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1.
Dis Esophagus ; 34(4)2021 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-32944749

RESUMO

Vasopressor use during esophagectomy has been reported to increase the risk of postoperative anastomotic leak and associated morbidity. We sought to assess the association between vasopressor use and fluid (crystalloid and colloid) administration and anastomotic leak following open esophagectomy. Patients who underwent open Ivor Lewis esophagectomy were identified from a prospective institutional database. The primary outcome was postoperative anastomotic leak (any grade) and analyzed using logistic regression models. Postoperative anastomotic leak developed in 52 of 327 consecutive patients (16%) and was not significantly associated with vasopressor use or fluid administered in either univariable or multivariable analyses. Increasing body mass index was the only significant characteristic of both univariable (P = 0.004) and multivariable analyses associated with anastomotic leak (odds ratio, 1.05; 95% confidence interval, 1.01-1.09; P = 0.007). Of the 52 patients that developed an anastomotic leak, 12 (23%) were grade 1, 21 (40%) were grade 2 and 19 (37%) were grade 3. In our cohort, only body mass index, and not intraoperative vasopressor use and fluid administration, was significantly associated with increased odds of postoperative anastomotic leak following open Ivor Lewis esophagectomy.


Assuntos
Neoplasias Esofágicas , Esofagectomia , Anastomose Cirúrgica/efeitos adversos , Fístula Anastomótica/etiologia , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Estudos Retrospectivos
2.
Anesth Analg ; 125(1): 190-199, 2017 07.
Artigo em Inglês | MEDLINE | ID: mdl-28598916

RESUMO

BACKGROUND: Protective lung ventilation (PLV) during one-lung ventilation (OLV) for thoracic surgery is frequently recommended to reduce pulmonary complications. However, limited outcome data exist on whether PLV use during OLV is associated with less clinically relevant pulmonary morbidity after lung resection. METHODS: Intraoperative data were prospectively collected in 1080 patients undergoing pulmonary resection with OLV, intentional crystalloid restriction, and mechanical ventilation to maintain inspiratory peak airway pressure <30 cm H2O. Other ventilator settings and all aspects of anesthetic management were at the discretion of the anesthesia care team. We defined PLV and non-PLV as <8 or ≥8 mL/kg (predicted body weight) mean tidal volume. The primary outcome was the occurrence of pneumonia and/or acute respiratory distress syndrome (ARDS). Propensity score matching was used to generate PLV and non-PLV groups with comparable characteristics. Associations between outcomes and PLV status were analyzed by exact logistic regression, with matching as cluster in the anatomic and nonanatomic lung resection cohorts. RESULTS: In the propensity score-matched analysis, the incidence of pneumonia and/or ARDS among patients who had an anatomic lung resection was 9/172 (5.2%) in the non-PLV compared to the PLV group 7/172 (4.1%; odds ratio, 1.29; 95% confidence interval, 0.48-3.45, P= .62). The incidence of pneumonia and/or ARDS in patients who underwent nonanatomic resection was 3/118 (2.5%) in the non-PLV compared to the PLV group, 1/118 (0.9%; odds ratio, 3.00; 95% confidence interval, 0.31-28.84, P= .34). CONCLUSIONS: In this prospective observational study, we found no differences in the incidence of pneumonia and/or ARDS between patients undergoing lung resection with tidal volumes <8 or ≥8 mL/kg. Our data suggest that when fluid restriction and peak airway pressures are limited, the clinical impact of PLV in this patient population is small. Future randomized trials are needed to better understand the benefits of a small tidal volume strategy during OLV on clinically important outcomes.


Assuntos
Pneumopatias/mortalidade , Pulmão/cirurgia , Pontuação de Propensão , Síndrome do Desconforto Respiratório/mortalidade , Lesão Pulmonar Aguda , Idoso , Feminino , Humanos , Incidência , Pneumopatias/cirurgia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Ventilação Monopulmonar , Respiração com Pressão Positiva/efeitos adversos , Estudos Prospectivos , Pneumologia/métodos , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório/etiologia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Volume de Ventilação Pulmonar , Resultado do Tratamento
3.
Anesth Analg ; 123(5): 1302-1306, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27763916

RESUMO

BACKGROUND: Spray cryotherapy (SCT) of airway lesions is used to effectively palliate respiratory symptoms related to airway obstruction, but significant intraoperative hemodynamic complications have been noted. We reviewed the experience at a single institution using SCT for the treatment of obstructive airway tumors. METHODS: A retrospective review of a single institution experience with intraoperative and postoperative hemodynamic complications associated with SCT was performed. Descriptive statistics were performed. RESULTS: Between June 2009 and April 2010, 34 treatment sessions were performed on 28 patients. Median age was 60 years (range, 15-88 years). Tumor characteristics were as follows: 13 primary lung cancers (43%), 11 pulmonary metastases (50%), 1 direct extension of an esophageal cancer (3%), and 2 benign pulmonary lesions (7%). Twenty-one tumors (75%) were distal to the carina; 14 (50%) were >95% occlusive. Median procedure length was 78 minutes (range, 15-176 minutes). Eleven sessions (31%) led to severe hypotension and/or bradycardia, with 2 patients requiring cardiopulmonary resuscitation. One patient died intraoperatively after cardiac arrest; a second patient was stable intraoperatively but died within 24 hours of SCT. Four patients required reintubation and short-term mechanical ventilation. CONCLUSIONS: Unpredictable life-threatening hemodynamic instability can follow endobronchial SCT. We propose that the most likely cause is pulmonary venous gaseous emboli entering the right heart, the coronary arteries, and the systemic circulation. Although SCT may offer advantages over airway laser therapy (such as no risk of fire and rapid hemostasis), further study is needed to delineate the relative likelihood of therapeutic benefit versus catastrophic complications.


Assuntos
Obstrução das Vias Respiratórias/terapia , Crioterapia/efeitos adversos , Hemodinâmica/fisiologia , Sprays Orais , Traqueia/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Obstrução das Vias Respiratórias/diagnóstico , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Masculino , Pessoa de Meia-Idade , Respiração Artificial/efeitos adversos , Respiração Artificial/métodos , Estudos Retrospectivos , Traqueia/efeitos dos fármacos , Resultado do Tratamento , Adulto Jovem
4.
Anesth Analg ; 126(1): 367, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29135591
5.
Anesth Analg ; 106(2): 379-83, table of contents, 2008 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-18227288

RESUMO

BACKGROUND: Some anesthesiologists choose smaller than body size-appropriate left sided double-lumen tubes (DLTs) ("down-size") for lung isolation in an attempt to limit the risk of airway trauma. There are few data on the effects of DLT size on intraoperative outcome measures. METHODS: In 300 adults undergoing thoracic surgery requiring lung isolation, we conducted a prospective pilot study to evaluate whether the use of 35 FR DLT, regardless of gender and/or height (care standard of two investigators), was associated with a similar incidence of intraoperative hypoxemia, lung isolation failure, or need for DLT repositioning during surgery (noninferiority) than with the conventional goal of inserting the largest possible DLT (care standard of two other investigators). DLT insertion position was immediately confirmed with fiberoptic bronchoscopy after direct laryngoscopic placement and after lateral positioning. RESULTS: The combined incidence of transient hypoxemia, inadequate lung isolation, or need for DLT repositioning during surgery did not differ among patients receiving 35, 37, or 39 FR DLT, regardless of gender or height. Despite the high frequency of 35 FR DLT use, 2% of patients required further down-sizing due to the inability to introduce the DLT into the left mainstem bronchus or when no inflation of the bronchial cuff was needed for lung isolation. CONCLUSIONS: Under the conditions of this pilot study, the use of smaller than conventionally sized DLT was not associated with any differences in clinical intraoperative outcomes.


Assuntos
Comportamento de Escolha , Intubação Intratraqueal/instrumentação , Prática Profissional , Procedimentos Cirúrgicos Torácicos/instrumentação , Idoso , Desenho de Equipamento/efeitos adversos , Feminino , Humanos , Complicações Intraoperatórias/prevenção & controle , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Procedimentos Cirúrgicos Torácicos/efeitos adversos
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