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1.
Rev. esp. enferm. dig ; 111(3): 193-198, mar. 2019. tab, graf
Artigo em Inglês | IBECS-Express | ID: ibc-ET1-4618

RESUMO

Background: the aim of this study was to analyze the clinical results of the multidisciplinary management of elderly patients with colorectal cancer in a single center and to describe postoperative quality of life. Methods: a comparative study was designed to compare the results and quality of life of patients treated in our center for colon cancer, aged from 80 to 84 years (study group) compared to a control group (aged form 75 to 79 years of age). Morbidity, mortality, oncological results and quality of life were analyzed. Results: eighty-seven patients aged between 80 and 84 years of age (study group) were compared to a control group, which was formed by 91 patients aged from 75 to 79 years of age. There were no significant differences in technique and morbidity. Survival at 30 days, 90 days and at the end of follow-up (median 48 months) were similar in both groups. There were no differences in quality of life except for one item with regard to physical function (p = 0.0138). Conclusion: similar clinical results and quality of life were achieved after treating elderly patients with colon cancer with a multidisciplinary management approach


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2.
Rev Esp Enferm Dig ; 111(3): 193-198, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30545228

RESUMO

BACKGROUND: the aim of this study was to analyze the clinical results of the multidisciplinary management of elderly patients with colorectal cancer in a single center and to describe postoperative quality of life. METHODS: a comparative study was designed to compare the results and quality of life of patients treated in our center for colon cancer, aged from 80 to 84 years (study group) compared to a control group (aged form 75 to 79 years of age). Morbidity, mortality, oncological results and quality of life were analyzed. RESULTS: eighty-seven patients aged between 80 and 84 years of age (study group) were compared to a control group, which was formed by 91 patients aged from 75 to 79 years of age. There were no significant differences in technique and morbidity. Survival at 30 days, 90 days and at the end of follow-up (median 48 months) were similar in both groups. There were no differences in quality of life except for one item with regard to physical function (p = 0.0138). CONCLUSION: similar clinical results and quality of life were achieved after treating elderly patients with colon cancer with a multidisciplinary management approach.

3.
Eur J Anaesthesiol ; 36(2): 93-104, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30431500

RESUMO

BACKGROUND: Postoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems. OBJECTIVE: To identify independent variables associated with the occurrence of postoperative pneumonia. DESIGN: A prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database). SETTING: Sixty-three hospitals in Europe. PATIENTS: Patients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period. MAIN OUTCOME MEASURE: The primary outcome was postoperative pneumonia. DEFINITION: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 µl. RESULTS: Postoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P < 0.001). We identified five variables independently associated with postoperative pneumonia: functional status [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.58 to 3.12], pre-operative SpO2 values while breathing room air (OR 0.83, 95% CI 0.78 to 0.84), intra-operative colloid administration (OR 2.97, 95% CI 1.94 to 3.99), intra-operative blood transfusion (OR 2.19, 95% CI 1.41 to 4.71) and surgical site (open upper abdominal surgery OR 3.98, 95% CI 2.19 to 7.59). The model had good discrimination (c-statistic 0.89) and calibration (Hosmer-Lemeshow P = 0.572). CONCLUSION: We identified five variables independently associated with postoperative pneumonia. The model performed well and after external validation may be used for risk stratification and management of patients at risk of postoperative pneumonia. TRIAL REGISTRATION: NCT 01346709 (ClinicalTrials.gov).


Assuntos
Modelos Biológicos , Pneumonia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pneumonia/etiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos
4.
Eur J Anaesthesiol ; 35(9): 691-701, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29916860

RESUMO

BACKGROUND: Currently used pre-operative prediction scores for postoperative pulmonary complications (PPCs) use patient data and expected surgery characteristics exclusively. However, intra-operative events are also associated with the development of PPCs. OBJECTIVE: We aimed to develop a new prediction score for PPCs that uses both pre-operative and intra-operative data. DESIGN: This is a secondary analysis of the LAS VEGAS study, a large international, multicentre, prospective study. SETTINGS: A total of 146 hospitals across 29 countries. PATIENTS: Adult patients requiring intra-operative ventilation during general anaesthesia for surgery. INTERVENTIONS: The cohort was randomly divided into a development subsample to construct a predictive model, and a subsample for validation. MAIN OUTCOME MEASURES: Prediction performance of developed models for PPCs. RESULTS: Of the 6063 patients analysed, 10.9% developed at least one PPC. Regression modelling identified 13 independent risk factors for PPCs: six patient characteristics [higher age, higher American Society of Anesthesiology (ASA) physical score, pre-operative anaemia, pre-operative lower SpO2 and a history of active cancer or obstructive sleep apnoea], two procedure-related features (urgent or emergency surgery and surgery lasting ≥ 1 h), and five intra-operative events [use of an airway other than a supraglottic device, the use of intravenous anaesthetic agents along with volatile agents (balanced anaesthesia), intra-operative desaturation, higher levels of positive end-expiratory pressures > 3 cmH2O and use of vasopressors]. The area under the receiver operating characteristic curve of the LAS VEGAS risk score for prediction of PPCs was 0.78 [95% confidence interval (95% CI), 0.76 to 0.80] for the development subsample and 0.72 (95% CI, 0.69 to 0.76) for the validation subsample. CONCLUSION: The LAS VEGAS risk score including 13 peri-operative characteristics has a moderate discriminative ability for prediction of PPCs. External validation is needed before use in clinical practice. TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, number NCT01601223.


Assuntos
Pneumopatias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Fatores Etários , Estudos de Coortes , Feminino , Nível de Saúde , Humanos , Período Intraoperatório , Pulmão/fisiopatologia , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Valor Preditivo dos Testes , Período Pré-Operatório , Estudos Prospectivos , Reprodutibilidade dos Testes , Fatores de Risco
5.
Ann Intensive Care ; 8(1): 39, 2018 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-29564726

RESUMO

BACKGROUND: The majority of critically ill patients do not suffer from acute respiratory distress syndrome (ARDS). To improve the treatment of these patients, we aimed to identify potentially modifiable factors associated with outcome of these patients. METHODS: The PRoVENT was an international, multicenter, prospective cohort study of consecutive patients under invasive mechanical ventilatory support. A predefined secondary analysis was to examine factors associated with mortality. The primary endpoint was all-cause in-hospital mortality. RESULTS: 935 Patients were included. In-hospital mortality was 21%. Compared to patients who died, patients who survived had a lower risk of ARDS according to the 'Lung Injury Prediction Score' and received lower maximum airway pressure (Pmax), driving pressure (ΔP), positive end-expiratory pressure, and FiO2 levels. Tidal volume size was similar between the groups. Higher Pmax was a potentially modifiable ventilatory variable associated with in-hospital mortality in multivariable analyses. ΔP was not independently associated with in-hospital mortality, but reliable values for ΔP were available for 343 patients only. Non-modifiable factors associated with in-hospital mortality were older age, presence of immunosuppression, higher non-pulmonary sequential organ failure assessment scores, lower pulse oximetry readings, higher heart rates, and functional dependence. CONCLUSIONS: Higher Pmax was independently associated with higher in-hospital mortality in mechanically ventilated critically ill patients under mechanical ventilatory support for reasons other than ARDS. Trial Registration ClinicalTrials.gov (NCT01868321).

6.
Lancet Respir Med ; 6(3): 193-203, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29371130

RESUMO

BACKGROUND: The effects of individualised perioperative lung-protective ventilation (based on the open-lung approach [OLA]) on postoperative complications is unknown. We aimed to investigate the effects of intraoperative and postoperative ventilatory management in patients scheduled for abdominal surgery, compared with standard protective ventilation. METHODS: We did this prospective, multicentre, randomised controlled trial in 21 teaching hospitals in Spain. We enrolled patients who were aged 18 years or older, were scheduled to have abdominal surgery with an expected time of longer than 2 h, had intermediate-to-high-risk of developing postoperative pulmonary complications, and who had a body-mass index less than 35 kg/m2. Patients were randomly assigned (1:1:1:1) online to receive one of four lung-protective ventilation strategies using low tidal volume plus positive end-expiratory pressure (PEEP): open-lung approach (OLA)-iCPAP (individualised intraoperative ventilation [individualised PEEP after a lung recruitment manoeuvre] plus individualised postoperative continuous positive airway pressure [CPAP]), OLA-CPAP (intraoperative individualised ventilation plus postoperative CPAP), STD-CPAP (standard intraoperative ventilation plus postoperative CPAP), or STD-O2 (standard intraoperative ventilation plus standard postoperative oxygen therapy). Patients were masked to treatment allocation. Investigators were not masked in the operating and postoperative rooms; after 24 h, data were given to a second investigator who was masked to allocations. The primary outcome was a composite of pulmonary and systemic complications during the first 7 postoperative days. We did the primary analysis using the modified intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT02158923. FINDINGS: Between Jan 2, 2015, and May 18, 2016, we enrolled 1012 eligible patients. Data were available for 967 patients, whom we included in the final analysis. Risk of pulmonary and systemic complications did not differ for patients in OLA-iCPAP (110 [46%] of 241, relative risk 0·89 [95% CI 0·74-1·07; p=0·25]), OLA-CPAP (111 [47%] of 238, 0·91 [0·76-1·09; p=0·35]), or STD-CPAP groups (118 [48%] of 244, 0·95 [0·80-1·14; p=0·65]) when compared with patients in the STD-O2 group (125 [51%] of 244). Intraoperatively, PEEP was increased in 69 (14%) of patients in the standard perioperative ventilation groups because of hypoxaemia, and no patients from either of the OLA groups required rescue manoeuvres. INTERPRETATION: In patients who have major abdominal surgery, the different perioperative open lung approaches tested in this study did not reduce the risk of postoperative complications when compared with standard lung-protective mechanical ventilation. FUNDING: Instituto de Salud Carlos III of the Spanish Ministry of Economy and Competitiveness, and Grants Programme of the European Society of Anaesthesiology.


Assuntos
Abdome/cirurgia , Assistência Perioperatória/métodos , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/etiologia , Respiração Artificial/métodos , Idoso , Feminino , Humanos , Pulmão/fisiopatologia , Pulmão/cirurgia , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/efeitos adversos , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Espanha , Resultado do Tratamento
8.
BMJ Open ; 7(7): e016765, 2017 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-28760799

RESUMO

INTRODUCTION: Surgical site infection (SSI) is a serious postoperative complication that increases morbidity and healthcare costs. SSIs tend to increase as the partial pressure of tissue oxygen decreases: previous trials have focused on trying to reduce them by comparing high versus conventional inspiratory oxygen fractions (FIO2) in the perioperative period but did not use a protocolised ventilatory strategy. The open-lung ventilatory approach restores functional lung volume and improves gas exchange, and therefore it may increase the partial pressure of tissue oxygen for a given FIO2. The trial presented here aims to compare the efficacy of high versus conventional FIO2 in reducing the overall incidence of SSIs in patients by implementing a protocolised and individualised global approach to perioperative open-lung ventilation. METHODS AND ANALYSIS: This is a comparative, prospective, multicentre, randomised and controlled two-arm trial that will include 756 patients scheduled for abdominal surgery. The patients will be randomised into two groups: (1) a high FIO2 group (80% oxygen; FIO2 of 0.80) and (2) a conventional FIO2 group (30% oxygen; FIO2 of 0.30). Each group will be assessed intra- and postoperatively. The primary outcome is the appearance of postoperative SSI complications. Secondary outcomes are the appearance of systemic and pulmonary complications. ETHICS AND DISSEMINATION: The iPROVE-O2 trial has been approved by the Ethics Review Board at the reference centre (the Hospital Clínico Universitario in Valencia). Informed consent will be obtained from all patients before their participation. If the approach using high FIO2 during individualised open-lung ventilation decreases SSIs, use of this method will become standard practice for patients scheduled for future abdominal surgery. Publication of the results is anticipated in early 2019. TRIAL REGISTRATION NUMBER: NCT02776046; Pre-results.


Assuntos
Abdome/cirurgia , Pulmão/fisiopatologia , Oxigênio/administração & dosagem , Respiração Artificial/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Estudos Prospectivos , Respiração Artificial/efeitos adversos
9.
BMJ Open ; 7(5): e015560, 2017 05 29.
Artigo em Inglês | MEDLINE | ID: mdl-28554935

RESUMO

OBJECTIVE: To assess the diagnostic accuracy of peripheral capillary oxygen saturation (SpO2) while breathing room air for 5 min (the 'Air-Test') in detecting postoperative atelectasis. DESIGN: Prospective cohort study. Diagnostic accuracy was assessed by measuring the agreement between the index test and the reference standard CT scan images. SETTING: Postanaesthetic care unit in a tertiary hospital in Spain. PARTICIPANTS: Three hundred and fifty patients from 12 January to 7 February 2015; 170 patients scheduled for surgery under general anaesthesia who were admitted into the postsurgical unit were included. INTERVENTION: The Air-Test was performed in conscious extubated patients after a 30 min stabilisation period during which they received supplemental oxygen therapy via a venturi mask. The Air-Test was defined as positive when SpO2 was ≤96% and negative when SpO2 was ≥97%. Arterial blood gases were measured in all patients at the end of the Air-Test. In the subsequent 25 min, the presence of atelectasis was evaluated by performing a CT scan in 59 randomly selected patients. MAIN OUTCOME MEASURES: The primary study outcome was assessment of the accuracy of the Air-Test for detecting postoperative atelectasis compared with the reference standard. The secondary outcome was the incidence of positive Air-Test results. RESULTS: The Air-Test diagnosed postoperative atelectasis with an area under the receiver operating characteristic curve of 0.90 (95% CI 0.82 to 0.98) with a sensitivity of 82.6% and a specificity of 87.8%. The presence of atelectasis was confirmed by CT scans in all patients (30/30) with positive and in 5 patients (17%) with negative Air-Test results. Based on the Air-Test, postoperative atelectasis was present in 36% of the patients (62 out of 170). CONCLUSION: The Air-Test may represent an accurate, simple, inexpensive and non-invasive method for diagnosing postoperative atelectasis. TRIAL REGISTRATION: NCT02650037.


Assuntos
Ar/análise , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Atelectasia Pulmonar/diagnóstico , Atelectasia Pulmonar/terapia , Adulto , Idoso , Anestesia Geral/efeitos adversos , Gasometria , Reações Falso-Negativas , Feminino , Humanos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigenoterapia , Projetos Piloto , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Atelectasia Pulmonar/etiologia , Sensibilidade e Especificidade , Espanha , Centros de Atenção Terciária , Tomografia Computadorizada por Raios X
10.
Lancet Respir Med ; 4(11): 882-893, 2016 11.
Artigo em Inglês | MEDLINE | ID: mdl-27717861

RESUMO

BACKGROUND: Scant information exists about the epidemiological characteristics and outcome of patients in the intensive care unit (ICU) at risk of acute respiratory distress syndrome (ARDS) and how ventilation is managed in these individuals. We aimed to establish the epidemiological characteristics of patients at risk of ARDS, describe ventilation management in this population, and assess outcomes compared with people at no risk of ARDS. METHODS: PRoVENT (PRactice of VENTilation in critically ill patients without ARDS at onset of ventilation) is an international, multicentre, prospective study undertaken at 119 ICUs in 16 countries worldwide. All patients aged 18 years or older who were receiving mechanical ventilation in participating ICUs during a 1-week period between January, 2014, and January, 2015, were enrolled into the study. The Lung Injury Prediction Score (LIPS) was used to stratify risk of ARDS, with a score of 4 or higher defining those at risk of ARDS. The primary outcome was the proportion of patients at risk of ARDS. Secondary outcomes included ventilatory management (including tidal volume [VT] expressed as mL/kg predicted bodyweight [PBW], and positive end-expiratory pressure [PEEP] expressed as cm H2O), development of pulmonary complications, and clinical outcomes. The PRoVENT study is registered at ClinicalTrials.gov, NCT01868321. The study has been completed. FINDINGS: Of 3023 patients screened for the study, 935 individuals fulfilled the inclusion criteria. Of these critically ill patients, 282 were at risk of ARDS (30%, 95% CI 27-33), representing 0·14 cases per ICU bed over a 1-week period. VT was similar for patients at risk and not at risk of ARDS (median 7·6 mL/kg PBW [IQR 6·7-9·1] vs 7·9 mL/kg PBW [6·8-9·1]; p=0·346). PEEP was higher in patients at risk of ARDS compared with those not at risk (median 6·0 cm H2O [IQR 5·0-8·0] vs 5·0 cm H2O [5·0-7·0]; p<0·0001). The prevalence of ARDS in patients at risk of ARDS was higher than in individuals not at risk of ARDS (19/260 [7%] vs 17/556 [3%]; p=0·004). Compared with individuals not at risk of ARDS, patients at risk of ARDS had higher in-hospital mortality (86/543 [16%] vs 74/232 [32%]; p<0·0001), ICU mortality (62/533 [12%] vs 66/227 [29%]; p<0·0001), and 90-day mortality (109/653 [17%] vs 88/282 [31%]; p<0·0001). VT did not differ between patients who did and did not develop ARDS (p=0·471 for those at risk of ARDS; p=0·323 for those not at risk). INTERPRETATION: Around a third of patients receiving mechanical ventilation in the ICU were at risk of ARDS. Pulmonary complications occur frequently in patients at risk of ARDS and their clinical outcome is worse compared with those not at risk of ARDS. There is potential for improvement in the management of patients without ARDS. Further refinements are needed for prediction of ARDS. FUNDING: None.


Assuntos
Estado Terminal/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Respiração com Pressão Positiva/efeitos adversos , Respiração Artificial/efeitos adversos , Síndrome do Desconforto Respiratório do Adulto/epidemiologia , Idoso , Estado Terminal/terapia , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva/métodos , Prevalência , Estudos Prospectivos , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório do Adulto/etiologia , Fatores de Risco , Volume de Ventilação Pulmonar
13.
Minerva Anestesiol ; 82(3): 332-42, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25990430

RESUMO

Pulmonary complications are a source of greater postoperative morbidity and mortality and longer hospital stays. Although many factors have been implicated as predictors, few models have been developed with the rigorous methodology required for clinically useful tools. In this article we attempt to describe what to look for when developing or assessing a newly proposed predictive tool and to discuss what must be taken into consideration on incorporating a model into clinical practice. Above all, we stress that we still lack evidence for the clinical and cost effectiveness of many measures proposed for reducing risk or for managing complications perioperatively. For a good predictive model to truly prove its utility in clinical decision-making, such evidence is required.


Assuntos
Pneumopatias/diagnóstico , Pneumopatias/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Humanos , Pneumopatias/etiologia , Modelos Biológicos , Período Pós-Operatório , Fatores de Risco
14.
Best Pract Res Clin Anaesthesiol ; 29(3): 315-30, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26643097

RESUMO

Post-operative pulmonary complications (PPCs) can have severe consequences and their incidence is high. In recent years, PPCs have been the subject of numerous studies and articles, which have provided a great deal of information that is beneficial but that can cause confusion on a practical level. This review focusses on three main points: (1) the definitions of PPCs, which are heterogeneous and often vary from one report to another, despite emerging consensus; (2) the risk as reflected in the pool of PPC predictors, with each study identifying some but leaving us with a myriad of combinations; and (3) the many PPC prediction scores proposed, each with its strengths and limitations. We attempt to clarify the practical and research implications of the current situation.


Assuntos
Pneumopatias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Humanos , Incidência , Pneumopatias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Valor Preditivo dos Testes , Fatores de Risco
16.
Anesthesiology ; 123(3): 692-713, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26120769

RESUMO

Postoperative pulmonary complications are associated with increased morbidity, length of hospital stay, and mortality after major surgery. Intraoperative lung-protective mechanical ventilation has the potential to reduce the incidence of postoperative pulmonary complications. This review discusses the relevant literature on definition and methods to predict the occurrence of postoperative pulmonary complication, the pathophysiology of ventilator-induced lung injury with emphasis on the noninjured lung, and protective ventilation strategies, including the respective roles of tidal volumes, positive end-expiratory pressure, and recruitment maneuvers. The authors propose an algorithm for protective intraoperative mechanical ventilation based on evidence from recent randomized controlled trials.


Assuntos
Cuidados Intraoperatórios/métodos , Pulmão/fisiologia , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Respiração Artificial/métodos , Volume de Ventilação Pulmonar/fisiologia , Animais , Humanos , Respiração Artificial/efeitos adversos , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle
17.
Trials ; 16: 193, 2015 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-25927183

RESUMO

BACKGROUND: Postoperative pulmonary and non-pulmonary complications are common problems that increase morbidity and mortality in surgical patients, even though the incidence has decreased with the increased use of protective lung ventilation strategies. Previous trials have focused on standard strategies in the intraoperative or postoperative period, but without personalizing these strategies to suit the needs of each individual patient and without considering both these periods as a global perioperative lung-protective approach. The trial presented here aims at comparing postoperative complications when using an individualized ventilatory management strategy in the intraoperative and immediate postoperative periods with those when using a standard protective ventilation strategy in patients scheduled for major abdominal surgery. METHODS: This is a comparative, prospective, multicenter, randomized, and controlled, four-arm trial that will include 1012 patients with an intermediate or high risk for postoperative pulmonary complications. The patients will be divided into four groups: (1) individualized perioperative group: intra- and postoperative individualized strategy; (2) intraoperative individualized strategy + postoperative continuous positive airway pressure (CPAP); (3) intraoperative standard ventilation + postoperative CPAP; (4) intra- and postoperative standard strategy (conventional strategy). The primary outcome is a composite analysis of postoperative complications. DISCUSSION: The Individualized Perioperative Open-lung Ventilatory Strategy (iPROVE) is the first multicenter, randomized, and controlled trial to investigate whether an individualized perioperative approach prevents postoperative pulmonary complications. TRIAL REGISTRATION: Registered on 5 June 2014 with identification no. NCT02158923 .


Assuntos
Abdome/cirurgia , Pressão Positiva Contínua nas Vias Aéreas , Pneumopatias/prevenção & controle , Pulmão/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Respiração Artificial/métodos , Protocolos Clínicos , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Feminino , Humanos , Pneumopatias/diagnóstico , Pneumopatias/etiologia , Pneumopatias/fisiopatologia , Masculino , Assistência Perioperatória , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Projetos de Pesquisa , Respiração Artificial/efeitos adversos , Espanha , Fatores de Tempo , Resultado do Tratamento
18.
Anesthesiology ; 122(5): 1123-41, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25985024

RESUMO

BACKGROUND: Chronic postsurgical pain (CPSP) has been linked to many surgical settings. The authors aimed to analyze functional genetic polymorphisms and clinical factors that might identify CPSP risk after inguinal hernia repair, hysterectomy, and thoracotomy. METHODS: This prospective multicenter cohort study enrolled 2,929 patients scheduled for inguinal hernia repair, hysterectomy (vaginal or abdominal), or thoracotomy. The main outcome was the incidence of CPSP confirmed by physical examination 4 months after surgery. The secondary outcome was CPSP incidences at 12 and 24 months. The authors also tested the associations between CPSP and 90 genetic markers plus a series of clinical factors and built a CPSP risk model. RESULTS: Within a median of 4.4 months, CPSP had developed in 527 patients (18.0%), in 13.6% after hernia repair, 11.8% after vaginal hysterectomy, 25.1% after abdominal hysterectomy, and 37.6% after thoracotomy. CPSP persisted after a median of 14.6 months and 26.3 months in 6.2% and 4.1%, respectively, after hernia repair, 4.1% and 2.2% after vaginal hysterectomy, 9.9% and 6.7% after abdominal hysterectomy, and 19.1% and 13.2% after thoracotomy. No significant genetic differences between cases and controls were identified. The risk model included six clinical predictors: (1) surgical procedure, (2) age, (3) physical health (Short Form Health Survey-12), (4) mental health (Short Form Health Survey-12), (5) preoperative pain in the surgical field, and (6) preoperative pain in another area. Discrimination was moderate (c-statistic, 0.731; 95% CI, 0.705 to 0.755). CONCLUSIONS: Until unequivocal genetic predictors of CPSP are understood, the authors encourage systematic use of clinical factors for predicting and managing CPSP risk.


Assuntos
Herniorrafia/efeitos adversos , Histerectomia/efeitos adversos , Dor Pós-Operatória/genética , Dor Pós-Operatória/terapia , Toracotomia/efeitos adversos , Adulto , Fatores Etários , Idoso , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Dor Pós-Operatória/epidemiologia , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento
19.
Anesthesiology ; 123(1): 66-78, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25978326

RESUMO

BACKGROUND: Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end-expiratory pressure (PEEP) level and occurrence of PPC. METHODS: Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression. RESULTS: Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose-response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08). CONCLUSIONS: These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.


Assuntos
Respiração com Pressão Positiva/métodos , Estatística como Assunto/métodos , Humanos , Respiração com Pressão Positiva/normas , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Respiração Artificial/métodos , Respiração Artificial/normas , Volume de Ventilação Pulmonar/fisiologia
20.
Eur J Anaesthesiol ; 32(7): 458-70, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26020123

RESUMO

BACKGROUND: Postoperative respiratory failure (PRF) is the most frequent respiratory complication following surgery. OBJECTIVE: The objective of this study was to build a clinically useful predictive model for the development of PRF. DESIGN: A prospective observational study of a multicentre cohort. SETTING: Sixty-three hospitals across Europe. PATIENTS: Patients undergoing any surgical procedure under general or regional anaesthesia during 7-day recruitment periods. MAIN OUTCOME MEASURES: Development of PRF within 5 days of surgery. PRF was defined by a partial pressure of oxygen in arterial blood (PaO2) less than 8 kPa or new onset oxyhaemoglobin saturation measured by pulse oximetry (SpO2) less than 90% whilst breathing room air that required conventional oxygen therapy, noninvasive or invasive mechanical ventilation. RESULTS: PRF developed in 224 patients (4.2% of the 5384 patients studied). In-hospital mortality [95% confidence interval (95% CI)] was higher in patients who developed PRF [10.3% (6.3 to 14.3) vs. 0.4% (0.2 to 0.6)]. Regression modelling identified a predictive PRF score that includes seven independent risk factors: low preoperative SpO2; at least one preoperative respiratory symptom; preoperative chronic liver disease; history of congestive heart failure; open intrathoracic or upper abdominal surgery; surgical procedure lasting at least 2 h; and emergency surgery. The area under the receiver operating characteristic curve (c-statistic) was 0.82 (95% CI 0.79 to 0.85) and the Hosmer-Lemeshow goodness-of-fit statistic was 7.08 (P = 0.253). CONCLUSION: A risk score based on seven objective, easily assessed factors was able to predict which patients would develop PRF. The score could potentially facilitate preoperative risk assessment and management and provide a basis for testing interventions to improve outcomes.The study was registered at ClinicalTrials.gov (identifier NCT01346709).


Assuntos
Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/prevenção & controle , Adulto , Idoso , Anestesia por Condução , Anestesia Geral , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Europa (Continente) , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigênio/sangue , Oxiemoglobinas/análise , Oxiemoglobinas/metabolismo , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Insuficiência Respiratória/mortalidade , Fatores de Risco , Resultado do Tratamento
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