RESUMO
BACKGROUND: Cardiopulmonary bypass (CPB) is associated with intravascular hemolysis which depletes endogenous nitric oxide (NO). The impact of hemolysis on pulmonary arterial compliance (PAC) and right ventricular systolic function has not been explored yet. We hypothesized that decreased NO availability is associated with worse PAC and right ventricular systolic function after CPB. METHODS: This is a secondary analysis of an observational cohort study in patients undergoing cardiac surgery with CPB at Massachusetts General Hospital, USA (2014-2015). We assessed PAC (stroke volume/pulmonary artery pulse pressure ratio), and right ventricular function index (RVFI) (systolic pulmonary arterial pressure/cardiac output), as well as NO consumption at 15 min, 4 h and 12 h after CPB. Patients were stratified by CPB duration. Further, we assessed the association between changes in NO consumption with PAC and RVFI between 15min and 4 h after CPB. RESULTS: PAC was lowest at 15min after CPB and improved over time (n = 50). RVFI was highest -worse right ventricular function- at CPB end and gradually decreased. Changes in hemolysis, PAC and RVFI differed over time by CPB duration. PAC inversely correlated with total pulmonary resistance (TPR). TPR and PAC positively and negatively correlated with RVFI, respectively. NO consumption between 15min and 4 h after CPB correlated with changes in PAC (-0.28 ml/mmHg, 95%CI -0.49 to -0.01, p = 0.012) and RVFI (0.14 mmHg*L-1*min, 95%CI 0.10 to 0.18, p < 0.001) after multivariable adjustments. CONCLUSION: PAC and RVFI are worse at CPB end and improve over time. Depletion of endogenous NO may contribute to explain changes in PAC and RVFI after CPB.
Assuntos
Ponte Cardiopulmonar , Hemólise , Artéria Pulmonar , Função Ventricular Direita , Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Função Ventricular Direita/fisiologia , Idoso , Artéria Pulmonar/fisiologia , Artéria Pulmonar/fisiopatologia , Óxido Nítrico/metabolismo , Sístole/fisiologia , Estudos de Coortes , Complacência (Medida de Distensibilidade)RESUMO
BACKGROUND: In the last decades, the use of the helmet interface to deliver noninvasive respiratory support has steadily increased. When delivering oxygen therapy, conditioning of inspired gas is mandatory, as the water content of medical gas is neglectable. To minimize the risk of airway damage, it is recommended to achieve an absolute humidity greater than 10 mg H2O/L. The primary aim of the study was to assess the performance of 3 different heated humidifiers to condition gas during helmet continuous positive airway pressure and to compare them with a setting without active humidification. METHODS: We performed a crossover randomized physiological study in healthy volunteers. Absolute humidity, relative humidity, and temperature were measured during 4 steps (no humidification and the 3 heated humidifiers, performed in a randomized order) and at 3 time points (after 1, 5, and 10 minutes). RESULTS: Eight subjects participated to the study. Without active humidification, absolute humidity was constantly below the recommended level. All humidifiers conditioned the inspired gases to an average absolute humidity greater than 10 mg H2O/L. Overall, the best performance, in terms of absolute humidity, was obtained with H900 (19.74 ± 0.50 mg H2O/L), followed by TurbH2O (-6.82 mg H2O/L vs H900; 95% confidence interval, -8.49 to -5.14; P < .05) and F&P 810 (-9.03 mg H2O/L vs H900; 95% confidence interval, -10.70 to -7.35; P < .05). CONCLUSIONS: Active humidification is required to achieve adequate conditioning of inspired gas during helmet continuous positive airway pressure. The choice between different humidifiers available on the market should be made according to the local needs and expertise.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Temperatura Alta , Humanos , Voluntários Saudáveis , Umidade , OxigenoterapiaRESUMO
Los programas de analgesia postoperatoria que cuentan con sistemas de registro de dolor, sedación y efectos adversos de los fármacos, utilizados junto al resto de los controles sistemáticos que se realizan en todos los pacientes, mejoran la calidad de atención del postoperatorio. La puesta en práctica de normativas generales implica la adecuación de las normas a la realidad de cada institución, la capacitación y el entrenamiento de todo el personal, la transformación de conductas y hábitos contrarios a las normas, la selección cuidadosa de pacientes y sectores de internación y la evaluación periódica de los resultados. Es claro que la solución a los problemas del manejo del dolor postoperatorio no se encuentran en el desarrollo de nuevas técnicas, sino en la organización y explotación de los recursos existentes. El desarrollo del nuevo proyecto no es dependiente de cuánto se tiene, sino de cuánto se puede hacer con lo que se tiene. El objetivo del presente trabajo es revisar, en base a la experiencia acumulada en nuestros hospitales, los aspectos prácticos de la puesta en funcionamiento de programas de analgesia postoperatoria en el ámbito hospitalario.
Assuntos
Humanos , Analgesia , Dor Pós-Operatória , Sistema de Registros , Analgesia Epidural , Analgesia Controlada pelo Paciente , Clínicas de Dor/normas , Clínicas de Dor , Clínicas de Dor/tendências , Estudo de Avaliação , Guias como AssuntoRESUMO
Antecedentes: Las técnicas de anestesia regional y combinada en pediatría son utilizadas desde hace años en cirugías de alto impacto aferente o en pacientes con problemas especiales. Objetivo: Evaluación de las ventajas, desventajas y complicaciones de técnicas de anestesia regional y combinada con bloqueos centrales en pediatría. Lugar de aplicación: Servicio de Anestesiología del Hospital Nacional de Pediatría "Prof. Dr. Juan P. Garrahan", Buenos Aires, Argentina. Unità Operativa di Anestesia e Rianimazione III. Terapia Intensiva Pediatrica, Azienda Ospiedaliera "Ospedali Riuniti", Bergamo, Italia. Diseño: case control study. Población: 250 pacientes ASA I a III, menores de 16 años. Método: Selección de pacientes con beneficios teóricos de recibir anestesia regional o combinada, según el tipo de intervención, por el tipo de estimulación quirúrgica o por riesgo potencial frente al uso de anestesia general convencional. Resultados: 100 bloqueos epidurales lumbares o torácicos, 100 caudales, 50 raquídeos. Efectividad: 97 por ciento. Se registraron complicaciones menores en 10 pacientes. Conclusiones: Las técnicas de anestesia regional o combinada en pediatría permiten un excelente nivel de bloqueo aferente, brindando excelentes condiciones quirúrgicas. Presentan múltiples ventajas en cirugía pediátrica con adecuados niveles de seguridad.