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PURPOSE: To demonstrate the utility of machine learning models for predicting difficult airways using clinical and ultrasound parameters. METHODS: This is a prospective non-consecutive cohort of patients undergoing elective surgery. We collected as predictor variables age, sex, BMI, OSA, Mallampatti, thyromental distance, bite test, cervical circumference, cervical ultrasound measurements, and Cormack-Lehanne class after laryngoscopy. We univariate analyzed the relationship of the predictor variables with the Cormack-Lehanne class to design machine learning models by applying the random forest technique with each predictor variable separately and in combination. We found each design's AUC-ROC, sensitivity, specificity, and positive and negative predictive values. RESULTS: We recruited 400 patients. Cormack-Lehanne patients≥III had higher age, BMI, cervical circumference, Mallampati class membership≥III, and bite test≥II and their ultrasound measurements were significantly higher. Machine learning models based on physical examination obtained better AUC-ROC values than ultrasound measurements but without reaching statistical significance. The combination of physical variables that we call the "Classic Model" achieved the highest AUC-ROC value among all the models [0.75 (0.67-0.83)], this difference being statistically significant compared to the rest of the ultrasound models. CONCLUSIONS: The use of machine learning models for diagnosing VAD is a real possibility, although it is still in a very preliminary stage of development. CLINICAL REGISTRY: ClinicalTrials.gov: NCT04816435.
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The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Manuseio das Vias Aéreas , Humanos , Manuseio das Vias Aéreas/normas , Manuseio das Vias Aéreas/métodos , Medicina de Emergência/normas , Adulto , Intubação IntratraquealRESUMO
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Manuseio das Vias Aéreas , Humanos , Manuseio das Vias Aéreas/normas , Manuseio das Vias Aéreas/métodos , Medicina de Emergência/normas , Adulto , Intubação IntratraquealRESUMO
INTRODUCTION AND OBJECTIVE: The implementation of Enhanced Recover After Surgery (ERAS) multimodal rehabilitation protocols in radical cystectomy has shown to improve outcomes in hospital stay and complications. The aim of this analysis is to evaluate the impact of laparoscopic surgery on radical cystectomy within a multimodal rehabilitation program. MATERIAL AND METHODS: The study was carried out in a third level center between 2011 and 2020 including patients with bladder cancer submitted to radical cystectomy according to an ERAS (Enhanced Recovery After Surgery) protocol and the Spanish Multimodal Rehabilitation Group (GERM) with 20 items to be fulfilled. RESULTS: A total of 250 radical cystectomies were performed throughout the study period, 42.8% by open surgery (OS) and 57.2% by laparoscopic surgery (LS). The groups are comparable in demographic and clinical variables (pâ¯>â¯0.05). Operative time was longer in the LS group (248.4⯱â¯55.0 vs. 286.2⯱â¯51.9â¯min; pâ¯<â¯0.001). However, bleeding was significantly lower in the LS group (417.5⯱â¯365.7 vs. 877.9⯱â¯529.7 cc; pâ¯<â¯0.001), as was the need for blood transfusion (33.6% vs. 58.9%; pâ¯<â¯0.001). Postoperative length of stay (11.5⯱â¯10.5 vs. 20.1⯱â¯17.2 days; pâ¯<â¯0.001), total and major complications were also significantly lower in this group (LS). The readmission rate was lower in the LS group but not significantly (36.4% vs. 29.4%; pâ¯=â¯0.237). The difference between 90-day mortality in both groups was not statistically significant (2.8% LS vs. 4.3% OS; pâ¯=â¯0.546). The differences were maintained in the multivariate models. CONCLUSIONS: Laparoscopic surgery within a multimodal rehabilitation program increases operative time but significantly decreases intraoperative bleeding, transfusion requirements, postoperative length of stay, and complications.
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Cistectomia , Laparoscopia , Neoplasias da Bexiga Urinária , Humanos , Cistectomia/reabilitação , Cistectomia/métodos , Masculino , Laparoscopia/reabilitação , Feminino , Neoplasias da Bexiga Urinária/cirurgia , Neoplasias da Bexiga Urinária/reabilitação , Idoso , Resultado do Tratamento , Pessoa de Meia-Idade , Recuperação Pós-Cirúrgica Melhorada , Estudos Retrospectivos , Complicações Pós-Operatórias/epidemiologia , Protocolos Clínicos , Tempo de Internação/estatística & dados numéricos , Terapia CombinadaRESUMO
The TotaltrackTM is a new video laryngeal mask, which combines a supraglottic airway with a videolaryngoscope. We evaluated the performance of this device in an observational study in 300 adult patients. The Totaltrack was inserted at the first attempt and the glottis seen in all cases. In 249 patients (83%; 95%CI 78.7-87.3%) the glottis was seen at the first attempt. Adequate ventilation and tracheal intubation were achieved in all patients. The median time to visualisation of vocal cords, to confirmation of ventilation and to successful tracheal intubation was 5 s, 13 s and 24 s, respectively. Nineteen patients (6.3%; 95%CI 3.55-9.05%) suffered minor complications, such as mucosal lesion or blood staining. The Totaltrack appears effective for airway management.
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Manuseio das Vias Aéreas/instrumentação , Máscaras Laríngeas , Gravação de Videoteipe/instrumentação , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Manuseio das Vias Aéreas/métodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto JovemRESUMO
Healthcare is in constant transformation. Health systems should focus on improving efficiency to meet a growing demand for high-quality, low-cost health care. The operating room is one of the biggest sources of revenue and one of the largest areas of expense. Therefore, operating room management is a critical key to success. The aim of this article is to analyze the current principles of organization, optimization and clinical management of the operating room and its impact on the quality and safety of care.
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Eficiência Organizacional , Salas Cirúrgicas/organização & administração , Duração da Cirurgia , Qualidade da Assistência à Saúde , Emergências , Salas Cirúrgicas/estatística & dados numéricos , Fatores de TempoRESUMO
The importance of the safety of our patients in the surgical theatre, has driven many projects. The majority of them aimed at better control and clinical performance; mainly of the variables that intervene or modulate the results of surgical procedures, and have a direct relationship with them. The Spanish Society of Anesthesiology, Critical Care and Therapeutic Pain (SEDAR), maintains a constant concern for a variable that clearly determines the outcomes of our clinical processes, "unintentional hypothermia" that develops in all patients undergoing an anesthetic or surgical procedure. SEDAR has promoted, in collaboration with other scientific Societies and patient Associations, the elaboration of this clinical practice guideline, which aims to answer clinical questions not yet resolved and for which, up to now, there are no documents based in the best scientific evidence available. With GRADE methodology and technical assistance from the Ibero-American Cochrane Collaboration office, this clinical practice guideline presents three recommendations (weak in favor) for active heating methods for the prevention of hypothermia (skin, fluid or gas); three for the prioritization of strategies for the prevention of hypothermia (too weak in favor and one strongly in favor); two of preheating strategies prior to anesthetic induction (both weak in favor); and two for research.
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Hipotermia/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Reaquecimento/métodos , Adulto , Anestesia/efeitos adversos , Transfusão de Sangue , Medicina Baseada em Evidências , Hidratação , Prioridades em Saúde , Humanos , Hipotermia/etiologia , Hipotermia/fisiopatologia , Hipotermia/terapia , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/terapia , Monitorização Intraoperatória/métodos , Estudos Observacionais como Assunto , Cuidados Pré-Operatórios , Ensaios Clínicos Controlados Aleatórios como Assunto , Reaquecimento/instrumentação , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Termometria/métodosRESUMO
BACKGROUND: The aim of this study was to evaluate postoperative complications in patients having major elective surgery using oesophageal Doppler monitor-guided goal-directed haemodynamic therapy (GDHT), in which administration of fluids, inotropes, and vasopressors was guided by stroke volume, mean arterial pressure, and cardiac index. METHODS: The FEDORA trial was a prospective, multicentre, randomised, parallel-group, controlled patient- and observer-blind trial conducted in adults scheduled for major elective surgery. Randomization and allocation were carried out by a central computer system. In the control group, intraoperative fluids were given based on traditional principles. In the GDHT group, the intraoperative goals were to maintain a maximal stroke volume, with mean arterial pressure >70 mm Hg, and cardiac index ≥2.5 litres min-1 m-2. The primary outcome was percentage of patients with moderate or severe postoperative complications during the first 180 days after surgery. RESULTS: In total, 450 patients were randomized to the GDHT group (n=224) or control group (n=226). Data from 420 subjects were analysed. There were significantly fewer with complications in the GDHT group (8.6% vs 16.6%, P=0.018). There were also fewer complications (acute kidney disease, pulmonary oedema, respiratory distress syndrome, wound infections, etc.), and length of hospital stay was shorter in the GDHT group. There was no significant difference in mortality between groups. CONCLUSIONS: Oesophageal Doppler monitor-guided GDHT reduced postoperative complications and hospital length of stay in low-moderate risk patients undergoing intermediate risk surgery, with no difference in mortality at 180 days. CLINICAL TRIAL REGISTRATION: ISRCTN93543537.
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Cardiotônicos/administração & dosagem , Hidratação/métodos , Hemodinâmica/fisiologia , Complicações Pós-Operatórias/terapia , Ultrassonografia de Intervenção/métodos , Vasoconstritores/administração & dosagem , Procedimentos Cirúrgicos Eletivos , Esôfago , Feminino , Objetivos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Risco , Ultrassonografia Doppler/métodosAssuntos
Abdome/cirurgia , Compartimentos de Líquidos Corporais/fisiologia , Hidratação/normas , Assistência Perioperatória/normas , Complicações Pós-Operatórias/prevenção & controle , Débito Cardíaco/efeitos dos fármacos , Coloides/uso terapêutico , Soluções Cristaloides , Endotélio Vascular/fisiopatologia , Hidratação/métodos , Glicocálix/fisiologia , Hemodinâmica/efeitos dos fármacos , Humanos , Soluções Isotônicas/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Estresse Fisiológico , Desequilíbrio Hidroeletrolítico/fisiopatologia , Desequilíbrio Hidroeletrolítico/prevenção & controle , Desequilíbrio Hidroeletrolítico/terapiaAssuntos
Abdome/cirurgia , Hidratação/normas , Hemodinâmica/efeitos dos fármacos , Assistência Perioperatória/normas , Resistência Vascular/efeitos dos fármacos , Vasoconstrição/efeitos dos fármacos , Anestésicos/farmacologia , Débito Cardíaco/efeitos dos fármacos , Cardiotônicos/administração & dosagem , Cardiotônicos/uso terapêutico , Hidratação/métodos , Objetivos , Humanos , Hipotensão/fisiopatologia , Hipotensão/prevenção & controle , Hipotensão/terapia , Consumo de Oxigênio , Oxigenoterapia , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/terapia , Soluções/administração & dosagem , Soluções/efeitos adversos , Soluções/farmacologia , Soluções/uso terapêutico , Vasoconstritores/administração & dosagem , Vasoconstritores/uso terapêutico , Vasodilatação/efeitos dos fármacos , Desequilíbrio Hidroeletrolítico/fisiopatologia , Desequilíbrio Hidroeletrolítico/prevenção & controle , Desequilíbrio Hidroeletrolítico/terapiaAssuntos
Abdome/cirurgia , Hidratação/normas , Hemodinâmica/efeitos dos fármacos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/prevenção & controle , Volume Sanguíneo/efeitos dos fármacos , Permeabilidade Capilar , Débito Cardíaco/efeitos dos fármacos , Hidratação/efeitos adversos , Hidratação/métodos , Objetivos , Humanos , Microcirculação , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/terapia , Soluções/administração & dosagem , Soluções/efeitos adversos , Soluções/uso terapêutico , Volume Sistólico/efeitos dos fármacos , Vasodilatação , Desequilíbrio Hidroeletrolítico/fisiopatologia , Desequilíbrio Hidroeletrolítico/prevenção & controle , Desequilíbrio Hidroeletrolítico/terapiaRESUMO
There are currently various projects underway that attempt to monitor the nociceptive responses caused by surgical stress and ensure patients the best analgesic conditions. The systemic response to surgical stress has repercussions in the postoperative period, such as worse pain control, delayed recovery, greater complications, longer stay in resuscitation and hospital units, and increased healthcare costs. However, treatment with higher doses of opioids than necessary may lead to slower awakening, increased drowsiness and adverse effects, as well as situations of postoperative opioid-induced hyperalgesia. There are 2 large groups of nociceptive monitoring according to the origin of the theoretical objective of monitoring response to the stimulus, that may derive from changes in the electroencephalogram or the response of the autonomic nervous system.
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Monitorização Neurofisiológica Intraoperatória/métodos , Nociceptividade/fisiologia , Eletroencefalografia , HumanosRESUMO
OBJECTIVE: To evaluate the results of the implementation of an enhanced recovery program (ERAS) for open approach radical cystectomy compared to the historical cohort of the same hospital. MATERIAL AND METHODS: A retrospective analysis of 138 consecutive patients who underwent radical cystectomy with Bricker or Studer ileal derivation (97 historical vs. 41 ERAS). Overall complication rate, Clavien-Dindo stage>2 complications, mortality, hospital and critical care length of stay and readmission rates, as well as need for reoperation, nasogastric intubation, transfusion or parenteral nutrition were compared. RESULTS: No statistically significant differences in overall complication rate were found (73.171 vs. 77.32%; OR 1.25, 95% CI 0.54-2.981; P=.601) nor in Clavien-Dindo>2 complications (41.463 vs. 42.268%; OR 1.033, 95% CI 0.492-2.167; P=.93), mortality, lengths of stays readmission and reoperation rates. The need for nasogastric tube insertion was lower in the ERAS group (43.902 vs. 78.351%; OR 4.624, 95% CI 2.112-10.123; P<.0001), as well as the need for total parenteral nutrition (26.829 vs. 34.021%; OR 12.234, 95% CI 5.165-28.92; P<.0001), and time under endotracheal intubation since anaesthesia induction (median [IRQ]=325 (285-355) vs. 540 (360-600) min; P<.0001). CONCLUSION: Enhanced recovery programs in radical cystectomy decrease interventionism on the patient without increasing morbidity and mortality.