RESUMO
BACKGROUND: Inadequate antinociception can cause haemodynamic instability. The nociception level (NOL) index measures response to noxious stimuli, but its capacity to predict optimal antinociception is unknown. OBJECTIVE: To determine if NOL index change to a tetanic stimulus in cardiac and noncardiac surgery patients could predict the required remifentanil concentration for haemodynamic stability at skin incision. DESIGN: A prospective two-phase cohort study. SETTING: University hospital. PATIENTS: Patients undergoing remifentanil-propofol target controlled infusion (TCI) anaesthesia. INTERVENTIONS: During the calibration phase, investigators evaluated the tetanic stimulus induced NOL index change under standardised TCI remifentanil-propofol anaesthesia during a no-touch period [bispectral index (BIS) between 40 and 60, NOL index under 15]. If the NOL index change was 20 or greater following tetanic stimulation, investigators repeated the tetanus at higher remifentanil concentrations until the response was blunted. Surgeons incised the skin at this remifentanil concentration. The investigators derived a prediction model and in the validation phase calculated, using the NOL response to a single tetanus, the required incision remifentanil concentration for the start of surgery. MAIN OUTCOME: Haemodynamic stability at incision [i.e. maximum heart rate (HR) < 20% increase from baseline, minimum HR (40âbpm) and mean arterial pressure (MAP) ± <20% of baseline]. RESULTS: During the calibration phase, no patient had hypertension. Two patients had a HR increase slightly greater than 20% (25.4 and 26.7%) within the first 2âmin of surgery, but neither of these two patients had a HR above 76âbpm. Two patients were slightly hypotensive after incision (MAP 64 and 73âmmHg). During the validation phase, neither tachycardia nor hypotension occurred, but MAP increased to 21.5% above baseline for one patient. CONCLUSION: During a no-touch period in patients under steady-state general anaesthesia [propofol effect site concentration (Ce) required for BIS between 40 and 60], the NOL index response to a tetanic stimulus under remifentanil antinociception can be used to personalise remifentanil Ce for the start of surgery and ensure stable haemodynamics. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03324269.
Assuntos
Propofol , Ferida Cirúrgica , Tétano , Humanos , Calibragem , Estudos de Coortes , Frequência Cardíaca , Nociceptividade , Piperidinas , Propofol/farmacologia , Estudos Prospectivos , Remifentanil/farmacologiaRESUMO
BACKGROUND: Hypotension occurs frequently during surgery and may be associated with adverse complications. Vasopressor titration is frequently used to correct hypotension, but requires considerable time and attention, potentially reducing the time available for other clinical duties. To overcome this issue, we have developed a closed-loop vasopressor (CLV) controller to help correct hypotension more efficiently. The aim of this randomised controlled study was to evaluate whether the CLV controller was superior to traditional vasopressor management at minimising hypotension in patients undergoing abdominal surgery. METHODS: Thirty patients scheduled for elective intermediate-to high-risk abdominal surgery were randomised into two groups. In the CLV group, hypotension was corrected automatically via the CLV controller system, which adjusted the rate of a norepinephrine infusion according to MAP values recorded using an advanced haemodynamic device. In the control group, management of hypotension consisted of standard, manual adjustment of the norepinephrine infusion. The primary outcome was the percentage of time that a patient was hypotensive, defined as MAP <90% of their baseline value, during surgery. RESULTS: The percentage of time patients were hypotensive during surgery was 10 times less in the CVL group than in the control group (1.6 [0.9-2.3]% vs 15.4 [9.9-24.3]%; difference: 13 [95% confidence interval: 9-19]; P<0.0001). The CVL group also spent much less time with MAP <65 mm Hg (0.2 [0.0-0.4]% vs 4.5 [1.1-7.9]%; P<0.0001). CONCLUSIONS: In patients undergoing intermediate- to high-risk surgery under general anaesthesia, computer-assisted adjustment of norepinephrine infusion significantly decreases the incidence of hypotension compared with manual control. CLINICAL TRIAL REGISTRATION: NCT04089644.
Assuntos
Abdome/cirurgia , Hipotensão/tratamento farmacológico , Complicações Intraoperatórias/tratamento farmacológico , Norepinefrina/administração & dosagem , Vasoconstritores/administração & dosagem , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Norepinefrina/uso terapêutico , Risco , Resultado do Tratamento , Vasoconstritores/uso terapêuticoRESUMO
BACKGROUND: The effect of dexmedetomidine on Nociception Level Index-guided (Medasense, Israel) antinociception to reduce intra-operative opioid requirements has not been previously investigated. OBJECTIVE: We aimed to determine if low-dose dexmedetomidine would reduce remifentanil requirements during Nociception Level Index-guided antinociception without increasing complications associated with dexmedetomidine. DESIGN: Double-blind randomised controlled trial. SETTING: Two university teaching hospitals in Brussels, Belgium. PATIENTS: American Society of Anesthesiologists 1 and 2 patients (nâ=â58) undergoing maxillofacial or cervicofacial surgery under propofol--remifentanil target-controlled infusion anaesthesia. INTERVENTIONS: A 30âmin infusion of dexmedetomidine, or equal volume of 0.9% NaCl, was infused at 1.2âµgâkg-1âh-1 immediately preceding induction and then decreased to 0.6âµgâkg-1âh-1 until 30âmin before ending surgery. Nociception Level Index and frontal electroencephalogram guided the remifentanil and propofol infusions, respectively. MAIN OUTCOMES: The primary outcome was the remifentanil requirement. Other outcomes included the propofol requirement, cardiovascular status and postoperative outcome. RESULTS: Meanâ±âSD remifentanil (3.96â±â1.95 vs. 4.42â±â2.04ângâml-1; Pâ=â0.0024) and propofol (2.78â±â1.36 vs. 3.06â±â1.29âµgâml-1; Pâ=â0.0046) TCI effect site concentrations were lower in the dexmedetomidine group at 30âmin postincision and remained lower throughout surgery. When remifentanil (0.133â±â0.085 vs. 0.198â±â0.086âµgâkg-1âmin-1; Pâ=â0.0074) and propofol (5.7â±â2.72 vs. 7.4â±â2.80âmgâkg-1âh-1; Pâ=â0.0228) requirements are represented as infusion rates, this effect became statistically significant at 2âh postincision. CONCLUSION: In ASA 1 and 2 patients receiving Nociception Level Index-guided antinociception, dexmedetomidine decreases intra-operative remifentanil requirements. Combined frontal electroencephalogram and Nociception Level Index monitoring can measure dexmedetomidine's hypnotic and opioid-sparing effects during remifentanil-propofol target-controlled infusion anaesthesia. TRIAL REGISTRATIONS: Clinicaltrials.gov: NCT03912740, EudraCT: 2018-004512-22.
Assuntos
Dexmedetomidina , Propofol , Anestésicos Intravenosos , Bélgica , Humanos , Nociceptividade , RemifentanilRESUMO
BACKGROUND: Cognitive changes after anesthesia and surgery represent a significant public health concern. We tested the hypothesis that, in patients 60 yr or older scheduled for noncardiac surgery, automated management of anesthetic depth, cardiac blood flow, and protective lung ventilation using three independent controllers would outperform manual control of these variables. Additionally, as a result of the improved management, patients in the automated group would experience less postoperative neurocognitive impairment compared to patients having standard, manually adjusted anesthesia. METHODS: In this single-center, patient-and-evaluator-blinded, two-arm, parallel, randomized controlled, superiority study, 90 patients having noncardiac surgery under general anesthesia were randomly assigned to one of two groups. In the control group, anesthesia management was performed manually while in the closed-loop group, the titration of anesthesia, analgesia, fluids, and ventilation was performed by three independent controllers. The primary outcome was a change in a cognition score (the 30-item Montreal Cognitive Assessment) from preoperative values to those measures 1 week postsurgery. Secondary outcomes included a battery of neurocognitive tests completed at both 1 week and 3 months postsurgery as well as 30-day postsurgical outcomes. RESULTS: Forty-three controls and 44 closed-loop patients were assessed for the primary outcome. There was a difference in the cognition score compared to baseline in the control group versus the closed-loop group 1 week postsurgery (-1 [-2 to 0] vs. 0 [-1 to 1]; difference 1 [95% CI, 0 to 3], P = 0.033). Patients in the closed-loop group spent less time during surgery with a Bispectral Index less than 40, had less end-tidal hypocapnia, and had a lower fluid balance compared to the control group. CONCLUSIONS: Automated anesthetic management using the combination of three controllers outperforms manual control and may have an impact on delayed neurocognitive recovery. However, given the study design, it is not possible to determine the relative contribution of each controller on the cognition score.
Assuntos
Anestesia Geral/métodos , Anestésicos Intravenosos/administração & dosagem , Cognição/fisiologia , Monitores de Consciência , Monitorização Intraoperatória/métodos , Recuperação de Função Fisiológica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/tendências , Cognição/efeitos dos fármacos , Monitores de Consciência/tendências , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Masculino , Testes de Estado Mental e Demência , Pessoa de Meia-Idade , Monitorização Intraoperatória/tendências , Recuperação de Função Fisiológica/efeitos dos fármacosRESUMO
Automated titration of intravenous anesthesia and analgesia using processed electroencephalography monitoring is no longer a novel concept. Closed-loop control of fluid administration to provide goal-directed fluid therapy has also been increasingly described. However, simultaneously combining 2 independent closed-loop systems together in patients undergoing major vascular surgery has not been previously detailed. The aim of this pilot study was to evaluate the clinical performance of fully automated hypnosis, analgesia, and fluid management using 2 independent closed-loop controllers in patients undergoing major vascular surgery before implementation within a larger study evaluating true patient outcomes.
Assuntos
Analgesia/métodos , Anestesia com Circuito Fechado/métodos , Hidratação/métodos , Hipnóticos e Sedativos/uso terapêutico , Monitorização Intraoperatória/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Anestesia Intravenosa/métodos , Automação , Estudos de Viabilidade , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Projetos Piloto , Resultado do TratamentoRESUMO
BACKGROUND: Pulse pressure variation (PPV) can be used to predict fluid responsiveness in anesthetized patients receiving controlled mechanical ventilation but usually requires dedicated advanced monitoring. Capstesia (Galenic App, Vitoria-Gasteiz, Spain) is a novel smartphone application that calculates PPV and cardiac output (CO) from a picture of the invasive arterial pressure waveform obtained from any monitor screen. The primary objective was to compare the ability of PPV obtained using the Capstesia (PPVCAP) and PPV obtained using a pulse contour analysis monitor (PPVPC) to predict fluid responsiveness. A secondary objective was to assess the agreement and the trending of CO values obtained with the Capstesia (COCAP) against those obtained with the transpulmonary bolus thermodilution method (COTD). METHODS: We studied 57 mechanically ventilated patients (tidal volume 8 mL/kg, positive end-expiratory pressure 5 mm Hg, respiratory rate adjusted to keep end tidal carbon dioxide [32-36] mm Hg) undergoing elective coronary artery bypass grafting. COTD, COCAP, PPVCAP, and PPVPC were measured before and after infusion of 5 mL/kg of a colloid solution. Fluid responsiveness was defined as an increase in COTD of >10% from baseline. The ability of PPVCAP and PPVPC to predict fluid responsiveness was analyzed using the area under the receiver-operating characteristic curve (AUROC), the agreement between COCAP and COTD using a Bland-Altman analysis and the trending ability of COCAP compared to COTD after volume expansion using a 4-quadrant plot analysis. RESULTS: Twenty-eight patients were studied before surgical incision and 29 after sternal closure. There was no significant difference in the ability of PPVCAP and PPVPC to predict fluid responsiveness (AUROC 0.74 [95% CI, 0.60-0.84] vs 0.68 [0.54-0.80]; P = .30). A PPVCAP >8.6% predicted fluid responsiveness with a sensitivity of 73% (95% CI, 0.54-0.92) and a specificity of 74% (95% CI, 0.55-0.90), whereas a PPVPC >9.5% predicted fluid responsiveness with a sensitivity of 62% (95% CI, 0.42-0.88) and a specificity of 74% (95% CI, 0.48-0.90). When measured before surgery, PPV predicted fluid responsiveness (AUROC PPVCAP = 0.818 [P = .0001]; PPVPC = 0.794 [P = .0007]) but not when measured after surgery (AUROC PPVCAP = 0.645 [P = .19]; PPVPC = 0.552 [P = .63]). A Bland-Altman analysis of COCAP and COTD showed a mean bias of 0.3 L/min (limits of agreement: -2.8 to 3.3 L/min) and a percentage error of 60%. The concordance rate, corresponding to the proportion of CO values that changed in the same direction with the 2 methods, was poor (71%, 95% CI, 66-77). CONCLUSIONS: In patients undergoing cardiac surgery, PPVCAP and PPVPC both weakly predict fluid responsiveness. However, COCAP is not a good substitute for COTD and cannot be used to assess fluid responsiveness.
Assuntos
Determinação da Pressão Arterial/instrumentação , Pressão Sanguínea , Débito Cardíaco , Procedimentos Cirúrgicos Cardíacos , Monitorização Intraoperatória/instrumentação , Pulso Arterial , Smartphone , Adulto , Idoso , Algoritmos , Área Sob a Curva , Pressão Arterial , Determinação da Pressão Arterial/métodos , Feminino , Hidratação , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Aplicativos Móveis , Monitorização Intraoperatória/métodos , Estudos Prospectivos , Curva ROC , Reprodutibilidade dos Testes , Respiração Artificial , Termodiluição/métodosRESUMO
BACKGROUND: Mismanagement of remifentanil leads to severe side effects such as opioid-induced tolerance and hyperalgesia. Recently studies revealed an alternative withdrawal method to limit these side effects. A gradual withdrawal of remifentanil seems to be associated with less pain. The hypothesis of this double-blinded, randomized controlled trial was that a gradual withdrawal of remifentanil would be associated with less immediate post-operative pain compared to after an abrupt discontinuation of remifentanil in patients who underwent thyroid surgery. METHODS: This double-blinded, randomized controlled trial was conducted in a tertiary level hospital in Brussels (Belgium) from April until August 2017. 34 patients undergoing thyroid surgery were randomized and 29 patients completed the study. After randomization, patients undergoing thyroid surgery were allocated to two groups: one with an abrupt discontinuation of remifentanil after surgery and one with a gradual withdrawal of remifentanil after surgery. The primary outcome was the initial post-operative demand of analgesic medication. RESULTS: Gradual withdrawal of remifentanil was associated with a delayed initial post-operative demand of analgesic medication (P = 0.006). The first morphine bolus was given after 76.3 +/- 89.0 min in the group with a gradual withdrawal of remifentanil versus after 9.0 +/- 13.5 min in the group with an abrupt discontinuation of remifentanil. However, overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) were similar in both groups (P > 0.05). CONCLUSION: Though overall morphine consumption, numeric rating scale scores, Ramsay Sedation Scale scores, and quality of recovery scores (QoR-40) are not altered, a gradual withdrawal of remifentanil after thyroid surgery is safe and associated with a delayed initial post-operative demand of analgesic drugs. The withdrawal process does, however, require vigilance and training. TRIAL REGISTRATION: Clinicaltrials.gov NCT03110653 (PI: Luc Barvais; date of registration: 03/31/2017).
Assuntos
Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Medição da Dor/métodos , Dor Pós-Operatória/tratamento farmacológico , Remifentanil/administração & dosagem , Doenças da Glândula Tireoide/cirurgia , Adulto , Analgésicos Opioides/efeitos adversos , Método Duplo-Cego , Esquema de Medicação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Remifentanil/efeitos adversosRESUMO
Noxious stimulation influences the autonomic nervous system activity. Sympathetic tone monitoring is currently used to assess the adequacy of the balance between nociception and anti-nociception during general anesthesia. The Surgical Plethysmographic Index (SPI) and the EBMi software (Custos©) are commercial devices that use different algorithms to measure it. We aimed at determining whether those devices provide similar information during routine surgical procedures under general anesthesia. Data acquired during a previously published study in patients undergoing surgery under general anesthesia were retrospectively analyzed and passed through the EBMi software. The occurrence of EBMi alarms of increased sympathetic tone was compared to the occurrence of SPI values ≥ 60, a commonly recommended intraoperative SPI threshold. Trends in classical parameters of sympathetic tone during the 5 min preceding a SPI ≥ 60, namely blood pressure, heart rate, and plethysmographic pulse amplitude were assessed. SPI ≥ 60 episodes (n = 307) were more frequent than EBMi alerts (n = 240). Approximately 70% of EBMi alerts occurred during periods where the SPI was below 60. Among all episodes of SPI ≥ 60, absence of any EBMi alerts was much more frequent than the inverse. A majority, but not all SPI ≥ 60 episodes were consistently preceded by an increase in heart rate and/or a decrease in pulse amplitude. Blood pressure did not significantly change before SPI ≥ 60. Longer SPI ≥ 60 episodes were associated with lower anti-nociception anesthetic regimen. Different methods of sympathetic tone assessment during general anesthesia provide conflicting information. Prospective studies should be undertaken to clarify the clinical indications of both techniques.
Assuntos
Anestesia Geral , Monitorização Intraoperatória/métodos , Pletismografia/métodos , Sistema Nervoso Simpático/fisiopatologia , Algoritmos , Anestésicos , Anestésicos Intravenosos/farmacologia , Sistema Nervoso Autônomo , Pressão Sanguínea/efeitos dos fármacos , Desenho de Equipamento , Frequência Cardíaca , Humanos , Nociceptividade , Propofol/farmacologia , Remifentanil/farmacologia , Estudos Retrospectivos , SoftwareRESUMO
BACKGROUND: Goal-directed fluid therapy (GDFT) has been associated with improved patient outcomes. However, implementation of GDFT protocols remains low despite growing published evidence and the recommendations of multiple regulatory bodies in Europe. We developed a closed-loop-assisted GDFT management system linked to a pulse contour monitor to assist anaesthesiologists in applying GDFT. OBJECTIVE: To assess the impact of our closed-loop system in patients undergoing major abdominal surgery in an academic hospital without a GDFT programme. DESIGN: A case-control study with propensity matching. SETTING: Operating rooms, Erasme Hospital, Brussels. PATIENTS: All patients who underwent elective open major abdominal surgery between January 2013 and December 2016. INTERVENTION: Implementation of our closed-loop-assisted GDFT in April 2015. METHODS: A total of 104 patients managed with closed-loop-assisted GDFT were paired with a historical cohort of 104 consecutive non-GDFT patients. The historical control group consisted of patients treated before the implementation of the closed-loop-system, and who did not receive GDFT. In the closed-loop group, the system delivered a baseline crystalloid infusion of 3âmlâkgâh and additional 100âml fluid boluses of either a crystalloid or colloid for haemodynamic optimisation. MAIN OUTCOME MEASURES: The primary outcome was intra-operative net fluid balance. Secondary outcomes were composite major postoperative complications, composite minor postoperative complications and hospital length of stay (LOS). RESULTS: Baseline characteristics were similar in both groups. Patients in the closed-loop group had a lower net intra-operative fluid balance compared with the historical group (median interquartile range [IQR] 2.9 [1.6 to 4.4] vs. 6.2 [4.0 to 8.3]âmlâkgâh; Pâ<â0.001). Incidences of major and minor postoperative complications were lower (17 vs. 32%, Pâ=â0.015 and 31 vs. 45%, Pâ=â0.032, respectively) and hospital LOS shorter [median (IQR) 10 (6 to 15) vs. 12 (9 to 18) days, Pâ=â0.022] in the closed-loop group. CONCLUSION: Implementation of our closed-loop-assisted GDFT strategy resulted in a reduction in intra-operative net fluid balance, which was associated with reduced postoperative complications and shorter hospital LOS. TRIAL REGISTRATION NUMBER: NCT02978430.
Assuntos
Procedimentos Cirúrgicos Eletivos/métodos , Hidratação/métodos , Objetivos , Cuidados Intraoperatórios/métodos , Pontuação de Propensão , Abdome/cirurgia , Idoso , Estudos de Casos e Controles , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Hidratação/normas , Humanos , Cuidados Intraoperatórios/normas , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controleRESUMO
BACKGROUND: The type of fluid and volume regimen given intraoperatively both can impact patient outcome after major surgery. This two-arm, parallel, randomized controlled, double-blind, bi-center superiority study tested the hypothesis that when using closed-loop assisted goal-directed fluid therapy, balanced colloids are associated with fewer postoperative complications compared to balanced crystalloids in patients having major elective abdominal surgery. METHODS: One hundred and sixty patients were enrolled in the protocol. All patients had maintenance-balanced crystalloid administration of 3 ml · kg · h. A closed-loop system delivered additional 100-ml fluid boluses (patients were randomized to receive either a balanced-crystalloid or colloid solution) according to a predefined goal-directed strategy, using a stroke volume and stroke volume variation monitor. All patients were included in the analysis. The primary outcome was the Post-Operative Morbidity Survey score, a nine-domain scale, at day 2 postsurgery. Secondary outcomes included all postoperative complications. RESULTS: Patients randomized in the colloid group had a lower Post-Operative Morbidity Survey score (median [interquartile range] of 2 [1 to 3] vs. 3 [1 to 4], difference -1 [95% CI, -1 to 0]; P < 0.001) and a lower incidence of postoperative complications. Total volume of fluid administered intraoperatively and net fluid balance were significantly lower in the colloid group. CONCLUSIONS: Under our study conditions, a colloid-based goal-directed fluid therapy was associated with fewer postoperative complications than a crystalloid one. This beneficial effect may be related to a lower intraoperative fluid balance when a balanced colloid was used. However, given the study design, the mechanism for the difference cannot be determined with certainty.
Assuntos
Coloides/administração & dosagem , Procedimentos Cirúrgicos Eletivos/métodos , Hidratação/métodos , Cuidados Intraoperatórios/métodos , Soluções Isotônicas/administração & dosagem , Planejamento de Assistência ao Paciente , Abdome/cirurgia , Idoso , Soluções Cristaloides , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: The surgical plethysmographic index (SPI) is one of the available indexes of the nociception-antinociception (NAN) balance. Individually adjusting the NAN balance to prevent somatic responses to noxious stimulation remains a challenge. OBJECTIVES: To assess whether guiding remifentanil administration according to the SPI response to a calibrated noxious stimulus (NANCAL) can blunt the haemodynamic response to tracheal intubation and surgical incision. DESIGN: Randomised multicentre study. SETTING: Two Belgian university hospitals from January 2014 to April 2015. PATIENTS: After ethic review board approval and informed consent, 48 American Society of Anesthesiologists I or II adult patients scheduled for surgery under general anaesthesia were enrolled. INTERVENTIONS: Patients were randomly assigned to a SPI group, where remifentanil effect-site concentration was adjusted according to NANCAL, or a control group, where it was fixed at 4âng ml. Propofol concentration was always adjusted to maintain the bispectral index close to 40. NANCAL consisted of a 100âHz, 60âmA electrical tetanic stimulation during 30âs at the wrist before tracheal intubation and before surgical incision. MAIN OUTCOME MEASURES: The primary endpoint was the efficacy of the NANCAL-guided remifentanil administration to prevent the haemodynamic response to tracheal intubation and surgical incision. The secondary aim was to compare the ability of SPI, analgesia nociception index, pupil diameter and mean arterial pressure response to NANCAL to predict the haemodynamic response to tracheal intubation and surgical incision. RESULTS: Our SPI response to NANCAL-based correcting scheme for remifentanil administration was not superior to a fixed remifentanil concentration at blunting the haemodynamic response to tracheal intubation or surgical incision. Among all tested NAN balance indices, only mean arterial pressure had significant predictive ability with regard to the haemodynamic response to surgical incision. CONCLUSION: Further research is needed to define the best NANCAL stimulus and the best remifentanil correcting scheme to help individualised tailoring of antinociception for each specific subpopulation of surgical patients. TRIAL REGISTRATION: Clinicaltrials.gov NCT: 02884310; https://clinicaltrials.gov/ct2/show/NCT02884310.
Assuntos
Hemodinâmica/efeitos dos fármacos , Laringoscopia/normas , Monitorização Intraoperatória/normas , Medição da Dor/normas , Remifentanil/administração & dosagem , Ferida Cirúrgica/tratamento farmacológico , Adulto , Analgésicos Opioides/administração & dosagem , Feminino , Hemodinâmica/fisiologia , Humanos , Infusões Intravenosas/efeitos adversos , Infusões Intravenosas/normas , Laringoscopia/métodos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Medição da Dor/métodos , Pletismografia/métodos , Pletismografia/normas , Ferida Cirúrgica/complicações , Adulto JovemRESUMO
BACKGROUND: Cardiac output (CO) is a physiological variable that should be monitored during cardiac surgery. The purpose of this study was to assess the trending ability of two CO monitors, esCCO (Nihon Kohden™, Tokyo, Japan) and Volume View (VV) (Edwards Lifesciences, Irvine, USA). METHODS: A total of 19 patients were included in the study. Before cardiopulmonary bypass (CPB), CO was measured simultaneously using both esCCO and VV devices before and after three CO-modifying manoeuvres (passive leg raise [PLR], the end expiratory occlusion test [EEOT] and positive end expiratory pressure [PEEP] at 10 cm H2O). Five CO values for esCCO and three for VV were averaged and compared during a one-minute period of time before and after each manoeuvre. RESULTS: A total of 114 paired readings were collected. Median CO values were 4.3 L min⻹ (IQR: 3.8; 5.2) and 3.8 L min⻹ (IQR: 3.5; 4.5) for esCCO and VV, respectively. The precision error was 1.4% (95% CI:1.0-1.7) for esCCO and 2.2% (95% CI: 1.8-2.7) for VV. The bias between esCCO and VV values was normally distributed (P = 0.0596). Between esCCO and VV, the mean bias was +0.6 L min⻹ with a Limit of Agreement (LOA) of -1.8 L min⻹ and +3.0 L min⻹. The concordance rate was 43% (95% CI: 29-58) between esCCO and VV. CONCLUSION: Both single and trended measurements of CO using esCCO and VV were not in agreement. This large discrepancy leads one to the conclusion that any outcome study conducted with one of these devices cannot be applied to the other.
Assuntos
Débito Cardíaco/fisiologia , Ponte Cardiopulmonar/métodos , Monitorização Intraoperatória/métodos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/métodos , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Respiração com Pressão PositivaRESUMO
Automated delivery of anesthesia guided by processed electroencephalogram monitoring using a closed-loop system is no longer a novel concept. However, combining multiple independent physiologic closed-loop systems together has never been documented before. The purpose of this case report was to evaluate the feasibility of automated anesthesia and fluid management based on a combination of physiological variables (bispectral index, stroke volume, and stroke volume variations) using 2 independent closed-loop systems.
Assuntos
Anestesia Geral/métodos , Automação , Ponte de Artéria Coronária/métodos , Hidratação/métodos , Hemodinâmica/fisiologia , Monitorização Intraoperatória/métodos , Idoso , Analgesia/instrumentação , Analgesia/métodos , Débito Cardíaco/fisiologia , Eletrocardiografia , Eletrodos , Hidratação/instrumentação , Frequência Cardíaca/fisiologia , Humanos , Masculino , Monitorização Intraoperatória/instrumentação , Volume Sistólico/fisiologia , Resultado do TratamentoRESUMO
This study sought to compare the effect of tranexamic acid (TXA) administration on cardiopulmonary bypass-induced platelet dysfunction in patients who received preoperative aspirin or not. We performed a prospective, randomized, double-blind pilot study, including patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB). Patients without aspirin interruption were enrolled in the 'group ASPIRIN' (nâ=â18) and those who had never been treated with aspirin were included in the 'group NO ASPIRIN' (nâ=â10). Patients were then randomized to receive either TXA or the same infusion of normal saline. Multiple electrode aggregometry was used to assess platelet function at the different time points throughout the surgery: baseline, post-TXA loading dose, aortic unclamping (End CPB), and 5âmin after protamine (Protamine). Compared to those included in the group NO ASPIRIN, patients included in the group ASPIRIN presented a decreased baseline platelet function measured by ASP test (Pâ<â0.01) and collagen test (Pâ<â0.01). In the group NO ASPIRIN, treatment group (TXA vs. placebo) significantly influenced the results for ADP test (Pâ<â0.01), thrombin receptor-activating peptide test (Pâ=â0.01), and ASP test (Pâ=â0.01). We observed that TXA improved platelet function, as measured using multiple electrode aggregometry on ADP test, thrombin receptor-activating peptide test, and ASP test, at the end of CPB (Pâ<â0.05). TXA might decrease the magnitude of platelet dysfunction in aspirin-free patients undergoing cardiac surgery. Further studies are needed to confirm these results and assess a potential relationship with clinical endpoints.
Assuntos
Antifibrinolíticos/uso terapêutico , Plaquetas/efeitos dos fármacos , Ponte Cardiopulmonar/métodos , Ácido Tranexâmico/uso terapêutico , Idoso , Antifibrinolíticos/administração & dosagem , Método Duplo-Cego , Feminino , Fibrinólise , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Ácido Tranexâmico/administração & dosagemRESUMO
BACKGROUND: Tranexamic acid is used to decrease bleeding and transfusions during cardiac surgery. However, dosing based on pharmacokinetic data to optimally inhibit fibrinolysis is unknown. With increasing concerns regarding seizures associated with higher doses, lower dosing schemes may be important. OBJECTIVE: To determine the effect of two dosing schemes compared with placebo on fibrinolysis and clinical outcomes. DESIGN: A double-blind, randomised, controlled, pilot trial. SETTING: Single tertiary centre. PATIENTS: Cardiac surgery patients requiring cardiopulmonary bypass. INTERVENTION: Patients were randomised to receive a 30âmgâ kg(-1) bolus and continuous infusion of 16 âmg âkgâ(-1) h(-1) (Group HIGH), a 5âmgâ kg(-1) bolus followed by 5âmgâ kg(-1) âh(-1) (Group LOW) or Sodium chloride (Placebo). MAIN OUTCOME MEASURE: Fibrinolysis was evaluated by thromboelastography and D-dimers. Secondary endpoints were blood loss, transfusion requirement and side effects. RESULTS: Thirty-three patients were included. Significant fibrinolysis was defined by LY30 more than 7.5% based on thromboelastography and was not observed after cardiopulmonary bypass in any groups. After protamine administration, LY30 differences between groups were 0.7 [95% confidence interval (95% CI) -0.04 to 1.4] between Groups HIGH and Placebo, -0.08 (95% CI -0.82 to 0.66) between Groups HIGH and LOW, and 0.78 (95% CI 0.02 to 1.5) between Groups LOW and Placebo. A significant increase in D-dimers was observed in the Group Placebo compared with the two treatment groups. There were no differences in bleeding or transfusion requirement. CONCLUSION: In this dose-finding study, there were no differences in fibrinolysis or clinical outcomes among the two tranexamic acid schemes and placebo. Any difference in fibrinolytic inhibition requires a larger adequately powered study. TRIAL REGISTRATION: EudraCT number: 2010-024104-99.
Assuntos
Antifibrinolíticos/administração & dosagem , Ponte Cardiopulmonar/métodos , Tromboelastografia/métodos , Ácido Tranexâmico/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Antifibrinolíticos/farmacologia , Perda Sanguínea Cirúrgica/prevenção & controle , Relação Dose-Resposta a Droga , Método Duplo-Cego , Produtos de Degradação da Fibrina e do Fibrinogênio/metabolismo , Fibrinólise/efeitos dos fármacos , Humanos , Pessoa de Meia-Idade , Projetos Piloto , Protaminas/administração & dosagem , Ácido Tranexâmico/farmacologiaRESUMO
BACKGROUND: Penile nerve block (PNB) is a well-established technique used for circumcision; it requires the injection of local anesthetics close to the dorsal nerve of the penis. The goal of this study was to compare the efficacy of ultrasound-guided PNB versus the classical landmark-based technique (LBT) in children undergoing circumcision. METHODS: Forty boys, aged 1-14 years old that were scheduled for circumcision were randomly assigned to ultrasound-guided and landmark-based groups. All patients were placed under standard anesthesia with sevoflurane. In each group, patients received the penile block with ropivacaine, 0.75 mg·kg(-1) per side, and 0.05 mg·kg(-1) at the penis base. Groups were compared for intraoperative failure rate of the block, anesthesia time, postoperative pain scale, time of first required dose of paracetamol, time to first micturition, and average duration of stay in the postanesthesia care unit. RESULTS: The failure rate of dorsal PNB was not statistically different between groups (P = 0.5). Ultrasound guidance improved the efficacy of the PNB compared to the LBT in terms of postoperative pain scores on arrival in the PACU (P < 0.01) and after 30 min (P < 0.01). The ultrasound-guided technique also delayed the time to the first paracetamol dose administration (P < 0.0001), but the duration of the procedure, defined as the time between anesthesia induction and the end of surgery, was increased by 10 min in the US-guided group (P = 0.001). CONCLUSION: Ultrasound-guided PNB improved the efficacy of the block compared with the LBT in terms of the postoperative pain during the first postoperative hour and the time to the first requirement for postoperative analgesia.
Assuntos
Bloqueio Nervoso/métodos , Pênis/diagnóstico por imagem , Pênis/cirurgia , Adolescente , Anestésicos Locais/farmacocinética , Criança , Pré-Escolar , Circuncisão Masculina , Humanos , Lactente , Masculino , Medição da Dor , Cuidados Pós-Operatórios , Medicação Pré-Anestésica , Sala de Recuperação , Método Simples-Cego , UltrassonografiaRESUMO
OBJECTIVE: To investigate the relationships between 2 anesthetic techniques, or the extent of allodynia around the surgical wound, and the occurrence of chronic post-thoracotomy pain. DESIGN: Prospective, randomized study. SETTING: A single-institution, university hospital. PARTICIPANTS: Thirty-eight patients who underwent elective thoracotomy under general anesthesia. INTERVENTIONS: High-dose remifentanil (average effect-site concentration 5.61 +/- 0.84 ng/mL) with epidural analgesia started and at the end of surgery or low-dose remifentanil (average effect site concentration 1.99 +/- 0.02 ng/mL) with epidural analgesia with 0.5% ropivacaine started at the beginning of anesthesia. MEASUREMENTS AND MAIN RESULTS: Pain intensity and the extent of allodynia around the wound were measured during the hospital stay. The presence and intensity of residual pain were assessed 1, 3, and 6 months after surgery and at the end of the study (6-13 months, average 9 months). A DN4 neuropathic pain diagnostic questionnaire was conducted at the same times. In the high-dose group, the area with allodynia was three times larger than the area in the low-dose group. The increased allodynia was associated with a higher incidence of chronic pain (RR: 2.7-4.2) 3 and 6 months after surgery and at the end of the study (median follow-up: 9.5 months). CONCLUSIONS: High-dose remifentanil (0.14-0.26 microg/kg/min) without epidural analgesia during surgery is associated with a large area of allodynia around the wound. These patients develop a much higher incidence of chronic pain than those receiving low-dose remifentanil with epidural analgesia during surgery.