RESUMO
BACKGROUND: Breast cancer is the most common cancer among women and tumour resection carries a high prevalence of chronic persistent postsurgical pain (CPSP). Perioperative i.v. lidocaine infusion has been proposed as protective against CPSP; however, evidence of its benefits is conflicting. This review evaluates the effectiveness of perioperative lidocaine infusions for breast cancer surgery. METHODS: Randomised trials comparing perioperative lidocaine infusions with parenteral analgesia in breast cancer surgery patients were sought. The two co-primary outcomes were the odds of CPSP at 3 and 6 months after operation. Secondary outcomes included rest pain at 1, 6, 12, and 24 h; analgesic consumption at 0-24 and 25-48 h; quality of recovery; opioid-related side-effects; and lidocaine infusion side-effects. Hartung-Knapp-Sidik-Jonkman (HKSJ) random effects modelling was used. RESULTS: Thirteen trials (1039 patients; lidocaine: 518, control: 521) were included. Compared with control, perioperative lidocaine infusion did not decrease the odds of developing CPSP at 3 and 6 months. Lidocaine infusion improved postoperative pain at 1 h by a mean difference (95% confidence interval) of -0.65 cm (-0.73 to -0.57 cm) (P<0.0001); however, this difference was not clinically important (1.1 cm threshold). Similarly, lidocaine infusion reduced oral morphine consumption by 7.06 mg (-13.19 to -0.93) (P=0.029) over the first 24 h only; however, this difference was not clinically important (30 mg threshold). The groups were not different for any of the remaining outcomes. CONCLUSIONS: Our results provide moderate-quality evidence that perioperative lidocaine infusion does not reduce CPSP in patients undergoing breast cancer surgery. Routine use of lidocaine infusions for perioperative analgesia and CPSP prevention is not supported in this population. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42023420888.
Assuntos
Anestésicos Locais , Neoplasias da Mama , Dor Crônica , Lidocaína , Dor Pós-Operatória , Assistência Perioperatória , Humanos , Dor Pós-Operatória/prevenção & controle , Dor Pós-Operatória/tratamento farmacológico , Lidocaína/administração & dosagem , Lidocaína/uso terapêutico , Neoplasias da Mama/cirurgia , Feminino , Anestésicos Locais/administração & dosagem , Anestésicos Locais/uso terapêutico , Dor Crônica/prevenção & controle , Dor Crônica/tratamento farmacológico , Assistência Perioperatória/métodos , Infusões Intravenosas , Resultado do Tratamento , Dor Aguda/prevenção & controle , Dor Aguda/tratamento farmacológico , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND CONTEXT: Surgical decompression is the definitive treatment for managing symptomatic lumbar spinal stenosis; however, select patients are poor surgical candidates. Consequently, minimally invasive procedures have gained popularity, but there exists the potential for failure of therapy necessitating eventual surgical decompression. PURPOSE: To evaluate the incidence and characteristics of patients who require surgical decompression following minimally invasive procedures to treat lumbar spinal stenosis. STUDY DESIGN/SETTING: Retrospective review. PATIENT SAMPLE: Patients who underwent minimally invasive procedures for lumbar spinal stenosis (Percutaneous Image-guided Lumbar Decompression [PILD] or interspinous spacer device [ISD]) and progressed to subsequent surgical decompression within 5 years. OUTCOME MEASURES: The primary outcome was the rate of surgical decompression within 5 years following the minimally invasive approach. Secondary outcomes included demographic and comorbid factors associated with increased odds of requiring subsequent surgery. METHODS: Patient data were collected using the PearlDiver-Mariner database. The rate of subsequent decompression was described as a percentage while univariable and multivariable regression analysis was used for the analysis of predictors. RESULTS: A total of 5278 patients were included, of which 3222 (61.04%) underwent PILD, 1959 (37.12%) underwent ISD placement, and 97 (1.84%) had claims for both procedures. Overall, the incidence of subsequent surgical decompression within 5 years was 6.56% (346 of 5278 patients). Variables associated with a significantly greater odds ratio (OR) [95% confidence interval (CI)] of requiring subsequent surgical decompression included male gender and a prior history of surgical decompression by 1.42 ([1.14, 1.77], p = 0.002) and 2.10 times ([1.39, 3.17], p < 0.001), respectively. In contrast, age 65 years and above, a diagnosis of obesity, and a Charlson Comorbidity Index score of three or greater were associated with a significantly reduced OR [95% CI] by 0.64 ([0.50, 0.81], p < 0.001), 0.62 ([0.48, 0.81], p < 0.001), and 0.71 times ([0.56, 0.91], p = 0.007), respectively. CONCLUSIONS: Minimally invasive procedures may provide an additional option to treat symptomatic lumbar spinal stenosis in patients who are poor surgical candidates or who do not desire open decompression; however, there still exists a subset of patients who will require subsequent surgical decompression. Factors such as gender and prior surgical decompression increase the likelihood of subsequent surgery, while older age, obesity, and a higher Charlson Comorbidity Index score reduce it. These findings aid in selecting suitable surgical candidates for better outcomes in the elderly population with lumbar spinal stenosis.
Assuntos
Estenose Espinal , Humanos , Masculino , Idoso , Estenose Espinal/complicações , Estudos Retrospectivos , Resultado do Tratamento , Incidência , Vértebras Lombares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Descompressão Cirúrgica/métodos , Obesidade/complicaçõesRESUMO
The remede System (ZOLL Medical, Minnetonka, MN; Fig 1), which was approved by the Food and Drug Administration in October of 2017, is a transvenous device that stimulates the phrenic nerve for the treatment of central sleep apnea, which is often associated with heart failure and atrial fibrillation. Given the similarity in implantation procedure to pacemakers and implantable cardioverter/defibrillators, the remede System implantation often occurs in the electrophysiology laboratory. Despite the transvenous nature and close proximity to cardiac structures on radiographic imaging, the remede System does not have any cardiac pacing function/antiarrhythmia therapies, and it is important for an anesthesiologist to be able to recognize and manage such a device if they were to come across one preoperatively.
Assuntos
Desfibriladores Implantáveis , Apneia do Sono Tipo Central , Procedimentos Cirúrgicos Torácicos , Humanos , Resultado do Tratamento , Nervo Frênico , Apneia do Sono Tipo Central/terapiaRESUMO
This special article is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the Editor-in-Chief, Dr Kaplan, the Associate Editor-in-Chief, Dr Augoustides, and the editorial board for the opportunity to author this series, which summarizes the key research papers in the electrophysiology (EP) field relevant to cardiothoracic and vascular anesthesiologists. These articles are shaping perioperative EP procedures and practices, such as pulsed-field ablation, cryoablation for first-line treatment for atrial fibrillation, advancements in conduction system pacing, safety issues related to smartphones and cardiac implantable electronic devices, and alterations in EP workflow as the world emerges from the COVID-19 pandemic. Special emphasis is placed on the implications of these advancements for the anesthetic care of patients undergoing EP procedures.
Assuntos
Anestesiologia , Fibrilação Atrial , COVID-19 , Humanos , Pandemias , Fibrilação Atrial/cirurgia , EletrofisiologiaRESUMO
OBJECTIVES: Placement of percutaneous spinal cord stimulator (SCS) implant has become a therapeutic option for various chronic pain conditions; however, early surgical explant still occurs. Unfortunately, evidence regarding the incidence of early surgical explant, and patient-specific factors and comorbidities associated with such, is limited and mixed. The objective of this retrospective analysis was to elucidate the incidence and predictors of percutaneous SCS explant within the first two years of device placement. MATERIALS AND METHODS: The PearlDiver-Mariner Patient Record Database of all payer claims was used to identify patients who underwent percutaneous lead SCS implant (leads and generator) with subsequent explant within two years of initial device implant. The primary outcome was to determine the incidence of SCS explant within the first two years of device placement. Secondary outcomes included evaluating the effects of several patient-specific comorbidities on explant rates using univariate regression analysis. RESULTS: Across the database, a total of 52,070 patients who underwent percutaneous lead SCS implant were included, of whom 3104 (5.96%) had SCS explant within the first two years. Most explants occurred within the first-year time interval at 72.8% (2260 patients), whereas only 27.2% (844 patients) had SCS explant between years one and two. At the one-year time interval, covariates associated with an increased odds ratio (OR) (95% CI) of SCS explant were 1) depression (1.39 [1.26, 1.52]), 2) chronic preoperative (1.27 [1.16, 1.39]) or postoperative (1.23 [1,13, 1.36]) opioid use, 3) cannabis abuse (1.58 [1.20, 2.02]), 4) tobacco use (1.13 [1.04, 1.23]), and 5) coagulopathy (1.22 [1.07, 1.38]). In contrast, the OR of explant was lower in patients who were older, men, or had diabetes (complicated or uncomplicated). All associated covariates became nonsignificant after the first year of SCS implant (ie, between the first and second years), and only depression and tobacco use remained as associated factors for device explant. CONCLUSIONS: Our retrospective analysis highlights that the rate of percutaneous SCS explant appears to considerably decrease after the first year of device implant. Furthermore, this analysis sheds additional insights into patients who may be at risk of early percutaneous SCS explant, especially within the first year of device placement, and underscores the importance of a continued multidimensional/biopsychologic assessment in patients with chronic pain.
Assuntos
Dor Crônica , Estimulação da Medula Espinal , Masculino , Humanos , Estudos Retrospectivos , Dor Crônica/terapia , Estimulação da Medula Espinal/efeitos adversos , Bases de Dados Factuais , Medula EspinalRESUMO
BACKGROUND: Antithrombin (AT) activity is reduced during cardiac operations with cardiopulmonary bypass (CPB), which is associated with adverse outcomes. Preoperative AT supplementation, to achieve >58% and <100% AT activity, may potentially reduce postoperative morbidity and mortality in cardiac operations with CPB. This prospective, multicenter, randomized, double-blind, placebo-controlled study was designed to evaluate the safety and efficacy of preoperative treatment with AT supplementation in patients at risk for low AT activity after undergoing cardiac surgery with CPB. METHODS: A total of 425 adult patients were randomized (1:1) to receive either a single dose of AT (n = 213) to achieve an absolute increase of 20% above pretreatment AT activity or placebo (n = 212) before surgery. The study duration was approximately 7 weeks. The primary efficacy end point was the percentage of patients with any component of a major morbidity composite (postoperative mortality, stroke, acute kidney injury [AKI], surgical reexploration, arterial or venous thromboembolic events, prolonged mechanical ventilation, and infection) in the 2 groups. Secondary end points included AT activity, blood loss, transfusion requirements, duration of intensive care unit (ICU), and hospital stays. Safety was also assessed. RESULTS: Overall, 399 patients (men, n = 300, 75.2%) with a mean (standard deviation [SD]) age of 66.1 (11.7) years, with the majority undergoing complex surgical procedures (n = 266, 67.9%), were analyzed. No differences in the percentage of patients experiencing morbidity composite outcomes between groups were observed (AT-treated 68/198 [34.3%] versus placebo 58/194 [29.9%]; P = .332; relative risk, 1.15). After AT infusion, AT activity was significantly higher in the AT group (108% [42-143]) versus placebo group (76% [40-110]), and lasted up to postoperative day 2. At ICU, the frequency of patients with AT activity ≥58% in the AT group (81.5%) was significantly higher ( P < .001) versus placebo group (43.2%). Secondary end point analysis did not show any advantage of AT over placebo group. There were significantly more patients with AKI ( P < .001) in the AT group (23/198; 11.6%) than in the placebo group (5/194, 2.6%). Safety results showed no differences in treatment-emergent adverse events nor bleeding events between groups. CONCLUSIONS: AT supplementation did not attenuate adverse postoperative outcomes in our cohort of patients undergoing cardiac surgery with CPB.
Assuntos
Injúria Renal Aguda , Procedimentos Cirúrgicos Cardíacos , Injúria Renal Aguda/etiologia , Adulto , Idoso , Antitrombinas/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/efeitos adversos , Suplementos Nutricionais , Método Duplo-Cego , Humanos , Masculino , Estudos Prospectivos , Resultado do TratamentoRESUMO
The Aveir VR Leadless Pacemaker (Abbott, Chicago, IL) recently was approved by the US Food and Drug Administration, and joined the Micra (Medtronic, Minneapolis, MN) transcatheter pacing system in the realm of nontransvenous cardiovascular implantable devices. The Aveir VR offers design improvements over its predecessor, the Nanostim (St. Jude Medical). There are recommendations for the perioperative management of conventional transvenous pacemakers, but leadless pacemakers add a new layer of consideration. Although there have been prior documented experiences with the Micra device, there are enough differences between the Aveir VR and the Micra that it is important to understand what makes the Aveir VR unique if an anesthesiologist were to come across one preoperatively.
Assuntos
Anestésicos , Marca-Passo Artificial , Humanos , Anestesiologistas , Tecnologia , Desenho de EquipamentoRESUMO
Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.
Assuntos
Estenose da Valva Aórtica , Delírio , Embolia Intracraniana , Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Valva Aórtica/cirurgia , Estenose da Valva Aórtica/complicações , Delírio/etiologia , Humanos , Embolia Intracraniana/etiologia , Embolia Intracraniana/prevenção & controle , Embolia Intracraniana/cirurgia , Neuroproteção , Fatores de Risco , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/cirurgia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do TratamentoRESUMO
Liver transplantation is associated with significant blood loss, often requiring massive blood product transfusion. Transfusion-related acute lung injury (TRALI) is a devastating cause of transfusion-related deaths. While reports have investigated the general incidence of TRALI, the incidence of TRALI specifically following transfusion during liver transplant remains unclear. This scoping review summarizes existing literature regarding TRALI during the liver transplantation perioperative period. Databases were searched for all articles and abstracts reporting on TRALI after liver transplantation. Data collected included number of patients studied, patient characteristics, incidences of TRALI, TRALI characteristics, and patient outcomes. The primary outcome investigated was the incidence of TRALI in the setting of liver transplantation. Thirteen full-text citations were included in this review. The incidence of TRALI post-liver transplant was 0.68% (65 of 9,554). Based on reported transfusion data, patients diagnosed with TRALI received an average of 10.92 ± 10.81 units of packed red blood cells (pRBC), 20.05 ± 15.72 units of fresh frozen plasma, and 5.75 ± 10.00 units of platelets. Common interventions following TRALI diagnosis included mechanical ventilation with positive end-expiratory pressure, inhaled high-flow oxygen, inhaled pulmonary vasodilator, and pharmacologic treatment using pressors or inotropes, corticosteroids, or diuretics. Based on reported mortality data, 26.67% of patients (12 of 45) diagnosed with TRALI died during the postoperative period. This scoping review underscores the importance of better understanding the incidence and presentation of TRALI after liver transplant surgery. The clinical implications of these results warrant the development of identification and management strategies for liver transplant patients at increased risk for developing TRALI.
Assuntos
Lesão Pulmonar Aguda , Transplante de Fígado , Reação Transfusional , Lesão Pulmonar Aguda Relacionada à Transfusão , Lesão Pulmonar Aguda/diagnóstico , Lesão Pulmonar Aguda/epidemiologia , Lesão Pulmonar Aguda/etiologia , Transfusão de Sangue/métodos , Humanos , Transplante de Fígado/efeitos adversos , Reação Transfusional/epidemiologia , Reação Transfusional/etiologia , Lesão Pulmonar Aguda Relacionada à Transfusão/diagnóstico , Lesão Pulmonar Aguda Relacionada à Transfusão/epidemiologia , Lesão Pulmonar Aguda Relacionada à Transfusão/etiologiaRESUMO
Critical care after cardiothoracic surgery is an inseparable component of any successful surgical program addressing intrathoracic pathologies, including heart failure treatment with mechanical circulatory support, and respiratory failure requiring extracorporeal membrane oxygenation (ECMO) therapy [...].
Assuntos
Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Insuficiência Respiratória , Humanos , Insuficiência Cardíaca/cirurgia , Cuidados CríticosRESUMO
BACKGROUND: Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics. METHODS: The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm · h. RESULTS: Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores ± SD at 24 to 72 h were 7.6 ± 4.9 cm · h and 6.6 ± 4.6 cm · h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm · h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm · h [-0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported. CONCLUSIONS: Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.
Assuntos
Analgesia/métodos , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Anestésicos Locais/administração & dosagem , Bupivacaína/administração & dosagem , Humanos , Lipossomos , Nervos Periféricos/efeitos dos fármacos , Resultado do TratamentoRESUMO
This article is the third in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the Editor-in-Chief Dr. Kaplan, the Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to continue this series; namely, the highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This third article focuses on the convergent procedure, His-bundle pacing, a comparison of subcutaneous and transvenous defibrillator therapies, the 2020 practice advisory update for the perioperative management of patients with cardiac implantable electronic devices, and a technology update regarding the Micra AV (Medtronic, Moundsview, MN), the EMPOWER leadless pacemaker (Boston Scientific, Marlborough, MA), WiSE-CRT (EBR Systems, Sunnyvale, CA), the Extravascular Implantable Cardioverter Defibrillator (Medtronic, Moundsview, MN), and the BAROSTIM NEO (CVRx Inc, Minneapolis, MN).
Assuntos
Anestesia , Anestesiologia , Desfibriladores Implantáveis , Marca-Passo Artificial , Eletrofisiologia , HumanosRESUMO
Despite advances in cardiac surgery and anesthesia, the rates of brain injury remain high in aortic arch surgery requiring circulatory arrest. The mechanisms of brain injury, including permanent and temporary neurologic dysfunction, are multifactorial, but intraoperative brain ischemia is likely a major contributor. Maintaining optimal cerebral perfusion during cardiopulmonary bypass and circulatory arrest is the key component of intraoperative management for aortic arch surgery. Various brain monitoring modalities provide different information to improve cerebral protection. Electroencephalography gives crucial data to ensure minimal cerebral metabolism during deep hypothermic circulatory arrest, transcranial Doppler directly measures cerebral arterial blood flow, and near-infrared spectroscopy monitors regional cerebral oxygen saturation. Various brain protection techniques, including hypothermia, cerebral perfusion, pharmacologic protection, and blood gas management, have been used during interruption of systemic circulation, but the optimal strategy remains elusive. Although deep hypothermic circulatory arrest and retrograde cerebral perfusion have their merits, there have been increasing reports about the use of antegrade cerebral perfusion, obviating the need for deep hypothermia. With controversy and variability of surgical practices, moderate hypothermia, when combined with unilateral antegrade cerebral perfusion, is considered safe for brain protection in aortic arch surgery performed with circulatory arrest. The neurologic outcomes of brain protection in aortic arch surgery largely depend on the following three major components: cerebral temperature, circulatory arrest time, and cerebral perfusion during circulatory arrest. The optimal brain protection strategy should be individualized based on comprehensive monitoring and stems from well-executed techniques that balance the major components contributing to brain injury.
Assuntos
Aorta Torácica , Hipotermia Induzida , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/cirurgia , Encéfalo/diagnóstico por imagem , Circulação Cerebrovascular , Parada Circulatória Induzida por Hipotermia Profunda , Humanos , Perfusão , Resultado do TratamentoRESUMO
BACKGROUND: Continuous epidural infusion (CEI) is commonly used for labour analgesia, but concerns over potential motor block, second-stage labour complications, and ineffective analgesia in late labour have prompted examining intermittent epidural bolus (IEB) as an alternative. However, evidence comparing these modalities is conflicting. The meta-analysis evaluates the analgesic efficacy of CEI vs IEB. METHODS: Databases were searched for trials comparing CEI to IEB for labour analgesia. The two co-primary outcomes were risk of breakthrough pain and difference in area under the curve (AUC) for pain scores during the first 4 h post-epidural initiation. Local anaesthetic consumption, maternal outcomes (i.e. delivery mode, labour duration, and maternal satisfaction), and side-effects of epidural analgesia were also evaluated. Results were pooled using random-effects modelling. Trial sequential analysis (TSA) was used to evaluate evidence reliability. RESULTS: Twenty-seven studies (3133 patients) were analysed. Compared with CEI, IEB decreased risk of breakthrough pain by 38% (risk ratio [95% confidence interval {CI}] of 0.62 [0.48, 0.81]; P=0.0004; I2=47%; 1164 patients) and reduced AUC of pain during the 4 h interval by 32.9% (mean difference [95% CI] of -16.7 mm h-1 [-18.9, -14.4]; P<0.0001; 1638 patients). Intermittent epidural bolus enhanced maternal satisfaction, shortened labour duration, decreased motor block, and reduced local anaesthetic consumption. The difference between the two groups was not statistically significant for epidural side-effects or mode of delivery. The TSA indicated adequate power for reliable inferences. CONCLUSIONS: Intermittent epidural bolus provides improved labour pain control during the first 4 h after epidural initiation with less breakthrough pain. Moderate- to high-quality evidence of intermittent epidural bolus superiority support its use as a safe and effective continuous epidural infusion alternative for labour analgesia.
Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Anestésicos Locais/farmacologia , Feminino , Humanos , Trabalho de Parto , Satisfação do Paciente , GravidezRESUMO
This is the final review article in a 4-part series focusing on the perioperative management of the 4 major companies' cardiovascular implantable electronic devices (CIEDs) in the United States. This article presents information pertinent to the perioperative management of Medtronic (Minneapolis, MN) transvenous CIEDs, including responses to magnet application, interpretation of interrogation reports, and basic programming (eg, mode, rate, rate modulation, and tachyarrhythmia therapies). Information regarding the Medtronic Micra (Medtronic, Minneapolis, MN) has been published previously. In addition, it contains an introduction to the concept of magnetic resonance (MR) conditional devices and magnetic resonance imaging (MRI) practices.
Assuntos
Desfibriladores Implantáveis , Marca-Passo Artificial , Anestesiologistas , Eletrônica , Humanos , Imageamento por Ressonância Magnética , Estados UnidosRESUMO
Biotronik cardiovascular implantable electronic devices, specifically Biotronik pacemakers, contain unique features that are relevant to perioperative management. For example, Biotronik pacemakers have a programmable response to magnet application, a default magnet response that does not result in sustained asynchronous pacing, and a unique method of rate adaptation (eg, closed loop stimulation). This review article focuses on these unique features; the interpretation of Biotronik interrogation reports; and the basic programming (eg, mode, rate, rate adaptation, tachyarrhythmia therapies) relevant to the perioperative management of Biotronik cardiovascular implantable electronic devices.
Assuntos
Anestesiologistas/normas , Estenose das Carótidas/cirurgia , Desfibriladores Implantáveis/normas , Assistência Perioperatória/normas , Guias de Prática Clínica como Assunto/normas , Idoso de 80 Anos ou mais , Estenose das Carótidas/fisiopatologia , Eletrocardiografia/métodos , Eletrocardiografia/normas , Humanos , Masculino , Assistência Perioperatória/métodosRESUMO
This article is the first in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, the associate editor-in-chief, Dr. Augoustides, and the editorial board for the opportunity to start this series, namely the research highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This first article focuses on esophageal thermal injury during radiofrequency ablation, perioperative management of patients presenting for ablation procedures, left atrial appendage occlusion devices, and, finally, heart failure diagnostic devices.
Assuntos
Anestesia/métodos , Anestesiologia , Fibrilação Atrial/cirurgia , Ablação por Cateter/métodos , Eletrofisiologia/tendências , Monitorização Fisiológica/métodos , Humanos , Monitorização Fisiológica/tendências , Publicações Periódicas como AssuntoRESUMO
BACKGROUND AND OBJECTIVE: Worldwide adoption of the subcutaneous implantable cardioverter-defibrillator (S-ICD) for preventing sudden cardiac death continues to increase, as longer-term evidence demonstrating the safety and efficacy of the S-ICD expands. As a relatively new technology, comprehensive anesthesia guidance for the management of patients undergoing S-ICD placement is lacking. This article presents advantages and disadvantages of different periprocedural sedation and anesthesia options for S-ICD implants including general anesthesia, monitored anesthesia care, regional anesthesia, and nonanesthesia personnel administered sedation and analgesia. METHODS: Guidance, for approaches to anesthesia care during S-ICD implantation, is presented based upon literature review and consensus of a panel of high-volume S-ICD implanters, a regional anesthesiologist, and a cardiothoracic anesthesiologist with significant S-ICD experience. The panel developed suggested actions for perioperative sedation, anesthesia, surgical practices, and a decision algorithm for S-ICD implantation. CONCLUSIONS: While S-ICD implantation currently requires higher sedation than transvenous ICD systems, the panel consensus is that general anesthesia is not required or is obligatory for the majority of patients for the experienced S-ICD implanter. The focus of the implanting physician and the anesthesia services should be to maximize patient comfort and take into consideration patient-specific comorbidities, with a low threshold to consult the anesthesiology team.