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1.
J Clin Monit Comput ; 38(5): 945-959, 2024 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-38381359

RESUMO

Haemodynamic monitoring and management are cornerstones of perioperative care. The goal of haemodynamic management is to maintain organ function by ensuring adequate perfusion pressure, blood flow, and oxygen delivery. We here present guidelines on "Intraoperative haemodynamic monitoring and management of adults having non-cardiac surgery" that were prepared by 18 experts on behalf of the German Society of Anaesthesiology and Intensive Care Medicine (Deutsche Gesellschaft für Anästhesiologie und lntensivmedizin; DGAI).


Assuntos
Anestesiologia , Cuidados Críticos , Monitorização Hemodinâmica , Hemodinâmica , Monitorização Intraoperatória , Sociedades Médicas , Humanos , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/normas , Alemanha , Cuidados Críticos/métodos , Cuidados Críticos/normas , Anestesiologia/métodos , Anestesiologia/normas , Adulto , Monitorização Hemodinâmica/métodos , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Procedimentos Cirúrgicos Operatórios , Sociedades Científicas
2.
Anesth Analg ; 132(2): 420-429, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33264119

RESUMO

BACKGROUND: Diastolic dysfunction is a risk factor for postoperative major cardiovascular events. During anesthesia, patients with diastolic dysfunction might experience impaired hemodynamic function and worsening of diastolic function, which in turn, might be associated with a higher incidence of postoperative complications.We aimed to investigate whether patients with diastolic dysfunction require higher doses of norepinephrine during general anesthesia. Furthermore, we aimed to examine the association between the grade of diastolic dysfunction and the E/e' ratio during anesthesia. A high E/e' ratio corresponds to elevated filling pressures and is an important measure of impaired diastolic function. METHODS: We conducted a prospective observational cohort study at a German university hospital from February 2017 to September 2018. Patients aged ≥60 years and undergoing general anesthesia (ie, propofol and sevoflurane) for elective noncardiac surgery were enrolled. Exclusion: mitral valve disease, atrial fibrillation, and implanted mechanical device.The primary outcome parameter was the administered dose of norepinephrine within 30 minutes after anesthesia induction (µg·kg-1 30 min-1). The secondary outcome parameter was the change of Doppler echocardiographic E/e' from ECHO1 (baseline) to ECHO2 (anesthesia). Linear models and linear mixed models were used for statistical evaluation. RESULTS: A total of 247 patients were enrolled, and 200 patients (75 female) were included in the final analysis. Diastolic dysfunction at baseline was not associated with a higher dose of norepinephrine during anesthesia (P = .6953). The grade of diastolic dysfunction at baseline was associated with a decrease of the E/e' ratio during anesthesia (P < .001). CONCLUSIONS: We did not find evidence for an association between diastolic dysfunction and impaired hemodynamic function, as expressed by high vasopressor support during anesthesia. Additionally, our findings suggest that diastolic function, as expressed by the E/e' ratio, does not worsen during anesthesia.


Assuntos
Agonistas alfa-Adrenérgicos/administração & dosagem , Anestesia Geral , Norepinefrina/administração & dosagem , Procedimentos Cirúrgicos Operatórios , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Diástole , Ecocardiografia Doppler , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico por imagem
3.
J Clin Monit Comput ; 31(1): 213-219, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26621389

RESUMO

The problem of high rates of false alarms in patient monitoring in anesthesiology and intensive care medicine is well known but remains unsolved. False alarms desensitize the medical staff, leading to ignored true alarms and reduced quality of patient care. A database of intra-operative monitoring data was analyzed to find characteristic alarm patterns. The original data were re-evaluated to find relevant events and to rate the severity of these events. Based on this analysis an adaptive time delay was developed that individually delays the alarms depending on the grade of threshold deviation. The conventional threshold algorithm led to 4893 alarms. 3515 (71.84 %) of these alarms were annotated as clinically irrelevant. In total 81.0 % of all clinically irrelevant alarms were caused by only mild and/or brief threshold violations. We implemented the new algorithm for selected parameters. These parameters equipped with adaptive validation delays led to 1729 alarms. 931 (53.85 %) alarms were annotated as clinically irrelevant. 632 alarms indicated the 645 clinically relevant events. The positive predictive value of occurring alarms improved from 28.16 % (conventional algorithm) to 46.15 % (new algorithm). 13 events were missed. The false positive alarm reduction rate of the algorithm ranged from 33 to 86.75 %. The overall reduction was 73.51 %. The implementation of this algorithm may be able to suppress a large percentage of false alarms. The effect of this approach has not been demonstrated but shows promise for reducing alarm fatigue. Its safety needs to be proven in a prospective study.


Assuntos
Alarmes Clínicos , Fadiga Mental/prevenção & controle , Monitorização Intraoperatória/métodos , Monitorização Fisiológica/métodos , Algoritmos , Anestesiologia/métodos , Cuidados Críticos , Bases de Dados Factuais , Humanos , Unidades de Terapia Intensiva , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Tempo
5.
J Cardiothorac Vasc Anesth ; 28(5): 1273-7, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25281044

RESUMO

OBJECTIVE: In critical illness, hypoglycemia and hyperglycemia seem to influence outcome. While hypoglycemia can lead to organ dysfunction, hyperglycemia can lead to surgical site infections (SSI). In cardiac surgery, the use of blood cardioplegia is associated with high blood glucose levels. A computer-based algorithm (CBA) for guiding insulin towards normoglycemia might be beneficial. The authors' primary study end-point was the duration in a predefined blood glucose target range of 80 mg/dL to 150 mg/dL. Patients with conventional therapy served as controls. DESIGN: Prospective, randomized trial. SETTING: University hospital. PARTICIPANTS: Seventy-five patients. INTERVENTIONS: The start of therapy was the beginning of cardiopulmonary bypass. Group A: Therapy with CBA and measurement of blood glucose every 30 minutes. Group B: Measurement of blood glucose every 15 minutes using the identical CBA. Group C: Conventional therapy using a fixed insulin dosing scheme. End of therapy was defined as discharge from ICU. MEASUREMENT AND MAIN RESULTS: Glucose administration during cardioplegia did not differ between groups (A: 33 ± 12 g; B: 32 ± 12 g; C: 38 ± 20 g). Glucose levels in groups A and B stayed significantly longer in the target interval compared with group C (A: 75 ± 20%; B: 72 ± 19%; C: 50 ± 34%, p < 0.01 n = 25, respectively). There were no significant differences regarding ICU stay and SSI rates. CONCLUSIONS: Early computer-based insulin therapy allows practitioners to better achieve normoglycemia in patients undergoing major cardiac surgery with the use of blood cardioplegia.


Assuntos
Algoritmos , Ponte Cardiopulmonar/métodos , Simulação por Computador , Índice Glicêmico/fisiologia , Parada Cardíaca Induzida/métodos , Assistência Perioperatória/métodos , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Ponte Cardiopulmonar/normas , Estudos de Viabilidade , Feminino , Parada Cardíaca Induzida/normas , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória/normas , Estudos Prospectivos
6.
Eur J Anaesthesiol ; 31(9): 482-90, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-24927118

RESUMO

BACKGROUND: Electroencephalographic-based monitoring systems such as the bispectral index (BIS) may reduce anaesthetic overdose rates. OBJECTIVE: We hypothesised that goal-directed sevoflurane administration (guided by BIS monitoring) could reduce the sevoflurane plasma concentration (SPC) and intraoperative vasopressor doses during on-pump cardiac surgery. DESIGN: A prospective, controlled, sequential two-arm clinical study. SETTING: German university medical centre with more than 2500 cardiac surgery interventions per year. PATIENTS: Sixty elective on-pump cardiac surgery patients. INTERVENTION: In group Sevo1.8% (n = 29), the sedation depth was maintained with a sustained inspired concentration of sevoflurane 1.8% before and during cardiopulmonary bypass (CPB). In group SevoBIS (n = 31), the inspired sevoflurane concentration was titrated to maintain a BIS target between 40 and 60. OUTCOME MEASURES: SPC during CPB and the intraoperative administration of noradrenaline. Additional analyses were performed on intraoperative awareness, postoperative blood lactate concentration, duration of mechanical ventilation, intensive care unit length of stay and kidney injury. RESULTS: Mean inspired sevoflurane concentration was 0.8% in group SevoBIS, representing a 57.1% reduction (P < 0.001) compared with group Sevo1.8%. The mean SPC was 42.3 µg ml(-1) [95% confidence interval (CI) 40.0 to 44.6] in group Sevo1.8% and 21.0 µg ml(-1) (95% CI 18.8 to 23.3) in group SevoBIS, representing a 50.2% reduction (P < 0.001). During CPB, the mean cumulative dose of noradrenaline administered was 13.48 µg kg(-1) (95% CI 10.52 to 17.19) in group Sevo1.8% and 4.06 µg kg(-1) (95% CI 2.67 to 5.97) in group SevoBIS (P < 0.001). Pearson's correlation coefficient (between the cumulative applied dosage of sevoflurane calculated from the area under the curve of the SPC over time and the administered cumulative noradrenaline dose) was 0.607 (P < 0.001). No intraoperative awareness signs were detected. CONCLUSION: BIS-guided titration of sevoflurane reduces the SPC and decreases noradrenaline administration compared with routine care during on-pump cardiac surgery.


Assuntos
Anestésicos Inalatórios/administração & dosagem , Ponte de Artéria Coronária/métodos , Éteres Metílicos/administração & dosagem , Norepinefrina/administração & dosagem , Centros Médicos Acadêmicos , Idoso , Anestésicos Inalatórios/farmacocinética , Monitores de Consciência , Relação Dose-Resposta a Droga , Eletroencefalografia/métodos , Feminino , Seguimentos , Alemanha , Humanos , Masculino , Éteres Metílicos/farmacocinética , Pessoa de Meia-Idade , Estudos Prospectivos , Sevoflurano , Vasoconstritores/administração & dosagem
8.
Anesthesiology ; 119(4): 824-36, 2013 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-23732173

RESUMO

BACKGROUND: The authors hypothesized that goal-directed hemodynamic therapy, based on the combination of functional and volumetric hemodynamic parameters, improves outcome in patients with cardiac surgery. Therefore, a therapy guided by stroke volume variation, individually optimized global end-diastolic volume index, cardiac index, and mean arterial pressure was compared with an algorithm based on mean arterial pressure and central venous pressure. METHODS: This prospective, controlled, parallel-arm, open-label trial randomized 100 coronary artery bypass grafting and/or aortic valve replacement patients to a study group (SG; n = 50) or a control group (CG; n = 50). In the SG, hemodynamic therapy was guided by stroke volume variation, optimized global end-diastolic volume index, mean arterial pressure, and cardiac index. Optimized global end-diastolic volume index was defined before and after weaning from cardiopulmonary bypass and at intensive care unit (ICU) admission. Mean arterial pressure and central venous pressure served as hemodynamic goals in the CG. Therapy was started immediately after induction of anesthesia and continued until ICU discharge criteria, serving as primary outcome parameter, were fulfilled. RESULTS: Intraoperative need for norepinephrine was decreased in the SG with a mean (±SD) of 9.0 ± 7.6 versus 14.9 ± 11.1 µg/kg (P = 0.002). Postoperative complications (SG, 40 vs. CG, 63; P = 0.004), time to reach ICU discharge criteria (SG, 15 ± 6 h; CG, 24 ± 29 h; P < 0.001), and length of ICU stay (SG, 42 ± 19 h; CG, 62 ± 58 h; P = 0.018) were reduced in the SG. CONCLUSION: Early goal-directed hemodynamic therapy based on cardiac index, stroke volume variation, and optimized global end-diastolic volume index reduces complications and length of ICU stay after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hemodinâmica/fisiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/prevenção & controle , Agonistas alfa-Adrenérgicos/uso terapêutico , Idoso , Valva Aórtica/cirurgia , Pressão Arterial/efeitos dos fármacos , Pressão Arterial/fisiologia , Pressão Venosa Central/efeitos dos fármacos , Pressão Venosa Central/fisiologia , Ponte de Artéria Coronária/métodos , Diástole/efeitos dos fármacos , Diástole/fisiologia , Epinefrina/uso terapêutico , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Derivados de Hidroxietil Amido/uso terapêutico , Soluções Isotônicas/uso terapêutico , Masculino , Substitutos do Plasma/uso terapêutico , Estudos Prospectivos , Solução de Ringer , Volume Sistólico/efeitos dos fármacos , Volume Sistólico/fisiologia
10.
Anesth Analg ; 112(1): 78-83, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20966440

RESUMO

BACKGROUND: Vital sign monitors and ventilator/anesthesia workstations are equipped with multiple alarms to improve patient safety. A high number of false alarms can lead to a "crying wolf" phenomenon with consecutively ignored critical situations. Systematic data on alarm patterns and density in the perioperative phase are missing. Our objective of this study was to characterize the patterns of alarming of a commercially available patient monitor and a ventilator/anesthesia workstation during elective cardiac surgery. METHODS: We performed a prospective, observational study in 25 consecutive elective cardiac surgery patients. In all patients, identically fixed alarm settings were used. All incoming patient data and all alarms from the patient monitor and the anesthetic workstation were digitally recorded. Additionally, the anesthesia workplace was videotaped from 2 different angles to allow retrospective annotation and correlation of alarms with the clinical situation and assessment of the anesthesiologists' reaction to the alarms. RESULTS: Of the 8975 alarms, 7556 were hemodynamic alarms and 1419 were ventilatory alarms. For each procedure, 359 ± 158 alarms were recorded, representing a mean density of alarms of 1.2/minute. CONCLUSION: Approximately 80% of the total 8975 alarms had no therapeutic consequences. Implementation of procedure-specific settings and optimization in artifact and technical alarm detection could improve patient surveillance and safety.


Assuntos
Anestesia/normas , Procedimentos Cirúrgicos Cardíacos/normas , Alarmes Clínicos/normas , Monitorização Intraoperatória/normas , Salas Cirúrgicas/normas , Idoso , Anestesia/métodos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Procedimentos Cirúrgicos Cardíacos/métodos , Falha de Equipamento , Circulação Extracorpórea/instrumentação , Circulação Extracorpórea/métodos , Circulação Extracorpórea/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Monitorização Intraoperatória/métodos , Salas Cirúrgicas/métodos , Estudos Prospectivos , Estudos Retrospectivos
11.
Intensive Care Med ; 33(1): 96-103, 2007 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-17119923

RESUMO

OBJECTIVE: We examined whether guiding therapy by an algorithm based on optimizing the global end-diastolic volume index (GEDVI) reduces the need for vasopressor and inotropic support and helps to shorten ICU stay in cardiac surgery patients. DESIGN AND SETTING: Single-center clinical study with a historical control group at an university hospital. PATIENTS: Forty cardiac bypass surgery patients were included prospectively and compared with a control group. INTERVENTIONS: In the goal-directed therapy (GDT) group hemodynamic management was guided by an algorithm based on GEDVI. Hemodynamic goals were: GEDVI above 640 ml/m2, cardiac index above 2.5 l/min/m2, and mean arterial pressure above 70 mmHg. The control group was treated at the discretion of the attending physician based on central venous pressure, mean arterial pressure, and clinical evaluation. RESULTS: In the GDT group duration of catecholamine and vasopressor dependence was shorter (187+/-70 vs. 1458+/-197 min), and fewer vasopressors (0.73+/-0.32 vs. 6.67+/-1.21 mg) and catecholamines (0.01+/-0.01 vs. 0.83+/-0.27mg) were administered. They received more colloids (6918+/-242 vs. 5514+/-171ml). Duration of mechanical ventilation (12.6+/-3.6 vs. 15.4+/4.3 h) and time until achieving status of fit for ICU discharge (25+/-13 vs. 33+/-17h) was shorter in the GDT group. CONCLUSIONS: Guiding therapy by an algorithm based on GEDVI leads to a shortened and reduced need for vasopressors, catecholamines, mechanical ventilation, and ICU therapy in patients undergoing cardiac surgery.


Assuntos
Algoritmos , Procedimentos Cirúrgicos Cardíacos , Catecolaminas/uso terapêutico , Cuidados Críticos/estatística & dados numéricos , Vasoconstritores/uso terapêutico , Pressão Sanguínea , Diástole , Uso de Medicamentos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Fatores de Tempo
12.
Intensive Care Med ; 29(3): 476-80, 2003 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-12579420

RESUMO

OBJECTIVE: Real-time measurement of stroke volume variation by arterial pulse contour analysis (SVV) is useful in predicting volume responsiveness and monitoring volume therapy in mechanically ventilated patients. This study investigated the influence of the depth of tidal volume (V(t)) on SVV both during the state of fluid responsiveness and after fluid loading in mechanically ventilated patients. DESIGN AND SETTING: Prospective study in a university hospital, adult cardiac surgery intensive care unit. PATIENTS AND PARTICIPANTS: 20 hemodynamically stable patients immediately after cardiac surgery. INTERVENTIONS: Stepwise fluid loading using colloids until stroke volume index (SVI) did not increase by more than 10%. Before and after fluid loading V(t) was varied (5, 10, and 15 ml/kg body weight) in random order. MEASUREMENTS AND RESULTS: Pulse contour SVV was measured before and after volume loading at the respective V(t) values. Thirteen patients responded to fluid loading with an increase in SVI greater than 10%, which confirmed volume responsiveness at baseline measurements. These were included in further analysis. During volume responsiveness SVV at V(t) of 5 ml/kg (7+/-0.7%) and SVV at V(t) of 15 ml/kg (21+/-2.5%) differed significantly from that at V(t) of 10 ml/kg (15+/-2.1%). SVV was correlated significantly with the magnitude of V(t). After volume resuscitation SVV at the respective V(t) was significantly reduced; further, SVV at V(t) of 5 ml/kg(-1) (5.3+/-0.6%) and 15 ml/kg (16.2+/-2.0%) differed significantly from that at V(t) of 10 ml/kg (10.2+/-1.0%). SVV and depth of V(t) were significantly related. CONCLUSIONS: In addition to intravascular volume status SVV is affected by the depth of tidal volume under mechanical ventilation. This influence must be regarded when using SVV for functional preload monitoring.


Assuntos
Hidratação , Monitorização Fisiológica/métodos , Respiração Artificial , Volume Sistólico/fisiologia , Volume de Ventilação Pulmonar/fisiologia , Função Ventricular Esquerda/fisiologia , Análise de Variância , Pressão Sanguínea/fisiologia , Ponte de Artéria Coronária , Feminino , Hemodinâmica/fisiologia , Humanos , Derivados de Hidroxietil Amido/administração & dosagem , Modelos Lineares , Masculino , Valor Preditivo dos Testes , Estudos Prospectivos , Termodiluição
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