Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 27
Filtrar
1.
Transplantation ; 108(7): e106-e109, 2024 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-38750639

RESUMO

BACKGROUND: Withdrawal of life-sustaining therapy (WLST) performed in the circulatory determination of death (DCD) donors leads to cardiac arrest, challenging the utilization of the myocardium for transplantation. The rapid initiation of normothermic regional perfusion or extracorporeal membrane oxygenation after death helps to optimize organs before implantation. However, additional strategies to mitigate the effects of stress response during WLST, hypoxic/ischemic injury, and reperfusion injury are required to allow myocardium recovery. METHODS: To this aim, our team routinely used a preconditioning protocol for each DCD donation before and during the WLST and after normothermic regional perfusion/extracorporeal membrane oxygenation. The protocol includes pharmacological treatments combined to reduce oxidative stress (melatonin, N -acetylcysteine, and ascorbic acid), improve microcirculation (statins), and mitigate organ's ischemic injury (steroids) and organ ischemia/reperfusion injury (remifentanil and sevoflurane when the heart is available for transplantation). RESULTS: This report presents the first case of recovery of cardiac function, with the only support of normothermic regional reperfusion, following 20 min of a no-touch period and 41 min of functional warm ischemic time in a DCD donor after the preconditioning protocol. CONCLUSIONS: Our protocol seems to be effective in abolishing the stress response during WLST and, on the other hand, particularly organ protective (and heart protective), giving a chance to donate organs less impaired from ischemia/reperfusion injury.


Assuntos
Oxigenação por Membrana Extracorpórea , Recuperação de Função Fisiológica , Humanos , Masculino , Doadores de Tecidos , Transplante de Coração , Fatores de Tempo , Perfusão/métodos , Resultado do Tratamento , Estresse Oxidativo , Morte , Pessoa de Meia-Idade , Adulto , Isquemia Quente/efeitos adversos
2.
J Clin Med ; 13(7)2024 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-38610865

RESUMO

Background/Objectives: Managing postoperative pain in patients with obesity is challenging. Although using a combination of pain relief methods is recommended for these patients, the true effectiveness of various intravenous non-opioid analgesics and adjuvants in multimodal anesthesia needs to be better defined. Methods: A systematic review and network meta-analysis was performed to evaluate the efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ketamine, α-2 agonists, lidocaine, magnesium, and oral gabapentinoids in adult surgical patients with obesity. The analysis aimed to compare these treatments to a placebo/no treatment or alternative analgesics, with a primary focus on postoperative pain and secondary endpoints including rescue analgesia, postoperative nausea and vomiting (PONV), and recovery quality. English-language randomized controlled trials across PubMed, Scopus, Web of Science, CINAHL, and EMBASE were considered. Quality and evidence certainty were assessed with the RoB 2 tool and GRADE, and data was analyzed with R software. Results: NSAIDs, along with acetaminophen, lidocaine, α-2 agonists, ketamine, and oral gabapentinoids, effectively reduce early postoperative pain. NSAIDs, particularly ibuprofen, as well as acetaminophen, ketamine, and lidocaine, also show benefits in later postoperative stages. Intravenous non-opioid analgesics and adjuvants show some degree of benefit in reducing PONV and the need for rescue analgesic therapy when using α-2 agonists alone or combined with oral gabapentinoids, notably decreasing the likelihood of PONV. Ketamine, lidocaine, and α-2 agonists are shown to enhance postoperative recovery and care quality. Conclusions: Intravenous non-opioid analgesics and adjuvants are valuable in multimodal anesthesia for pain management in adult surgical patients suffering from obesity.

3.
Life (Basel) ; 13(10)2023 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-37895446

RESUMO

BACKGROUND: Various pharmacokinetic/pharmacodynamic (PK/PD) models have been developed to accurately dose propofol administration during total intravenous anesthesia with target-controlled infusion (TIVA-TCI). We aim to clinically compare the performance of the Schnider model and the new and general-purpose Eleveld PK/PD model during TIVA-TCI. METHODS: We conducted a prospective observational study at a single center, enrolling 78 female patients, including 37 adults (aged < 65 years) and 41 elderly patients (aged ≥ 65 years). These patients underwent breast surgery with propofol-remifentanil TIVA-TCI guided by the bispectral index (BIS) for depth of anesthesia monitoring (target value 40-60) and the surgical plethysmographic index (SPI) for antinociception monitoring (target value 20-50) without neuromuscular blockade. The concentration at the effect site of propofol (CeP) at loss of responsiveness (LoR) during anesthesia maintenance (MA) and at return of responsiveness (RoR), the duration of surgery and anesthesia (min), the time to RoR (min), the propofol total dose (mg), the deepening of anesthesia events (DAEs), burst suppression events (BSEs), light anesthesia events (LAEs) and unwanted spontaneous responsiveness events (USREs) were considered to compare the two PK/PD models. RESULTS: Patients undergoing BIS-SPI-guided TIVA-TCI with the Eleveld PK/PD model showed a lower CeP at LoR (1.7 (1.36-2.25) vs. 3.60 (3.00-4.18) µg/mL, p < 0.001), higher CePMA (2.80 (2.55-3.40) vs. 2.30 (1.80-2.50) µg/mL, p < 0.001) and at RoR (1.48 (1.08-1.80) vs. 0.64 (0.55-0.81) µg/mL, p < 0.001) than with the Schnider PK/PD model. Anesthetic hysteresis was observed only in the Schnider PK/PD model group (p < 0.001). DAEs (69.2% vs. 30.8%, p = 0.001) and BSEs (28.2% vs. 5.1%, p = 0.013) were more frequent with the Eleveld PK/PD model than with the Schnider PK/PD model in the general patient population. DAEs (63.2% vs. 27.3%, p = 0.030) and BSEs (31.6% vs. 4.5%, p = 0.036) were more frequent with the Eleveld PK/PD model than with the Schnider PK/PD model in the elderly. CONCLUSIONS: The Schnider and Eleveld PK/PD models impact CePs differently. A greater incidence of DAEs and BSEs in the elderly suggests more attention is necessary in this group of patients undergoing BIS-SPI-guided TIVA-TCI with the Eleveld PK/PD than with the Schnider model.

5.
J Clin Anesth ; 86: 111045, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-36680980

RESUMO

STUDY OBJECTIVE: To estimate the incidence of unwanted spontaneous responsiveness and burst suppression (BSupp) in patients undergoing state entropy (SE) and surgical pleth index (SPI)-guided total intravenous anesthesia (TIVA) with target-controlled infusion (TCI). DESIGN: Observational, prospective, single-center study. SETTINGS: Operating room. PATIENTS: 107 adult (<65 years) and elderly (≥65 years) women undergoing breast surgery. INTERVENTIONS: Propofol-remifentanil TIVA-TCI-guided by SE for depth of anesthesia monitoring (target value 40-60) and SPI for antinociception monitoring (target value 20-50) without neuromuscular blockade. MEASUREMENTS: Age; body mass index; American Society of Anesthesiologists physical status classification; concentration at the effect site of propofol (CeP) and remifentanil (CeR) at loss of responsiveness (LoR), median during anesthesia maintenance (MdM), and at return of responsiveness (RoR); propofol infusion duration; incidence of postoperative delirium (POD) with Confusing Assessment Method for the Intensive Care Unit. MAIN RESULTS: During SE-SPI-guided TIVA-TCI, 13.1% of patients showed unwanted spontaneous responsiveness, whereas 45.8% showed BSupp. Unwanted spontaneous responsiveness was observed mainly in adults (p < 0.05), and higher CeP RoR (p < 0.05) was registered. BSupp was observed mainly in patients showing a lower CeP MdM (p < 0.01) and CeP RoR (p < 0.05). Unwanted spontaneous responsiveness and BSupp were not associated with significant differences in CeRs. An age-related hysteresis effect was observed, resulting in higher CeP LoR than CeP RoR (p < 0.001). 12.2% of patients showed POD. Only preoperative serum albumin was associated with increased likelihood of POD (p = 0.046). CONCLUSIONS: The SE-SPI-guided TIVA-TCI did not prevent unwanted spontaneous responsiveness and BSupp. CeP RoR may be used as a proxy for anesthetic sensitivity.


Assuntos
Anestesia Intravenosa , Propofol , Remifentanil , Adulto , Idoso , Feminino , Humanos , Anestesia Intravenosa/efeitos adversos , Anestesia Intravenosa/métodos , Anestésicos Intravenosos/efeitos adversos , Propofol/efeitos adversos , Propofol/uso terapêutico , Estudos Prospectivos , Remifentanil/efeitos adversos , Remifentanil/uso terapêutico
7.
Front Hum Neurosci ; 16: 810046, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35652004

RESUMO

Introduction: Preoperative neurocognitive disorder (preO-NCD) is a common condition affecting 14-51. 7% of the elderly population. General anesthesia has already been associated with the one-year post-operative neurocognitive disorder (PostO-NCD), specifically, a deficit in executive function, measured by the Trail Making Test B (TMT-B), but its long-term effects on cognitive function have not been investigated. We aimed to detect preO-NCD prevalence in patients scheduled for cardiac surgery and further investigate the possible role of previous general anesthesia (pGA) in general preoperative cognitive status [measured via the Montreal Cognitive Assessment (MoCA)] and/or in executive functioning (measured via TMT-B). Methods: In this observational, prospective study, 151 adult patients scheduled for elective cardiac surgery underwent MoCA and TMT-B. Data on age, education, pGA, comorbidities, and laboratory results were collected. Results: We discovered a general cognitive function impairment of 79.5% and an executive function impairment of 22%. Aging is associated with an increased likelihood (OR 2.99, p = 0.047) and education with a decreased likelihood (OR 0.35, p = 0.0045) of general cognitive impairment, but only education was significantly associated with a decreased likelihood (OR 0.22, p = 0.021) of executive function impairment. While pGA did not significantly affect preO-NCD, a noteworthy interaction between aging and pGA was found, resulting in a synergistic effect, increasing the likelihood of executive function impairment (OR 9.740, p = 0.0174). Conclusion: We found a high prevalence of preO-NCD in patients scheduled for cardiac surgery. General cognitive function impairment is highly associated with advancing age (not pGA). However, older patients with at least one pGA appeared to be at an increased risk of preO-NCD, especially executive function impairment, suggesting that TMT-B should be associated with MoCA in the preoperative cognitive evaluation in this population.

9.
J Anesth Analg Crit Care ; 2(1): 16, 2022 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-37386651

RESUMO

The manuscript describes a case report of 2 prolonged prone position cycles (72 h each) of a coronavirus disease 2019 pneumonia in an intubated pregnant woman (at 22 weeks of gestational age), being successfully discharged from intensive care unit after 20 days. There were no signs of fetal sufferance at daily obstetric monitoring during prone position, and the fetus was born fully vital and without consequences.At our knowledge, this is the first case of prolonged prone position in a pregnant woman, and we feel that our manuscript could be a valuable contribution to the literature and help intensivists in providing intensive care in these patients, confirming that prone position seems to be a valid therapeutic choice, limiting maternal and fetal hypoxia, and reducing their morbidity, even if the oculate risk/benefit should be performed. Further studies are however necessary to increase the knowledge and the good management of COVID-19 in pregnancy.

10.
BJA Open ; 4: 100098, 2022 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37588780

RESUMO

Background: The use of high-flow nasal oxygen (HFNO) has the potential to improve patient safety by limiting hypoxaemia during gastrointestinal endoscopy. The degree of benefit is not adequately established. Methods: English language literature searches of PubMed, Scopus, Web of Science, and Cochrane Library electronic databases were performed to identify randomised controlled trials comparing HFNO and conventional oxygen therapy (COT) for patients undergoing gastrointestinal endoscopy under deep sedation. The primary endpoint was the incidence of hypoxic events observed during endoscopic procedures. The secondary endpoints were the incidence of recourse to rescue manoeuvres, procedure interruption, and adverse events. A meta-analysis and a post hoc trial sequence analysis were performed. Results: A total of 2867 patients from six randomised controlled trials were considered. Desaturation was observed in 5.2% and 27.2% of patients receiving HFNO and COT, respectively. Desaturation <90% was observed in 1.8% and 12.6% of the patients receiving HFNO and COT, respectively. In the subgroup analysis, desaturation occurrence was lower during HFNO than during COT in non-obese patients (2.2% vs 25.2%) and obese patients (22.9% vs 43.3%). Desaturation occurrence was lower during maximum (3.6% vs 26.9%) and minimum (15.9% vs 29.8%) HFNO therapy than during COT. HFNO showed a lower recurrence to rescue manoeuvres rate (4.7% vs 34.3%), a lower procedure interruption rate (0.4% vs 6.7%), and a lower adverse events rate (18.7% vs 21%) than COT. A high level of heterogeneity between the studies precluded confidence in drawing inference from the meta-analysis. Conclusions: The evidence reviewed suggests that compared with COT, HFNO has fewer hypoxaemic events during gastrointestinal endoscopy, but this may not apply to all patients and clinical scenarios.

11.
Br J Anaesth ; 128(1): 11-25, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-34862000

RESUMO

BACKGROUND: Postoperative cognitive decline occurs commonly after cardiac surgery. The available literature is inconclusive on the role of intraoperative causal or protective factors. METHODS: We systematically reviewed studies evaluating delayed neurocognitive recovery (DNR), postoperative neurocognitive disorder (NCD), stroke, and the mortality rates among patients undergoing hypothermic or normothermic cardiopulmonary bypass (CPB). We further performed a subgroup analysis for age, surgery type (coronary artery bypass grafting [CABG], valve surgery, or combined), and the mean arterial blood pressure (MAP) during CPB, and conducted a proportion meta-analysis after calculation of single proportions and confidence intervals (CIs). RESULTS: We included a total of 58 studies with 9609 patients in our analysis. Among these, 1906 of 4010 patients (47.5%) had DNR, and 2071 of 7160 (28.9%) had postoperative NCD. Ninety of 4625 patients (2.0%) had a stroke, and 174 of 7589 (2.3%) died. There was no statistically significant relationship between the considered variables and DNR, NCD, stroke, and mortality. In the subgroup analysis comparing hypothermic with normothermic CPB, we found higher NCD rates after combined surgery; for normothermic CPB cases only, the rates of DNR and NCD were lower after combined surgery compared with CABG surgery. A MAP >70 mm Hg compared with MAP=50-70 mm Hg during CPB was associated with a lower rate of DNR. CONCLUSIONS: Temperature, MAP during cardiopulmonary bypass age, and surgery type were not associated with neurocognitive disorders, stroke, and mortality in cardiac surgery. Normothermic cardiopulmonary bypass, particularly when performed with MAP >70 mm Hg, may reduce the risk of postoperative neurocognitive decline after cardiac surgery. PROSPERO REGISTRATION NUMBER: CRD42019140844.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hipotermia Induzida/métodos , Complicações Cognitivas Pós-Operatórias/epidemiologia , Pressão Arterial/fisiologia , Ponte Cardiopulmonar/métodos , Humanos , Complicações Cognitivas Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Acidente Vascular Cerebral/epidemiologia
12.
Life (Basel) ; 11(8)2021 Aug 19.
Artigo em Inglês | MEDLINE | ID: mdl-34440594

RESUMO

General anesthesia should induce unconsciousness and provide amnesia. Amnesia refers to the absence of explicit and implicit memories. Unlike explicit memory, implicit memory is not consciously recalled, and it can affect behavior/performance at a later time. The impact of general anesthesia in preventing implicit memory formation is not well-established. We performed a systematic review with meta-analysis of studies reporting implicit memory occurrence in adult patients after deep sedation (Observer's Assessment of Alertness/Sedation of 0-1 with spontaneous breathing) or general anesthesia. We also evaluated the impact of different anesthetic/analgesic regimens and the time point of auditory task delivery on implicit memory formation. The meta-analysis included the estimation of odds ratios (ORs) and 95% confidence intervals (CIs). We included a total of 61 studies with 3906 patients and 119 different cohorts. For 43 cohorts (36.1%), implicit memory events were reported. The American Society of Anesthesiologists (ASA) physical status III-IV was associated with a higher likelihood of implicit memory formation (OR:3.48; 95%CI:1.18-10.25, p < 0.05) than ASA physical status I-II. Further, there was a lower likelihood of implicit memory formation for deep sedation cases, compared to general anesthesia (OR:0.10; 95%CI:0.01-0.76, p < 0.05) and for patients receiving premedication with benzodiazepines compared to not premedicated patients before general anesthesia (OR:0.35; 95%CI:0.13-0.93, p = 0.05).

19.
PLoS One ; 15(12): e0244145, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33351856

RESUMO

PURPOSE: Aging affects pharmacodynamics/pharmacokinetics of anesthetics, but age effects on Entropy-guided total intravenous anesthesia with target-controlled infusions (TIVA-TCI) are not fully characterized. We compared aging effects on effective estimated brain concentration of Propofol (CeP) during TIVA-TCI Entropy-guided anesthesia, without neuromuscular blockade (NMB). METHODS: We performed an observational, prospective, single-center study enrolling 75 adult women undergoing Entropy-guided Propofol-Remifentanil TIVA-TCI for breast surgery. Primary endpoint was the relationship between age and CeP at maintenance of anesthesia (MA) during Entropy-guided anesthesia. Secondary endpoints were relationships between age and CeP at arousal reaction (AR), return of consciousness (ROC) and explicit recall evenience. We calculated a linear model to evaluate the age's impact on observational variable and performed pairwise tests to compare old (≥65 years, n = 50) and young (<65 years, n = 25) patients or patients with and without an AR. RESULTS: We did not observe age-related differences in CeP during MA, but CeP significantly (p = 0,01) decreased with age at ROC. Entropy values during MA increased with age and were significantly higher in the elderly (RE: median 56[IQR49.3-61] vs 47.5[42-52.5],p = 0.001; SE: 51.6[45-55.5] vs 44[IQR40-50],p = 0.005). 18 patients had an AR, having higher maximum RE (92.5[78-96.3] vs 65[56.5-80.5],p<0.001), SE (79[64.8-84] vs 61[52.5-69],p = 0.03, RE-SE (12.5[9.5-16.5] vs 6 [3-9],p<0.001. CONCLUSION: Older age was associated with lower CeP at ROC, but not during MA in unparalysed patients undergoing breast surgery. Although RE and SE during MA, at comparable CeP, were higher in the elderly, Entropy, and in particular an increasing RE-SE, is a reliable index to detect an AR.


Assuntos
Envelhecimento , Anestesia Intravenosa , Anestésicos Intravenosos/administração & dosagem , Encéfalo/fisiopatologia , Estado de Consciência , Eletroencefalografia , Propofol/administração & dosagem , Idoso , Entropia , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA