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OBJECTIVES: The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN: Multicenter, randomized, single-blind, controlled trial. SETTING: Sixteen Italian hospitals. PARTICIPANTS: A total of 880 patients undergoing elective major lung resection. INTERVENTIONS: Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS: ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS: In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.
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Ventilación Unipulmonar , Síndrome de Dificultad Respiratoria , Adulto , Humanos , Método Simple Ciego , Pulmón , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Síndrome de Dificultad Respiratoria/epidemiología , Síndrome de Dificultad Respiratoria/etiología , Volumen de Ventilación Pulmonar , Peso CorporalRESUMEN
CASE PRESENTATION: A 30-year-old transgender woman who was HIV positive presented to the ED with progressive severe dyspnea and hemoptysis that started 1 day earlier. The patient was undergoing antiretroviral therapy with emtricitabine-rilpivirine-tenofovir with good compliance and feminizing hormone therapy with cyproterone acetate. She was otherwise healthy and was not taking any other medications.
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Técnicas Cosméticas/efectos adversos , Embolia/complicaciones , Hemoptisis/etiología , Síndrome de Dificultad Respiratoria/etiología , Insuficiencia Respiratoria/etiología , Siliconas/efectos adversos , Adulto , Antagonistas de Andrógenos/uso terapéutico , Fármacos Anti-VIH/uso terapéutico , Acetato de Ciproterona/uso terapéutico , Disnea/etiología , Embolia/diagnóstico por imagen , Embolia/patología , Embolia/fisiopatología , Combinación Emtricitabina, Rilpivirina y Tenofovir/uso terapéutico , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/tratamiento farmacológico , Hemoptisis/patología , Hemoptisis/fisiopatología , Humanos , Inyecciones , Masculino , Respiración Artificial , Síndrome de Dificultad Respiratoria/diagnóstico por imagen , Síndrome de Dificultad Respiratoria/fisiopatología , Síndrome de Dificultad Respiratoria/terapia , Insuficiencia Respiratoria/diagnóstico por imagen , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapia , Tomografía Computarizada por Rayos X , Personas TransgéneroRESUMEN
BACKGROUND: The delayed graft function (DGF) in kidney transplantation (KT) is a risk factor for long-term poor graft survival. The pathogenesis is multifactorial but mainly related to an ischemia-reperfusion injury. However, the graft hemodynamics have been recently identified as a key aspect for early DGF risk assessment and potential therapeutic intervention. METHODS: A pilot study on 20 single kidney grafts from donor after brain death with intraoperative measurement of graft arterial flowmetry, 30 minutes after reperfusion. Exclusion criteria were grafts with multiple arteries or severe atherosclerosis of the recipient's external iliac artery. RESULTS: KT recipients with DGF (n = 4, 20%) were homogenous with controls (n = 16) in terms of cold ischemia time, donor age, recipients' hemodynamic parameters, renal artery, and recipients' external iliac artery diameters. Nonetheless, at transplant, the kidney grafts that developed DGF were characterized by a significantly higher renal artery resistive index (DGF vs no-DGF 0.96 ± 0.04 vs 0.77 ± 0.13, P = .02), as well as lower flow extraction rate (24.8% ± 11.8 vs 59.2% ± 21.1, P < .01). CONCLUSIONS: Intraoperative arterial graft flowmetry seems to be an effective tool to identify grafts at high risk of DGF.
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Funcionamiento Retardado del Injerto/diagnóstico por imagen , Trasplante de Riñón/efectos adversos , Monitoreo Intraoperatorio/estadística & datos numéricos , Reología/estadística & datos numéricos , Ultrasonografía Doppler/estadística & datos numéricos , Adulto , Funcionamiento Retardado del Injerto/fisiopatología , Femenino , Supervivencia de Injerto , Hemodinámica , Humanos , Riñón/irrigación sanguínea , Trasplante de Riñón/métodos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Proyectos Piloto , Valor Predictivo de las Pruebas , Arteria Renal/fisiopatología , Daño por Reperfusión/diagnóstico por imagen , Daño por Reperfusión/fisiopatología , Estudios Retrospectivos , Reología/métodos , Medición de Riesgo , Factores de Riesgo , Trasplantes/irrigación sanguínea , Ultrasonografía Doppler/métodosRESUMEN
BACKGROUND: One-lung ventilation (OLV) in thoracic anesthesia is required to provide good surgical exposure. OLV is commonly achieved through a double lumen tube (DLT) or a bronchial blocker (BB). Malposition is a relevant issue related to these devices use. No prospective studies with adequately large sample size have been performed to evaluate the malposition rate of DLTs and BBs. METHODS: A total of 2,127 patients requiring OLV during thoracic surgery were enrolled. The aim of this multicenter prospective observational study performed across 26 academic and community hospitals is to evaluate intraoperative malposition rate of DLTs and BBs. We also aim to assess: which device is the most used to achieve OLV, the frequency of bronchoscope (BRO) use, the incidence rate of desaturation during OLV and the role of other factors that can correlate to this event, and incidence of difficult airway. RESULTS: Malposition rate for DLTs was 14%, for BBs 33%. DLTs were used in 95% of patients and BBs in 5%. Mean positioning time was shorter for DLT than BB (156±230 vs. 321±290 s). BRO was used in 54% of patients to check the correct positioning of the DLT. Desaturation occurred in 20% of all cases during OLV achieved through a DLT. Predicting factors of desaturation were dislocation (OR 2.03) and big size of DLT (OR 1.15). BRO use (OR 0.69) and left surgical side (OR 0.41) proved to be protective factors. Difficult airway prevalence was 16%; 10.8% predicted and 5.2% unpredicted. CONCLUSIONS: DLT has a low malpositioning rate and is the preferred device to achieve OLV. BRO use recorded was unexpectedly low. The possibility of encountering a difficult airway is frequent, with an overall prevalence of 16%. Risk factors of desaturation are malposition and increased size of DLT. Left procedures and BRO use could lead to fewer episodes of desaturation.
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Of the various muscles that make up the respiratory system, the diaphragm is the prima donna. In the past, only specialist research centers were able to estimate and challenge the effort of this muscle; this was achieved by measuring transdiaphragmatic pressure-an invasive technique involving a double-balloon probe inserted through the esophagus-or by measuring twitch pressure (ie, the pressure generated at the outside tip of the endotracheal tube). However, the prevalence of diaphragm dysfunction in critically ill patients requiring intubation can exceed 60% (at the time of hospital admission) and may rise to as high as 80% in patients requiring prolonged mechanical ventilation and experiencing difficult weaning. Although still in its infancy, modern ultrasound (US) provides a fascinating way to study the diaphragm, permitting the assessment of its excursion, thickness, and thickening. Furthermore, US enables the course of diaphragmatic function to be followed on a day-to-day basis, from intensive care admission to discharge, and it can help us understand the different causes of underlying disease: trauma, infection (eg, sepsis-induced diaphragm dysfunction), cancer, weaning problems (eg, ventilation-induced diaphragm dysfunction), etc. Today, the assessment of diaphragm dysfunction with US provides an important first step toward improving the detection of diaphragm dysfunction and as a protective and supportive strategy for its management. The purposes of this review are as follows: (1) to explore which US method is best for evaluating diaphragm function in the intensive care unit and how and when it should be used, and (2) to discuss which diseases may involve the diaphragm, and what therapies should be used.
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Cuidados Críticos/métodos , Diafragma/diagnóstico por imagen , Diafragma/fisiopatología , Ultrasonografía Intervencional/métodos , HumanosRESUMEN
During liver transplantation surgery, the pulmonary artery catheter-despite its invasiveness-remains the gold standard for measuring cardiac output. However, the new EV1000 transpulmonary thermodilution calibration technique was recently introduced into the market by Edwards LifeSciences. We designed a single-center prospective observational study to determine if these two techniques for measuring cardiac output are interchangeable in this group of patients. Patients were monitored with both pulmonary artery catheter and the EV1000 system. Simultaneous intermittent cardiac output measurements were collected at predefined steps: after induction of anesthesia (T1), during the anhepatic phase (T2), after liver reperfusion (T3), and at the end of the surgery (T4). The 4-quadrant and polar plot techniques were used to assess trending ability between the two methods. We enrolled 49 patients who underwent orthotopic liver transplantation surgery. We analyzed a total of 588 paired measurements. The mean bias between pulmonary artery catheter and the EV1000 system was 0.35 L/min with 95% limits of agreement of - 2.30 to 3.01 L/min, and an overall percentage error of 35%. The concordance rate between the two techniques in 4-quadrant plot analysis was 65% overall. The concordance rate of the polar plot showed an overall value of 83% for all pairs. In the present study, in liver transplantation patients we found that intermittent cardiac output monitoring with EV1000 system showed a percentage error compared with pulmonary artery catheter in the acceptable threshold of 45%. On the others hand, our results showed a questionable trending ability between the two techniques.
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Gasto Cardíaco , Enfermedad Hepática en Estado Terminal/cirugía , Trasplante de Hígado , Monitoreo Intraoperatorio/métodos , Adulto , Anciano , Anestesia , Anestesiología , Cateterismo de Swan-Ganz , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Reproducibilidad de los Resultados , Termodilución , Resultado del TratamientoRESUMEN
BACKGROUND: While interscalenic nerve block (INB) is still considered the gold standard for shoulder arthroscopy, its postoperative analgesic effectiveness has recently been called into question. Meanwhile, in light of its high-quality postoperative pain relief, a renewed interest has emerged in suprascapular nerve block (SNB). The first aim of our study was to compare the postoperative analgesia effects of these two types of block at two, four and six hours after surgery. We also assessed shoulder functional recovery over a 6-month follow-up period. METHODS: All patients requiring arthroscopic shoulder surgery for rotator cuff repair during the study period were enrolled. INB or SNB was performed under ultrasound guidance. The patients underwent general anaesthesia. Numerical rate scores (NRS) at rest and in motion at two, four and six postoperative hours were recorded. RESULTS: Over two years, 280 patients were screened. Of these, 136 were excluded. Pain scores after surgery were lower at two hours in INB at rest (0.70±1.50 versus 2.1±2.2; P<0.0067) and after movement (1.0±2.2 versus 2.5±2.3; P=0.01). A significant difference in terms of arm extrarotation degrees at week 6 and month 2 (P<0.01) in SNB was found. CONCLUSIONS: INB showed better analgesic efficacy in the immediate postoperative period. Both types of block showed similar results in terms of functional recovery over the six-month follow-up. SNB without motor block seems matched better with ambulatory surgery and with an early rehabilitation program.
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Analgesia/métodos , Bloqueo del Plexo Braquial/métodos , Dolor Postoperatorio/prevención & control , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Recuperación de la Función , Estudios Retrospectivos , Hombro/fisiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND: The aim of this study was to evaluate pre- and post-operative brain natriuretic peptide (BNP) levels and compare the power of this test in predicting in-hospital major adverse cardiac events (MACE: atrial fibrillation, flutter, acute heart failure or non-fatal/fatal myocardial infarction) in patients undergoing elective prosthesis orthopedic surgery to that of the Revised Cardiac Risk Index (RCRI) and American Society of Anesthesiology (ASA) class, the most useful scores identified to date. METHODS: The study was an observational study of consecutive patients undergoing elective prosthesis orthopedic surgery. Surgical risk was established using RCRI score and ASA class criteria. Venous blood was sampled before surgery and on postoperative day 1 for the measurement of BNP. The intraoperative data collected included details of the surgery and anesthesia and any MACE experienced up until hospital discharge. RESULTS: MACE occurred in 14 of the 227 patients treated (6.2%). Age was statistical associated with MACE (p < 0.004). Preoperative BNP levels were higher (p < 0.0007) in patients who experienced MACE than in event-free patients (median values: 92 and 35 pg/mL, respectively). Postoperative BNP levels were also greater (p < 0.0001) in patients sustaining MACE than in event-free patients (median values: 165 and 45 pg/mL, respectively). ROC curve analysis demonstrated that for a cut-off point ≥ 39 pg/mL, the area under the curve for preoperative BNP was equal to 0.77, while a postoperative BNP cut-off point ≥ 69 pg/mL gave an AUC of 0.82. CONCLUSIONS: Both pre- and post-operative BNP concentrations are predictors of MACE in patients undergoing elective prosthesis orthopedic surgery.
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Enfermedades Cardiovasculares/sangre , Procedimientos Quirúrgicos Electivos/efectos adversos , Péptido Natriurético Encefálico/sangre , Procedimientos Ortopédicos/efectos adversos , Complicaciones Posoperatorias/sangre , Anciano , Anciano de 80 o más Años , Anestesiología/normas , Biomarcadores/sangre , Enfermedades Cardiovasculares/diagnóstico , Enfermedades Cardiovasculares/epidemiología , Femenino , Humanos , Masculino , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/epidemiología , Valor Predictivo de las Pruebas , Factores de Riesgo , Sociedades Médicas/normasRESUMEN
OBJECTIVE: The object of this study was to conduct and analyze the output of a survey involving a cohort of all Italian hospitals performing thoracic surgery to gather data on anesthetic management, one-lung ventilation (OLV) management, and post-thoracotomy pain relief in thoracic anesthesia. DESIGN: Survey. SETTING: Italy. PARTICIPANTS: An invitation to participate in the survey was e-mailed to all the members of the Italian Society of Anesthesia and Intensive Care Medicine. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: A total of 62 responses were received from 47 centers. The key findings were: Double-lumen tube is still the first choice lung separation technique in current use; pressure-controlled ventilation and volume-controlled ventilation modes are homogenously distributed across the sample and, a tidal volumes (VT) of 4-6 mL/kg during OLV was preferred to all others; moderate or restrictive fluid management were the most used strategies of fluid administration in thoracic anesthesia; thoracic epidural analgesia represented the "gold standard" for post-thoracotomy pain relief in combination with intravenous analgesia. CONCLUSION: The results of this survey showed that Italian anesthesiologist follow the recommended standard of care for anesthetic management during OLV.
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Anestesia/tendencias , Anestesiología/tendencias , Procedimientos Quirúrgicos Torácicos/tendencias , Manejo de la Vía Aérea/estadística & datos numéricos , Manejo de la Vía Aérea/tendencias , Anestesia/estadística & datos numéricos , Anestesiología/estadística & datos numéricos , Estudios de Cohortes , Monitores de Conciencia , Fluidoterapia/estadística & datos numéricos , Fluidoterapia/tendencias , Encuestas de Atención de la Salud , Humanos , Italia , Monitoreo Intraoperatorio , Ventilación Unipulmonar , Dolor Postoperatorio/tratamiento farmacológico , Encuestas y Cuestionarios , Procedimientos Quirúrgicos Torácicos/estadística & datos numéricos , Toracotomía/efectos adversosRESUMEN
INTRODUCTION: Total hip replacement is one of the most commonly performed major orthopaedic operations. Goal-directed therapy (GDT) using haemodynamic monitoring has previously demonstrated outcome benefits in high-risk surgical patients under general anaesthesia. GDT has never been formally assessed during regional anaesthesia. METHODS: Patients undergoing total hip replacement while under regional anaesthesia were randomised to either the control group (CTRL) or the protocol group (GDT). Patients in the GDT group, in addition to standard monitoring, were connected to the FloTrac sensor/Vigileo monitor haemodynamic monitoring system, and a GDT protocol was used to maximise the stroke volume and target the oxygen delivery index to > 600 mL/minute/m2. RESULTS: Patients randomised to the GDT group were given a greater volume of intravenous fluids during the intraoperative period (means ± standard deviation (SD): 6,032 ± 1,388 mL vs. 2,635 ± 346 mL; P < 0.0001), and more of the GDT patients received dobutamine (0 of 20 CTRL patients vs. 11 of 20 GDT patients; P < 0.0003). The GDT patients also received more blood transfused during the intraoperative period (means ± SD: 595 ± 316 mL vs. 0 ± 0 mL; P < 0.0001), although the CTRL group received greater volumes of blood replacement postoperatively (CTRL patients 658 ± 68 mL vs. GDT patients 198 ± 292 mL; P < 0.001). Overall blood consumption (intraoperatively and postoperatively) was not different between the two groups. There were an increased number of complications in the CTRL group (20 of 20 CTRL patients (100%) vs. 16 of 20 GDT patients (80%); P = 0.05). These outcomes were predominantly due to a difference in minor complications (20 of 20 CTRL patients (100%) vs. 15 of 20 GDT patients (75%); P = 0.047). CONCLUSIONS: GDT applied during regional anaesthesia in patients undergoing elective total hip replacement changes intraoperative fluid management and may improve patient outcomes by decreasing postoperative complications. Larger trials are required to confirm our findings.
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Anestesia de Conducción , Artroplastia de Reemplazo de Cadera/métodos , Fluidoterapia/métodos , Hemodinámica/fisiología , Cuidados Intraoperatorios/métodos , Anciano , Procedimientos Quirúrgicos Electivos , Estudios de Factibilidad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Fisiológico , Complicaciones Posoperatorias/prevención & control , Resultado del TratamientoRESUMEN
BACKGROUND: We prospectively followed patients who underwent esthetic abdominoplasty and flank liposuction to determine the influence of the amount of fat removed on the occurrence of pulmonary embolism. MATERIALS AND METHODS: We recruited patients undergoing abdominoplasties and flank liposuction and composed 2 groups according to the amount of fat removed, one of small resections (<1500 g) and the other of great resections (>1500 g). All patients received deep vein thrombosis prophylaxis. RESULTS: Since January 2005, we enrolled 103 patients and registered 3 embolisms (2.9%). All occurred in nonsmokers, had no risk factor for deep vein thrombosis, and a resection weight greater than 1500 g (21.4%; 3/14). The calculated relative risk conferred by the amount of fat greater than 1500 g was 7.4. An association was also found with duration of surgery: all embolisms occurred in patients that underwent long operation (>140 minutes; 8.8%; 3/34) with a relative risk of 3.0. CONCLUSIONS: The amount of fat removed during plastic surgery is a factor influencing the occurrence of pulmonary embolism in patients undergoing abdominoplasty/flank liposuction, and the duration of surgery is a concomitant factor. Should this data be confirmed, specific measures for prevention of this serious complication could be developed.