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1.
Anesthesiology ; 133(6): 1214-1222, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32960954

RESUMO

BACKGROUND: The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. METHODS: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg. RESULTS: Among 214 enrolled patients, guidance was provided for 105 (49%) patients randomly assigned to the index guidance group. The median (first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14 (0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0 (-0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than 60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened. CONCLUSIONS: In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment, presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment.

2.
Cleve Clin J Med ; 2020 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-32493735

RESUMO

In response to the COVID-19 pandemic, quality improvement teams at Cleveland Clinic initiated a number of measures to guide the care of patients with suspected or confirmed COVID-19 infection and protect care givers. This included increasing the frequency of team meetings from monthly to daily or weekly and creating task forces to create protocols for patient transport, airway management, and management of personal protective equipment and medications in short supply. Enterprise wide, we postponed non-essential surgeries, set up an overflow intensive care unit onsite, created a web-based COVID-19 toolkit for all care givers, and sent daily emails about the most recent developments, decisions, and recommendations from national and international societies.

3.
Cleve Clin J Med ; 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32434805

RESUMO

The operating room environment is very dynamic with many unique challenges for anesthesia teams caring for patients with confirmed or suspected COVID-19. Specific recommendations by national organizations and institution specific step-by-step guidelines and education materials are required to maintain safety for both patients and caregivers perioperatively, with transport, and medication management.

4.
Transplant Direct ; 6(4): e545, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32309631

RESUMO

Patients with hepatopulmonary syndrome (HPS) reportedly experience posttransplant morbidity and require more resources to care during perioperative period. The exact incremental increase of resources utilization compared with non-HPS population remains unknown. Methods: In this single-center retrospective investigation, we compared the perioperative resources utilization of HPS patients undergoing orthotopic liver transplant (n = 28) to cohort without HPS (n = 739). Potential confounding variables were adjusted in the analysis and the multivariable log-linear regression were used. Results: The overall hospital costs for HPS patients were about 27% higher compared with non-HPS patients (the ratio of geometric means, 1.27; 98.3% confidence interval, 1.09-1.47; P < 0). HPS diagnosis was independently associated with both longer intensive care unit stay (P < 0.001) and hospital stay (P < 0.001). The odds of being discharged to extended care facility were about 15 times higher for HPS patients comparing to non-HPS patients (odds ratio, 14.9; 97.5% confidence interval, 4.98-44.29; P < 0.001). There were no differences observed in odds of being readmitted to the hospital within 6 mo after the transplant (P = 0.75). Conclusions: HPS diagnosis was associated with longer intensive care unit stay, hospital stay, and increased hospital cost, together with higher odds of being discharged to extended care facility compared with non-HPS patients.

5.
Surgery ; 168(1): 33-39, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32268937

RESUMO

BACKGROUND: Transjugular intrahepatic portosystemic shunt has been established as an effective treatment for complicated portal hypertension. This retrospective study investigated the effect of pretransplant transjugular intrahepatic portosystemic shunt placement on intraoperative graft hemodynamics and surgical outcomes after liver transplantation. METHODS: Of 1,081 patients who underwent liver transplantation between January 2007 and June 2017 at Cleveland Clinic (OH, USA), 130 patients had transjugular intrahepatic portosystemic shunt placement before liver transplant. We performed a 1:2 propensity score matching to compare intraoperative graft hemodynamics and surgical outcomes between the transjugular intrahepatic portosystemic shunt group (n = 130) and the no-transjugular intrahepatic portosystemic shunt group (n = 260). RESULTS: The transjugular intrahepatic portosystemic shunt did not increase operative time, the volume of blood transfusion, duration of hospital stay, or complication rates. Graft and patient survivals were similar between the groups. Mean intraoperative cardiac output and graft portal flow in the transjugular intrahepatic portosystemic shunt group were greater than in the no-transjugular intrahepatic portosystemic shunt group (P = .03 and P = .003, respectively). In multivariate analysis, male sex, younger age, low platelet count, absence of portal vein thrombosis, and pretransplant transjugular intrahepatic portosystemic shunt placement were independently associated with increased portal flow volume (P < or = 0.03 each). Transjugular intrahepatic portosystemic shunt malposition was observed in 17 patients (13.1%). The 1-year patient survival was 70.6% with transjugular intrahepatic portosystemic shunt malposition and 92.0% without transjugular intrahepatic portosystemic shunt malposition (P = .01). CONCLUSION: Our findings suggest that pretransplant transjugular intrahepatic portosystemic shunt placement increases graft portal flow but does not compromise surgical outcomes after liver transplantation. Transjugular intrahepatic portosystemic shunt malposition, however, is not uncommon and may increase the complexity of transplantation.


Assuntos
Transplante de Fígado/mortalidade , Derivação Portossistêmica Transjugular Intra-Hepática/efeitos adversos , Complicações Pós-Operatórias/etiologia , Idoso , Feminino , Sobrevivência de Enxerto , Humanos , Circulação Hepática , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Derivação Portossistêmica Transjugular Intra-Hepática/estatística & dados numéricos , Pontuação de Propensão , Estudos Retrospectivos
6.
Anesth Analg ; 129(3): 896-904, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31425235

RESUMO

BACKGROUND: Hypotension is associated with acute kidney injury, but vasopressors used to treat hypotension may also compromise renal function. We therefore tested the hypothesis that vasopressor infusion during complex spine surgery is not associated with impaired renal function. METHODS: In this retrospective cohort analysis, we considered adults who had complex spine surgery between January 2005 and September 2014 at the Cleveland Clinic Main Campus. Our primary outcome was postoperative estimated glomerular filtration rate. Secondarily, we evaluated renal function using Acute Kidney Injury Network criteria. We obtained data for 1814 surgeries, including 689 patients (38%) who were given intraoperative vasopressors infusion for ≥30 minutes and 1125 patients (62%) who were not. Five hundred forty patients with and 540 patients without vasopressor infusions were well matched across 32 potential confounding variables. RESULTS: In matched patients, vasopressor infusions lasted an average of 173 ± 100 minutes (SD) and were given a median dose (1st quintile, 3rd quintile) of 3.4-mg (1.5, 6.7 mg) phenylephrine equivalents. Mean arterial pressure and the amounts of hypotension were similar in each matched group. The postoperative difference in mean estimated glomerular filtration rate in patients with and without vasopressor infusions was only 0.8 mL/min/1.73 m (95% CI, -0.6 to 2.2 mL/min/1.73 m) (P = .28). Intraoperative vasopressor infusion was also not associated with increased odds of augmented acute kidney injury stage. CONCLUSIONS: Clinicians should not avoid typical perioperative doses of vasopressors for fear of promoting kidney injury. Tolerating hypotension to avoid vasopressor use would probably be a poor strategy.


Assuntos
Lesão Renal Aguda/diagnóstico , Pressão Sanguínea/efeitos dos fármacos , Posicionamento do Paciente/métodos , Decúbito Ventral , Vasoconstritores/administração & dosagem , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/fisiopatologia , Adulto , Idoso , Pressão Sanguínea/fisiologia , Estudos de Coortes , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Decúbito Ventral/fisiologia , Estudos Retrospectivos , Vasoconstritores/efeitos adversos
7.
Anesth Analg ; 127(2): 424-431, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29916861

RESUMO

BACKGROUND: Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. METHODS: Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared using 2-sample Wilcoxon rank-sum tests and Hodges Lehmann estimation of location shift with corresponding asymptotic 95% CI. RESULTS: Among 320 randomized patients, 316 were included in the intention-to-treat analysis. With 158 patients in each group, those assigned to continuous blood pressure monitoring had significantly lower time-weighted average mean arterial pressure <65 mm Hg, 0.05 [0.00, 0.22] mm Hg, versus intermittent blood pressure monitoring, 0.11 [0.00, 0.54] mm Hg (P = .039, significance criteria P < .048). CONCLUSIONS: Continuous noninvasive hemodynamic monitoring nearly halved the amount of intraoperative hypotension. Hypotension reduction with continuous monitoring, while statistically significant, is currently of uncertain clinical importance.


Assuntos
Determinação da Pressão Arterial/métodos , Pressão Sanguínea , Monitorização Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios , Idoso , Anestesia Geral , Anestesiologia/métodos , Pressão Arterial , Feminino , Hemodinâmica , Humanos , Hipotensão/diagnóstico , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Oscilometria , Reprodutibilidade dos Testes , Resultado do Tratamento
8.
Arch Med Sci ; 14(3): 655-670, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29765455

RESUMO

Introduction: Hemorrhagic shock leads to systemic oxygen deficit (hypoxaemia) that results in systemic inflammatory response syndrome (SIRS), a recognised cause of late mortality in this case. The aim of this study was to analyse the impact of fluid resuscitation, using two Ringer solutions, on the microcirculation changes that take place during experimentally induced haemorrhagic shock. Material and methods: A model of the rat cremaster muscle was used to assess microcirculation in vivo. The experimental groups (n = 10 each) included: control (CTRL); shock (HSG); Ringer's acetate (RAG); and Ringer's lactate (RLG). Microhaemodynamic parameters were measured during the experiment. Results: A statistically significantly higher level of leukocytes, both those attached to the endothelium and those located in the extravascular space (p < 0.05), was reported in the lactate Ringer (LR) group compared with the AR group. There were significant differences in the activity of A3 arterioles compared with A1 and A2 arterioles. Ringer's lactate solution seemed to the inflammation response during fluid resuscitation from haemorrhagic shock. A3 arterioles are likely to play a role as a pre-capillary sphincter in the skeletal muscle. Conclusions: The present study revealed that fluid resuscitation with Ringer's lactate solution exacerbates inflammation in the skeletal muscle. It is worth noting that Ringer's acetate solution reduces local inflammation and could therefore be recommended as the "first line" crystalloid of the fluid resuscitation during haemorrhagic shock.

9.
Clin Transplant ; 32(3): e13199, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29323769

RESUMO

Although most patients presenting for liver transplantation have normal left ventricular function, some develop left ventricular failure after transplantation. The primary objective of our study was to determine the predictors of systolic heart failure (HF) occurring immediately after liver transplantation. Its etiology, prospects of recovery, and factors associated with nonrecovery were also studied. Liver transplantations performed at our institution from January 2006 to February 2015 were evaluated using prospectively collected institutional registries. Patients with echocardiographically documented decline in ejection fraction to <45% within 6 months after liver transplantation were identified. Four controls were chosen per case: matched for age, gender, transplant year, and model for end-stage liver disease score. Conditional multivariable logistic regression was used for primary analysis and nonparametric tests for comparison between groups. In a cohort of 1284 adult patients, 45 cases and 180 controls were identified. Diastolic dysfunction (DD) was an independent predictor (OR 5.26, 95% CI 1.03-28.57, P = .04) of systolic HF in multivariable analysis. Stress-induced cardiomyopathy was the most common etiology. Left ventricular function recovered in 21 patients. Pretransplant DD decreased the chances of recovery (P = .05). In conclusion, patients with pretransplant DD need close post-transplant follow-up for timely identification of HF.


Assuntos
Insuficiência Cardíaca Sistólica/epidemiologia , Insuficiência Cardíaca Sistólica/mortalidade , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias , Adulto , Estudos de Casos e Controles , Ecocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca Sistólica/induzido quimicamente , Humanos , Incidência , Masculino , Ohio/epidemiologia , Prognóstico , Estudos Prospectivos , Volume Sistólico , Taxa de Sobrevida
10.
Eur J Anaesthesiol ; 35(4): 256-265, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29023246

RESUMO

BACKGROUND: Preoperative smoking cessation is commonly advised in an effort to improve postoperative outcomes. However, it remains unclear for how long smoking cessation is necessary, and even whether a brief preoperative period of abstinence is helpful and well tolerated. OBJECTIVE: We evaluated associations between various periods of preoperative smoking cessation and major morbidity and death. DESIGN: Retrospective cohort analysis. SETTING: Adults who had noncardiac surgery at the Cleveland Clinic Main Campus between May 2007 and December 2013. PATIENTS: A total of 37 511 patients whose smoking history was identified from a preoperative Health Quest questionnaire. Of these patients, 26 269 (70%) were former smokers and 11 242 (30%) were current smokers. Of the current smokers, 9482 (84%) were propensity matched with 9482 former smokers (36%). We excluded patients with American Society of Anesthesiologists' physical status exceeding four, patients who did not have general anaesthesia, and patients with missing outcomes and/or covariables. When multiple procedures were performed within the study period, only the first operation for each patient was included in the analysis. MAIN OUTCOME MEASURES: The relationship between smoking cessation and in-hospital morbidity/mortality. RESULTS: The incidence of the primary composite of in-hospital morbidity/mortality was 6.9% (656/9482) for all former smokers; the incidence was 7.8% (152/1951) for patients who stopped smoking less than 1 year before surgery, 6.3% (118/1977) for 1 to 5 years, 7.2% (115/1596) for 5 to 10 years and 6.9% (271/3457) for more than 10 years. CONCLUSION: Smoking cessation was associated with reduced in-hospital morbidity and mortality which was independent of cessation interval.


Assuntos
Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Abandono do Hábito de Fumar , Fumar/mortalidade , Fumar/terapia , Adulto , Idoso , Estudos de Coortes , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Abandono do Hábito de Fumar/métodos , Fatores de Tempo , Resultado do Tratamento
12.
Anesth Analg ; 124(4): 1135-1152, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28107274

RESUMO

BACKGROUND: It has been suggested that longer-term postsurgical outcome may be adversely affected by less than severe hypotension under anesthesia. However, evidence-based guidelines are unavailable. The present study was designed to develop a method for identifying patients at increased risk of death within 30 days in association with the severity and duration of intraoperative hypotension. METHODS: Intraoperative mean arterial blood pressure recordings of 152,445 adult patients undergoing noncardiac surgery were analyzed for periods of time accumulated below each one of the 31 thresholds between 75 and 45 mm Hg (hypotensive exposure times). In a development cohort of 35,904 patients, the associations were sought between each of these 31 cumulative hypotensive exposure times and 30-day postsurgical mortality. On the basis of covariable-adjusted percentage increases in the odds of mortality per minute elapsed of hypotensive exposure time, certain sets of exposure time limits were calculated that portended certain percentage increases in the odds of mortality. A novel risk-scoring method was conceived by counting the number of exposure time limits that had been exceeded within each respective set, one of them being called the SLUScore. The validity of this new method in identifying patients at increased risk was tested in a multicenter validation cohort consisting of 116,541 patients from Cleveland Clinic, Vanderbilt and Saint Louis Universities. Data were expressed as 95% confidence interval, P < .05 considered significant. RESULTS: Progressively greater hypotensive exposures were associated with greater 30-day mortality. In the development cohort, covariable-adjusted (age, Charlson score, case duration, history of hypertension) exposure limits were identified for time accumulated below each of the thresholds that portended certain identical (5%-50%) percentage expected increases in the odds of mortality. These exposure time limit sets were shorter in patients with a history of hypertension. A novel risk score, the SLUScore (range 0-31), was conceived as the number of exposure limits exceeded for one of these sets (20% set). A SLUScore > 0 (average 13.8) was found in 40% of patients who had twice the mortality, adjusted odds increasing by 5% per limit exceeded. When tested in the validation cohort, a SLUScore > 0 (average 14.1) identified 35% of patients who had twice the mortality, each incremental limit exceeded portending a 5% compounding increase in adjusted odds of mortality, independent of age and Charlson score (C = 0.73, 0.72-0.74, P < .05). CONCLUSIONS: The SLUScore represents a novel method for identifying nearly 1 in every 3 patients experiencing greater 30-day mortality portended by more severe intraoperative hypotensive exposures.


Assuntos
Hipotensão/diagnóstico , Hipotensão/mortalidade , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/mortalidade , Monitorização Intraoperatória/métodos , Índice de Gravidade de Doença , Adulto , Estudos de Coortes , Registros Eletrônicos de Saúde/tendências , Feminino , Humanos , Hipotensão/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Masculino , Monitorização Intraoperatória/tendências , Mortalidade/tendências
13.
Clin Transplant ; 30(9): 986-93, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27292629

RESUMO

Cirrhotic cardiomyopathy causes variable degree of systolic and diastolic dysfunction (DD) and conduction abnormalities. The primary aim of our study was to determine whether pre-transplant DD and prolonged corrected QT (QTc) predict a composite of mortality, graft failure, and major cardiovascular events after liver transplantation. We also evaluated the reversibility of cirrhotic cardiomyopathy after transplantation. Adult patients who underwent liver transplantation at our institution from January 2007 to March 2009 were included. Data were obtained from institutional registry, medical record review, and evaluation of echocardiographic images. Among 243 patients, 113 (46.5%) had grade 1 DD, 16 (6.6%) had grade 2 DD, and none had grade 3 DD. The mean pre-transplant QTc was 453 milliseconds. After a mean post-transplant follow-up of 5.2 years, 75 (31%) patients satisfied the primary composite outcome. Cox regression analysis did not show any significant association between DD and the composite outcome (P=.17). However, longer QTc was independently associated with the composite outcome (HR: 1.01, 95% confidence interval: 1.00-1.02, P=.05). DD (P<.001) and left ventricular mass index (P=.001) worsened after transplantation. In conclusion, QTc prolongation appears to be associated with worse outcomes. Although DD did not impact outcomes, it significantly worsened after transplantation.


Assuntos
Cardiomiopatias/etiologia , Doença Hepática Terminal/cirurgia , Ventrículos do Coração/fisiopatologia , Cirrose Hepática/complicações , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias , Função Ventricular Esquerda/fisiologia , Cardiomiopatias/diagnóstico , Cardiomiopatias/epidemiologia , Causas de Morte/tendências , Diástole , Ecocardiografia Doppler , Eletrocardiografia , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Incidência , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Fatores de Tempo
14.
Can J Anaesth ; 62(7): 745-52, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25920903

RESUMO

BACKGROUND: Serum creatinine is the most commonly used indicator of renal function, but its derivative, estimated glomerular filtration rate (eGFR), has been shown to be superior in non-surgical settings. It remains unknown if eGFR better predicts postoperative mortality in non-cardiac surgical patients. We thus tested the hypothesis that eGFR predicts 30-day mortality after non-cardiac surgery better than serum creatinine. METHODS: We evaluated patients who had inpatient non-cardiac surgery of at least one hour duration during January 2006 to December 2011 at the Cleveland Clinic Main Campus and whose preoperative serum creatinine was measured within 30 days before surgery. The eGFR was calculated using the Chronic Kidney Disease-Epidemiology Collaboration equation. Preoperative eGFR was compared in a multivariable analysis with preoperative serum creatinine (both assessed as continuous variables) on the ability to predict 30-day mortality in all patients. Secondarily, the comparison was made within subgroups based on amount of blood loss, blood transfusion, and sex. RESULTS: There were 92,888 patients included in the final analysis. The eGFR was a modestly better discriminator of 30-day mortality than serum creatinine, with an estimated c-statistic (95% confidence interval) of 0.67 (0.65 to 0.68) for eGFR vs 0.61 (0.59 to 0.63) for serum creatinine (P < 0.001). Furthermore, the eGFR was consistently a better discriminator of 30-day mortality across blood loss, transfusion, and sex groups. Reclassification analyses suggested improved individual predictions of 30-day mortality using eGFR compared with serum creatinine. Nevertheless, a multivariable combination of baseline characteristics of American Society of Anesthesiologists physical status, age, and body mass index (all P < 0.001) discriminated 30-day mortality with a c-statistic of 0.850. Adding eGFR to the model improved the c-statistic to only 0.851, while separately adding serum creatinine did not change the c-statistic. CONCLUSION: The eGFR is a modestly better predictor of 30-day mortality than serum creatinine in patients having inpatient non-cardiac surgery. Given that eGFR is often reported by clinical laboratories and is otherwise easy to calculate, it should generally be used in preference to creatinine alone.


Assuntos
Creatinina/sangue , Taxa de Filtração Glomerular/fisiologia , Procedimentos Cirúrgicos Operatórios/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Testes de Função Renal , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
15.
Clin Transplant ; 29(3): 197-203, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25528882

RESUMO

With the increasing age of recipients undergoing orthotopic liver transplant (OLT), there is need for better risk stratification among them. Our study aims to identify predictors of poor outcome among OLT recipients ≥ 60 yr of age. All patients who underwent OLT at Cleveland Clinic from January 2004 to April 2010 were included. Baseline patient characteristics and post-OLT outcomes (mortality, graft failure, length of stay, and major post-OLT cardiovascular events) were obtained from prospectively collected institutional registry. Among patients ≥ 60 yr of age, multivariate regression modeling was performed to identify independent predictors of poor outcome. Of the 738 patients included, 223 (30.2%) were ≥ 60 yr. Hepatic encephalopathy, platelet counts < 45,000/µL, total serum bilirubin > 3.5 mg/dL, and serum albumin < 2.65 mg/dL independently predicted poor short-term outcomes. The presence of pre-OLT coronary artery disease and arrhythmia were independent predictors of poor long-term outcomes. Cardiac causes represented the second most common cause of mortality among the elderly cohort. Despite that, this carefully selected cohort of older OLT recipients had outcomes that were comparable with the younger recipients. Thus, our results show the need for better pre-OLT evaluation and optimization, and for closer post-OLT surveillance, of cardiovascular disease among the elderly.


Assuntos
Transplante de Fígado , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Sobrevivência de Enxerto , Humanos , Tempo de Internação , Transplante de Fígado/mortalidade , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco
16.
Clin Exp Otorhinolaryngol ; 7(4): 307-11, 2014 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-25436051

RESUMO

OBJECTIVES: Premedication with clonidine has been found to reduce the bleeding during endoscopic sinus surgery (ESS), therefore lowering the risk of surgical complications. Premedication is an essential part of pre-surgical care and can potentially affect magnitude of systemic stress response to a surgical procedure. The aim of this study was to compare the efficacy of premedication with clonidine and midazolam in patients undergoing sinus surgery. METHODS: Forty-four patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or midazolam as a premedication before receiving propofol/remifentanil total intravenous anesthesia. The effect of this premedication choice on anesthetic requirements, intraoperative hemodynamic profile, preoperative anxiety and sedation as well as postoperative pain and shivering were examined in each premedication group. RESULTS: Total intraoperative remifentanil requirement was lower in the clonidine group as compared to the midazolam group 503.2±147.0 µg vs. 784.5±283.8 µg, respectively (P<0.001). There was no difference between groups in required induction dose of propofol, level of preoperative anxiety, level of sedation and postoperative shivering. Intraoperative systemic blood pressure and heart rate response had a more favorable profile in patients premedicated with clonidine. Postoperative pain assessed by visual analogue scale for pain was lower in the clonidine group compared with to the midazolam premedication group. CONCLUSION: Premedication with clonidine provides better attenuation of hemodynamic response and reduction of intraoperative remifentanil requirements in patients undergoing ESS. Postoperative pain seems to be better controlled after clonidine premedication as well.

17.
Int Forum Allergy Rhinol ; 4(7): 542-7, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24591266

RESUMO

BACKGROUND: Inadequate surgical field visualization due to intraoperative bleeding during endoscopic sinus surgery (ESS) can cause major complications. The aim of this prospective study was to compare the effect of preoperative administration of clonidine and melatonin on the quality of the surgical field visualization and selected aspects of presurgical premedication. METHODS: Twenty-six patients undergoing ESS for chronic sinusitis and polyp removal were enrolled and randomly assigned to receive either oral clonidine or melatonin as preoperative premedication. During the operation, the quality of the surgical field was assessed and graded using the scale proposed by Boezaart. The evaluations were done at 15, 30, and 60 minutes after incision. The effect of this premedication choice on the intraoperative and postoperative hemodynamic profile was examined in each group. Anxiolytic effects of both premedication agents were assessed using the visual analogue scale for anxiety (VAS-A). Propofol dose and induction time (the time for bispectral index [BIS] to reach 45), anesthesia and surgical procedures time, and recovery time (the time for BIS to reach 90) were assessed in both groups as well. RESULTS: The quality of the surgical field was consistently better in 2 of 3 time points in the clonidine group. Perioperative mean arterial pressure and intraoperative heart rate had a more favorable profile in patients premedicated with clonidine. There were no differences in other measured parameters between groups. CONCLUSION: Premedication with clonidine before ESS provides better quality of surgical field and more favorable hemodynamic profile as compared to melatonin.


Assuntos
Clonidina/administração & dosagem , Endoscopia , Hemorragia/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Melatonina/administração & dosagem , Pólipos Nasais/cirurgia , Sinusite/cirurgia , Adulto , Pressão Arterial/efeitos dos fármacos , Doença Crônica , Feminino , Frequência Cardíaca/efeitos dos fármacos , Hemodinâmica/efeitos dos fármacos , Hemorragia/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios , Estudos Prospectivos , Resultado do Tratamento
18.
Anesth Analg ; 118(2): 428-37, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24445640

RESUMO

BACKGROUND: Predicting blood product transfusion requirements during orthotopic liver transplantation (OLT) remains difficult. Our primary aim in this study was to determine which patient variables best predict recipient risk for large blood transfusion requirements during OLT. The secondary aim was to determine whether the amount of blood products transfused during OLT impacted patient survival. METHODS: Eight hundred four primary adult OLTs performed during a 9-year period were retrospectively analyzed, and predictive models were developed for blood product usage, usage >20 and usage >30 units of red blood cells (RBCs) plus cell salvage (CS). For survival analysis, potential predictors included all blood products administered during OLT. RESULTS: For analyses of RBC + CS usage, we used several statistical techniques: regression analysis, logistic regression, and classification and regression tree analysis. Several preoperative factors were highly statistically significant predictors of intraoperative blood product usage in each of the analyses, namely lower platelet count and higher Model for End-Stage Liver Disease Score or one or more of its components (creatinine, total bilirubin, international normalized ratio). Despite these highly significant associations, the models were unable to predict reliably that patients might require the largest amount of blood products during OLT. For example, the classification and regression tree analyses were able to predict only 32% and 11% of patients requiring >20 and >30 units of RBC + CS, respectively. Survival analysis demonstrated poorer survival among patients receiving larger amounts of RBC + CS during OLT. CONCLUSION: Prediction of intraoperative blood product requirements based on preoperatively available variables is unreliable; however, there is a strong measurable association between transfusion and postoperative mortality.


Assuntos
Transfusão de Sangue , Transplante de Fígado/mortalidade , Transplante de Fígado/métodos , Adulto , Perda Sanguínea Cirúrgica , Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/terapia , Transfusão de Eritrócitos/métodos , Eritrócitos/citologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Transfusão de Plaquetas , Período Pós-Operatório , Análise de Regressão , Reoperação , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
19.
Liver Transpl ; 19(11): 1181-8, 2013 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-23813754

RESUMO

Investigations have demonstrated conflicting results regarding the influence of the red blood cell (RBC) storage duration on outcomes. We evaluated whether graft failure or mortality after orthotopic liver transplantation (OLT) increased when recipients were transfused with older RBCs. This study included 637 patients who underwent OLT between January 2001 and June 2011. Baseline and perioperative data were obtained from our blood bank, the Unified Transplant Center database, and the United Network for Organ Sharing database. Recipients whose transfused RBCs were all stored for ≤ 15 days were grouped in a younger group, and recipients who were transfused with RBCs stored for >15 days were placed in an older group. The relationship between graft survival/mortality and the age of intraoperatively transfused RBCs was studied by Kaplan-Meier estimation with a log-rank test and multivariate Cox proportional hazards regression. Three hundred thirty-four patients and 303 patients were grouped in the younger and the older RBC groups, respectively, on the basis of the ages of intraoperatively transfused RBCs. Kaplan-Meier estimates of graft survival/mortality as a function of the posttransplant time were significantly different: the older group experienced the outcome sooner than the younger group [P = 0.02 (log-rank test)]. After covariate adjustments, the risk of graft failure/mortality was significantly different at any given time after transplantation between patients receiving intraoperative transfusions of older RBC units and patients receiving intraoperative transfusions of younger RBC units (hazard ratio = 1.65, 95% confidence interval = 1.18-2.31). In conclusion, patients who received intraoperative transfusions of RBCs with longer storage times had an increased risk of adverse outcomes.


Assuntos
Preservação de Sangue , Transfusão de Eritrócitos , Sobrevivência de Enxerto , Transplante de Fígado , Adulto , Humanos , Transplante de Fígado/mortalidade , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais
20.
Liver Transpl ; 19(8): 907-15, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23744721

RESUMO

Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m(2) . Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI ≥ 38 kg/m(2) and lean patients with a BMI between 20 and 26 kg/m(2) . We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) = 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio = 4.76, 99.5% CI = 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation.


Assuntos
Sobrevivência de Enxerto , Falência Hepática/complicações , Falência Hepática/terapia , Obesidade/complicações , Idoso , Índice de Massa Corporal , Feminino , Humanos , Unidades de Terapia Intensiva , Falência Hepática/mortalidade , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Resultado do Tratamento
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