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1.
Anesth Analg ; 132(4): 1138-1145, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33617181

RESUMO

BACKGROUND: Epidural block are often used for analgesia after open nephrectomy surgery. Subcostal anterior quadratus lumborum block may be an alternative. We therefore tested the hypothesis that the continuous subcostal anterior quadratus lumborum block is noninferior to epidural block for analgesia in patients having open partial nephrectomies. METHODS: Adults having open partial nephrectomies were randomly allocated to epidural or unilateral subcostal anterior quadratus lumborum block. The joint primary outcomes were opioid consumption measured in morphine equivalents and pain measured on a numeric rating scale (0-10) from postanesthesia care unit (PACU) until 72 hours after surgery. The noninferiority deltas were 30% for opioid consumption and 1 point on a 0-10 scale for pain. Secondary outcomes included patient global assessment of pain management on the third postoperative day, the number of antiemetic medication doses through the third postoperative day, duration of PACU stay, and postoperative duration of hospitalization. RESULTS: Twenty-six patients were randomized to anterior quadratus lumborum block and 29 to epidural analgesia. Neither pain scores nor opioid consumption in the quadratus lumborum patients were noninferior to epidural analgesia. At 72 hours, mean ± standard deviation pain scores in subcoastal anterior quadratus lumborum block and epidural group were 4.7 ± 1.8 and 4.1 ± 1.7, with an estimated difference in pain scores of 0.62 (95% confidence interval [CI], 0.74-1.99; noninferiority P = .21). The median [Q1, Q3] opioid consumption was more than doubled in quadratus lumborum patients at 70 mg [43, 125] versus 30 mg [18, 75] in the epidural group with an estimated ratio of geometric means of 1.69 (95% CI, 0.66-4.33; noninferiority P = .80). Patient global assessment and duration of PACU and hospital stays did not differ significantly in the 2 groups. CONCLUSIONS: We were unable to show that subcostal anterior quadratus lumborum block are noninferior to epidural analgesia in terms of pain scores and opioid consumption for open partial nephrectomies. Effectiveness of novel blocks should be rigorously tested in specific surgical setting before widespread adoption.


Assuntos
Analgesia Epidural , Nefrectomia , Bloqueio Nervoso , Dor Pós-Operatória/prevenção & controle , Idoso , Analgesia Epidural/efeitos adversos , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nefrectomia/efeitos adversos , Bloqueio Nervoso/efeitos adversos , Ohio , Medição da Dor , Limiar da Dor/efeitos dos fármacos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
2.
Medicine (Baltimore) ; 99(28): e21084, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664127

RESUMO

CONTEXT: Endotracheal intubation of pediatric patients is challenging, especially in the pre-hospital emergency setting and if performed by less experienced providers. Securing an airway should be achieved with a single intubation attempt, as each intubation attempt contributes to morbidity and mortality. A new airway device, the VieScope, was recently introduced into clinical market, but efficacy to reduced intubation attempts remains unclear thus far. OBJECTIVE: We aimed to compare endotracheal intubation by paramedics using the Vie Scope in different pediatric airway simulation conditions. METHODS: We conducted a randomized, cross-over simulation study. Following a theoretical and practical training session, paramedics performed endotracheal intubation in 3 different pediatric emergency scenarios: normal airway; tongue edema; cardiopulmonary resuscitation using the VieScope. Overall intubation success rate was the primary outcome. Secondary outcomes included number of intubation attempts, time to intubation, Cormack-Lehane grade, POGO score, and ease of use (using 1-100 scale). RESULTS: Fifty-five paramedics with at least 2 years of clinical experience and without any previous experience with the VieScope participated in this study. The overall intubation success rate was 100% in all 3 scenarios. The median intubation time was 27 (24-34) versus 27 (25-37) versus 29 (25-40) s for scenarios A, B, and C, respectively. In scenario A, all paramedics performed successful intubation with 1 single intubation attempt, whereas 2% of the paramedics had to perform 2 intubation attempts in scenario B and 9% in scenario C. CONCLUSIONS: Results of this simulation study indicate preliminary evidence, that the VieScope enables adequate endotracheal intubation in the pediatric setting. Further clinical studies are needed to confirm these results.


Assuntos
Pessoal Técnico de Saúde , Intubação Intratraqueal/instrumentação , Laringoscópios , Pediatria/instrumentação , Reanimação Cardiopulmonar/métodos , Estudos Cross-Over , Desenho de Equipamento , Feminino , Humanos , Masculino , Manequins , Projetos Piloto
4.
Medicine (Baltimore) ; 99(16): e19740, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32311968

RESUMO

BACKGROUND: There is considerable evidence that prolonged use of cervical collars potentially cause detrimental effects including increase in optic nerve sheath diameter (ONSD) among healthy volunteers. Different types of cervical collars immobilize cervical spine variably well and may presumably differently influence the venous compression and hence the intracranial pressure. We therefore aimed to evaluate the influence of cervical spine immobilization with 5 different types of cervical collars on ONSD measured noninvasively by ultrasound on healthy volunteers. METHODS: We conducted a randomized crossover trial including 60 adult healthy volunteers. Control assessment of the optic nerve sheath thickness was performed in both sagittal and transverse planes. Patient was placed supine on a transport stretcher, cervical collar was placed, and ONSD measurement was performed after 5 and 20 minutes. During the next days, the procedure was repeated with random allocation of participants and random cervical collar. RESULTS: Sixty healthy volunteers were included in our study. ONSD left diameter [mm] for the baseline was 3.8 [interquartile range (IQR): 3.65-3.93)] mm. Using AMBU after 5 min, ONSD was changed up to 4.505 (IQR 4.285-4.61; P < .001) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.73 (IQR: 4.49-4.895; P < .001) and 4.925 (IQR: 4.65-5.06; P < .001), respectively. Necklite reported the lower change in ONSD: 3.92 (IQR: 3.795-4; P = 1.0) mm in 5 minutes and 3.995 (IQR: 3.875 - 4.1; P = 1.0) mm in 20 minutes. ONSD right diameter [mm] for the baseline was 3.8 (IQR 3.675-3.9) mm. Using AMBU after 5 minutes, ONSD was changed up to 4.5 (IQR 4.21-4.6) mm. The largest change at 5 minutes and 20 minutes was using Philly 4.705 (IQR 4.455-4.9) and 4.93 (IQR 4.645-5.075), respectively. Necklite reported the lower change in ONSD -33.9 (IQR 3.795-3.99) mm in 5 minutes and 3.995 (IQR 3.86-4.09) mm in 20 minutes. CONCLUSION: We report significant increase of ONSD from the baseline after cervical collar placement among healthy volunteers at 5 minutes and 20 minutes interval. In addition, no significant difference was noted between ONSD measurements at 5 and 20 minutes. Clinicians should take proactive steps to assess the actual need of cervical collar case by case basis. Nonetheless, when needed, Necklite moldable neck brace seems to be a reasonable option.Registration: ClinicalTrials database (www.clinicaltrials.gov, NCT03609879).


Assuntos
Doenças do Nervo Óptico/etiologia , Restrição Física/efeitos adversos , Adulto , Vértebras Cervicais , Estudos Cross-Over , Feminino , Voluntários Saudáveis , Humanos , Imobilização , Masculino
5.
BMC Anesthesiol ; 20(1): 90, 2020 04 20.
Artigo em Inglês | MEDLINE | ID: mdl-32312225

RESUMO

BACKGROUND: Incidence of difficult endotracheal intubation ranges between 3 and 10%. Bougies have been recommended as an airway adjunct for difficult intubation, but reported success rates are variable. A new generation flexible tip bougie appears promising but was not investigated so far. We therefore compared the new flexible tip with a standard bougie in simulated normal and difficult airway scenarios, and used by experienced anesthesiologists. METHODS: We conducted a observational, randomized, cross-over simulation study. Following standardized training, experienced anesthesiologists performed endotracheal intubation using a Macintosh blade and one of the bougies in six different airway scenarios in a randomized sequence: normal airway, tongue edema, pharyngeal obstruction, manual cervical inline stabilization, cervical collar stabilization, cervical collar stabilization and pharyngeal obstruction. Overall success rate with a maximum of 3 intubation attempts was the primary endpoint. Secondary endpoints included number of intubation attempts, time to intubation and dental compression. RESULTS: Thirty-two anesthesiologist participated in this study between January 2019 and May 2019. Overall success rate was similar for the flexible tip bougie and the standard bougie. The flexible tip bougie tended to need less intubation attempts in more difficult airway scenarios. Time to intubation was less if using the flexible tip bougie compared to the standard bougie. Reduced severity of dental compression was noted for the flexible tip bougie in difficult airway scenarios except cervical collar stabilization. CONCLUSION: In this simulation study of normal and difficult airways scenarios, overall success rate was similar for the flexible tip and standard bougie. Especially in more difficult airway scenarios, less intubation attempts, and less optimization maneuvers were needed if using the flexible tip bougie. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03733158. 7th November 2018.

7.
Anesthesiology ; 132(2): 291-306, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31939844

RESUMO

BACKGROUND: Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. METHODS: The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients' lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. RESULTS: Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. CONCLUSIONS: Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.


Assuntos
Lesão Renal Aguda/fisiopatologia , Pressão Sanguínea/fisiologia , Monitorização Intraoperatória/métodos , Isquemia Miocárdica/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
8.
Anesth Analg ; 130(3): 636-643, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31725024

RESUMO

BACKGROUND: Postoperative delirium is common in critically ill patients, with a reported incidence of 11%-43%, and is associated with significant morbidity and cost. Perioperative hypotension and consequent brain hypoperfusion may contribute. We, therefore, tested the hypotheses that intraoperative and postoperative hypotension are associated with critical care delirium. METHODS: We included 1083 postoperative patients who were admitted directly from an operating room to the surgical intensive care unit. Delirium was assessed with the Confusion Assessment Method for Intensive Care Unit patients at 12-hour intervals. We used a confounder-adjusted Cox proportional hazard survival model to assess the association between the amount of intraoperative hypotension, which was measured as the time-weighted average of mean arterial pressure <65 mm Hg, and delirium while in critical care. Thereafter, we used a Cox model with the lowest mean arterial pressure on each intensive care day as a time-varying covariate to assess the relationship between critical care hypotension and delirium, adjusted for confounders and amount of intraoperative hypotension. RESULTS: Three hundred seventy-seven (35%) patients had delirium within the first 5 postoperative days in the surgical intensive care unit. Intraoperative hypotension was moderately associated with higher odds of postoperative delirium. The adjusted hazard ratio associated with 1 mm Hg increase in time-weighted average of mean arterial pressure <65 mm Hg was 1.11 (95% confidence interval [CI], 1.03-1.20; P = .008). Postoperatively, a 10 mm Hg reduction in the lowest mean pressure on each day in the critical care unit was significantly associated with a higher hazard of delirium, with an adjusted hazard ratio 1.12 (95% CI, 1.04-1.20; P = .003). CONCLUSIONS: Both intraoperative and postoperative hypotension are associated with delirium in postoperative critical care patients. The extent to which these relationships are causal remains unknown, but to the extent that they are, hypotension prevention may help reduce delirium and should be studied in prospective clinical trials.


Assuntos
Pressão Arterial , Delírio/epidemiologia , Hipotensão/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Estado Terminal , Delírio/diagnóstico , Delírio/psicologia , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Período Perioperatório , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
9.
Pediatr Emerg Care ; 36(10): e568-e572, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30106870

RESUMO

BACKGROUND: Obtaining intravascular access can be challenging or even impossible in several clinical situations. As an alternative, medications and fluids can be administered via the intraosseous (IO) route, which is a well-tolerated and established alternative, especially in the emergency setting. METHODS: Seventy-five novice physicians participated in this randomized simulation study. After a single educational session and 6 months without any clinical application, participants were asked to identify the correct puncture site and obtain IO access using 3 widely used mechanical devices (BIG Pediatric, Arrow EZ-IO, NIO Pediatric) and a manual device (Jamshidi needle) on a pediatric manikin and turkey bone, respectively. RESULTS: Sixty-eight participants correctly identified the puncture site and performed IO cannulations. First placement attempt success rate was similar with mechanical devices (NIO Pediatric, 100%; Arrow EZ-IO, 97%; and BIG Pediatric, 90%), whereas was only 43% using the manual Jamshidi device. Also, procedure time was much faster using mechanical devices (ranging between 18 and 23 seconds) compared with the manual Jamshidi device (34 seconds). CONCLUSIONS: Although the efficacy of devices was demonstrated in simulated environment in novice users, further studies are needed to assess the efficacy and safety of devices in clinical comparative settings. With more experienced users, the success rate may differ considerably as compared with naive users.

10.
Anesth Analg ; 130(2): 360-366, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-30882520

RESUMO

BACKGROUND: We previously reported that the duration of hospitalization was not different between isoflurane and sevoflurane. But more plausible consequences of using soluble volatile anesthetics are delayed emergence from anesthesia and prolonged stays in the postanesthesia care unit (PACU). We therefore compared isoflurane and sevoflurane on emergence time and PACU duration. METHODS: We reanalyzed data from 1498 adults who participated in a previous alternating intervention trial comparing isoflurane and sevoflurane. Patients, mostly having colorectal surgery, were assigned to either volatile anesthetic in 2-week blocks that alternated for half a year. Emergence time was defined as the time from minimum alveolar concentration fraction reaching 0.3 at the end of the procedure until patients left the operating room. PACU duration was defined from admission to the end of phase 1 recovery. Treatment effect was assessed using Cox proportional hazards regression, adjusted for imbalanced baseline variables. RESULTS: A total of 674 patients were given isoflurane, and 824 sevoflurane. Emergence time was slightly longer for isoflurane with a median (quartiles) of 16 minutes (12-22 minutes) vs 14 minutes (11-19 minutes) for sevoflurane, with an adjusted hazard ratio of 0.81 (97.5% CI, 0.71-0.92; P < .001). Duration in the PACU did not differ, with a median (quartiles) of 2.6 hours (2.0-3.6 hours) for isoflurane and 2.6 hours (2.0-3.7 hours) hours for sevoflurane. The adjusted hazard ratio for PACU discharge time was 1.04 (97.5% CI, 0.91-1.18; P = .56). CONCLUSIONS: Isoflurane prolonged emergence by only 2 minutes, which is not a clinically important amount, and did not prolong length of stay in the PACU. The more soluble and much less-expensive anesthetic isoflurane thus seems to be a reasonable alternative to sevoflurane.


Assuntos
Período de Recuperação da Anestesia , Anestésicos Inalatórios/administração & dosagem , Isoflurano/administração & dosagem , Tempo de Internação/tendências , Cuidados Pós-Operatórios/tendências , Sevoflurano/administração & dosagem , Adulto , Idoso , Anestésicos Inalatórios/efeitos adversos , Feminino , Humanos , Isoflurano/efeitos adversos , Masculino , Pessoa de Meia-Idade , Sevoflurano/efeitos adversos , Fatores de Tempo
11.
Best Pract Res Clin Anaesthesiol ; 33(2): 229-245, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31582102

RESUMO

The postoperative ward is considered an ideal nursing environment for stable patients transitioning out of the hospital. However, approximately half of all in-hospital cardiorespiratory arrests occur here and are associated with poor outcomes. Current monitoring practices on the hospital ward mandate intermittent vital sign checks. Subtle changes in vital signs often occur at least 8-12 h before an acute event, and continuous monitoring of vital signs would allow for effective therapeutic interventions and potentially avoid an imminent cardiorespiratory arrest event. It seems tempting to apply continuous monitoring to every patient on the ward, but inherent challenges such as artifacts and alarm fatigue need to be considered. This review looks to the future where a continuous, smarter, and portable platform for monitoring of vital signs on the hospital ward will be accompanied with a central monitoring platform and machine learning-based pattern detection solutions to improve safety for hospitalized patients.


Assuntos
Hospitalização/tendências , Monitorização Fisiológica/tendências , Cuidados Pós-Operatórios/tendências , Complicações Pós-Operatórias/prevenção & controle , Sinais Vitais/fisiologia , Inteligência Artificial/tendências , Parada Cardíaca/diagnóstico , Parada Cardíaca/fisiopatologia , Parada Cardíaca/prevenção & controle , Humanos , Monitorização Fisiológica/métodos , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia
12.
J Thorac Dis ; 11(6): 2555-2563, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31372292

RESUMO

Background: Less invasive procedures such as video-assisted thoracoscopic surgery (VATS) are desirable for patent ductal artery (PDA) ligation when pharmacologic or conservative approaches fail. Studies done on VATS-PDA ligation showed better outcomes when compared to open thoracotomies, however, complication rates remain conflicting. Learning curve can be a postulated reason which may also precludes the acceptability. We therefore sought to report our single centered 7-year experience of PDA closure with VATS. Methods: Single centered retrospective study of 127 patients who underwent PDA ligature with VATS from February 2012 to October 2018. The cohort was divided into two groups, i.e., 2012-2014 (early phase) and 2015-2018 (late phase) and were further compared. Early and late outcomes, including mortality and morbidity, were analyzed. Results: The included patients had a mean age of 1.7 years. Among them, preterm infants accounted for 38.6%, there was no operative mortality. Six deaths (4.7%) occurred during in-hospital stay, predominantly in the neonatal intensive care unit (NICU) due to massive cerebral bleeding and cardiopulmonary failure. Overall conversion rate to thoracotomy was 16.5%. It decreased from 20% in early phase to less than 5% in late phase. Fifty patients (39.4%) required transfer to the NICU. The mean in-hospital stay for the remainders was only 2.2±1.6 days. All but two patients discharged home survived follow-up period without any adverse events and nobody among non-converted cases expressed concerns regarding chest deformity. A 5-year probability of survival estimated according to the Kaplan-Meier curve was 93.6%. Conclusions: VATS is a safe as well as efficient method for closure of PDA that ensures satisfactory late cosmetic results. Postoperative mortality and extended hospital stay may be attributed to prematurity. Although learning curve exists it does not affect the safety and late outcomes.

13.
Anesth Analg ; 128(6): 1160-1166, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094783

RESUMO

BACKGROUND: Postoperative pain is common and promotes opioid use. Surgical wounds are hypoxic because normal perfusion is impaired. Local wound ischemia and acidosis promote incisional pain. Some evidence suggests that improving oxygen supply to surgical wounds might reduce pain. We therefore tested the hypothesis that supplemental (80% inspired) intraoperative oxygen reduces postoperative pain and opioid consumption. METHODS: We conducted a post hoc analysis of a large, single-center alternating cohort trial allocating surgical patients having general anesthesia for colorectal surgery to either 30% or 80% intraoperative oxygen concentration in 2-week blocks for a total of 39 months. Irrespective of allocation, patients were given sufficient oxygen to maintain saturation ≥95%. Patients who had regional anesthesia or nerve blocks were excluded. The primary outcome was pain and opioid consumption during the initial 2 postoperative hours, analyzed jointly. The secondary outcome was pain and opioid consumption over the subsequent 24 postoperative hours. Subgroup analyses of the primary outcome were conducted for open versus laparoscopic procedures and for patients with versus without chronic pain. RESULTS: A total of 4702 cases were eligible for analysis: 2415 were assigned to 80% oxygen and 2287 to 30% oxygen. The groups were well balanced on potential confounding factors. Average pain scores and opioid consumption were similar between the groups (mean difference in pain scores, -0.01 [97.5% CI, -0.16 to 0.14; P = .45], median difference in opioid consumption, 0.0 [97.5% CI, 0 to 0] mg morphine equivalents; P = .82). There were also no significant differences in the secondary outcome or subgroup analyses. CONCLUSIONS: Supplemental intraoperative oxygen does not reduce acute postoperative pain or reduce opioid consumption.


Assuntos
Hiperóxia , Manejo da Dor/métodos , Dor Pós-Operatória/terapia , Acidose , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Anestesia/métodos , Estudos de Coortes , Cirurgia Colorretal/métodos , Interpretação Estatística de Dados , Feminino , Humanos , Hipóxia , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Oxigênio/uso terapêutico , Medição da Dor , Resultado do Tratamento
14.
J Neurosurg ; : 1-9, 2019 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-30684941

RESUMO

OBJECTIVECurrent management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts.METHODSThe authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed.RESULTSA total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months.CONCLUSIONSIn this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

15.
J Anesth ; 33(1): 148-154, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30659364

RESUMO

In the case of open urological surgeries, analgesic coverage at mid thoracic dermatomal levels is required. As shown in cadaveric studies, the site of QL block injection is an important determinant of the extent of dye spread and presumably local anesthetic dermatomal coverage. In this case series, we evaluated dermatomal blockade and analgesic efficacy of a subcostal approach to anterior QL block following open urological surgeries. Twenty-two adult patients undergoing renal transplant surgery (60%) and open nephrectomy (40%) received unilateral ultrasound-guided subcostal anterior QL block with catheter insertion. Sensory level, pain score (numeric rating scale, NRS), local anesthetic consumption, and opioid consumption (morphine equivalent dose, MED) were assessed daily for 3 days. The block achieved sensory blockade between T6-7 and L1-2. The most frequently affected dermatomes were T8 -T12 and the number of blocked segments was 3 (mean 2.8). The median (interquartile range Q1, Q3) of NRS pain score was 3.7 (2.8-5.5), 3.3 (2.4-4.7), 2.9 (1.9-3.6), and 2.3 (1.0-4.2) on POD0, POD1, POD2, and POD3, respectively. Our preliminary data showed that the subcostal approach to anterior QL block provides appropriate thoracic dermatome level needed for analgesia following open urological surgical procedures between T6-7 and L1-2.


Assuntos
Anestésicos Locais/administração & dosagem , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Adulto , Idoso , Analgésicos/administração & dosagem , Analgésicos Opioides/administração & dosagem , Feminino , Humanos , Injeções , Masculino , Pessoa de Meia-Idade
16.
J Neurosurg Anesthesiol ; 31(1): 7-17, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30334936

RESUMO

Cognitive aids and evidence-based checklists are frequently utilized in complex situations across many disciplines and sectors. The purpose of such aids is not simply to provide instruction so as to fulfill a task, but rather to ensure that all contingencies related to the emergency are considered and accounted for and that the task at hand is completed fully, despite possible distractions. Furthermore, utilization of a checklist enhances communication to all team members by allowing all stakeholders to know and understand exactly what is occurring, what has been accomplished, and what remains to be done. Here we present a set of evidence-based critical event cognitive aids for neuroanesthesia emergencies developed by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee.


Assuntos
Anestesiologia/métodos , Lista de Checagem/métodos , Técnicas de Apoio para a Decisão , Tratamento de Emergência/métodos , Neurocirurgia , Cognição , Consenso , Cuidados Críticos , Emergências , Humanos , Neurociências , Sociedades Médicas
17.
J Clin Neurosci ; 46: 1-8, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28890045

RESUMO

The traditional renin-angiotensin system (RAS) is indispensable system in adjusting sodium homeostasis, body fluid volume, and controlling arterial blood pressure. The key elements are renin splitting inactive angiotensinogen to yield angiotensin (Ang-I). Ang-1 is then changed by angiotensin-1 converting enzyme (ACE) into angiotensin II (Ang-II). Using PubMed, Google Scholar, and other means, we searched the peer-reviewed literature from 1990 to 2013 for articles on newly discovered findings related to the RAS, especially focusing on how the system influences the central nervous system (CNS). The classical RAS is now considered to be only part of the picture; the discovery of additional RAS pathways in the brain and elsewhere has yielded a vastly improved understanding of how the RAS influences the CNS. Newly discovered effects of the RAS on brain tissue include neuroprotection, cognition, and cerebral vasodilation. A number of brain biochemical pathways are influenced by the brain RAS. Within various pathways, there are potential opportunities for classical pharmacologic interventions as well as the possibility of controlling gene expression.


Assuntos
Encéfalo/fisiologia , Sistema Renina-Angiotensina/fisiologia , Animais , Humanos
18.
Anaesthesiol Intensive Ther ; 49(4): 274-282, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28953308

RESUMO

BACKGROUND: Immobilization of the cervical spine is indicated in all patients with the potential risk of any cervical spine injury. Airway management in these patients is challenging and direct laryngoscopy is the standard of care. Videolaryngoscopes like the ET-View were introduced into clinical practice to provide better airway visualization and ease intubation. The ET-View is essentially a conventional endotracheal tube, but is equipped with a miniature camera on the tip. The ET-View has not been investigated in patients with immobilized cervical spine so far. The aim was to evaluate the performance of the VivaSight SL compared with Macintosh when performed in patients with immobilized cervical spine by unexperienced physicians. METHODS: This was prospective, randomized, cross-over manikin trial. 50 novice physicians were randomly assigned to intubate a manikin in three airway scenarios including a normal airway and two cervical immobilization techniques. Overall and first intubation attempt success rate, time to intubation, dental compression and airway visualization according to the Cormack&Lehane graduation were assessed. RESULTS: All physicians were able to intubate the manikin in all scenarios using the ETView, whereas direct laryngoscopy failed in 16 % with immobilized cervical spine using the patriot cervical extraction collar. First intubation attempt success rate was higher and airway visualization was better in all three scenarios using the ET-View compared to direct laryngoscopy. CONCLUSION: The ET-View offered much better 62 airway visualization and provided higher overall and first intubation attempt success rates. Therefore, the ET-View is a valuable alternative in patients with difficult intubation due to immobilized cervical spine. Further clinical trials are indicated to confirm these findings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02733536.


Assuntos
Manuseio das Vias Aéreas/métodos , Imobilização/métodos , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Adulto , Vértebras Cervicais , Estudos Cross-Over , Feminino , Humanos , Laringoscópios , Laringoscopia/instrumentação , Masculino , Manequins , Médicos , Estudos Prospectivos , Gravação em Vídeo
19.
J Thorac Dis ; 8(11): 3431-3441, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28066624

RESUMO

Tracheobronchial surgeries require close cooperation and extensive communication between the anesthesia providers and the surgeons. Anesthetic management of tracheal and bronchial pathologies differ basically from regular upper airways management, due access to the patients airway is limited, mostly even practically impossible for the anesthesia providers. As a consequence, the surgeon overtakes responsibility for the airway access from the anesthesia provider in the variety of the cases. Preoperative recognition of a difficult airway, detailed planning and being aware of plan B and plan C are the elementary keys to success. Providers have to be aware, that preoperative airway assessment does not always correlate with the ease of oxygenation and ventilation. Therefore, various methods have been described in the literature and several authors have adopted unique ways to manage the airways in a successful manner. With the advancement of surgical techniques over the years, anesthetic management has also evolved tremendously to match the needs. The commonly encountered conditions requiring surgical interventions include post-intubation stenosis and foreign body aspiration. In this review we will discuss the most common pathologies of tracheobronchial lesions and specific anesthetic management considerations related to them.

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