RESUMO
BACKGROUND: The comparison between sedation and general anesthesia (GA) in terms of all-cause mortality remains a subject of ongoing debate. The primary objective of our study was to investigate the impact of GA and sedation on all-cause mortality in order to provide clarity on this controversial topic. METHODS: A systematic review and meta-analysis were conducted, incorporating cohort studies and RCTs about postoperative all-cause mortality. Comprehensive searches were performed in the PubMed, EMBASE, and Cochrane Library databases, with the search period extending until February 28, 2023. Two independent reviewers extracted the relevant information, including the number of deaths, survivals, and risk effect values at various time points following surgery, and these data were subsequently pooled and analyzed using a random effects model. RESULTS: A total of 58 studies were included in the analysis, with a majority focusing on endovascular surgery. The findings of our analysis indicated that, overall, and in most subgroup analyses, sedation exhibited superiority over GA in terms of in-hospital and 30-day mortality. However, no significant difference was observed in subgroup analyses specific to cerebrovascular surgery. About 90-day mortality, the majority of studies centered around cerebrovascular surgery. Although the overall pooled results showed a difference between sedation and GA, no distinction was observed between the pooled ORs and the subgroup analyses based on RCTs and matched cohort studies. For one-year all-cause mortality, all included studies focused on cardiac and macrovascular surgery. No difference was found between the HRs and the results derived from RCTs and matched cohort studies. CONCLUSIONS: The results suggested a potential superiority of sedation over GA, particularly in the context of cardiac and macrovascular surgery, mitigating the risk of in-hospital and 30-day death. However, for the longer postoperative periods, this difference remains uncertain. TRIAL REGISTRATION: PROSPERO CRD42023399151; registered 24 February 2023.
Assuntos
Anestesia Geral , Humanos , Anestesia Geral/métodos , Anestesia Geral/mortalidade , Mortalidade Hospitalar , Procedimentos Endovasculares/métodos , Sedação Consciente/métodos , Sedação Consciente/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto/métodosRESUMO
OBJECTIVE: Report long-term tracheostomy outcomes in patients with COVID-19. STUDY DESIGN: Review of prospectively collected data. METHODS: Prospectively collected data were extracted for adults with COVID-19 undergoing percutaneous or open tracheostomy between April 4, 2020 and June 2, 2020 at a major medical center in New York City. The primary endpoint was weaning from mechanical ventilation. Secondary outcomes included sedation weaning, decannulation, and discharge. RESULTS: One hundred one patients underwent tracheostomy, including 48 percutaneous (48%) and 53 open (52%), after a median intubation time of 24 days (IQR 20, 31). The most common complication was minor bleeding (n = 18, 18%). The all-cause mortality rate was 15% and no deaths were attributable to the tracheostomy. Eighty-three patients (82%) were weaned off mechanical ventilation, 88 patients (87%) were weaned off sedation, and 72 patients (71%) were decannulated. Censored median times from tracheostomy to sedation and ventilator weaning were 8 (95% CI 6-11) and 18 (95% CI 14-22) days, respectively (uncensored: 7 and 15 days). Median time from tracheostomy to decannulation was 36 (95% CI 32-47) days (uncensored: 32 days). Of those decannulated, 82% were decannulated during their index admission. There were no differences in outcomes or complication rates between percutaneous and open tracheostomy. Likelihood of discharge from the ICU was inversely related to intubation time, though the clinical relevance of this was small (HR 0.97, 95% CI 0.943-0.998; P = .037). CONCLUSION: Tracheostomy by either percutaneous or open technique facilitated sedation and ventilator weaning in patients with COVID-19 after prolonged intubation. Additional study on the optimal timing of tracheostomy in patients with COVID-19 is warranted. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2849-E2856, 2021.
Assuntos
COVID-19/terapia , SARS-CoV-2 , Traqueostomia/métodos , Idoso , Extubação/mortalidade , Extubação/estatística & dados numéricos , COVID-19/mortalidade , Causas de Morte , Sedação Consciente/mortalidade , Sedação Consciente/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Estudos Prospectivos , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Fatores de Tempo , Traqueostomia/mortalidade , Resultado do Tratamento , Desmame do Respirador/mortalidade , Desmame do Respirador/estatística & dados numéricosRESUMO
OBJECTIVE: To associate the sedation level, criteria for daily interruption of sedation and mortality of patients on mechanical ventilation in an Intensive Care Unit. METHOD: Prospective, longitudinal and quantitative study conducted with patients by using the Richmond Agitation-Sedation Scale (RASS) and the Sepsis-related Organ Failure Assessment (SOFA) score, through a care protocol managed by a nurse at the unit for the daily interruption of sedation once a day. The Chi Square test was used to check the association between variables and the T test for independent analyzes. RESULTS: Participation of 204 patients. Most were male, surgical, aged between 40 and 60 years, in sedoanalgesia with fentanyl, midazolam and propofol, with sedation time of one to five days and average stay of 10.7 days. They were in moderate sedation and at high risk for mortality. There was a statistical correlation between death in patients in deep sedation, and sensitivity in relation to discharge from the Intensive Care Unit of those who underwent daily interruption of sedation and were reassessed daily. CONCLUSION: Daily interruption of sedation guided by the Richmond Agitation-Sedation Scale assists in the control of sedation, which favors the treatment and recovery of patients and guides nurses' decision making. However, in this study, it was not configured as an independent factor for predicting mortality in intensive care.
Assuntos
Sedação Consciente/mortalidade , Sedação Profunda/mortalidade , Hipnóticos e Sedativos/administração & dosagem , Respiração Artificial/mortalidade , Adulto , Cuidados Críticos , Feminino , Fentanila/administração & dosagem , Humanos , Unidades de Terapia Intensiva , Masculino , Midazolam/administração & dosagem , Pessoa de Meia-Idade , Propofol/administração & dosagem , Estudos ProspectivosRESUMO
OBJECTIVES: The aims of this study were to examine variation in the use of conscious sedation (CS) for transcatheter aortic valve replacement (TAVR) across hospitals and over time and to evaluate outcomes of CS compared with general anesthesia (GA) using instrumental variable analysis, a quasi-experimental method to control for unmeasured confounding. BACKGROUND: Despite increasing use of CS for TAVR, contemporary data on utilization patterns are lacking, and existing studies evaluating the impact of sedation choice on outcomes may suffer from unmeasured confounding. METHODS: Among 120,080 patients in the TVT (Transcatheter Valve Therapy) Registry who underwent transfemoral TAVR between January 2016 and March 2019, the relationship between anesthesia choice and TAVR outcomes was evaluated using hospital proportional use of CS as an instrumental variable. RESULTS: Over the study period, the proportion of TAVR performed using CS increased from 33% to 64%, and CS was used in a median of 0% and 91% of cases in the lowest and highest quartiles of hospital CS use, respectively. On the basis of instrumental variable analysis, CS was associated with decreases in in-hospital mortality (adjusted risk difference: 0.2%; p = 0.010) and 30-day mortality (adjusted risk difference: 0.5%; p < 0.001), shorter length of hospital stay (adjusted difference: 0.8 days; p < 0.001), and more frequent discharge to home (adjusted risk difference: 2.8%; p < 0.001) compared with GA. The magnitude of benefit for most endpoints was less than in a traditional propensity score-based approach, however. CONCLUSIONS: In contemporary U.S. practice, the use of CS for TAVR continues to increase, although there remains wide variation across hospitals. The use of CS for TAVR is associated with improved outcomes (including reduced mortality) compared with GA, although the magnitude of benefit appears to be less than in previous studies.
Assuntos
Anestesia Geral/tendências , Sedação Consciente/tendências , Disparidades em Assistência à Saúde/tendências , Avaliação de Processos e Resultados em Cuidados de Saúde/tendências , Padrões de Prática Médica/tendências , Substituição da Valva Aórtica Transcateter/tendências , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Sedação Consciente/efeitos adversos , Sedação Consciente/mortalidade , Feminino , Mortalidade Hospitalar/tendências , Hospitalização/tendências , Humanos , Masculino , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND/PURPOSE: General Anesthesia (GA) and conscious sedation (CS) are anesthetics for transfemoral transcatheter aortic valve replacement (TF-TAVR). We compared TF-TAVR outcomes using a novel anesthetic approach with fascia iliaca block (FIB) plus minimal CS (MCS) versus GA. METHODS: This retrospective propensity-matched study included consecutive TF-TAVR patients from January 2013 to December 2017 and dichotomized into FIB-MCS vs. GA. Data were collected from electronic records, Society of Thoracic Surgery (STS) database, and the Transcatheter Valve Therapies (TVT) Registry. Primary endpoints were operating room (OR) time, intensive care unit (ICU) and hospital length of stay (LOS). Secondary endpoints were 30-day, 1-year mortality, quality of life, 30-day re-hospitalization rate, failure of FIB-MCS, and hospital safety outcomes. RESULTS: A total of 304 TF-TAVR patients; FIB-MCS (nâ¯=â¯219) vs. GA (nâ¯=â¯85). Propensity matched 162 patients; FIB-MCS (nâ¯=â¯108) vs. GA (nâ¯=â¯54). FIB-MCS had shorter OR time (197.6⯱â¯56.3 vs. 248.2⯱â¯46.3â¯min, pâ¯<â¯0.001), ICU (67.8⯱â¯71.7 vs. 84.9⯱â¯72.1â¯h, pâ¯=â¯0.004) and hospital LOS (3.2⯱â¯3.7 vs. 5.9⯱â¯3.5 d, pâ¯<â¯0.001). FIB-MCS had lower rate of blood transfusion. FIB-MCA vs. GA 30-day and 1-year mortality were similar in the entire (2.3 vs. 2.4%, pâ¯=â¯1.0; and 8.2 vs. 5.9%, pâ¯=â¯0.49) and matched cohorts (0 vs. 3.7%, pâ¯=â¯0.11 and 7.4 vs. 5.6%, pâ¯=â¯0.75). FIB-MCS were less likely to be re-hospitalized [Odd Ratio: 0.32, CI:0.13-0.76] and 2% to 3% higher KCCQ-12 score. CONCLUSION: TF-TAVR using FIB-MCS is feasible and safe with shorter OR time, ICU and hospital LOS, lower risk of 30-day re-hospitalization, similar 30-day and 1-year mortality with better quality of life at 1-year follow-up.
Assuntos
Anestesia Geral , Estenose da Valva Aórtica/cirurgia , Cateterismo Periférico , Sedação Consciente , Artéria Femoral , Bloqueio Nervoso , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/mortalidade , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/mortalidade , Sedação Consciente/efeitos adversos , Sedação Consciente/mortalidade , Bases de Dados Factuais , Registros Eletrônicos de Saúde , Feminino , Humanos , Tempo de Internação , Masculino , Bloqueio Nervoso/efeitos adversos , Bloqueio Nervoso/mortalidade , Duração da Cirurgia , Readmissão do Paciente , Punções , Qualidade de Vida , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
The association between periprocedural hypotension and conscious sedation (CS) during defibrillator implantation remains to be elucidated. The aim of the present study was to compare the occurrence of periprocedural hypotension after CS or local anesthesia (LA) during defibrillator implantation in a retrospective cohort study using a national inpatient database. Using the Japanese Diagnosis Procedure Combination database, we retrospectively collected data for adult inpatients who underwent implantation of a cardioverter defibrillator or cardiac resynchronization therapy device from July 2010 to March 2016. Multivariable logistic regression analyses were performed to compare the occurrence of periprocedural hypotension between the CS and LA groups with adjustment for patient background characteristics and hospital factors. Additional analysis was performed after dividing the CS group into each specific anesthetic use. We identified 4842 patients, comprising 1533 patients with CS and 3309 with LA. The CS group had a significantly higher proportion of periprocedural hypotension than the LA group (13.4% versus 9.7%; adjusted odds ratio, 1.56; 95% confidence interval, 1.19-2.04; p = 0.001). Body mass index < 18.5 kg/m2, New York Heart Association Class IV, and use of cardiac resynchronization therapy device were independently associated with occurrence of periprocedural hypotension. Additionally, ketamine and dexmedetomidine were significantly associated with higher incidence of hypotension than the LA group (adjusted odds ratio, 2.64; 95% confidence interval, 1.32-5.26; p = 0.006; adjusted odds ratio, 1.86; 95% confidence interval, 1.11-3.12; p = 0.019, respectively). Periprocedural hypotension was significantly more likely to occur in the CS group than the LA group, and was associated with CS.
Assuntos
Anestesia Local/efeitos adversos , Pressão Sanguínea , Sedação Consciente/efeitos adversos , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Hipotensão/etiologia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Anestesia Local/mortalidade , Sedação Consciente/mortalidade , Bases de Dados Factuais , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/mortalidade , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/mortalidade , Hipotensão/fisiopatologia , Pacientes Internados , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologiaRESUMO
OBJECTIVE: Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. METHODS: Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. RESULTS: General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours;P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes;P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days;P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%;P < 0.001). There was no difference in 30-day mortality (0% vs 3%;P = 0.15). CONCLUSIONS: Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.
Assuntos
Anestesia Geral/métodos , Sedação Consciente/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Anestesia Geral/mortalidade , Anestesia Intravenosa/métodos , Sedação Consciente/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Monitorização Intraoperatória/métodos , Pontuação de Propensão , Análise de Sobrevida , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
OBJECTIVES: Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. DESIGNS: Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. RESULTS: A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. CONCLUSIONS: This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients. TRIAL REGISTRATION NUMBER: DRKS00007768; Pre-results.
Assuntos
Sedação Consciente/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Doença Aguda , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Sedação Consciente/mortalidade , Endoscopia Gastrointestinal/métodos , Endoscopia Gastrointestinal/mortalidade , Endoscopia Gastrointestinal/estatística & dados numéricos , Feminino , Alemanha/epidemiologia , Humanos , Hipnóticos e Sedativos/efeitos adversos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Propofol/efeitos adversos , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Fatores de Tempo , Adulto JovemRESUMO
Opioid and sedative use are common 'active' practices in the provision of mainstream palliative care services, and are typically distinguished from euthanasia on the basis that they do not shorten survival time. Even supposing that they did, it is often argued that they are justified and distinguished from euthanasia via appeal to Aquinas' Doctrine of Double Effect. In this essay, I will appraise the empirical evidence regarding opioid/sedative use and survival time, and argue for a position of agnosticism. I will then argue that the Doctrine of Double Effect is a useful ethical tool but is ultimately not a sound ethical principle, and even if it were, it is unclear whether palliative opioid/sedative use satisfy its four criteria. Although this essay does not establish any definitive proofs, it aims to provide reasons to doubt-and therefore weaken-the often-claimed ethical distinction between euthanasia and palliative opioid/sedative use.
Assuntos
Analgésicos Opioides/uso terapêutico , Sedação Consciente/ética , Eutanásia/ética , Cuidados Paliativos/ética , Analgésicos Opioides/efeitos adversos , Sedação Consciente/métodos , Sedação Consciente/mortalidade , Humanos , Cuidados Paliativos/métodosRESUMO
BACKGROUND: Transfemoral TAVR (tf-TAVR) under conscious sedation (CS) has become popular. The need of anesthesiologic support during tf-TAVR has been questioned. Critical events during the procedure might require immediate action. We analyzed the frequency of periprocedural critical adverse events (CAE) during tf-TAVR with CS in our institution. METHODS: Tf-TAVR has been performed at our institution since 2007. We excluded patients from the first four years to minimize the influence of any learning curve. CAE were defined as occurrence of 1.) "CPR", 2.) "defibrillation", 3.) "emergency extracorporeal circulation (ECC)" and 4.) "conversion to general anesthesia (GA) not related to 1.)-3.)". Data was prospectively collected in our AVIATOR TAVR registry. RESULTS: 601 patients were analyzed retrospectively. Overall, CAE were recorded in 54 patients (9%). CPR was necessary in 12 patients (2%) and defibrillation in 10 patients (1.6%). ECC was rarely needed (nâ¯=â¯2, 0.3%). Conversion to GA was necessary in 34 patients (5.65%). Procedure-related conversion was necessary in 10 patients. With 24 patients, sedation-related conversion occurred more frequently. Unrest and pain were the most common reasons for conversion (nâ¯=â¯13, 2%) and respiratory distress in 11 patients (2%). Catecholaminergic support was needed in 269 (45%) patients. Vasopressors were more often applied (nâ¯=â¯249, 41%) than inotropes (nâ¯=â¯59, 10%). CONCLUSION: Even in a high-volume center, CAE may occur in nearly every tenth patient. Conversion to GA was the most common CAE. Catecholaminergic support (primary vasopressor support) was needed in nearly every second patient. These points underline the necessity of a cardiac anaesthesiologist to be in the room during the procedure. SUMMARY: Despite experience, critical adverse events (CAE) still occur in TAVR patients. We analyzed the occurrence of CAE and the need for catecholaminergic support in sedated TAVR patients.
Assuntos
Estenose da Valva Aórtica/cirurgia , Sedação Consciente/efeitos adversos , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Anestesia Geral/efeitos adversos , Estenose da Valva Aórtica/mortalidade , Valvuloplastia com Balão/efeitos adversos , Reanimação Cardiopulmonar , Cardiotônicos/uso terapêutico , Catecolaminas/uso terapêutico , Sedação Consciente/mortalidade , Circulação Extracorpórea , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Vasoconstritores/uso terapêuticoRESUMO
OBJECTIVES: In the absence of a universal definition of light or deep sedation, the level of sedation that conveys favorable outcomes is unknown. We quantified the relationship between escalating intensity of sedation in the first 48 hours of mechanical ventilation and 180-day survival, time to extubation, and delirium. DESIGN: Harmonized data from prospective multicenter international longitudinal cohort studies SETTING:: Diverse mix of ICUs. PATIENTS: Critically ill patients expected to be ventilated for longer than 24 hours. INTERVENTIONS: Richmond Agitation Sedation Scale and pain were assessed every 4 hours. Delirium and mobilization were assessed daily using the Confusion Assessment Method of ICU and a standardized mobility assessment, respectively. MEASUREMENTS AND MAIN RESULTS: Sedation intensity was assessed using a Sedation Index, calculated as the sum of negative Richmond Agitation Sedation Scale measurements divided by the total number of assessments. We used multivariable Cox proportional hazard models to adjust for relevant covariates. We performed subgroup and sensitivity analysis accounting for immortal time bias using the same variables within 120 and 168 hours. The main outcome was 180-day survival. We assessed 703 patients in 42 ICUs with a mean (SD) Acute Physiology and Chronic Health Evaluation II score of 22.2 (8.5) with 180-day mortality of 32.3% (227). The median (interquartile range) ventilation time was 4.54 days (2.47-8.43 d). Delirium occurred in 273 (38.8%) of patients. Sedation intensity, in an escalating dose-dependent relationship, independently predicted increased risk of death (hazard ratio [95% CI], 1.29 [1.15-1.46]; p < 0.001, delirium hazard ratio [95% CI], 1.25 [1.10-1.43]), p value equals to 0.001 and reduced chance of early extubation hazard ratio (95% CI) 0.80 (0.73-0.87), p value of less than 0.001. Agitation level independently predicted subsequent delirium hazard ratio [95% CI], of 1.25 (1.04-1.49), p value equals to 0.02. Delirium or mobilization episodes within 168 hours, adjusted for sedation intensity, were not associated with survival. CONCLUSIONS: Sedation intensity independently, in an ascending relationship, predicted increased risk of death, delirium, and delayed time to extubation. These observations suggest that keeping sedation level equivalent to a Richmond Agitation Sedation Scale 0 is a clinically desirable goal.
Assuntos
Sedação Consciente/mortalidade , Sedação Profunda/mortalidade , Respiração Artificial/mortalidade , Extubação/estatística & dados numéricos , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Sedação Profunda/efeitos adversos , Sedação Profunda/métodos , Delírio/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/métodosRESUMO
OBJECTIVES: The aims of this study were to report on the use of local anesthesia or conscious sedation (LACS) and general anesthesia in transcatheter aortic valve replacement and to analyze the impact on outcome. BACKGROUND: Transcatheter aortic valve replacement can be performed in LACS or general anesthesia. Potential benefits of LACS, such as faster procedures and shorter hospital stays, need to be balanced with safety. METHODS: A total of 16,543 patients from the German Aortic Valve Registry from 2011 to 2014 were analyzed, and propensity-matched analyses were performed to correct for potential selection bias. RESULTS: LACS was used in 49% of patients (8,121 of 16,543). In hospital, LACS was associated with lower rates of low-output syndrome, respiratory failure, delirium, cardiopulmonary resuscitation, and death. There was no difference in paravalvular leakage (II+) between LACS and general anesthesia in the entire population (5% vs. 4.8%; p = 0.76) or in the matched population (3.9% vs. 4.9%, p = 0.13). The risk for prolonged intensive care unit stay (≥3 days) was significantly reduced with LACS (odds ratio: 0.82; 95% confidence interval [CI]: 0.73 to 0.92; p = 0.001). Thirty-day mortality was lower with LACS in the entire population (3.5% vs. 4.9%; hazard ratio [HR]: 0.72; 95% CI: 0.60 to 0.86; p < 0.001) and in the matched population (2.8% vs. 4.6%; HR: 0.6; 95% CI: 0.45 to 0.8; p < 0.001). However, no differences in 1-year mortality between both groups in the entire population (16.5% vs. 16.9%; HR: 0.93; 95% CI: 0.85 to 1.02; p = 0.140) and in the propensity-matched population (14.1% vs. 15.5%; HR: 0.90; 95% CI: 0.78 to 1.03; p = 0.130) were observed. CONCLUSIONS: Use of LACS in transcatheter aortic valve replacement is safe, with fewer post-procedural complications and lower early mortality, suggesting its broad application.
Assuntos
Anestesia Geral , Sedação Consciente , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Sedação Consciente/efeitos adversos , Sedação Consciente/mortalidade , Feminino , Alemanha , Humanos , Tempo de Internação , Masculino , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Conscious sedation is used during transcatheter aortic valve replacement (TAVR) with limited evidence as to the safety and efficacy of this practice. METHODS: The National Cardiovascular Data Registry Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry was used to characterize the anesthesia choice and clinical outcomes of all US patients undergoing elective percutaneous transfemoral TAVR between April 1, 2014, and June 30, 2015. Raw and inverse probability of treatment-weighted analyses were performed to compare patients undergoing TAVR with general anesthesia with patients undergoing TAVR with conscious sedation on an intention-to-treat basis for the primary outcome of in-hospital mortality, and secondary outcomes including 30-day mortality, in-hospital and 30-day death/stroke, procedural success, intensive care unit and hospital length-of-stay, and rates of discharge to home. Post hoc falsification end point analyses were performed to evaluate for residual confounding. RESULTS: Conscious sedation was used in 1737/10 997 (15.8%) cases with a significant trend of increasing usage over the time period studied (P for trend<0.001). In raw analyses, intraprocedural success with conscious sedation and general anesthesia was similar (98.2% versus 98.5%, P=0.31). The conscious sedation group was less likely to experience in-hospital (1.6% versus 2.5%, P=0.03) and 30-day death (2.9% versus 4.1%, P=0.03). Conversion from conscious sedation to general anesthesia was noted in 102 of 1737 (5.9%) of conscious sedation cases. After inverse probability of treatment-weighted adjustment for 51 covariates, conscious sedation was associated with lower procedural success (97.9% versus 98.6%, P<0.001) and a reduced rate of mortality at the in-hospital (1.5% versus 2.4%, P<0.001) and 30-day (2.3% versus 4.0%, P<0.001) time points. Conscious sedation was associated with reductions in procedural inotrope requirement, intensive care unit and hospital length of stay (6.0 versus 6.5 days, P<0.001), and combined 30-day death/stroke rates (4.8% versus 6.4%, P<0.001). Falsification end point analyses of vascular complications, bleeding, and new pacemaker/defibrillator implantation demonstrated no significant differences between groups after adjustment. CONCLUSIONS: In US practice, conscious sedation is associated with briefer length of stay and lower in-hospital and 30-day mortality in comparison with TAVR with general anesthesia in both unadjusted and adjusted analyses. These results suggest the safety of conscious sedation in this population, although comparative effectiveness analyses using observational data cannot definitively establish the superiority of one technique over another.
Assuntos
Anestesia Geral , Estenose da Valva Aórtica/terapia , Sedação Consciente , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Anestesia Geral/tendências , Estenose da Valva Aórtica/diagnóstico , Estenose da Valva Aórtica/mortalidade , Estenose da Valva Aórtica/fisiopatologia , Pesquisa Comparativa da Efetividade , Sedação Consciente/efeitos adversos , Sedação Consciente/mortalidade , Sedação Consciente/tendências , Feminino , Mortalidade Hospitalar , Humanos , Análise de Intenção de Tratamento , Tempo de Internação , Masculino , Alta do Paciente , Padrões de Prática Médica/tendências , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Substituição da Valva Aórtica Transcateter/tendências , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVES: We conducted a systematic review and meta-analysis to identify the potential favourable effects of local anaesthesia plus sedation (LAS) compared with general anaesthesia (GA) in transcatheter aortic valve implantation (TAVI). METHODS: Electronic databases (PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials) and the reference lists of eligible publications were screened for randomised controlled trials (RCTs) and observational studies published between 1 January 2006 and 26 June 2016 that compare LAS to GA in an adult study population undergoing TAVI. We conducted study quality assessments using the Cochrane risk of bias tool and structured the review according to PRISMA. A meta-analysis calculating the pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) under the assumption of a random-effects model was performed. Statistical heterogeneity was evaluated using the I² statistic and Cochran's Q-test. RESULTS: After database screening, one RCT and 19 observational studies were included in the review. We found no differences between LAS and GA in terms of 30-day mortality, in-hospital mortality and other endpoints that addressed safety and complication rates. LAS was associated with a shorter ICU and hospital stay and with lower rates of catecholamine administration and red blood cell transfusion. New pacemaker implantations occurred more frequently under LAS. The overall conversion rate from LAS to GA was 6.2%. CONCLUSION: For TAVI, both LAS and GA are feasible and safe. LAS may have some benefits such as increased haemodynamic stability and shorter hospital and ICU stays, but it does not impact 30-day mortality. Since there is a paucity of randomised trial data and the findings are mainly based on observational study data, this review should be considered as a hypothesis-generating article for subsequent RCTs that are required to confirm the potential favourable effects we detected for LAS. REGISTRATION NUMBER: CRD42016048398 (PROSPERO).
Assuntos
Anestesia Geral , Anestesia Local , Sedação Consciente , Substituição da Valva Aórtica Transcateter , Anestesia Geral/efeitos adversos , Anestesia Geral/mortalidade , Anestesia Local/efeitos adversos , Anestesia Local/mortalidade , Estenose da Valva Aórtica/cirurgia , Sedação Consciente/efeitos adversos , Sedação Consciente/mortalidade , Mortalidade Hospitalar , Humanos , Tempo de Internação , Complicações Pós-Operatórias/etiologia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidadeAssuntos
Anestesia Dentária/efeitos adversos , Anestesia Geral/efeitos adversos , Sedação Consciente/efeitos adversos , Anestesia Dentária/mortalidade , Anestesia Geral/mortalidade , Criança , Sedação Consciente/mortalidade , Humanos , Índia , Procedimentos Cirúrgicos Bucais , Odontopediatria , Guias de Prática Clínica como Assunto , Sociedades OdontológicasRESUMO
OBJECTIVE To identify risk factors for anesthetic-related death in pet dogs and cats. DESIGN Matched case-control study. ANIMALS 237 dogs and 181 cats. PROCEDURES Electronic medical records from 822 hospitals were examined to identify dogs and cats that underwent general anesthesia (including sedation) or sedation alone and had death attributable to the anesthetic episode ≤ 7 days later (case animals; 115 dogs and 89 cats) or survived > 7 days afterward (control animals [matched by species and hospital]; 122 dogs and 92 cats). Information on patient characteristics and data related to the anesthesia session were extracted. Conditional multivariable logistic regression was performed to identify factors associated with anesthetic-related death for each species. RESULTS The anesthetic-related death rate was higher for cats (11/10,000 anesthetic episodes [0.11%]) than for dogs (5/10,000 anesthetic episodes [0.05%]). Increasing age was associated with increased odds of death for both species, as was undergoing nonelective (vs elective) procedures. Odds of death for dogs were significantly greater when preanesthetic physical examination results were not recorded (vs recorded) or when preanesthetic Hct was outside (vs within) the reference range. Odds of death for cats were greater when intra-anesthesia records for oxygen saturation as measured by pulse oximetry were absent. Underweight dogs had almost 15 times the odds of death as nonunderweight dogs; for cats, odds of death increased with increasing body weight (but not with overweight body condition). CONCLUSIONS AND CLINICAL RELEVANCE Several factors were associated with anesthetic-related death in cats and dogs. This information may be useful for development of strategies to reduce anesthetic-related risks when possible and for education of pet owners about anesthetic risks.
Assuntos
Anestesia/veterinária , Gatos , Sedação Consciente/veterinária , Cães , Anestesia/mortalidade , Animais , Sedação Consciente/mortalidade , Hospitais Veterinários , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/veterinária , Modelos Logísticos , Análise Multivariada , Período Perioperatório/veterinária , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/veterinária , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: During the last few years there is a shift from performing Transcatheter Aortic Valve Replacement (TAVR) under general anesthesia towards conscious sedation and local anesthesia only. In the vast majority of centers, sedation is guided by a qualified anesthesiologist. In our center, all TAVR procedures are being performed under local anesthesia and mild sedation, however, since September 2014, a large portion of TAVR procedures are being performed under local anesthesia without the presence of an anesthesiologist. Here we compare 30days outcome of patients undergoing TAVR with and without the presence of anesthesiologist in the catheterization laboratory. METHODS AND RESULTS: From September 2014 through April 2016, 324 patients (mean age 82.8±6) with severe symptomatic aortic stenosis were assigned to transfemoral TAVR with (150 patients) or without (174 patients) the attendance of an anesthesiologist. Baseline clinical and echocardiographic characteristics were similar between the groups. No difference in procedural and 30-day mortality, vascular complications, and major/life threatening bleeding were observed between the groups (p>0.1, for all). CONCLUSIONS: The presence of an anesthesiologist in the catheterization laboratory during transfemoral TAVR procedures did not significantly change 30-day outcome.
Assuntos
Anestesia Local/tendências , Anestesiologistas/tendências , Sedação Consciente/tendências , Complicações Pós-Operatórias/diagnóstico , Substituição da Valva Aórtica Transcateter/tendências , Idoso , Idoso de 80 Anos ou mais , Anestesia Local/mortalidade , Estudos de Coortes , Sedação Consciente/mortalidade , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Sistema de Registros , Estudos Retrospectivos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND AND PURPOSE: The impact of anesthesia technique on the outcomes of mechanical thrombectomy for acute ischemic stroke remains an issue of debate. We investigated the association of general anesthesia with outcomes in patients undergoing mechanical thrombectomy for ischemic stroke. METHODS: We performed a cohort study involving patients undergoing mechanical thrombectomy for ischemic stroke from 2009 to 2013, who were registered in the New York Statewide Planning and Research Cooperative System database. An instrumental variable (hospital rate of general anesthesia) analysis was used to simulate the effects of randomization and investigate the association of anesthesia technique with case-fatality and length of stay. RESULTS: Among 1174 patients, 441 (37.6%) underwent general anesthesia and 733 (62.4%) underwent conscious sedation. Using an instrumental variable analysis, we identified that general anesthesia was associated with a 6.4% increased case-fatality (95% confidence interval, 1.9%-11.0%) and 8.4 days longer length of stay (95% confidence interval, 2.9-14.0) in comparison to conscious sedation. This corresponded to 15 patients needing to be treated with conscious sedation to prevent 1 death. Our results were robust in sensitivity analysis with mixed effects regression and propensity score-adjusted regression models. CONCLUSIONS: Using a comprehensive all-payer cohort of acute ischemic stroke patients undergoing mechanical thrombectomy in New York State, we identified an association of general anesthesia with increased case-fatality and length of stay. These considerations should be taken into account when standardizing acute stroke care.
Assuntos
Anestesia Geral/mortalidade , Isquemia Encefálica/mortalidade , Sedação Consciente/mortalidade , Trombólise Mecânica/mortalidade , Acidente Vascular Cerebral/mortalidade , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Anestesia Geral/tendências , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/terapia , Estudos de Coortes , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Trombólise Mecânica/efeitos adversos , Trombólise Mecânica/tendências , Pessoa de Meia-Idade , New York/epidemiologia , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Resultado do TratamentoRESUMO
INTRODUCTION: The goal of this study was to identify the etiology of events and demographics of patients that experience complications requiring activation of the Rapid Response Team (RRT) during the first 24 h following anesthetic care. METHODS: We performed a retrospective review of the Quality Improvement database from the Department of Anesthesiology & Pain Medicine at Nationwide Children's Hospital. The database was searched to identify those patients who had a RRT evaluation activated within 24 h of receiving anesthesia or procedural sedation. These patients' charts were reviewed to obtain demographic information, etiology of the RRT call, and outcomes. RESULTS: The study cohort included 106 RRT calls that were made over a 3-year period. Six patients were excluded from analysis due to incomplete datasets. One hundred patients remained for analysis including 60 males and 40 females. Patients ranged in age from 0.08 to 31.21 years (7.8 ± 7.7 years, median 5.3 years). Seventy-one patients were American Society of Anesthesiologists' (ASA) status 3 or 4 and 29 patients were ASA status 1 or 2. Five calls were made for patients who had undergone procedural sedation while the other 95 were on patients who received general anesthesia. The average time to the RRT call after the end of anesthetic care was 11.4 ± 6.6 h. Respiratory concern was the most common reason for RRT initiation, accounting for 71 of the 100 calls. Forty-nine patients had a recent respiratory illness, chronic respiratory-related disease, or history of preterm birth. Fifty patients (50%) were transferred to a higher level of care following the RRT consult. There was no significant difference between age, gender, ASA status, or etiology of the event for patients transferred vs. those who were not. A significant difference was noted in the Pediatric Early Warning Score of patients transferred to a higher level of care in comparison to patients who remained on the floor (4 ± 2 vs. 3 ± 2, P = 0.0097). CONCLUSION: RRT calls were most common for respiratory concerns. High ASA status, general anesthesia administration, and the presence of acute or chronic conditions prior to anesthetic administration predispose a patient to perioperative complications resulting in the need for an RRT call.