RESUMO
BACKGROUND: In Europe, within the scope of the General Data Protection Regulation, more and more digital infrastructures are created to allow for large-scale access to patients' health data and their use for research. When the research is performed on the basis of patient consent, traditional study-specific consent appears too cumbersome for many researchers. Alternative models of consent are currently being discussed and introduced in different contexts. OBJECTIVE: This study explores stakeholder perspectives on ethical, legal, and practical concerns regarding models of consent for health data research at German university medical centers. METHODS: Semistructured focus group interviews were conducted with medical researchers at German university medical centers, health IT specialists, data protection officers, and patient representatives. The interviews were analyzed using a software-supported structuring qualitative content analysis. RESULTS: Stakeholders regarded broad consent to be only marginally less laborious to implement and manage than tiered consent. Patient representatives favored specific consent, with tiered consent as a possible alternative. All stakeholders lamented that information material was difficult to understand. Oral information and videos were mentioned as a means of improvement. Patient representatives doubted that researchers had a sufficient degree of data security expertise to act as sole information providers. They were afraid of undue pressure if obtaining health data research consent were part of medical appointments. IT specialists and other stakeholders regarded the withdrawal of consent to be a major challenge and called for digital consent management solutions. On the one hand, the transfer of health data to non-European countries and for-profit organizations is seen as a necessity for research. On the other hand, there are data security concerns with regard to these actors. Research without consent is legally possible under certain conditions but deemed problematic by all stakeholder groups, albeit for differing reasons and to different degrees. CONCLUSIONS: More efforts should be made to determine which options of choice should be included in health data research consent. Digital tools could improve patient information and facilitate consent management. A unified and strict regulation for research without consent is required at the national and European Union level. Obtaining consent for health data research should be independent of medical appointments, and additional personnel should be trained in data security to provide information on health data research.
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Consentimento Livre e Esclarecido , Pesquisa Qualitativa , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/legislação & jurisprudência , Grupos Focais , Alemanha , Entrevistas como Assunto , Segurança ComputacionalRESUMO
While Specific Informed Consent has been the established standard for obtaining consent for medical research for many years, it does not appear suitable for large-scale biobank and health data research. Thus, alternative forms of consent have been suggested, based on a variety of ethical background assumptions. This article identifies five main ethical perspectives at stake. Even though Tiered Consent, Dynamic Consent and Meta Consent are designed to the demands of the self-determination perspective as well as the perspective of research as a public good, they are still also criticized from both perspectives. In addition, criticisms based on concerns of justice, participation and democratic deliberation, and relational concerns have been levelled at each of the models. As all of these perspectives have valid points to make, the task at hand lies in balancing these ethical perspectives. What constitutes an adequate balancing depends on contextual factors. These factors include digital infrastructure and digital literacy, data safety regulation, good scientific and clinical practice, transparent debates on ethically relevant features of research, social inequalities, anti-discrimination laws and practices, trust in health care institutions and recognition of patient preferences, and consensus on unethical research. We argue that the role of context in determining acceptable models of consent puts the ethical importance of models of consent into perspective. Since altering contextual factors can help to live up to the ethical concerns at stake in debates about models of consent, opting for such a shift of focus comes without ethical loss.
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Pesquisa Biomédica , Consentimento Livre e Esclarecido , Humanos , Princípios Morais , ConfiançaRESUMO
The elderly are often considered a vulnerable group in public and academic bioethical debates and regulations. In this paper, we examine and challenge this assumption and its ethical implications. We begin by systematically delineating the different concepts of vulnerability commonly used in bioethics, before then examining whether these concepts can be applied to old age. We argue that old age should not, in and of itself, be used as a marker of vulnerability, since ageing is a process that can develop in a variety of different ways and is not always associated with particular experiences of vulnerability. We, therefore, turn to more fundamental phenomenological considerations in order to reconstruct from a first person perspective the intricate interconnections between the experiences of ageing and vulnerability. According to this account, ageing and old age are phenomena in which the basic anthropological vulnerability of human beings can manifest itself in an increased likelihood of harm and exploitation. Thus, we plead for a combined model of vulnerability that helps to avoid problems related to the current concepts of vulnerability. We conclude first that old age as such is not a sufficient criterion for being categorized as vulnerable in applied ethics, and second that reflections on ageing can help to develop a better understanding of the central role of vulnerability in human existence and in applied ethics.
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Envelhecimento/ética , Temas Bioéticos , Autonomia Pessoal , Populações Vulneráveis , Idoso , Bioética , Humanos , Pessoalidade , Valores SociaisRESUMO
Synthetic biology can be understood as expanding the abilities and aspirations of genetic engineering. Nonetheless, whereas genetic engineering has been subject to criticism due to its endangering biodiversity, synthetic biology may actually appear to prove advantageous for biodiversity. After all, one might claim, synthesizing novel forms of life increases the numbers of species present in nature and thus ought to be ethically recommended. Two perspectives on how to spell out the conception of intrinsic value of biodiversity are examined in order to assess this line of thought. At the cost of introducing two separate capacities of human knowledge acquisition, the 'admiration stance' turns out to reject outright the assumption of a synthetic species' intrinsic value and of an imperative to create novel species. The 'kinship stance' by contrast does ascribe value to both synthetic and natural species and organisms. Nonetheless, while from this perspective creating novel species may become an ethical demand under certain conditions, it favours changing organisms by getting in contact with them rather than synthesizing them. It is concluded that neither the admiration nor the kinship stance warrants a supposed general moral obligation to create novel species to increase biodiversity.
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Biodiversidade , Princípios Morais , Biologia Sintética/ética , Animais , Engenharia Genética/ética , Humanos , Conhecimento , Valor da VidaRESUMO
OBJECTIVES: Antiplatelet therapy commonly is used for the prevention of cardiovascular complications but increases the risk of perioperative bleeding. Multiple-electrode aggregometry (MEA) was investigated for monitoring platelet inhibition by acetylsalicylic acid (ASA) and clopidogrel in patients undergoing elective coronary artery bypass graft (CABG) surgery with regard to clinical outcome as measured by postoperative blood loss and transfusion requirements. DESIGN: A prospective observational study. SETTING: A teaching hospital. PARTICIPANTS: One hundred fifty patients scheduled for elective CABG surgery were included: without antiplatelet therapy (group A, n = 50), single ASA exposure (group B, n = 50), and combined therapy with ASA and clopidogrel (group C, n = 50). MEASUREMENTS AND MAIN RESULTS: MEA was assessed preoperatively using either collagen (COL-MEA) or ADP (ADP-MEA). Postoperative blood loss and transfusion requirements were recorded for 24 hours after surgery. Postoperative blood loss significantly increased only from combined antiplatelet therapy (group A: 572 ± 297 mL, group B: 721 ± 356 mL, group C: 865 ± 346, p < 0.01) and correlated with ADP (r(p) = -0.35, p < 0.01) and COL-MEA (r(p) = -0.23, p > 0.01). COL-MEA and ADP-MEA discriminated between preoperative ASA and clopidogrel intake (ASA: sensitivity = 86.3%, and specificity = 89.3%; clopidogrel: sensitivity = 87.5%, and specificity = 95.1%). The postoperative transfusion risk was increased in patients diagnosed for clopidogrel treatment by ADP-MEA (odds ratio = 2.92; confidence interval: 1.44-5.92; p = 0.005). CONCLUSIONS: MEA is a suitable method for the detection of platelet inhibition by ASA and clopidogrel in patients undergoing CABG surgery. In these patients, preoperative ADP MEA seems to indicate patients at risk for postoperative transfusion requirements.
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Ponte de Artéria Coronária , Monitorização Intraoperatória/métodos , Agregação Plaquetária/fisiologia , Testes de Função Plaquetária/instrumentação , Idoso , Anestesia Geral , Aspirina/uso terapêutico , Transfusão de Sangue/estatística & dados numéricos , Volume Sanguíneo , Clopidogrel , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Humanos , Derivados de Hidroxietil Amido/uso terapêutico , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/uso terapêutico , Inibidores da Agregação Plaquetária/uso terapêutico , Sistemas Automatizados de Assistência Junto ao Leito , Cuidados Pós-Operatórios , Hemorragia Pós-Operatória/induzido quimicamente , Hemorragia Pós-Operatória/tratamento farmacológico , Hemorragia Pós-Operatória/epidemiologia , Medicação Pré-Anestésica , Estudos Prospectivos , Curva ROC , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Resultado do TratamentoRESUMO
The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.
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COVID-19/terapia , Cuidados Críticos/organização & administração , Alocação de Recursos para a Atenção à Saúde/organização & administração , Pandemias/prevenção & controle , Triagem/organização & administração , Comitês Consultivos/organização & administração , Comitês Consultivos/normas , COVID-19/epidemiologia , Cuidados Críticos/economia , Cuidados Críticos/normas , Cuidados Críticos/estatística & dados numéricos , Tomada de Decisões Gerenciais , Saúde Global/economia , Saúde Global/normas , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/normas , Política de Saúde , Humanos , Colaboração Intersetorial , Pandemias/economia , Guias de Prática Clínica como Assunto , Padrão de Cuidado/economia , Triagem/normasRESUMO
BACKGROUND: Good postoperative recovery is increasingly recognized as an important outcome after surgery. The authors created a new Post-operative Quality Recovery Scale (PQRS) that tracks multiple domains of recovery from immediate to long-term time periods in patients of varying ages, languages, and cultures. METHODS: The parameters of importance to both clinicians and patients were identified. After an initial pilot study of 133 patients, the PQRS was refined. It consists of six domains (physiologic, nociceptive, emotive, activities of daily living, cognitive, and overall patient perspective). An observational study of 701 patients was performed with the refined PQRS to assess its capacity to evaluate and track recovery and to discriminate between patients. It was conducted in eight countries and in five languages, involving patients more than or equal to 6 yr undergoing elective surgery with general anesthesia. Recovery was assessed before surgery and at multiple time periods postoperatively. Recovery was defined as return to baseline values or better. RESULTS: Seven hundred one patients completed the PQRS. Mean completion time was 4.8 (SD 2.8) min. Recovery scores improved with time. Physiologic recovery was complete in 34% of subjects by 40 min. By the third postoperative day, complete recovery was obtained in 11% of cases (all domains): 48.7% nociceptive, 81.8% emotive, 68.8% activities of daily living, and only 33.5% cognitive. Overall, 95.8% of the patients reported that they were "satisfied or totally satisfied" with their anesthetic care. CONCLUSION: The scores on the PQRS demonstrated an improvement over time, consistent with an expected recovery after surgery and anesthesia, and an ability to discriminate between individuals. Many patients had incomplete recovery by the third postoperative day.
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Período de Recuperação da Anestesia , Cuidados Pós-Operatórios/normas , Período Pós-Operatório , Atividades Cotidianas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Envelhecimento/fisiologia , Anestesia Geral , Criança , Cognição/fisiologia , Cultura , Emoções/fisiologia , Estudos de Viabilidade , Feminino , Humanos , Idioma , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Monitorização Fisiológica , Dor Pós-Operatória/diagnóstico , Satisfação do Paciente , Projetos Piloto , Cuidados Pós-Operatórios/psicologia , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Several studies have shown that goal-directed hemodynamic and fluid optimization may result in improved outcome. However, the methods used were either invasive or had other limitations. The aim of this study was to perform intraoperative goal-directed therapy with a minimally invasive, easy to use device (FloTrac/Vigileo), and to evaluate possible improvements in patient outcome determined by the duration of hospital stay and the incidence of complications compared to a standard management protocol. METHODS: In this randomized, controlled trial 60 high-risk patients scheduled for major abdominal surgery were included. Patients were allocated into either an enhanced hemodynamic monitoring group using a cardiac index based intraoperative optimization protocol (FloTrac/Vigileo device, GDT-group, n = 30) or a standard management group (Control-group, n = 30), based on standard monitoring data. RESULTS: The median duration of hospital stay was significantly reduced in the GDT-group with 15 (12 - 17.75) days versus 19 (14 - 23.5) days (P = 0.006) and fewer patients developed complications than in the Control-group [6 patients (20%) versus 15 patients (50%), P = 0.03]. The total number of complications was reduced in the GDT-group (17 versus 49 complications, P = 0.001). CONCLUSIONS: In high-risk patients undergoing major abdominal surgery, implementation of an intraoperative goal-directed hemodynamic optimization protocol using the FloTrac/Vigileo device was associated with a reduced length of hospital stay and a lower incidence of complications compared to a standard management protocol. CLINICAL TRIAL REGISTRATION INFORMATION: Unique identifier: NCT00549419.
Assuntos
Pressão Sanguínea , Período Intraoperatório , Tempo de Internação , Monitorização Fisiológica/instrumentação , Idoso , Calibragem , Feminino , Humanos , Masculino , Monitorização Fisiológica/métodos , Fatores de Risco , Procedimentos Cirúrgicos OperatóriosRESUMO
OBJECTIVE: Preparing hydroxyethyl starch (HES) in a plasma-adapted solution is supposed to improve safety with regard to coagulation. The influence of a new plasma-adapted HES preparation on coagulation was studied. DESIGN: Operator-blinded, randomized study. SETTING: Laboratory in vitro study. PARTICIPANTS: Fifteen healthy young men scheduled for blood donation. INTERVENTIONS: Blood was diluted by 10%, 30%, and 50% using either a plasma-adapted or nonplasma-adapted (prepared in saline solution) potato-derived 6% HES 130/0.42. Only the composition of the solvent of the 2 HES preparations was different. MEASUREMENTS AND MAIN RESULTS: Rotation thromboelastometry (ROTEM; Pentapharm, Munich, Germany) was used to assess changes in coagulation; whole blood aggregometry with 3 inducers was used to assess effects of dilution with HES on platelet function. Clotting time (CT) and clot formation time were significantly prolonged by 30% and 50% dilution, showing significantly longer times in the non-plasma-adapted than in the plasma-adapted HES group (eg, intrinsic CT at the 30% dilution level: plasma-adapted HES 228 +/- 26 seconds [within normal range] v 269 +/- 29 seconds in the nonplasma-adapted HES group). Clot strengthening and clot firmness were significantly reduced by the non-plasma-adapted HES at the 30% dilution level. Platelet aggregation was significantly more reduced by the non-plasma-adapted HES at the 30% and 50% dilution levels. CONCLUSIONS: Dilution with the nonplasma-adapted HES 130/0.42 was associated with more negative effects on thromboelastometry and platelet aggregation than the same HES 130/0.4 dissolved in a plasma-adapted solution. The benefits of using a plasma-adapted modern HES preparation on blood loss and use of blood/blood products in cardiac surgery need to be studied.
Assuntos
Coagulação Sanguínea/efeitos dos fármacos , Derivados de Hidroxietil Amido/farmacologia , Substitutos do Plasma/farmacologia , Difosfato de Adenosina/farmacologia , Adulto , Testes de Coagulação Sanguínea , Plaquetas/efeitos dos fármacos , Retração do Coágulo/efeitos dos fármacos , Colágeno/farmacologia , Fibrinogênio/química , Hemoglobinas/análise , Humanos , Derivados de Hidroxietil Amido/química , Masculino , Soluções Farmacêuticas , Substitutos do Plasma/química , Agregação Plaquetária/efeitos dos fármacos , Testes de Função Plaquetária , Tromboelastografia , Tempo de Coagulação do Sangue TotalRESUMO
OBJECTIVE: Balanced fluids appear to be have advantages over unbalanced fluids for correcting hypovolemia. The effects of a new balanced hydroxyethyl starch (HES) were studied in cardiac surgery patients. DESIGN: Prospective, randomized, unblinded study. SETTING: Clinical study in a single cardiac surgery institution. PARTICIPANTS: Sixty patients undergoing elective cardiac surgery with cardiopulmonary bypass. INTERVENTION: Patients received either a balanced 6% HES 130/0.4 plus a balanced crystalloid (n = 30) or an unbalanced HES-in-saline plus saline (n = 30) to keep cardiac index >2.5 L/min/m(2). MEASUREMENTS AND MAIN RESULTS: Base excess (BE), kidney function, inflammatory response (interleukins-6, -10), endothelial activation (intercellular adhesion molecule-1 [ICAM]), and coagulation (thromboelastometry, whole blood aggregation) were measured after induction of anesthesia, after surgery and 5 hours later, and at the 1st and 2nd postoperative days; 2,950 +/- 530 mL of balanced and 3,050 +/- 560 mL of unbalanced HES were given. BE was reduced significantly in the unbalanced group (from 1.11 +/- 0.71 mmol/L to -5.11 +/- 0.48 mmol/L after surgery) and remained unchanged in the balanced group. Balanced volume replacement resulted in significantly lower IL-6, IL-10, and ICAM plasma concentrations and lower urine concentrations of kidney-specific proteins than in the unbalanced group. After surgery, thromboelastometry data and platelet function were changed significantly in both groups; 5 hours thereafter they were significantly changed only in the unbalanced group. CONCLUSION: A plasma-adapted HES preparation in addition to a balanced crystalloid resulted in significantly less decline in BE, less increase in concentrations of kidney-specific proteins, less inflammatory response and endothelial damage, and fewer changes in hemostasis compared with an unbalanced fluid strategy.
Assuntos
Volume Sanguíneo/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos , Hidratação/métodos , Derivados de Hidroxietil Amido/uso terapêutico , Substitutos do Plasma/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Anestesia , Perda Sanguínea Cirúrgica , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar , Catecolaminas/uso terapêutico , Cuidados Críticos , Diuréticos/uso terapêutico , Feminino , Hemodinâmica/efeitos dos fármacos , Hemostasia/efeitos dos fármacos , Humanos , Derivados de Hidroxietil Amido/química , Inflamação/epidemiologia , Inflamação/etiologia , Rim/efeitos dos fármacos , Rim/fisiologia , Masculino , Pessoa de Meia-Idade , Substitutos do Plasma/química , Testes de Função Plaquetária , Terapia de Substituição Renal , Tromboelastografia , Equilíbrio Hidroeletrolítico/efeitos dos fármacosRESUMO
A variety of different fluids are promoted to correct hypovolaemia. Apart from the crystalloid versus colloid debate, there exists also a colloid versus colloid discussion as different protein (albumin) and nonprotein colloids (dextrans, gelatins, hydroxyethyl starch preparations) are available for this purpose. The different plasma substitutes largely differ with regard to their composition and their physicochemical properties. All currently used strategies for correcting hypovolaemia have their pros and cons. At present, there is an ongoing interest in the major problems associated with the use of plasma substitutes such as their influence on coagulation and kidney function. There are, however, also some less often addressed questions concerning the use of plasma substitutes that need to be answered. Although nonblood plasma substitutes are often administered worldwide, there is still uncertainty with regard to using them in pregnancy, effects on cross-matching and blood typing, mixing with other drugs, dose limitations, the risk of calcium-containing and potassium-containing solutions, the risk of producing itching, the influence on blood sugar level or whether warming can be done safely. Unfortunately, data to answer these very practical questions are limited or are even lacking for some plasma substitutes. To further increase safety in the treatment of the hypovolaemic patient, all possible problems must be discussed and contraindications of nonblood plasma substitutes must be clearly defined.
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Hipovolemia/terapia , Substitutos do Plasma/efeitos adversos , Complicações na Gravidez/terapia , Cálcio/administração & dosagem , Cálcio/efeitos adversos , Dextranos/efeitos adversos , Relação Dose-Resposta a Droga , Feminino , Gelatina/efeitos adversos , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Potássio/administração & dosagem , Potássio/efeitos adversos , Gravidez , Prurido/induzido quimicamente , Albumina Sérica/efeitos adversosRESUMO
PURPOSE OF REVIEW: Motility disturbances often occur in critically ill patients resulting in an increased rate of morbidity and mortality. Only limited options for treatment of gastrointestinal dysfunction have been introduced. Factors contributing to motility disorders in the ICU patient, and recent therapeutic approaches are reviewed in the following. RECENT FINDINGS: Despite the growing use of early enteral nutrition in the ICU and improvements in patients' outcome, feed intolerance and motility disorders in critical illness remain unsolved. Evaluation of pathophysiological patterns such as antro-pyloric dysfunction has led to a better knowledge of gut function, whereas development of new prokinetic agents is scarce, and enthusiasm has been cut by the withdrawal of some propulsive agents from the market. SUMMARY: The complexity of gastrointestinal motor function poses a challenge to the pharmacological modulation of gut motility. There has been progress in the understanding of pathophysiologic patterns, whereas therapeutic options are still rare. Metoclopramide and erythromycin are the best evaluated and still the most promising prokinetic agents. Only a few studies in critical illness are available, and the definite value of novel propulsive agents such as motilin agonists and mu-receptor antagonists is unclear due to small patient populations. The most reasonable approach of motility disorders in critical illness seems to be an individual assessment of all associated risk factors combined with early enteral nutrition and use of prokinetic agents.
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Fármacos Gastrointestinais/uso terapêutico , Gastroenteropatias/tratamento farmacológico , Motilidade Gastrointestinal/fisiologia , Adulto , Cuidados Críticos , Nutrição Enteral , Eritromicina/uso terapêutico , Fármacos Gastrointestinais/farmacologia , Gastroenteropatias/fisiopatologia , Motilidade Gastrointestinal/efeitos dos fármacos , Humanos , Unidades de Terapia Intensiva , Metoclopramida/uso terapêutico , Fatores de RiscoRESUMO
Hydroxyethyl starch (HES) is a widely used plasma substitute for correcting perioperative hypovolemia. HES preparations are defined by concentration, molar substitution (MS), mean molecular weight (M(w)), the C(2)/C(6) ratio of substitution, the solvent, and the origin. The possible unwanted side effects of HES are anaphylactic reactions, alterations of hemostasis resulting in increased bleeding, kidney dysfunction, accumulation, and pruritus. In view of the potential side effects, it is crucial to distinguish among the different HES preparations; all HES preparations are not the same. The first generation of HES preparation showing a high M(w) (>450 kD) and a high MS (>0.7) was associated with negative effects with regard to coagulation, organ function, and accumulation. This review is focused on whether modern (third generation), more rapidly degradable HES preparations with a lower M(w) (130 kD) and a lower MS (<0.5) are safer and have fewer side effects. Several studies demonstrated that such modern HES preparations appear to be safe with regard to hemostasis, kidney function, itching, and accumulation. Modern HES preparations are dissolved in balanced, plasma-adapted solutions that no longer contain unphysiological amounts of sodium and chloride and are thus suitable for correcting hypovolemia.
Assuntos
Derivados de Hidroxietil Amido/uso terapêutico , Hipovolemia/terapia , Substitutos do Plasma/uso terapêutico , Anafilaxia/induzido quimicamente , Coagulação Sanguínea/efeitos dos fármacos , Hemorragia/induzido quimicamente , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Derivados de Hidroxietil Amido/química , Derivados de Hidroxietil Amido/farmacocinética , Nefropatias/induzido quimicamente , Taxa de Depuração Metabólica , Peso Molecular , Substitutos do Plasma/efeitos adversos , Substitutos do Plasma/química , Substitutos do Plasma/farmacocinética , Prurido/induzido quimicamente , Medição de Risco , Solventes/química , Resultado do TratamentoRESUMO
BACKGROUND: Hypotension is the most common cardiovascular response to spinal anesthesia. We compared the effects of crystalloid/colloid versus crystalloid administration before spinal anesthesia on cardiac output (CO) in elderly patients undergoing transurethral resection of the prostate. METHODS: Sixty male ASA I-III patients were randomized to one of three groups the control group received no intravascular volume preload, the saline group received 500 mL saline, and the hydroxyethyl starch (HES) group received 500 mL of saline plus 500 mL of 6% HES 130/0.4 within 20 min before spinal anesthesia. Mean arterial blood pressure (MAP) and heart rate, CO, and stroke volume were recorded with a thoracic electrical bioimpedance device. RESULTS: MAP significantly decreased from baseline in the control group (from 104 +/- 20 mm Hg to 88 +/- 11 mm Hg [P = 0.005]) and was significantly lower than in the HES group (from 107 +/- 13 mm Hg to 97 +/- 12 mm Hg [P = 0.001]). In the saline group, MAP decreased (103 +/- 14 mm Hg to 92 +/- 17 mm Hg) with no significant differences compared with the control and HES groups. CO decreased significantly in the control group (from 4.9 +/- 1.6 L/min to 3.8 +/- 0.9 L/min [P = 0.002]) and was significantly lower than in the HES patients in whom CO increased significantly after volume preload (from 5.2 +/- 1.23 L/min to 6.2 +/- 1.43 L/min [P = 0.003]) and remained at baseline level until the end of the study. CONCLUSION: Intravascular volume preload with saline plus HES prevented a decrease of CO, but did not prevent spinal anesthesia-induced hypotension in elderly patients undergoing transurethral resection of the prostate.
Assuntos
Raquianestesia , Volume Sanguíneo/efeitos dos fármacos , Débito Cardíaco/efeitos dos fármacos , Coloides , Soluções Isotônicas , Substitutos do Plasma , Volume Sistólico/efeitos dos fármacos , Idoso , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Soluções Cristaloides , Método Duplo-Cego , Frequência Cardíaca/efeitos dos fármacos , Frequência Cardíaca/fisiologia , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Ressecção Transuretral da Próstata , Resultado do TratamentoRESUMO
BACKGROUND: The optimal priming solution for cardiopulmonary bypass (CPB) is unclear. In this study, we evaluated the influence of high-volume priming with a modern balanced hydroxyethyl starch (HES) preparation on coagulation, inflammation, and organ function compared with an albumin-based CPB priming regimen. METHODS: In 50 patients undergoing coronary artery bypass grafting, the CPB circuit was prospectively and randomly primed with either 1500 mL of 6% HES 130/0.42 in a balanced electrolyte solution (Na(+) 140 mmol/L, Cl(-) 118 mmol/L, K(+) 4 mmol/L, Ca(2+) 2.5 mmol/L, Mg(++) 1 mmol/L, acetate(-) 24 mmol/L, malate(-) 5 mmol/L) (n = 25) or with 500 mL of 5% human albumin plus 1000 mL 0.9% saline solution (n = 25). Inflammation (interleukins [IL]-6, -10), endothelial damage (soluble intercellular adhesion molecule-1), kidney function (kidney-specific proteins alpha-glutathione S-transferase, neutrophil gelatinase-associated lipocalin), coagulation (measured by thrombelastometry [ROTEM, Pentapharm, Munich, Germany]), and platelet function (measured by whole blood aggregometry [Multiplate analyzer, Dynabyte Medical, Munich, Germany]) were assessed after induction of anesthesia, immediately after surgery, 5 h after surgery, and on the morning of first and second postoperative days. RESULTS: Total volume given during and after CPB was 3090 +/- 540 mL of balanced HES and 3110 +/- 450 mL of albumin. Base excess after surgery was lower in the albumin-based priming group than in the balanced HES priming group (-5.9 +/- 1.2 mmol/L vs +0.2 +/- 0.2 mmol/L, P = 0.0003). Plasma levels of IL-6, IL-10, and intercellular adhesion molecule-1 were higher after CPB in the albumin-based priming group compared with the HES priming group at all time periods (P = 0.0002). Urinary concentrations of alpha-glutathione S-transferase and neutrophil gelatinase-associated lipocalin were higher after CPB through the end of the study in the albumin group compared with the balanced HES group (P = 0.00004). After surgery through the first postoperative day, thrombelastometry data (clotting time and clot formation time) revealed more impaired coagulation in the albumin-based priming group compared with the HES priming group (P = 0.004). Compared with baseline, platelet function was unchanged in the high-dose balanced HES priming group after CPB and 5 h after surgery, but it was significantly reduced in the albumin-based priming group. CONCLUSION: High-volume priming of the CPB circuit with a modern balanced HES solution resulted in reduced inflammation, less endothelial damage, and fewer alterations in renal tubular integrity compared with an albumin-based priming. Coagulation including platelet function was better preserved with high-dose balanced HES CPB priming compared with albumin-based CPB priming.
Assuntos
Albuminas/administração & dosagem , Ponte Cardiopulmonar/métodos , Coloides/administração & dosagem , Ponte de Artéria Coronária , Derivados de Hidroxietil Amido/administração & dosagem , Substitutos do Plasma/administração & dosagem , Proteínas de Fase Aguda , Idoso , Albuminas/efeitos adversos , Biomarcadores/sangue , Coagulação Sanguínea/efeitos dos fármacos , Transfusão de Sangue , Ponte Cardiopulmonar/efeitos adversos , Coloides/efeitos adversos , Creatinina/sangue , Endotélio Vascular/efeitos dos fármacos , Endotélio Vascular/imunologia , Feminino , Glutationa Transferase/sangue , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Inflamação/etiologia , Inflamação/imunologia , Mediadores da Inflamação/sangue , Molécula 1 de Adesão Intercelular/sangue , Interleucina-10/sangue , Interleucina-6/sangue , Isoenzimas/sangue , Rim/efeitos dos fármacos , Rim/metabolismo , Lipocalina-2 , Lipocalinas/sangue , Masculino , Substitutos do Plasma/efeitos adversos , Agregação Plaquetária/efeitos dos fármacos , Estudos Prospectivos , Proteínas Proto-Oncogênicas/sangue , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Increased inorganic fluoride levels after methoxyflurane exposure in the 1970s and prolonged intraoperative sevoflurane use have been suggested to be potentially nephrotoxic. In the intensive care unit we evaluated the effect on renal integrity of short-term inhaled postoperative sedation with sevoflurane using the Anesthetic Conserving Device (ACD) compared with propofol. METHODS: In this prospective, randomized, single-blinded study, after major abdominal, vascular or thoracic surgery 125 patients were allocated to receive either sevoflurane (n = 64) via the ACD (end-tidal 0.5-1 vol%) or i.v. propofol (n = 61) for postoperative sedation up to 24 h. Urinary alpha-glutathione-s-transferase as primary outcome variable, urinary N-acetyl-glucosaminidase, serum creatinine, and inorganic fluoride concentrations, urine output and fluid management were measured preoperatively, at the end of surgery, and at 24 and 48 h postoperatively. RESULTS: The sedation time in the intensive care unit was comparable between the sevoflurane (9.2 +/- 4.3 h) and the propofol (9.3 +/- 4.7 h) group. Alpha-glutathione-s-transferase levels were significantly increased at 24 and 48 h postoperatively compared with preoperative values in both groups, without significant differences between the groups. N-acetyl-glucosaminidase and serum creatinine remained unchanged in both study groups, and urine output and creatinine clearance were comparable between the groups throughout the study period. Inorganic fluoride levels increased significantly (P < 0.001) at 24 h after sevoflurane exposure (39 +/- 25 micromol/L) compared with propofol (3 +/- 6 micromol/L) and remained elevated 48 h later (33 +/- 26 vs 3 +/- 5 micromol/L). One patient in each group suffered from renal insufficiency, requiring intensive diuretic therapy, but not dialysis, during hospital stay. CONCLUSIONS: Short-term sedation with either sevoflurane using ACD or propofol did not negatively affect renal function postoperatively. Although inorganic fluoride levels were elevated after sevoflurane exposure, glomerular and tubular renal integrity were preserved throughout the hospital stay.
Assuntos
Anestésicos Inalatórios , Sedação Consciente , Hipnóticos e Sedativos , Nefropatias/induzido quimicamente , Nefropatias/diagnóstico , Éteres Metílicos , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/epidemiologia , Propofol , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica , Cuidados Críticos , Feminino , Hidratação , Fluoretos/sangue , Glutationa Transferase/sangue , Humanos , Hipnóticos e Sedativos/administração & dosagem , Injeções Intravenosas , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Propofol/administração & dosagem , Sevoflurano , Método Simples-CegoRESUMO
BACKGROUND AND OBJECTIVE: Haemostasis appears to be less altered with balanced than with unbalanced hydroxyethylstarch (HES) preparations. In a blinded in-vitro coagulation study, the effects of two HESs dissolved in different balanced solutions were measured. METHODS: Blood from 12 healthy young male volunteers was diluted by 10, 30 and 50% by using either a balanced 6% HES 130/0.42 or a balanced 6% HES 130/0.4. Composition of the solvent of the two HES preparations differed. An unbalanced gelatin solution was used as a control. Rotation thrombelastometry was used to assess changes in coagulation, and whole blood aggregometry using three different inductors was used to assess the effects of dilution on platelet function. RESULTS: Dilutions of 10 and 30% showed no significant changes in thrombelastometry data and platelet aggregation in all three groups. Fifty per cent haemodilution was associated with significantly more pronounced deterioration in clotting time, clot formation time and clot firmness, with the balanced HES 130/0.42 containing calcium than with the balanced HES without calcium. Platelet function was also more impaired by HES not containing calcium than by HES containing calcium. Extreme dilution with gelatin showed similar results to those of balanced HES 130/0.4. CONCLUSION: Our in-vitro studies showed that extreme haemodilution with HES 130/0.42 dissolved in a balanced solution containing calcium was associated with less negative effects on thrombelastometry and platelet aggregation than HES 130/0.4 prepared in a balanced solution without calcium. Gelatin prepared in a nonbalanced solution showed similar effects on coagulation to balanced HES without calcium.
Assuntos
Coagulação Sanguínea/efeitos dos fármacos , Derivados de Hidroxietil Amido/farmacologia , Agregação Plaquetária/efeitos dos fármacos , Tromboelastografia/métodos , Adulto , Relação Dose-Resposta a Droga , Gelatina/farmacologia , Humanos , Derivados de Hidroxietil Amido/administração & dosagem , Técnicas In Vitro , Masculino , Peso Molecular , Testes de Função Plaquetária/métodos , Resultado do Tratamento , Tempo de Coagulação do Sangue TotalRESUMO
BACKGROUND AND OBJECTIVE: Parenteral nutrition including lipids might be associated with liver disease. The cause leading to parenteral nutrition-related liver dysfunction remains largely unknown but is likely to be multifactorial. The study was performed to assess the effects of a lipid emulsion based on soybean oil, medium-chain triglycerides, olive and fish oil (SMOFlipid20%) compared with a lipid emulsion based on olive and soybean oil on hepatic integrity. METHODS: In a prospective, randomized, double-blinded trial, 44 postoperative patients with an indication for parenteral nutrition were allocated to one of two regimens: group A (n = 22) received SMOFlipid, group B (n = 22) a lipid emulsion based on olive and soybean oil for 5 days. Aspartate aminotransferase, alanin-aminotransferase, and serum alpha-glutathion S-transferase were measured before the start of parenteral nutrition (d0), at day 2 (d2), and day 5 (d5) after the start of parenteral nutrition. The significance level was defined at a P value of less than 0.05. RESULTS: There was no significant difference at d0, but at d2 and d5, significantly lower aspartate aminotransferase (d2: group A: 27 +/- 13 vs. group B: 47 +/- 36 U l(-1); d5: A: 31 +/- 14 vs. B: 56 +/- 45 U l(-1)), alanin-aminotransferase (d2: A: 20 +/- 12 vs. B: 42 +/- 39 U l(-1); d5: A: 26 +/- 15 vs. B: 49 +/- 44 U l(-1)), and alpha-glutathion S-transferase levels (d2: A: 5 +/- 6 vs. B: 17 +/- 21 U l(-1); d5: A: 6 +/- 7 vs. B: 24 +/- 27 microg l(-1)) were found in soybean oil, medium-chain triglycerides, olive and fish oil group compared with the control group. CONCLUSION: Hepatic integrity was well retained with the administration of SMOFlipid whereas in patients receiving a lipid emulsion based on olive and soybean oil liver enzymes were elevated indicating a lower liver tolerability.
Assuntos
Doença Hepática Induzida por Substâncias e Drogas/prevenção & controle , Emulsões Gordurosas Intravenosas/efeitos adversos , Óleos de Peixe/efeitos adversos , Nutrição Parenteral/efeitos adversos , Óleos de Plantas/efeitos adversos , Óleo de Soja/efeitos adversos , Triglicerídeos/efeitos adversos , Idoso , Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Doença Hepática Induzida por Substâncias e Drogas/sangue , Método Duplo-Cego , Emulsões , Feminino , Glutationa Transferase/sangue , Humanos , Masculino , Azeite de Oliva , Estudos Prospectivos , Índice de Gravidade de Doença , Triglicerídeos/sangueRESUMO
BACKGROUND: Healthcare is permeated by phenomena of vulnerability and their ethical significance. Nonetheless, application of this concept in healthcare ethics today is largely confined to clinical research. Approaches that further elaborate the concept in order to make it suitable for healthcare as a whole thus deserve renewed attention. METHODS: Conceptual analysis. RESULTS: Taking up the task to make the concept of vulnerability suitable for healthcare ethics as a whole involves two challenges. Firstly, starting from the concept as it used in research ethics, a more detailed characterization and systematization of the different realms of human abilities and the various ways in which these realms contain vulnerability is to be established. Secondly, at the same time, the sought-after concept of vulnerability should avoid picturing the relation between healthcare recipient and provider as a relation between a dependent individual in need and another individual capable of providing all the help necessary. An adequate concept of vulnerability should enable one to understand when and in which respects care providers may be vulnerable as well. Philosophical accounts of vulnerability can help to meet both of these challenges. CONCLUSIONS: Philosophical accounts of vulnerability can help to make the concept of vulnerability suitable for healthcare ethics as a whole. They come with a price, though. While the ethical role of vulnerability in medical ethics usually is to signify states of affairs that are to be diminished or overcome, philosophical accounts introduce forms of vulnerability that are regarded as valuable. Further analyzing and systematizing forms and degrees of vulnerability thus comprises the task to distinguish between amounts and types of vulnerability that can count as valuable, and amounts and types of vulnerability that are to be alleviated.