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1.
South Med J ; 111(1): 64-73, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29298372

RESUMO

OBJECTIVES: To describe the effect of implementing a contemporary perioperative pulmonary hypertension (PH)-targeted protocol in patients with pulmonary arterial hypertension (PAH) undergoing noncardiac surgery (NCS). METHODS: The data of consecutive patients with PAH diagnosed by right heart catheterization who underwent NCS between January 1, 2006 and February 9, 2016 were reviewed. Patient demographics, etiology of PAH, clinical features, diagnostic data, utilization of PH-specific medications, and trend of perioperative complications rate were recorded during the study period. RESULTS: In the base cohort of 375 patients, 37 had NCS. The mean age at surgery was 62 years. Most patients were women (78%) classified in group 1 PAH. At the time of the surgery, 86% were New York Heart Association functional class III/IV and 97% had American Society of Anesthesiologists classifications 3 and 4. A larger proportion of patients displayed lower PAH risk scores between 2006 and 2011 (P = 0.045). Conversely, a higher percentage of patients exhibited moderately high to very high PAH risk scores between 2012 and 2016 (P = 0.003). Perioperative and anesthetic-related morbidity was 27%, and no difference was observed between either period (P = 0.944). Most of the complications (70%) were related to general anesthesia. Two deaths (5%) occurred in our study group, both during the 2006-2011 period. CONCLUSIONS: The combination of a multidisciplinary perioperative approach, utilization of novel pulmonary vascular disease-targeted therapy, adequate perioperative optimization, and thoughtful selection of anesthetic technique seems to be a potential strategy to at least maintain similar perioperative outcomes among higher- and lower-risk patients with PAH undergoing NCS.


Assuntos
Hipertensão Pulmonar/terapia , Complicações Intraoperatórias/prevenção & controle , Equipe de Assistência ao Paciente , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Protocolos Clínicos , Terapia Combinada , Quimioterapia Combinada , Feminino , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/diagnóstico , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
2.
Neurocrit Care ; 29(3): 366-373, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-28932993

RESUMO

Pneumocephalus (PNC) is a condition in which when air is trapped inside the intracranial vault. The causes are varied, but include trauma and intracranial surgery. Treatment of PNC typically consists of augmenting patient oxygenation with the attempt of washing out pulmonary nitrogen, creating a gradient in which nitrogen in the intracranial air bubble diffuses out of the lungs via the blood. Though several high flow methods have been tested, the ideal mode of oxygenation has not fully been investigated. Here we present 3 cases of post-operative PNC who we felt were symptomatic from PNC. With administration of high-flow nasal cannula (HFNC), all patients improved both clinically and radiographically within a few hours, faster than in both anecdotal experience and published trials. Due to its steady FiO2 administration, positive pressure, comfort, and low side-effect profile, HFNC may be the ideal mode of oxygen delivery in PNC. We present a review of the physiology of PNC and the characteristics of several oxygen delivery systems to build a case for HFNC in this disease process.


Assuntos
Cânula , Craniotomia/efeitos adversos , Oxigenoterapia/métodos , Pneumocefalia/etiologia , Pneumocefalia/terapia , Complicações Pós-Operatórias/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/instrumentação , Pneumocefalia/fisiopatologia , Complicações Pós-Operatórias/etiologia
3.
BMJ Case Rep ; 20172017 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-28765187

RESUMO

A 54-year-old man presented to the emergency department with acute left-sided chest pain and left upper quadrant abdominal pain. He had a significant history of squamous cell carcinoma of the lung previously treated with right pneumonectomy who ; is currently receiving adjuvant chemotherapy with cisplatin. Physical examination was remarkable for tachycardia, hypertension and mild abdominal tenderness. CT angiography revealed an aortic mural thrombus in the ascending aorta and aortic arch without dissection, aneurysm or tortuosity of the aorta. In addition, an infarction of the inferior spleen was reported. Given the high risk of surgery for this patient, he was treated conservatively with esmolol and heparin infusion. His subsequent hospital course was uneventful, and he was successfully discharged on enoxaparin therapy that was successively bridged to rivaroxaban treatment. Follow-up transesophageal echocardiography and CT angiography at one month showed no thrombus in the aorta.


Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/diagnóstico por imagem , Tromboembolia/diagnóstico por imagem , Dor Abdominal/etiologia , Doenças da Aorta/tratamento farmacológico , Dor no Peito/etiologia , Angiografia por Tomografia Computadorizada/métodos , Tratamento Conservador , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Propanolaminas/uso terapêutico , Tromboembolia/tratamento farmacológico , Resultado do Tratamento
4.
Crit Ultrasound J ; 7(1): 29, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26123610

RESUMO

BACKGROUND: The evaluation of fluid responsiveness in patients with hemodynamic instability remains to be challenging. This investigation aimed to determine whether respiratory variation in carotid Doppler peak velocity (ΔCDPV) predicts fluid responsiveness in patients with septic shock and lung protective mechanical ventilation with a tidal volume of 6 ml/kg. METHODS: We performed a prospective cohort study at an intensive care unit, studying the effect of 59 fluid challenges on 19 mechanically ventilated patients with septic shock. Pre-fluid challenge ΔCDPV and other static or dynamic measurements were obtained. Fluid challenge responders were defined as patients whose stroke volume index increased more than 15 % on transpulmonary thermodilution. The area under the receiver operating characteristic curve (AUROC) was compared for each predictive parameter. RESULTS: Fluid responsiveness rate was 51 %. The ΔCDPV had an AUROC of 0.88 (95 % confidence interval (CI) 0.77-0.95); followed by stroke volume variation (0.72, 95 % CI 0.63-0.88), passive leg raising (0.69, 95 % CI 0.56-0.80), and pulse pressure variation (0.63, 95 % CI 0.49-0.75). The ΔCDPV was a statistically significant superior predictor when compared with the other parameters. Sensitivity, specificity, and positive and negative predictive values were also the highest for ΔCDPV, with an optimal cutoff at 14 %. There was good correlation between ΔCDPV and SVI increment after the fluid challenge (r = 0.84; p < 0.001). CONCLUSIONS: ΔCDPV can be more accurate than other methods for assessing fluid responsiveness in patients with septic shock receiving lung protective mechanical ventilation. ΔCDPV also has a high correlation with SVI increase after fluid challenge.

5.
J Cardiothorac Vasc Anesth ; 29(3): 576-81, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25622973

RESUMO

OBJECTIVE: To investigate the impact of a sequence of educational interventions in a one-day course on focused transthoracic echocardiography (FOTE) by anesthesia and critical care practitioners. DESIGN: A prospective analysis of the educational data. SETTING: Educational setting in two academic medical centers and a medical meeting workshop organized by one of these institutions. PARTICIPANTS: Fifty-six anesthesia and critical care providers, divided into three groups, participated separately in a FOTE training course. INTERVENTIONS: All participants received a sequence of educational intervention as follows: A standardized, multiple-choice pretest; a lecture on cardiac and lung ultrasound; and a FOTE "hands-on" training session. The same standardized test was administered and graded as a posttest. MEASUREMENTS AND MAIN RESULTS: Fifty-six professionals attended the course in three separate groups: The first were cardiothoracic anesthesia fellows (n = 16) (group 1), the second included critical care practitioners (n = 21) (group 2), and the third were general anesthesiologists (n = 19) (group 3). Parasternal views were most difficult to obtain for all groups (58.1, 63.8, and 58%, respectively). The mean written test scores increased from 14.9±2 to 21.0±2.3 in group 1; from 12.3±3.8 to 19.2±3.7 in group 2; 12±3.5 to 21±2.4 in group 3, (p = 0.0003, 0.00005, 0.0001, respectively). CONCLUSIONS: A FOTE training course improves image acquisition skills and knowledge to the same level independently of professional background and level of experience in critical care ultrasound.


Assuntos
Anestesiologia/educação , Cuidados Críticos/métodos , Ecocardiografia , Cirurgia Torácica/educação , Anestesia/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Competência Clínica , Avaliação Educacional , Humanos , Internato e Residência , Modelos Anatômicos , Estudos Prospectivos , Cirurgiões , Ultrassonografia de Intervenção
7.
J Clin Anesth ; 23(8): 603-10, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22137510

RESUMO

STUDY OBJECTIVES: To determine whether the first-attempt tracheal intubation incidence using the GlideScope videolaryngoscope is higher in patients with predicted increased risk of difficult laryngoscopy, and to assess the ability of other a priori defined standard risk factors to predict first-attempt intubation success, in aggregate and by forming scores. DESIGN: Prospective study. SETTING: Operating room in a tertiary-care academic center. PATIENTS: 357 patients intubated with the GlideScope for nonemergent general anesthesia. INTERVENTIONS AND MEASUREMENTS: Mallampati airway class was used to create two groups of patients, one with higher and the other, lower, potential difficult laryngoscopy (Mallampati classes 3-4 and 1-2, respectively). Intubation success on the first attempt with the GlideScope videolaryngoscope in patients with a Mallampati class 3 or 4 airway versus those with Mallampati class 1 or 2 airway was tested. We also evaluated the predictive ability of the Mallampati airway class (1 and 2 vs 3 and 4) along with 9 other possible predictors of difficult intubation on first-attempt intubation success: gender, age, body mass index, level of training within our anesthesia residency program (Clinical Anesthesia Resident years 1, 2, and 3), ASA physical status, mouth opening, thyromental distance, neck flexion, and neck extension. MAIN RESULTS: None of the standard predictors of difficult intubation was significantly associated with outcome after adjusting for other predictors. A multivariable model containing the aggregate set of variables predicted outcome significantly better than a risk score formed as the sum of 10 predictors ("Risk 10"; P = 0.0176). CONCLUSIONS: With GlideScope-assisted tracheal intubation, Mallampati airway class is not an independent risk factor for difficult intubation. Other standard clinical risk factors of difficulty with direct laryngoscopy also do not appear to be individually predictive of first-attempt success of tracheal intubation.


Assuntos
Intubação Intratraqueal/métodos , Laringoscópios , Laringoscopia/métodos , Centros Médicos Acadêmicos , Fatores Etários , Anestesia Geral/métodos , Índice de Massa Corporal , Feminino , Humanos , Masculino , Análise Multivariada , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Gravação em Vídeo
8.
J Clin Anesth ; 23(5): 414-7, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21741812

RESUMO

Sheehan's syndrome is a well described entity that refers to hypopituitarism with pituitary infarction secondary to postpartum shock or hemorrhage. Antepartum pituitary infarction is a very rare condition that has been reported only in patients with longstanding type 1 diabetes mellitus or uncontrolled gestational diabetes. A case of severe, acute hypopituitarism in the setting of hemorrhagic shock from a gunshot wound is presented. Our case report highlights the importance of including hypopituitarism in the differential diagnosis of a critically ill parturient.


Assuntos
Hipopituitarismo/etiologia , Choque Hemorrágico/etiologia , Ferimentos por Arma de Fogo/complicações , Doença Aguda , Adulto , Feminino , Humanos , Gravidez , Complicações na Gravidez/etiologia , Índice de Gravidade de Doença
9.
Ann Thorac Surg ; 90(1): 109-15, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20609758

RESUMO

BACKGROUND: Gastrointestinal (GI) complications after coronary artery bypass graft surgery (CABG) are uncommon but associated with a disproportionate share of mortality. We thus identified variables associated with GI complications and analyzed their effect on postoperative mortality in patients undergoing isolated CABG. METHODS: Information from patients who underwent isolated CABG at our institution during a 12-year period was obtained from the Anesthesiology Institute patient registry. Patients who experienced one or more postoperative GI complication(s) during their initial intensive care unit stay were identified. Multivariable logistic regression with backward variable selection was used to determine variables associated with GI complications and to evaluate their effect on mortality. RESULTS: Among 16,043 patients who underwent isolated CABG, 213 (1.43%) had one or more GI complication(s). The main patient variables associated with postoperative GI complications included preoperative (odds ratio, 2.43; 95% confidence interval [CI], 1.39 to 4.23; p < 0.001) and intraoperative (odds ratio, 5.07; 95% CI, 3.08 to 8.35; p < 0.001) intraaortic balloon pump insertion, patient age (odds ratio, 1.65; 95% CI, 1.41 to 1.94; p < 0.001), intraoperative fresh-frozen plasma transfusion (odds ratio, 3.38; 95% CI, 2.12 to 5.41; p < 0.001), and cardiogenic shock (odds ratio, 3.04; 95% CI, 1.12 to 8.24). No difference was detected in complication rates between off-pump and on-pump CABG procedures (1.50% versus 1.30%, respectively; p = 0.63). Postoperative GI complication(s) after CABG was associated with a 12.98 times increase in mortality (p < 0.001). CONCLUSIONS: This single-center cohort study indicates that GI complications after isolated CABG remain rare with an incidence 1.43%. However, GI complications portend a significant mortality. The implications of intraoperative administration of fresh-frozen plasma and insertion of an intraaortic balloon pump deserve further investigation as they are associated with GI complications.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Gastroenteropatias/mortalidade , Idoso , Estudos de Coortes , Ponte de Artéria Coronária/mortalidade , Feminino , Gastroenteropatias/etiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
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