RESUMO
Although mortality is low after the modified Fontan procedure, there is a significant percentage of patients with prolonged postoperative recovery. The objective of this study is to evaluate the usefulness of postoperative administration of oral sildenafil and inhaled nitric oxide on early postoperative outcome. A prospective interventional and comparison study with a historical cohort was conducted. Between January, 2010 and March, 2013, 16 patients received oral sildenafil during immediate modified Fontan postoperative period. Inhaled nitric oxide was also administered if the patient was kept intubated 12 hours after surgery. Early postoperative outcome was compared with a historical cohort of 32 patients on whom the modified Fontan procedure was performed between March, 2000 and December, 2009. Postoperative administration of sildenafil and nitric oxide had no influence on early postoperative outcome after the modified Fontan procedure in terms of duration of pleural effusions, mechanical ventilation time, length of stay in the ICU, and length of hospital stay.
Assuntos
Técnica de Fontan/efeitos adversos , Óxido Nítrico/administração & dosagem , Complicações Pós-Operatórias/tratamento farmacológico , Citrato de Sildenafila/administração & dosagem , Vasodilatadores/administração & dosagem , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Masculino , Período Pós-Operatório , Estudos Prospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
OBJECTIVE: Our objective was to evaluate the outcome of a training program on long-term confidence of interns and attending physicians. DESIGN: In this prospective cohort study, general surgery interns underwent a training program on informed consent that involved didactics, standardized patient encounters, and supplemental procedure specific guides at the start of the academic year. At the end of the academic year, we surveyed interns from the classes of 2020 (trained) and 2019 (untrained) about their experience and confidence in obtaining an informed consent. Further, we queried attending physicians on their experience and confidence in the interns at the end of each academic year. SETTING: Single academic general surgery residency program based at 2 urban tertiary hospitals. PARTICIPANTS: General surgery interns including unmatched preliminary residents and categorical interns from general surgery, interventional radiology, and urology. RESULTS: Twenty-four incoming interns participated in the training program. Intern confidence discussing operation benefits improved from a median score of 4 to 5 (pâ¯=â¯0.03), and total confidence improved from a median score of 15 to 17.5 (pâ¯=â¯0.08). There was no difference in median total confidence scores (15 vs. 17.5; pâ¯=â¯0.21) between classes. Attending physicians had similar median total confidence scores following intervention (10 vs. 11; pâ¯=â¯0.87). Intern satisfaction was 80% with the didactic session, and 90% with standardized patient encounters. Twenty percent of learners used the supplemental procedure specific guides. CONCLUSIONS: Implementation of an intern targeted program on informed consent that incorporated didactics and standardized patient encounters was viewed as useful and may contribute to long-term improvements in confidence.
Assuntos
Educação de Pós-Graduação em Medicina , Internato e Residência , Humanos , Educação de Pós-Graduação em Medicina/métodos , Estudos Prospectivos , Currículo , Consentimento Livre e Esclarecido , Competência ClínicaRESUMO
BACKGROUND: To compare opioid prescribing practices of resident physicians across a variety of surgical and nonsurgical specialties; to identify factors which influence prescribing practices; and to examine resident utilization of best practice supplemental resources. METHODS: An anonymous survey which assessed prescribing practices was completed by residents from one of several different subspecialties, including internal medicine, obstetrics and gynecology, general surgery, neurosurgery, orthopedic surgery, and urology. Fisher's exact test assessed differences in prescribing practices between specialties. RESULTS: Only 35% of residents reported receiving formal training in safe opioid prescribing. Overall, the most frequently reported influences on prescribing practices were the use of standardized order sets for specific procedures, attending preference, and patient's history of prescribed opioids. Resident physicians significantly underutilize best practice supplemental resources, such as counseling patients on pain expectations prior to prescribing opioid medication; contacting established pain specialists; screening patients for opioid abuse; referring to the Prescription Monitoring Program; and counseling patients on safe disposal of unused pills (P < .001). DISCUSSION: The incorporation of comprehensive prescribing education into resident training and the utilization of standardized order sets can promote safe opioid prescribing.
Assuntos
Internato e Residência , Médicos , Humanos , Analgésicos Opioides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Prescrições de Medicamentos , Padrões de Prática MédicaRESUMO
BACKGROUND: Graduating surgery residents often feel unprepared to practice autonomously in the current era of surgical training. We implemented an integrated simulation curriculum to improve residents' autonomy and increase their confidence to practice independently. In this study, we chose a laparoscopic ventral hernia repair (LVHR) as our pilot operation to test proof of concept and on which we would construct our integrated curriculum. STUDY DESIGN: The curriculum included a web-based cognitive component, inanimate model simulation session with follow-up at 2 weeks and 6 months, and self-confidence questionnaires. Faculty rated each resident's procedure-specific skill by using a modified Global Operative Assessment of Laparoscopic Skills (GOALS) criteria and a task-specific checklist. RESULTS: Thirteen junior residents, 7 senior residents, and 7 faculty surgeons completed the curriculum. Four junior residents (31%) achieved proficiency at their first session, 10 (77%) after the second session (p = 0.031), and 6 (67%) at 6 months (p ≥ 0.99). Three residents regressed and did not maintain proficiency after the second assessment. Performance (GOALS) scores improved (p = 0.0313) at week 2 and were maintained at 6 months (p = 0.5625). Required faculty direction decreased (p = 0.004), and resident confidence in completing the procedure independently improved (p < 0.004) over the 6-month curriculum. CONCLUSIONS: Assessing procedure-specific and global laparoscopic skills through a simulation-based curriculum is feasible and can be used to augment resident training. Our curriculum demonstrated improvement in proficiency and self-confidence while performing an LVHR. Additional study is needed to examine the optimal way to integrate procedure-specific simulation models into training programs.
Assuntos
Competência Clínica , Simulação por Computador , Currículo , Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Internato e Residência/métodos , Laparoscopia/educação , Treinamento por Simulação/métodos , HumanosRESUMO
BACKGROUND: Emergency surgical airway is a low frequency, high risk clinical scenario. Implementing a simulation-based curriculum may bridge the gap in surgical training and address quality assurance/performance improvement (QAPI) needs. METHODS: We designed and implemented an Advanced Surgical Airway Curriculum (ASAC) modeled after proficiency-based training. General Surgery residents and student nurse anesthetists were enrolled. Evaluation consisted of cognitive tests, procedure checklists and questionnaire. RESULTS: In total, 78 participants successfully completed the ASAC. Trainees agreed that the curriculum provided the cognitive and psychomotor skills necessary to perform both an open and needle cricothyroidotomy. CONCLUSIONS: In the age of increased patient safety concerns, QAPI initiatives can serve as a driver for simulation-based training curricula, with particular focus on individualized, active learning. This may be particularly useful in high risk, low frequency scenarios in which the traditional method of "See one, Do one, Teach one," is not feasible.
Assuntos
Anestesiologia/educação , Medicina de Emergência/educação , Cirurgia Geral/educação , Intubação Intratraqueal/métodos , Treinamento por Simulação , Adulto , Competência Clínica , Currículo , Educação de Pós-Graduação em Medicina , Educação de Pós-Graduação em Enfermagem , Avaliação Educacional , Feminino , Humanos , Masculino , Avaliação de Programas e Projetos de Saúde , Melhoria de QualidadeRESUMO
BACKGROUND: Variation in the surgical treatment of melanoma occurs despite efforts to standardize care. This may lead to morbidity, inaccurate staging, and poor outcomes, or it may be cost ineffective. The purpose of our study was to evaluate our institutional compliance with National Comprehensive Cancer Network (NCCN) melanoma treatment guidelines. METHODS: We studied 252 clinically node-negative melanoma patients identified from our cancer registry. Treatment data were confirmed by individual review of pathology and operative reports. RESULTS: Documented margins of excision conformed to NCCN guidelines in 87% of Tis-T1 tumors and 60% of T2-T4 tumors. Lymph node staging was performed in 11% of T1a, 64% of T1b, 74% of T2, 63% of T3, and 47% of T4 patients. Treatment by a surgical oncologist achieved margin and lymph node compliance in 95% and 92% of cases versus other practitioners in 38% and 67%, respectively (P < .0001). Documented compliance with margin guidelines improved from 46% to 73% for the years 1995 to 1999 versus 2000 to 2004 (P < .0001) and for lymph node staging and treatment from 74% to 84% (P = .04). Other factors associated with greater adherence to NCCN guidelines were patient age <80 years, upper extremity tumors, and thinner tumors (all P < .05). CONCLUSIONS: Our data suggest that our compliance with NCCN melanoma treatment guidelines was suboptimal. Treatment directed by a surgical oncologist showed the highest rate of adherence to national standards. Further investigation is needed to determine the effect of this on patient outcomes and how best to provide high-quality care to the greatest number of melanoma patients.
Assuntos
Fidelidade a Diretrizes , Hospitais Comunitários , Hospitais de Ensino , Melanoma/patologia , Melanoma/terapia , Neoplasias Cutâneas/patologia , Neoplasias Cutâneas/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Sistema de RegistrosRESUMO
BACKGROUND: Clinical practice guidelines have been developed to improve melanoma patient care. However, it is unclear whether failure to comply with these standards (either excessive or inadequate treatment) increases morbidity or relapse rates. Therefore, we undertook this study to evaluate the effect of variance from National Comprehensive Cancer Network (NCCN) recommendations on postoperative complication rates and disease recurrence. METHODS: We retrospectively reviewed our institutional cancer registry data on 327 clinically node-negative melanoma patients and assessed compliance with NCCN guidelines, complication rates, and outcome. Data were confirmed by chart, pathology report, and operative note review. Statistical analysis was performed by using the SAS statistical software package. RESULTS: Postoperative complications were documented in 17% of patients and were 3.4-fold higher for patients treated in a margin-noncompliant fashion and 2.4-fold higher for patients treated in a lymph-node-noncompliant manner (P < 0.001 for both). After mean follow-up of 51 months, disease recurred in 58 patients (18%) at a mean of 33 months (range 4-93 months). Locoregional disease alone as the first site of relapse was seen in 24% of margin-noncompliant versus 6% of margin-compliant cases and in 33% of lymph-node-noncompliant versus 6% of lymph-node-compliant cases (P < 0.0001). CONCLUSION: While there are valid reasons for variance from treatment algorithms, these data suggest that compliance with NCCN guidelines improves outcome and decreases morbidity in clinically node-negative melanoma patients.
Assuntos
Fidelidade a Diretrizes , Melanoma/terapia , Recidiva Local de Neoplasia/etiologia , Complicações Pós-Operatórias/etiologia , Neoplasias Cutâneas/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Intervalo Livre de Doença , Feminino , Humanos , Masculino , Melanoma/patologia , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Guias de Prática Clínica como Assunto , Sistema de Registros , Estudos Retrospectivos , Neoplasias Cutâneas/patologiaRESUMO
BACKGROUND: Although sentinel lymph node biopsy (SLNB) has become the standard for patients with clinically lymph node-negative breast cancer, less than one third of patients who undergo SLNB will have lymph node metastases. Therefore, we hypothesized that a subset of patients in whom SLNB can be avoided can be identified before operation. METHODS: We prospectively studied 220 patients with early stage breast cancer who underwent SLNB. We analyzed primary tumor features, biologic markers, and demographic data. RESULTS: Overall, 31% of the patients had lymph node metastases. Although patients with lymph node metastases had larger neoplasms than patients who were lymph node negative (mean, 2.3 +/- 0.1 cm versus 1.5 +/- 0.1 cm; P < .0001), 10% of patients with T1a tumors, 19% of patients with T1b tumors, and 30% of patients with T1c tumors had lymph node metastases. Palpable tumors were lymph node positive in 41% of patients versus 17% for nonpalpable tumors (P = .0001). Lymph node metastases were seen in 71% of patients with tumor angio or lymphatic invasion versus 17% of patients without (P < .0001). Seventy-five percent of patients with an increased preoperative serum CA 27.29 had lymph node metastases, and the mean levels were greater among patients who were lymph node positive (27 U/ml +/- 2 versus 20 +/- 1; P = .0002). There was no significant association between any other demographic, histologic, or molecular feature that was investigated and lymph node metastases. CONCLUSION: We did not identify histologic, demographic, or molecular variables that can exclude the risk of associated lymphatic metastases reliably. Furthermore, not all predictive factors are known before the operation (eg, whether the tumor is T1a or T1b). Therefore, we recommend that SLNB be performed in all patients with clinically lymph node-negative invasive breast cancer.
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Axila/patologia , Neoplasias da Mama/patologia , Metástase Linfática , Estadiamento de Neoplasias/métodos , Biópsia de Linfonodo Sentinela/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antígenos Glicosídicos Associados a Tumores/sangue , Biomarcadores Tumorais/sangue , Neoplasias da Mama/epidemiologia , Feminino , Humanos , Pessoa de Meia-Idade , Análise Multivariada , Estadiamento de Neoplasias/estatística & dados numéricos , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Biópsia de Linfonodo Sentinela/efeitos adversosRESUMO
Acute cholecystitis is one of the most common surgical diagnoses encountered by general surgeons. Despite its high incidence there remains a range of treatment of approaches. Current practices in biliary surgery vary as to timing, intraoperative utilization of biliary imaging, and management of bile duct stones despite growing evidence in the literature defining best practice. Management of patients with acute cholecystitis with early laparoscopic cholecystectomy (LC) results in better patient outcomes when compared with delayed surgical management techniques including antibiotic therapy or percutaneous cholecystostomy. Regardless of this data, many surgeons still prefer to utilize antibiotic therapy and complete an interval LC to manage acute cholecystitis. The use of intraoperative biliary imaging by cholangiogram or laparoscopic ultrasound has been demonstrated to facilitate the safe completion of cholecystectomy, minimizing the risk for inadvertent injury to surrounding structures, and lowering conversion rates, however it is rarely utilized. Choledocholithiasis used to be a diagnosis managed exclusively by surgeons but current practice favors referral to gastroenterologists for performance of preoperative endoscopic removal. Yet, there is evidence that intraoperative laparoscopic stone extraction is safe, feasible and may have added advantages. This review aims to highlight the differences between existing management of acute cholecystitis and evidence supported in the literature regarding best practice with the goal to change surgical practice to adopt these current recommendations.
RESUMO
BACKGROUND: Although sentinel lymph node biopsy has been accepted as a useful procedure for certain breast cancer patients, the value of this procedure in the elderly remains unknown. We undertook this study to evaluate changes in adjuvant treatment attributable to sentinel lymph node biopsy. METHODS: A total of 104 patients > or =65 years underwent sentinel lymph node biopsy plus lumpectomy or mastectomy for the treatment of clinically node-negative invasive breast cancer. Demographic, pathologic, and treatment data were evaluated using an SAS software package (SAS, Cary, North Carolina). RESULTS: Twenty-nine of 104 patients (28%) had metastatic disease in > or =1 sentinel lymph node. Nonsurgical treatment was modified in 38% of patients because of sentinel lymph node biopsy results. Changes included adjuvant chemotherapy and/or hormonal therapy, adjuvant axillary radiotherapy, and decisions against adjuvant therapy. CONCLUSIONS: These data suggest that sentinel lymph node biopsy in elderly breast cancer patients is beneficial.
Assuntos
Neoplasias da Mama/patologia , Biópsia de Linfonodo Sentinela , Idoso , Neoplasias da Mama/cirurgia , Feminino , Humanos , Estudos RetrospectivosRESUMO
BACKGROUND: Published guidelines recommend early cholecystectomy for acute cholecystitis in the elderly. Alternatively, percutaneous cholecystostomy can be used in compromised patients. METHODS: We reviewed 806 elderly patients diagnosed with biliary disease retrospectively identified through billing and diagnosis codes. Two hundred sixty-five patients with histologically documented acute cholecystitis were selected. RESULTS: Initially, 75 patients had percutaneous cholecystostomy (Group 1), 64 (24 % underwent interval cholecystectomy, 74 (28 %) early (Group 2), and 127 (48 %) delayed cholecystectomy (Group 3). Group 1 was more likely to have American Society of Anesthesiologists (ASA) scores of 4 when compared to those in Groups 2 and 3 (p = 0.04). No difference existed among the groups when patients with an ASA of 4 were excluded: conversion rates (11 %), biliary leak, bowel injury, need for reoperation, or 30 days mortality. Patients in Group 1 and in Group 3 were five times (p = 0.04) and four times (p = 0.06) more likely, respectively, than those in Group 2 to have recurrent episodes of pancreatitis, cholecystitis, and cholangitis. CONCLUSION: Patients were more likely to have delayed cholecystectomy after initial antibiotic therapy or cholecystostomy without the benefit of a lower conversion rate when compared to the early group, but they had higher recurrent episodes of cholecystitis/pancreatitis or cholangitis.
Assuntos
Colecistite Aguda/cirurgia , Colecistostomia/métodos , APACHE , Idoso , Idoso de 80 Anos ou mais , Fístula Anastomótica/etiologia , Colangite/etiologia , Colecistite Aguda/complicações , Colecistostomia/efeitos adversos , Colecistostomia/mortalidade , Conversão para Cirurgia Aberta , Feminino , Fidelidade a Diretrizes , Humanos , Intestinos/lesões , Laparoscopia , Masculino , Pancreatite/etiologia , Guias de Prática Clínica como Assunto , Recidiva , Estudos Retrospectivos , Fatores de TempoRESUMO
BACKGROUND: Simulation training may be an invaluable tool in training and assessing surgeons. Questions remain regarding its true impact on acquisition of laparoscopic skills and their transferability to the operating room. METHODS: Twenty general surgery residents completed 5 exercises: bean drop/rope drill, foam cutting/endoloop, checkerboard, endostitch, and suturing/intracorporeal knot. After baseline scoring, residents had 3 weeks to practice before re-testing. Statistical analysis of objective and subjective scores included the signed rank test or paired t-test, the Kruskal-Walis test, the McNemar test, and the Global Operative Assessment of Laparoscopic Skills (GOALS). P < .05 was considered significant. RESULTS: Five postgraduate year (PGY) 4 and 15 PGY 1-3 residents completed the curriculum. When compared with baseline, overall scores improved (P < .05) in all categories except for the bean drop/rope drill, which improved on objectively measured tasks only (dropped beads and beads threaded). The foam cutting/endoloop task was mastered by a majority of trainees at baseline leaving no room for improvement. CONCLUSION: The results of this study reinforce that simulation leads to improvement in laparoscopic skills and that our curriculum is a valid educational tool. Further studies are needed to validate whether this results in improved skills in the operating room.
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Instrução por Computador/métodos , Laparoscopia/educação , Centros Médicos Acadêmicos , Competência Clínica , Simulação por Computador , Currículo , Humanos , Illinois , Internato e Residência , Laboratórios HospitalaresRESUMO
INTRODUCTION AND OBJECTIVES: The Fontan operation is usually the final palliative procedure in patients with univentricular heart. The objectives of this study were, firstly, to describe the clinical and haemodynamic characteristics of a group of patients with univentricular physiology who had previously been palliated with a bidirectional Glenn procedure and, secondly, to identify risk factors that can influence postoperative outcomes after the Fontan operation. METHODS: Retrospective study with 32 patients who underwent a Fontan operation between March 2000 and December 2009. Clinical characteristics, catheterization data, type and duration of surgery were revised and analyzed as predictors of postoperative outcome. RESULTS: Hospital mortality was 3%. After a median follow-up of 44 months (interquartile range, 32-79), survival was 90%. Preoperative mean pulmonary artery pressure (measured during catheterization) was correlated with late mortality. Of the remaining variables analyzed, the Nakata and McGoon indices, and duration of cardiopulmonary bypass showed the highest correlations with postoperative outcomes. Interventional catheterization before the Fontan operation was performed in 42% of patients. CONCLUSIONS: Hospital mortality after the Fontan operation was very low. The performance of a haemodynamic study before the Fontan operation made it possible to select high-risk patients for surgery as well as permitting the performance of interventional procedures that could improve postoperative outcome in these patients.
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Técnica de Fontan , Cardiopatias Congênitas/cirurgia , Hemodinâmica/fisiologia , Cateterismo Cardíaco , Ponte Cardiopulmonar , Criança , Pré-Escolar , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Período Pós-Operatório , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do TratamentoRESUMO
HYPOTHESIS: Evaluation of 12 or more lymph nodes (LNs) with colorectal cancer (CRC) resection may not improve detection of stage III disease. DESIGN: Retrospective review after intervention. SETTING: Community teaching hospital. PATIENTS: We evaluated 701 consecutive operative CRC cases ascertained from our Cancer Registry. INTERVENTION: Patients undergoing resection before (n = 553) a multidisciplinary initiative emphasizing the importance of LN counts were compared with those undergoing operation afterward (n = 148). MAIN OUTCOME MEASURES: Number of LNs evaluated, proportion of patients with stage III disease, and proportion of patients with N1 vs N2 disease. RESULTS: Demographic, tumor, and treatment variables were similar for both groups, except for younger age, fewer white patients, and more laparoscopic resections in the late period. Lymph node counts increased from a mean (SEM [median]) of 12.8 (0.3 [12]) to 17.3 (0.7 [16]) (P < .001), with 53.0% of the early vs 71.6% of the late patients having at least 12 LNs examined. The proportion diagnosed as having stage III CRC was 204 of 553 (36.9%) for the early group vs 48 of 148 (32.4%) for the late group (P = .31). Among patients with positive LNs, the distribution of N1 and N2 disease was unchanged (early, 50.5% N1 and 49.5% N2; late, 54.2% N1 and 45.8% N2; P = .54). CONCLUSIONS: Increased LN retrieval does not identify a greater number of patients with stage III CRC nor does it increase the proportion of patients with positive LNs with N2 disease. Our data suggest that harvest of at least 12 LNs as a quality or performance measure appears unfounded.
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Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/normas , Feminino , Humanos , Laparoscopia , Excisão de Linfonodo , Linfonodos/patologia , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Qualidade da Assistência à Saúde , Sistema de Registros , Coleta de Tecidos e ÓrgãosAssuntos
Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Lipossarcoma/cirurgia , Neoplasias Primárias Múltiplas/cirurgia , Nefrectomia , Osteossarcoma/cirurgia , Neoplasias Retroperitoneais/cirurgia , Idoso , Carcinoma de Células Renais/diagnóstico , Humanos , Achados Incidentais , Neoplasias Renais/diagnóstico , Lipossarcoma/diagnóstico , Masculino , Neoplasias Primárias Múltiplas/diagnóstico , Osteossarcoma/diagnóstico , Neoplasias Retroperitoneais/diagnósticoRESUMO
BACKGROUND: The incidence of ductal carcinoma in situ (DCIS) of the breast is increasing. Optimal treatment remains controversial and, because of a long natural history, may not be evident for many years. We undertook this study to identify markers of disease recurrence. METHODS: We studied 131 pure DCIS patients with a 100-month mean follow-up. We performed a complete histologic review, immunohistochemical staining for p53 and vascular endothelial growth factor expression, and enumerated microvessel density/mm2 using factor VIII-Ab. Statistical analysis was performed by using an SAS software package (Cary, NC). RESULTS: Eleven patients (8%) developed ipsilateral recurrence at a mean of 55 months (11-137 months) after initial treatment. Three were DCIS, and 8 were invasive cancer. Recurrence was significantly predicted by p53 overexpression (in 55% of tumors that recurred versus 22% of those that did not, P = .02) but not other factors. CONCLUSIONS: These data suggest that biologic factors may have an important role in predicting recurrence in DCIS patients.
Assuntos
Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/metabolismo , Carcinoma Intraductal não Infiltrante/patologia , Proteína Supressora de Tumor p53/biossíntese , Fator A de Crescimento do Endotélio Vascular/biossíntese , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/química , Carcinoma Intraductal não Infiltrante/química , Seguimentos , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Tempo , Proteína Supressora de Tumor p53/análise , Fator A de Crescimento do Endotélio Vascular/análiseRESUMO
PURPOSE: To compare the Macintosh (M), McCoy (MC), Miller (MIL), Belscope (BP) and Lee-Fiberview (LF) laryngoscopes with respect to the grade of laryngeal visualization and the difficulty of intubation. METHODS: We included 500 patients scheduled to undergo elective surgery and who required tracheal intubation. Patients were randomly assigned to five groups of 100 patients each. Anesthesia was induced intravenously using 1-3 mg.kg(-1) of propofol, fentanyl 1.5 microg.kg(-1) and atracurium 0.5 mg.kg(-1) or suxamethonium 1 mg.kg(-1). The laryngeal view was classified according to Cormack and Lehane. The degree of difficulty with intubation was rated as: Grade 1, intubation easy; Grade 2, intubation requiring an increased anterior lifting force and assistance to pull the right corner of the mouth upwards to increase space; Grade 3, intubation requiring multiple attempts and a curved stylet; Grade 4, failure to intubate with the assigned laryngoscope. Data were examined using analysis of variance, chi(2) or Fisher test, Student's t test and odds ratio. P < 0.05 was considered statistically significant. RESULTS: Laryngoscopic views obtained with the BP and MIL laryngoscopes were similar, and better than with the other types of laryngoscopes (P < 0.001). The levering tip of the MC blade (P = 0.02) and the fibreoptic device of the LF (P < 0.001) significantly improved the laryngoscopic view. Regarding the degree of difficulty with intubation, the best results were obtained with the MC and M blades (P < 0.001). CONCLUSION: Laryngoscopy was better with straight blades but curved blades provided better intubating conditions.