RESUMEN
The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) is increasing rapidly for patients with diabetes, heart failure, and chronic kidney disease. These medications can cause euglycemic diabetic ketoacidosis in the perioperative period, and the Food and Drug Administration recently updated their recommendations that they be held for at least 3-to-4 days preoperatively. There is a paucity of guidelines for the perioperative management of patients taking SGLT2i who present for emergent surgery or elective surgery having not held the medications per Food and Drug Administration guidelines. At the University of Pennsylvania, a multidisciplinary team from the Departments of Anesthesiology, Endocrinology, and Pharmacy has developed comprehensive guidelines detailing preoperative, intraoperative, and postoperative management for patients using these medications. In this article, the authors present these guidelines and discuss challenges encountered while implementing them at a large academic medical center with satellite hospitals and surgery centers with varying resources and patient populations.
Asunto(s)
Diabetes Mellitus Tipo 2 , Cetoacidosis Diabética , Inhibidores del Cotransportador de Sodio-Glucosa 2 , Humanos , Diabetes Mellitus Tipo 2/tratamiento farmacológico , Diabetes Mellitus Tipo 2/complicaciones , Inhibidores del Cotransportador de Sodio-Glucosa 2/uso terapéutico , Cetoacidosis Diabética/tratamiento farmacológico , Glucosa , SodioRESUMEN
BACKGROUND: Atrial fibrillation after cardiac surgery is associated with increased rates of death, complications, and hospitalizations. In patients with postoperative atrial fibrillation who are in stable condition, the best initial treatment strategy--heart-rate control or rhythm control--remains controversial. METHODS: Patients with new-onset postoperative atrial fibrillation were randomly assigned to undergo either rate control or rhythm control. The primary end point was the total number of days of hospitalization within 60 days after randomization, as assessed by the Wilcoxon rank-sum test. RESULTS: Postoperative atrial fibrillation occurred in 695 of the 2109 patients (33.0%) who were enrolled preoperatively; of these patients, 523 underwent randomization. The total numbers of hospital days in the rate-control group and the rhythm-control group were similar (median, 5.1 days and 5.0 days, respectively; P=0.76). There were no significant between-group differences in the rates of death (P=0.64) or overall serious adverse events (24.8 per 100 patient-months in the rate-control group and 26.4 per 100 patient-months in the rhythm-control group, P=0.61), including thromboembolic and bleeding events. About 25% of the patients in each group deviated from the assigned therapy, mainly because of drug ineffectiveness (in the rate-control group) or amiodarone side effects or adverse drug reactions (in the rhythm-control group). At 60 days, 93.8% of the patients in the rate-control group and 97.9% of those in the rhythm-control group had had a stable heart rhythm without atrial fibrillation for the previous 30 days (P=0.02), and 84.2% and 86.9%, respectively, had been free from atrial fibrillation from discharge to 60 days (P=0.41). CONCLUSIONS: Strategies for rate control and rhythm control to treat postoperative atrial fibrillation were associated with equal numbers of days of hospitalization, similar complication rates, and similarly low rates of persistent atrial fibrillation 60 days after onset. Neither treatment strategy showed a net clinical advantage over the other. (Funded by the National Institutes of Health and the Canadian Institutes of Health Research; ClinicalTrials.gov number, NCT02132767.).
Asunto(s)
Amiodarona/uso terapéutico , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Procedimientos Quirúrgicos Cardíacos , Frecuencia Cardíaca/efectos de los fármacos , Complicaciones Posoperatorias/tratamiento farmacológico , Antagonistas Adrenérgicos beta/uso terapéutico , Anciano , Amiodarona/efectos adversos , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Antiarrítmicos/efectos adversos , Fibrilación Atrial/terapia , Procedimientos Quirúrgicos Cardíacos/mortalidad , Terapia Combinada , Cardioversión Eléctrica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/terapiaRESUMEN
After receiving a ventricular assist device, a patient experiences months of advances and setbacks in the ICU. She's one of a new subcategory of ICU patients: the chronically critically ill. Their stories reveal shortcomings of common perspectives on medical decision making.
Asunto(s)
Conducta de Elección , Enfermedad Crónica/terapia , Cuidados Críticos , Incertidumbre , Cuidados Críticos/psicología , Toma de Decisiones , Familia , Femenino , Cirugía General , Insuficiencia Cardíaca/terapia , Corazón Auxiliar , Humanos , Unidades de Cuidados Intensivos , Pacientes/psicologíaAsunto(s)
Anestesia , Anestésicos , Bangladesh , Recursos en Salud , Calidad de la Atención de SaludAsunto(s)
Oxigenación por Membrana Extracorpórea/efectos adversos , Complicaciones Intraoperatorias/prevención & control , Enfermedades del Sistema Nervioso/prevención & control , Anticoagulantes/uso terapéutico , Oxigenación por Membrana Extracorpórea/métodos , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/terapia , Humanos , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/fisiopatología , Enfermedades del Sistema Nervioso/etiología , Enfermedades del Sistema Nervioso/fisiopatología , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/fisiopatología , Insuficiencia Respiratoria/terapiaAsunto(s)
Anticoagulantes/uso terapéutico , Coagulación Sanguínea/efectos de los fármacos , Transfusión Sanguínea/métodos , Oxigenación por Membrana Extracorpórea/métodos , Anticoagulantes/farmacología , Coagulación Sanguínea/fisiología , Oxigenación por Membrana Extracorpórea/efectos adversos , Humanos , Trombosis/etiología , Trombosis/prevención & controlAsunto(s)
Fibrilación Atrial/etiología , Fibrilación Atrial/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/prevención & control , Fibrilación Atrial/tratamiento farmacológico , Fibrilación Atrial/fisiopatología , Humanos , Incidencia , Complicaciones Posoperatorias/tratamiento farmacológico , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/fisiopatología , Factores de RiesgoAsunto(s)
Procedimientos Quirúrgicos Cardíacos , Unidades de Cuidados Intensivos , Pase de Guardia , Atención Perioperativa/métodos , Cuidado de Transición , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Humanos , Unidades de Cuidados Intensivos/normas , Pase de Guardia/normas , Atención Perioperativa/normas , Cuidado de Transición/normasRESUMEN
OBJECTIVES: The incidence and severity of Clostridium difficile infection (CDI) have increased rapidly over the past 2 decades, particularly in elderly patients with multiple comorbidities. This study sought to characterize the incidence and risks of these infections in cardiac surgery patients. METHODS: A total of 5158 patients at 10 Cardiothoracic Surgical Trials Network sites in the US and Canada participated in a prospective study of major infections after cardiac surgery. Patients were followed for infection, readmission, reoperation, or death up to 65 days after surgery. We compared clinical and demographic characteristics, surgical data, management practices, and outcomes for patients with CDI and without CDI. RESULTS: C difficile was the third most common infection observed (0.97%) and was more common in patients with preoperative comorbidities and complex operations. Antibiotic prophylaxis for >2 days, intensive care unit stay >2 days, and postoperative hyperglycemia were associated with increased risk of CDI. The median time to onset was 17 days; 48% of infections occurred after discharge. The additional length of stay due to infection was 12 days. The readmission and mortality rates were 3-fold and 5-fold higher, respectively, in patients with CDI compared with uninfected patients. CONCLUSIONS: In this large multicenter prospective study of major infections following cardiac surgery, CDI was encountered in nearly 1% of patients, was frequently diagnosed postdischarge, and was associated with extended length of stay and substantially increased mortality. Patients with comorbidities, longer surgery time, extended antibiotic exposure, and/or hyperglycemic episodes were at increased risk for CDI.
Asunto(s)
Antibacterianos/efectos adversos , Profilaxis Antibiótica/efectos adversos , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Infecciones por Clostridium/epidemiología , Infección de la Herida Quirúrgica/prevención & control , Anciano , Antibacterianos/administración & dosificación , Canadá/epidemiología , Infecciones por Clostridium/diagnóstico , Infecciones por Clostridium/microbiología , Comorbilidad , Esquema de Medicación , Femenino , Humanos , Hiperglucemia/epidemiología , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Estudios Prospectivos , Medición de Riesgo , Factores de Riesgo , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/microbiología , Factores de Tiempo , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Mild or moderate sedation for procedures frequently is administered outside the operating room by resident physicians with varying degrees of training. An adverse event at our institution involving procedural sedation prompted us to conduct a survey among resident physicians. This survey investigated resident knowledge and attitudes about sedatives and analgesics, in addition to knowledge of risk factors for sedation-related adverse events. The survey identified a range of knowledge deficiencies among resident physicians and a lack of awareness of institutional sedation policies. Identification of knowledge gaps facilitated an educational initiative that promoted training in the pharmacology of sedatives and analgesics, safe sedation practices, and institutional sedation policies. Additional interventions included updating our sedation policy and creation of an electronic order set to facilitate the safe prescription of sedatives.
Asunto(s)
Sedación Consciente/efectos adversos , Servicio de Urgencia en Hospital/legislación & jurisprudencia , Conocimientos, Actitudes y Práctica en Salud , Médicos , Encuestas y Cuestionarios , Competencia Clínica/legislación & jurisprudencia , Competencia Clínica/estadística & datos numéricos , Sedación Consciente/métodos , Humanos , Calidad de la Atención de SaludAsunto(s)
Adenosina/uso terapéutico , Antiarrítmicos/uso terapéutico , Electrocardiografía/efectos de los fármacos , Taquicardia Supraventricular/tratamiento farmacológico , Adenosina/efectos adversos , Antiarrítmicos/efectos adversos , Bloqueo de Rama/complicaciones , Bloqueo de Rama/diagnóstico , Humanos , Factores de Riesgo , Taquicardia Supraventricular/etiología , Resultado del TratamientoRESUMEN
Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aortic valve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management.
RESUMEN
Transcatheter aortic valve replacement (TAVR) is rapidly gaining popularity as a technique to surgically manage aortic stenosis (AS) in high risk patients. TAVR is significantly less invasive than the traditional approach to aortic valve replacement via median sternotomy. Patients undergoing TAVR often suffer from multiple comorbidities, and their postoperative course may be complicated by a unique set of complications that may become evident in the intensive care unit (ICU). In this article, we review the common complications of TAVR that may be observed in the ICU, and different strategies for their management.