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Background: Laparoscopic partial nephrectomy, which minimizes renal function loss due to its nephron sparing nature, has become a standard technique among many experienced centers worldwide for surgical treatment of localized kidney tumors. Although partial nephrectomy will remain the gold standard, we need to improve perioperative management and surgical method to prevent postoperative acute kidney injury. Aims: To demonstrate the frequency of the development of postoperative acute kidney injury following laparoscopic partial nephrectomy in patients with healthy contralateral kidney and determine the early predictive effects of serum neutrophil gelatinase-associated lipocalin on ischemia-reperfusion injury and its association with warm ischemia time. Study Design: Cross-sectional study. Methods: Eighty patients were included. We analyzed tumor size, operating time, duration of anesthesia, and warm ischemia time. Serum samples were obtained for measurement of serum creatinine, estimated glomerular filtration rate, and neutrophil gelatinase-associated lipocalin level preoperatively, at the postoperative 2nd hour, and on postoperative days 1 and 2. We used receiver operating characteristic curve for determining the cut-off point of neutrophil gelatinase-associated lipocalin to detect postoperative acute kidney injury. Correlation analysis was performed using Spearman's test. Results: Twenty-seven patients developed acute kidney injury on postoperative day 2, and the neutrophil gelatinase-associated lipocalin level increased significantly at the postoperative 2nd hour in the acute kidney injury group (p=0.048). For a cut-off of 129.375 ng/mL neutrophil gelatinase-associated lipocalin, the test showed 70.0% sensitivity and 68.3% specificity for the detection of acute kidney injury at the postoperative 2nd hour. For a cut-off of 184.300 ng/mL neutrophil gelatinase-associated lipocalin, the test exhibited 73.3% sensitivity and 63.3% specificity for the detection of acute kidney injury on postoperative day 1. A significant correlation was found between warm ischemia time and neutrophil gelatinase-associated lipocalin level at the postoperative 2nd hour (r=0.398, p=0.003). The creatinine values were significantly higher and the estimated glomerular filtration rates were significantly lower on postoperative days 1 and 2 in the acute kidney injury group compared with those in the non-acute kidney injury group (p<0.001). Conclusion: The neutrophil gelatinase-associated lipocalin may be used as an alternative biomarker to serum creatinine in differentiation of ischemic damage in patients undergoing laparoscopic partial nephrectomy.
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Isquemia/sangre , Lipocalina 2/análisis , Nefrectomía/efectos adversos , Lesión Renal Aguda/sangre , Lesión Renal Aguda/etiología , Adulto , Anciano , Biomarcadores/análisis , Biomarcadores/sangre , Estudios Transversales , Femenino , Humanos , Riñón/lesiones , Riñón/cirugía , Laparoscopía/efectos adversos , Laparoscopía/métodos , Lipocalina 2/sangre , Masculino , Persona de Mediana Edad , Nefrectomía/métodos , Complicaciones Posoperatorias/sangre , Factores de TiempoRESUMEN
OBJECTIVE: Surgical stress combined with general anaesthesia (GA) suppresses the immune system and leads to cancer cell growth and premature metastasis in major oncological interventions. Epidural analgesia decreases the need for inhalation agents and opioids during surgery by suppressing sympathetic and neuroendocrine responses in the postoperative period. This study aimed to compare the effects of combined general/epidural anaesthesia (GEA)+patient-controlled epidural analgesia (PCEA) and GA+IV patient-controlled analgesia (PCA) on serum tumour necrosis factor-alpha TNF-α), interleukin-1 beta (IL-1ß) and interferon-gamma (IFN-γ) levels in patients undergoing radical cystectomy. METHODS: Sixty-five patients were enrolled in this prospective study. Patients were randomly enrolled to the GEA group, i.e., combined GEA+ PCEA (0.1% bupivacaine+1 µg mL-1 fentanyl), and the GA group, namely combined GA+IV PCA (0.03 mg mL-1 morphine). To evaluate the cytokine response, blood samples were collected at preoperative, postoperative 1st and 24th hours. RESULTS: There was no statistically significant difference in serum TNF-α, IL-1ß and IFN-γ levels between groups GA and GEA at preoperative and postoperative 1st hour and 24th hour. Total remifentanil consumption was significantly lower and length of hospital stay was significantly shorter in the GEA group than in the GA group (p<0.05). CONCLUSION: There is no difference between two anaesthesia methods in terms of serum cytokine levels; however, combined GEA+PCEA technique appeared to be superior to GA+IV PCA because of lower intraoperative narcotic analgesic consumption and shorter hospital stay.
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The success rate of cardiopulmonary resuscitation (CPR) may differ from institution to institution, even within different sites in the same institution. A variety of factors may influence the outcome. In this study, we assessed the adequacy of CPR attempts guided by the current standards and aimed to define the factors influencing the outcome following in-hospital cardiac arrest. One hundred and thirty-four patients who required CPR were studied prospectively. Different variables for the CPR performance were recorded using forms designed for this study in the light of the guidelines. In these CPR forms various data including the demographics, history, monitoring, number, composition and experience of the anaesthesiologists, the site of CPR, time of day, the delay before onset of CPR, tracheal intubation, duration of arrest, initial rhythm in ECG monitored patients, management of CPR, drug administration and reversible causes of cardiac arrest were recorded. Our rates of immediate survival, survival at 24 h and survival to discharge 49.3%, 28.5% and 13.4%, respectively. The extent of monitoring prior to arrest, the attendance of one or more experienced anesthesiologists in the CPR team, CPR during office hours, CPR in ICU or operating room, early initiation of CPR and tracheal intubation prior to arrest were found as the factors increasing discharge survival. We conclude that early initiation of CPR with an experienced team in a well-equipped hospital sites increases the discharge survival rate following cardiac arrest.
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Reanimación Cardiopulmonar/estadística & datos numéricos , Paro Cardíaco/terapia , Hospitales Universitarios/estadística & datos numéricos , Adolescente , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Anestesiología/estadística & datos numéricos , Reanimación Cardiopulmonar/métodos , Niño , Competencia Clínica/estadística & datos numéricos , Electrocardiografía/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Paro Cardíaco/epidemiología , Humanos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Quirófanos/estadística & datos numéricos , Evaluación de Procesos y Resultados en Atención de Salud , Grupo de Atención al Paciente/estadística & datos numéricos , Estudios Prospectivos , Factores de Riesgo , Análisis de Supervivencia , Turquía/epidemiologíaRESUMEN
OBJECTIVES: Arthroscopic rotator cuff surgery can result in severe postoperative pain. We compared a continuous subacromial infusion to a continuous interscalene block with levobupivacaine for patients undergoing arthroscopic rotator cuff surgery. METHODS: Sixty patients were randomized to two groups: 1) interscalene block with 0.5% levobupivacaine (30 mL) followed by a postoperative subacromial infusion: 0.125% levobupivacaine 5 mL/h basal infusion, 5 mL bolus dose and a 20 min lockout time or; 2) interscalene block with 0.5% levobupivacaine (30 mL) followed by a postoperative interscalene infusion: 0.125% levobupivacaine 5 mL/h basal infusion, 5 mL bolus dose and a 20 min lockout time. Infusions were maintained for 48 hours. RESULTS: The VAS scores in the postanesthesia care unit and at 4 h were not different. The VAS scores at 8, 12, 24, 36 and 48 h were lower than 4 in both groups; but they were significantly lower in the interscalene group. Additional analgesic requirements were lower in the interscalene group (16.6% vs 53.3%, p<0.05). Patients' satisfaction was higher in the interscalene group (9.4±0.8 vs 8±1.2, p<0.01). One patient had a toxicity related to interscalene block but; there was no complication related to subacromial catheters. CONCLUSION: This study demonstrates that subacromial infusions, although provided good postoperative analgesia, are not as effective as interscalene infusions and additional analgesics should be prescribed when subacromial infusions are started. Subacromial infusions could be considered as an alternative in case of any contraindication to interscalene block.
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Analgesia/métodos , Anestésicos Locales/administración & dosificación , Dolor Postoperatorio/prevención & control , Manguito de los Rotadores/cirugía , Adulto , Analgesia Epidural/métodos , Artroscopía , Bupivacaína/administración & dosificación , Bupivacaína/análogos & derivados , Femenino , Humanos , Infusiones Parenterales , Levobupivacaína , Masculino , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , HombroRESUMEN
In this prospective, randomized study we compared the recovery profiles of bispectral index (BIS)-guided anesthesia regimens with desflurane or propofol in ambulatory arthroscopy. Fifty ASA I-II adult patients who underwent knee arthroscopy were randomized to receive desflurane (D) or propofol (P) infusion accompanied by remifentanil and nitrous oxide during maintenance, titrated to maintain a bispectral index value between 50 and 60. Initial awakening, fast-track eligibility, and home readiness as well as intraoperative hemodynamics, were compared. The groups did not differ with respect to demographics, duration of operation, or intraoperative vital signs. Although the times for initial awakening parameters were shorter in group D, the differences between the groups were not significant. The time needed for the White fast-track score to reach 12 was shorter in group P than group D (9 +/- 3.5 min vs 12.5 +/- 5.3 min). However, home readiness did not differ significantly between the groups. Desflurane is an alternative to propofol for BIS-guided ambulatory anesthesia. Using desflurane in combination with opioid analgesics blunted its rapid emergence characteristics, and the higher frequency of emetic symptoms with desflurane diminished the success of its fast-track eligibility.
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Procedimientos Quirúrgicos Ambulatorios , Anestesia General , Anestésicos por Inhalación , Anestésicos Intravenosos , Artroscopía , Electroencefalografía/efectos de los fármacos , Isoflurano/análogos & derivados , Propofol , Adolescente , Adulto , Anciano , Desflurano , Método Doble Ciego , Femenino , Hemodinámica/efectos de los fármacos , Humanos , Rodilla/cirugía , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio , Oxígeno/sangreRESUMEN
OBJECTIVES: The purpose of this study was to investigate the effects of PEEP on oxygenation and airway pressures during PCV-OLV. DESIGN: Randomized, crossover, clinical study. SETTING: University hospital. PARTICIPANTS: Twenty-five patients undergoing thoracotomy. INTERVENTIONS: During the first 5 minutes of OLV, all patients were ventilated with VCV (PEEP: 0) (VCV-ZEEP). Afterward, ventilation was changed to PCV with PEEP: 0 (PCV-ZEEP) or PEEP: 4 cmH2O (PCV-PEEP) for 20 minutes. In the following 20 minutes, PCV-PEEP and PCV-ZEEP were applied in reverse sequence. MEASUREMENTS AND MAIN RESULTS: At the end of VCV-ZEEP airway pressures (peak airway pressure, plateau airway pressure, mean airway pressure, and pause airway pressure) were recorded. At the end of PCV-PEEP and PCV-ZEEP airway pressures, PaO2 and Qs/Qt were recorded. Ppeak and Pplat were significantly lower with PCV-PEEP compared with VCV-ZEEP (eg, Ppeak: 33.4+/-4.2, 28.3+/-4.1, and 28.9+/-3.7 cmH2O in VCV-ZEEP, PCV-ZEEP, and PCV-PEEP, respectively; p<0.05 for PCV-ZEEP v VCV-ZEEP and PCV-PEEP v VCV-ZEEP). PCV-PEEP was associated with an increased PaO2 (230.3+/-69.8 v 189.0+/-54.8 mmHg, p<0.05) and decreased Qs/Qt (33.4%+/-7.3% v 38.4%+/-5.7%, p<0.05) compared with PCV-ZEEP (mean+/-SD). Eighty-eight percent of the patients have benefited from PEEP. CONCLUSION: During OLV, PCV with a low level of PEEP leads to improved oxygenation with lower airway pressures.
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Pulmón/fisiología , Respiración con Presión Positiva/métodos , Ventilación Pulmonar/fisiología , Anciano , Estudios Cruzados , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
OBJECTIVE: To investigate the relationship between end-tidal carbon dioxide levels and augmentation of pulmonary blood flow achieved by insertion of systemic-pulmonary shunts. DESIGN: Prospective clinical study. SETTINGS: University hospital. PARTICIPANTS: Nineteen cyanotic children with tetralogy of Fallot. INTERVENTIONS: Modified Blalock-Taussig shunt operations were performed on the left side in 14 patients and on the right side in 5 patients. MEASUREMENTS AND MAIN RESULTS: End-tidal carbon dioxide tension was recorded, and an arterial blood gas sample was obtained simultaneously after thoracotomy (T0) and after completion of systemic-pulmonary shunt (T1). End-tidal carbon dioxide tension was significantly higher ( p < 0.01), and arterial to end-tidal carbon dioxide tension difference was significantly lower (p < 0.01) at T1 when compared with T0. The increase in end-tidal carbon dioxide showed a statistically significant correlation with the response of arterial oxygen saturation (r = 0.61, p < 0.01). The fall in arterial to end-tidal carbon dioxide tension difference correlated inversely with the change of oxygen saturation (r = -0.81, p < 0.0001). CONCLUSION: It is concluded that end-tidal carbon dioxide tension alterations offer an alternative intraoperative tool to monitor pulmonary blood flow during modified Blalock-Taussig shunt procedures.
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Implantación de Prótesis Vascular/métodos , Dióxido de Carbono/sangre , Procedimientos Quirúrgicos Cardiovasculares , Monitoreo Intraoperatorio/métodos , Arteria Pulmonar/cirugía , Tetralogía de Fallot/cirugía , Análisis de los Gases de la Sangre/métodos , Preescolar , Femenino , Hemodinámica , Humanos , Lactante , Masculino , Oxígeno/sangre , Cuidados Paliativos/métodos , Valor Predictivo de las Pruebas , Estudios Prospectivos , Arteria Pulmonar/fisiopatología , Circulación Pulmonar/fisiología , Estadísticas no Paramétricas , Arteria Subclavia/cirugía , Tetralogía de Fallot/fisiopatología , Toracotomía/métodos , Volumen de Ventilación Pulmonar/fisiología , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare the effects of thiopental and propofol during defibrillation threshold testing (DFT) on hemodynamics and recovery profile in patients requiring automatic internal cardioverter-defibrilator placement. DESIGN: Prospective clinical investigation. SETTING: University hospital. PARTICIPANTS: Thirty-four adult patients. INTERVENTIONS: After administration of midazolam, 0.025 mg/kg, and fentanyl, 0.5 to 1 mug/kg, surgery was performed under topical infiltration with 1% lidocaine. In group I (GI) (n = 17), patients received thiopental by slow injection and patients in group II (GII) (n = 17) received propofol before induction of ventricular fibrillation (VF). MEASUREMENTS AND MAIN RESULTS: Patients received 4.1 +/- 1.4 mg of midazolam, 114 +/- 34 mug of fentanyl, and 280 +/- 78 mg of thiopental in GI; and 4.6 +/- 1.7 mg of midazolam, 119 +/- 62 mug of fentanyl, and 147 +/- 40 mg of propofol in GII (p > 0.05). Hemodynamics did not show significant differences between the groups at any recording time. Average time needed to regain the pretest sedation level was 16.4 +/- 8.8 minutes in GI and 10.9 +/- 5.5 minutes in GII (p = 0.03). Time required to achieve a score of 10 using a modified Aldrete score was 26.4 +/- 9.3 minutes in GI and 17.4 +/- 4.9 in GII (p = 0.001). Seven patients in GII (41%) and 1 patient in GI (6%) became hypotensive after DFT (p = 0.04). CONCLUSIONS: Deepening the sedation level by slow injection of thiopental or propofol before DFT provided satisfactory conditions during brief episodes of VF. Delay in recovery of arterial pressure after DFT with propofol and delay in arousal and discharge of patients with thiopental are major disadvantages of the regimens.
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Desfibriladores Implantables , Disfunción Ventricular Izquierda/terapia , Agonistas Adrenérgicos beta/uso terapéutico , Adulto , Anciano , Anestésicos Intravenosos , Sedación Consciente , Dobutamina/uso terapéutico , Ecocardiografía , Técnicas Electrofisiológicas Cardíacas , Femenino , Humanos , Hipotensión/tratamiento farmacológico , Hipotensión/etiología , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico por imagen , Isquemia Miocárdica/fisiopatología , Isquemia Miocárdica/terapia , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Recuperación de la Función/efectos de los fármacos , Recuperación de la Función/fisiología , Índice de Severidad de la Enfermedad , Volumen Sistólico/efectos de los fármacos , Volumen Sistólico/fisiología , Resultado del Tratamiento , Disfunción Ventricular Izquierda/diagnóstico por imagen , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
OBJECTIVE: To investigate the relationship between peripheral and central venous pressures in different patient positions (supine, prone, lithotomy, Trendelenburg, and Fowler), different catheter diameters (18 G and 20 G), and catheterization sites (dorsal hand and forearm) during surgical procedures. DESIGN: Prospective clinical study. SETTINGS: University hospital. PARTICIPANTS: Five hundred adult patients. INTERVENTIONS: Peripheral over-the-needle intravenous catheters were placed in the dorsal hand or forearm. Central venous catheters were inserted via the internal jugular or subclavian vein after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: Simultaneous measurements of central and peripheral venous pressures were made during stable conditions at random time points in surgery; 1953 paired measurements were performed. Mean central venous pressure was 11 +/- 3.7 mmHg and peripheral venous pressure was 13 +/- 4 mmHg (p = 0.0001). The overall correlation between central venous and peripheral venous pressures was found to be statistically significant (r = 0.89, r(2) = 0.8, p = 0.0001). Mean difference between peripheral and central venous pressure was 2 +/- 1.8 mmHg. Ninety-five percent limits of agreement were 5.6 to -1.6 mmHg. CONCLUSION: It has been assumed that replacing central venous pressure by peripheral venous pressure would cause problems in clinical interpretation. If the validity of this data is confirmed by further studies, the authors suggest that central venous pressure could be estimated by using regression equations to compare the 2 methods.
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Brazo/irrigación sanguínea , Presión Sanguínea , Cateterismo , Presión Venosa Central , Monitoreo Intraoperatorio , Postura/fisiología , Adulto , Anestesia General , Cateterismo Venoso Central/instrumentación , Cateterismo Venoso Central/métodos , Cateterismo Periférico/instrumentación , Cateterismo Periférico/métodos , Humanos , Venas YugularesRESUMEN
UNLABELLED: In this clinical, randomized, prospective study, we compared the effects of three different analgesia techniques (thoracic epidural analgesia [TEA] with and without preoperative initiation and IV patient-controlled analgesia [IV-PCA]) on postthoracotomy pain in 69 patients. In two groups, a thoracic epidural catheter was inserted preoperatively. Group Pre-TEA had bupivacaine and morphine solution preoperatively and intraoperatively. Postoperative analgesia was maintained with epidural PCA with a similar solution. Group Post-TEA, with no intraoperative medication, had the same postoperative analgesia as Group Pre-TEA plus the bolus dose. Group IV-PCA received only IV-PCA with morphine for postoperative analgesia. Pain was evaluated every 4 h during the first 48 h at rest, cough, and movement. Pre-TEA was associated with decreased pain compared with the other groups. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = 0.0233; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. TEA with preoperative initiation is a preferable method in preventing acute and long-term thoracotomy pain. IMPLICATIONS: Preoperatively initiated thoracic epidural analgesia has the most satisfying results in controlling postthoracotomy pain in the acute and long-term period, and it is associated with a decreased incidence (and intensity) of chronic pain compared with postoperative (epidural or IV) analgesia. Chronic pain has an incidence of 62%.
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Analgesia Epidural , Analgesia Controlada por el Paciente , Dolor Postoperatorio/terapia , Toracotomía/efectos adversos , Analgesia Epidural/efectos adversos , Analgesia Controlada por el Paciente/efectos adversos , Analgésicos Opioides/administración & dosificación , Anestésicos Locales/administración & dosificación , Bupivacaína/administración & dosificación , Femenino , Humanos , Masculino , Persona de Mediana Edad , Morfina/administración & dosificación , Dimensión del Dolor , Dolor Postoperatorio/prevención & control , Cuidados Preoperatorios , Estudios Prospectivos , Vértebras TorácicasRESUMEN
Arthroscopic knee surgery is one of the most common surgeries done in outpatient settings; however, postoperative pain is believed to be the major barrier for discharge and early rehabilitation. In this study we evaluated and compared the efficacy of intraarticular application of long-lasting non-steroidal analgesic drug tenoxicam, a long-lasting local anaesthetic bupivacaine and combination of the two on postoperative pain after arthroscopic knee surgery. With the approval of the local ethics committee and signed informed consent of the patients, 75 American Society of Anesthesiologists I-II patients aged between 18 and 65 years going under elective arthroscopic meniscectomy were included in this randomized, blind, prospective study. The patients were divided into three groups: group-T (GT) patients ( n=25) had intraarticular 20 mg of tenoxicam in 20 ml normal saline; group-B (GB) patients ( n=25) had 50 mg bupivacaine in 20 ml normal saline (0.25%); group-BT (GBT) patients ( n=25) had intraarticular 20 mg of tenoxicam and 50 mg bupivacaine (0.25%) in 20 ml normal saline after completion of the surgery and before deflation of the tourniquet. Postoperative analgesia was maintained by intravenous tramadol hydrochloride 50 mg/s at the first 4 h and paracetamol 500 mg and codeine 7.5 mg preparation (Pacofen) as needed (maximum six per day) during the study period. The numeric rating scale (NRS) values were at rest and at active-passive motion at 4, 12, 24 and 48 h, total analgesic consumption, at 4 h for tramadol and at the end of 48 h for oral medication; and patient satisfaction at the end of 48 h was evaluated and recorded. The demographic features of the patients, and tourniquet times, were found to be similar between the groups. Group BT had significantly lower NRS values than GB at 12 h at rest. Group BT was found to have significantly lower NRS values at 4 h compared with GT, and significantly lower NRS values at 12 h compared with GB. Group BT was found to have significantly lower NRS values at 48 h compared with GB. Group T had significantly higher NRS values at 4 h compared with GB. Group B had significantly higher values at 12 h compared with GT and GBT. Group B used significantly more analgesics than GBT and GT throughout the study period. Group BT patients had significantly more satisfaction at the end of the study period when compared with GT and GB. Application of intraarticular tenoxicam-bupivacaine solution is a simple, safe and effective method of analgesia after arthroscopic meniscectomy with high patient satisfaction.