and drainage. The other parts deal with: building fabric; energy sources, overheating and ventilation; architecture, construction and sourcing.

Innovative approach to building systems integration problems: Using systems theory, technological forecasting and scenario planning

Building services are worth about 2% GDP and are essential for the effective and efficient operations of the building. It is increasingly recognised that the value of a building is related to the way it supports the client organisation’s ongoing business operations. Building services are central to the functional performance of buildings and provide the necessary conditions for health, well-being, safety and security of the occupants. They frequently comprise several technologically distinct sub-systems and their design and construction requires the involvement of numerous disciplines and trades. Designers and contractors working on the same project are frequently employed by different companies. Materials and equipment is supplied by a diverse range of manufacturers. Facilities managers are responsible for operation of the building service in use. The coordination between these participants is crucially important to achieve optimum performance, but too often is neglected. This leaves room for serious faults. The need for effective integration is important. Modern technology offers increasing opportunities for integrated personal-control systems for lighting, ventilation and security as well as interoperability between systems. Opportunities for a new mode of systems integration are provided by the emergence of PFI/PPP procurements frameworks. This paper attempts to establish how systems integration can be achieved in the process of designing, constructing and operating building services. The essence of the paper therefore is to envisage the emergent organisational responses to the realisation of building services as an interactive systems network.

Investigation of air quality, comfort parameters and effectiveness for two floor-level air supply systems in classrooms

The method of distributing the outdoor air in classrooms has a major impact on indoor air quality and thermal comfort of pupils. In a previous study, ([11] Karimipanah T, Sandberg M, Awbi HB. A comparative study of different air distribution systems in a classroom. In: Proceedings of Roomvent 2000, vol. II, Reading, UK, 2000. p. 1013-18; [13] Karimipanah T, Sandberg M, Awbi HB, Blomqvist C. Effectiveness of confluent jets ventilation system for classrooms. In: Idoor Air 2005, Beijing, China, 2005 (to be presented).) presented results for four and two types of air distribution systems tested in a purpose built classroom with simulated occupancy as well as computational fluid dynamics (CFD) modelling. In this paper, the same experimental setup has been used to investigate the indoor environment in the classroom using confluent jet ventilation, see also ([12]Cho YJ, Awbi HB, Karimipanah T. The characteristics of wall confluent jets for ventilated enclosures. In: Proceedings of Roomvent 2004, Coimbra, Portugal, 2004.) Measurements of air speed, air temperature and tracer gas concentrations have been carried out for different thermal conditions. In addition, 56 cases of CFD simulations have been carried to provide additional information on the indoor air quality and comfort conditions throughout the classroom, such as ventilation effectiveness, air exchange effectiveness, effect of flow rate, effect of radiation, effect of supply temperature, etc., and these are compared with measured data.