RESUMO
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Assuntos
Humanos , Idoso , Corpos Estranhos/diagnóstico por imagem , Achados Incidentais , Marca-Passo Artificial , Artéria Pulmonar/diagnóstico por imagem , Corpos Estranhos/cirurgiaRESUMO
Objetivo. La tromboelastometría evalúa la coagulación analizando la viscoelasticidad de una muestra de sangre. Nuestro objetivo principal fue evaluar los resultados de su uso como guía de administración de hemoderivados en cirugía cardiaca y, secundariamente, las complicaciones postoperatorias y el tiempo de hospitalización en UCI. Material y método. Estudio analítico, de intervención, cuasiexperimental, comparativo, no aleatorizado, prospectivo, con un grupo control retrospectivo. Se incluyeron 80 pacientes reintervenidos de cualquier cirugía cardiaca, o cirugías por endocarditis o del arco aórtico. En 31 pacientes los hemoderivados intraoperatorios se administraron según pautas clínicas tradicionales (grupo A). Los 49 pacientes restantes recibieron hemoderivados siguiendo algoritmos basados en el análisis tromboelastométrico (grupo B). El objetivo principal fue la administración de hemoderivados y los objetivos secundarios fueron: estancia en UCI y complicaciones postoperatorias. Resultados. Hubo una importante disminución en la administración de plasma fresco congelado en el grupo B respecto al A (p<0,001), así como una disminución en la transfusión intraoperatoria de sangre: 3,9 concentrados de hematíes de media por paciente en el grupo A frente a 2,67 en el grupo B (p=0,125). Se incrementó la administración de fibrinógeno, con una p<0,019. Se encontró una menor tasa de complicaciones respiratorias (p=0,019) en el grupo B y una reducción significativa de las estancias mayores de 7 días en el grupo B respecto al A (p=0,031). Conclusiones. La tromboelastometría condujo a una importante disminución en la utilización de plasma fresco congelado, contribuyendo muy probablemente al descenso en la incidencia de complicaciones respiratorias y en la menor estancia en UCI (AU)
Objective. Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay. Material and method. Analytical and comparative non-randomised quasi-experimental prospective study with a retrospective control group. The inclusion criteria for the 80 patients were: patients undergoing cardiac surgery who had had prior cardiac surgery, endocarditis surgery or aortic arch surgery. Thirty-one patients were treated following routine transfusion practice during surgery (group A). The other 49 patients were treated with thromboelastometrically guided transfusion algorithms (group B). The main objective was blood products transfused, and postoperative adverse events and ICU stay were the secondary objectives. Results. Statistical analysis showed lower transfusion rates of fresh-frozen plasma in group B compared to group A (P<.001), as well as red blood cell transfusion during surgery with an average transfusion rate of 3.9 units in group A in comparison to 2.67 units in group B (P=.125). Moreover, fibrinogen infusion was increased in group B compared to group A (P=.019). In addition, a lower rate of respiratory adverse events was found in group B (P=.019). There was a significant decrease in ICU stays over 7 days in group B compared to group A (P=.031). Conclusions. Using thromboelastometry guidance for blood management led to a meaningful reduction of fresh frozen plasma transfusion during surgery. This probably resulted in a reduction in respiratory adverse events after surgery and length of ICU stay in our patients (AU)
Assuntos
Humanos , Tromboelastografia/métodos , Hemoderivados , Procedimentos Cirúrgicos Cardíacos/métodos , Transfusão de Componentes Sanguíneos/métodos , Monitoramento de Medicamentos/métodos , Monitorização Intraoperatória/métodos , Complicações Intraoperatórias/prevenção & controleRESUMO
OBJECTIVE: Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay. MATERIAL AND METHOD: Analytical and comparative non-randomised quasi-experimental prospective study with a retrospective control group. The inclusion criteria for the 80 patients were: patients undergoing cardiac surgery who had had prior cardiac surgery, endocarditis surgery or aortic arch surgery. Thirty-one patients were treated following routine transfusion practice during surgery (group A). The other 49 patients were treated with thromboelastometrically guided transfusion algorithms (group B). The main objective was blood products transfused, and postoperative adverse events and ICU stay were the secondary objectives. RESULTS: Statistical analysis showed lower transfusion rates of fresh-frozen plasma in group B compared to group A (P<.001), as well as red blood cell transfusion during surgery with an average transfusion rate of 3.9 units in group A in comparison to 2.67 units in group B (P=.125). Moreover, fibrinogen infusion was increased in group B compared to group A (P=.019). In addition, a lower rate of respiratory adverse events was found in group B (P=.019). There was a significant decrease in ICU stays over 7 days in group B compared to group A (P=.031). CONCLUSIONS: Using thromboelastometry guidance for blood management led to a meaningful reduction of fresh frozen plasma transfusion during surgery. This probably resulted in a reduction in respiratory adverse events after surgery and length of ICU stay in our patients.
Assuntos
Transfusão de Componentes Sanguíneos/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos , Cuidados Intraoperatórios/métodos , Tromboelastografia , Idoso , Algoritmos , Coagulação Sanguínea , Viscosidade Sanguínea , Cuidados Críticos , Transfusão de Eritrócitos/estatística & dados numéricos , Feminino , Fibrinogênio/uso terapêutico , Estudo Historicamente Controlado , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Plasma , Complicações Pós-Operatórias/prevenção & controle , Utilização de Procedimentos e Técnicas , Sala de Recuperação , Transtornos Respiratórios/prevenção & controleRESUMO
El aneurisma toracoabdominal requiere de un manejo multidisciplinar debido a su complejidad tanto en la técnica quirúrgica como en el tratamiento anestésico. La complicación postoperatoria más temida es la isquemia medular, que se presenta con una clínica e instauración variable, a su vez que su recuperación puede ser parcial o completa. El manejo postoperatorio de la isquemia medular se basa en medidas que aumentan la perfusión medular, principalmente la optimización hemodinámica y el drenaje de líquido cefalorraquídeo (LCR). Presentamos 2 casos de paraplejía tardía, uno tras reparación abierta de aneurisma aórtico toracoabdominal y otro después del tratamiento endovascular de aneurisma de la aorta torácica descendente, con recuperación completa del déficit neurológico tras drenaje de LCR (AU)
Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage (AU)
Assuntos
Humanos , Masculino , Feminino , Paraplegia/complicações , Paraplegia/diagnóstico , Paraplegia/tratamento farmacológico , Aneurisma/complicações , Aneurisma/diagnóstico , Complicações Pós-Operatórias/tratamento farmacológico , Hemodinâmica , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares , Isquemia/complicações , Isquemia/diagnóstico , Isquemia do Cordão Espinal/complicações , Líquido CefalorraquidianoRESUMO
Objetivo. Presentar los resultados de las cirugías de los aneurismas de aorta toracoabdominal, realizadas por un mismo equipo de cirujanos y anestesiólogos, durante 17 años. Material y métodos. Estudio prospectivo y observacional. Se evaluó a todos los pacientes intervenidos desde el año 1995 hasta julio de 2011 de aneurisma de aorta toracoabdominal. Se registraron las características demográficas, tipo de aneurisma, complicaciones intra y postoperatorias y mortalidad. Resultados. Se evaluaron 65 pacientes (97% varones), 5 (7,6%) con aneurismas tipo i de Crawford, 22 (33,8%) de tipo ii, 17 (26,1%) tipo iii y 21 (32,3%) de tipo iv. La mortalidad a 30 días fue del 9,2% (6/65 pacientes), que fue igual que la incidencia de paraplejía. Esta complicación solo se presentó en los aneurismas tipos ii y iii de Crawford. Se presentó paraplejía en el 4,5% (1/22) de los pacientes en los que se utilizó bypass izquierdo, frente a un 29% (5/17) en los que la intervención se realizó mediante pinzamiento directo sin perfusión aórtica distal (p=0,068). La complicación postoperatoria más frecuente fue respiratoria, con ventilación mecánica prolongada (>48h) en el 20% (13 pacientes). La estancia media postoperatoria fue de 28 días (rango 7-92). Discusión. La mortalidad media en los centros de referencia es del 9,7% (rango 5-16%) similar a la de nuestros pacientes. Fuera de ellos, la mortalidad a los 30 días asciende hasta el 19 y el 31% al año. La incidencia de paraplejía en los hospitales con mayor experiencia oscila entre el 2,7 y el 16%, aceptándose como buena, en la actualidad, una incidencia inferior al 10%, que también es similar a la de nuestros casos (9,2%). Parece aceptada la utilización de drenaje de LCR en estos pacientes, así como el empleo de derivación izquierda e hipotermia moderada en los tipos i, ii y iii de Crawford, para la profilaxis de la paraplejía (AU)
Objective. To review the results after thoracoabdominal aortic aneurysms repair performed by the same team of surgeons and anesthesiologists over a 17 year period. Material and methods. A prospective and observational study carried out on 65 patients (97% male) who were operated on from 1995 until July 2011 for thoracoabdominal aneurysm, Crawford type i 5 (7.6%), ii 22 (33.8%), iii 17 (26.11%) and iv 21 (32.31%). Results. The 30-day mortality was 9.2% (6/65 patients), which was the same as the incidence of paraplegia. This complication only occurred in the Crawford types ii and iii aneurysms. Paraplegia was present in 4.5% (1/22) of patients in whom left bypass was used, compared with 29% (5/17) in which the intervention was performed by cross-clamping without distal aortic perfusion (P=.068). The most frequent complication was respiratory, with prolonged mechanical ventilation (>48h) in 20% (13 patients) of cases. The mean hospital stay was 28 days (7-92). Discussion. The average mortality in referral centers is 9.7%, ranging between 5% and 16%. In other centres the mortality at 30 days is between 19% and 31% per year. Our group had a 9.2% of mortality rate at 30 days. The incidence of paraplegia in hospitals with greater experience ranges between 2.7% and 16%. Nowadays, an incidence of less than 10% is accepted as good. We had 9.2%. The use of CSF drainage in these patients, as well as the use of left bypass and moderate hypothermia in the Crawford types i, ii and iii appear to be acceptable for prophylaxis of paraplegia (AU)
Assuntos
Humanos , Masculino , Anestesia , Anestesiologia/métodos , Aneurisma da Aorta Torácica/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Aneurisma da Aorta Torácica/epidemiologia , Aneurisma da Aorta Torácica/metabolismo , Estudos Prospectivos , Paraplegia/complicações , Paraplegia/epidemiologia , Complicações Pós-Operatórias/metabolismoRESUMO
Thoracoabdominal aneurysm requires multidisciplinary management due to its complexity both in surgical technique and anesthetic considerations. One of the most feared postoperative complication is spinal cord ischemia. It can be presented as different clinical patterns, and its recovery may be partial or complete. The postoperative management of spinal cord ischemia is mainly based on techniques to increase spinal cord perfusion, above all, hemodynamic stability and cerebrospinal fluid drainage. We present two cases of delayed paraplegia after an open repair of a thoracoabdominal aneurysm and a descending thoracic aortic aneurysm repair using an endovascular stent graft. They both had a complete neurological recovery after cerebrospinal fluid drainage.
Assuntos
Aneurisma da Aorta Torácica/cirurgia , Paraplegia , Complicações Pós-Operatórias , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Fatores de TempoRESUMO
OBJECTIVE: To review the results after thoracoabdominal aortic aneurysms repair performed by the same team of surgeons and anesthesiologists over a 17 year period. MATERIAL AND METHODS: A prospective and observational study carried out on 65 patients (97% male) who were operated on from 1995 until July 2011 for thoracoabdominal aneurysm, Crawford type i 5 (7.6%), ii 22 (33.8%), iii 17 (26.11%) and iv 21 (32.31%). RESULTS: The 30-day mortality was 9.2% (6/65 patients), which was the same as the incidence of paraplegia. This complication only occurred in the Crawford types ii and iii aneurysms. Paraplegia was present in 4.5% (1/22) of patients in whom "left bypass" was used, compared with 29% (5/17) in which the intervention was performed by cross-clamping without distal aortic perfusion (P=.068). The most frequent complication was respiratory, with prolonged mechanical ventilation (>48h) in 20% (13 patients) of cases. The mean hospital stay was 28 days (7-92). DISCUSSION: The average mortality in referral centers is 9.7%, ranging between 5% and 16%. In other centres the mortality at 30 days is between 19% and 31% per year. Our group had a 9.2% of mortality rate at 30 days. The incidence of paraplegia in hospitals with greater experience ranges between 2.7% and 16%. Nowadays, an incidence of less than 10% is accepted as good. We had 9.2%. The use of CSF drainage in these patients, as well as the use of left bypass and moderate hypothermia in the Crawford types i, ii and iii appear to be acceptable for prophylaxis of paraplegia.
Assuntos
Anestesia , Aneurisma da Aorta Torácica/cirurgia , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de TempoRESUMO
Objetivo. Determinar la relación de factores clínicos y arteriográficos preoperatorios con la aparición de intolerancia al clampaje carotideo durante la endarterectomía carotidea (EDC), que se realizó mediante anestesia locorregional, monitorizando la función neurológica del enfermo despierto. Pacientes y métodos. Estudio de cohortes clínicoprospectivo. 381 EDC con anestesia locorregional (1994-2002). Un 11,8 por ciento (n = 45) presentaba ictus homolateral previo, un 28,1 por ciento (n = 107) accidente isquémico transitorio (AI) o amaurosis homolateral y un 10,8 por ciento (n = 41) oclusión contralateral. Análisis uni y multivariante. Resultados. Un 11 (n = 42) de los pacientes presentaron intolerancia al clampaje carotídeo. La morbilidad neurológica global fue del 2 por ciento (n = 8) y la mortalidad de 0, 7 por ciento (n = 3). Factores asociados a intolerancia al clampaje carotideo: clínica neurológica previa ipsilaterales -accidente cerebrovascular (ACV), AIT o amaurosis; 15,1 frente al 8,3 por ciento; riesgo relativo (RR): 1,9; intervalo de confianza (IC) del 95 por ciento 1,13, 7, p = 0, 04- y pacientes con oclusión contralaleral y síntomas neurológicos previos ipsilaterales (28,6 frente al 10,4; RR: 3,4; IC 95 por ciento: 1,1-11,5; p = 0,04). La oclusión contralaleral de modo aislado no fue un factor de riesgo de intolerencia al clampaje (14,6 frente al 10,6 por ciento, p = 0,4). La selección de pacientes para shunt, en función de haber presentado síntomas neurológicos ipsilaterales, tiene una sensibilidad del 15,1 ?lá; para el grupo de pacientes con oclusión contralateral y síntomas ipsilaterales fue del 28 por ciento. La morbilidad neurológica en estos dos grupos de pacientes no mostró diferencias estadísticamente significativas respecto al resto de la serie. Conclusiones. La clínica ipsilateral, sobre todo asociada a oclusión contralaleral, incrementa el riesgo de intolerancia al clampaje carotideo. Este hecho no ha tenido influencia en la morbilidad neurológica ni en la mortalidad de la serie analizada. Los criterios clínicos de selección de shunt tienen poca sensibilidad para la predicción de intolerancia al clampaje carotídeo (AU)