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Ann Thorac Surg ; 107(1): 41-46, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30342046


BACKGROUND: There is an increased risk of medical errors overnight compared with the day, secondary to fatigue, paucity of resources, and decreased staffing. Whether this increased risk extends to liberation from mechanical ventilation is controversial. We evaluated the relationship between length of intubation and differences between diurnal and nocturnal extubation. METHODS: We studied patients who had cardiac surgical procedures between January 1, 2007, and March 31, 2016, who were intubated on arrival to the cardiovascular intensive care unit (ICU) immediately after operation. Patients were divided into those extubated 24 or fewer hours or more than 24 hours after ICU arrival and were further divided by time of extubation: daytime (7 AM to 7 PM) and nocturnal (7 PM to 7 AM). We used multivariable logistic regression to determine whether nocturnal extubation was associated with increased mortality compared with diurnal extubation. Subgroup analyses investigated the effect of laboratory values, fluid management, and infused medicines. RESULTS: Two hundred seventy-eight of 8,705 patients (3.2%) died in the hospital; 84 died without being extubated. Of the remaining 8,621 patients, 6,982 patients (81%) were extubated within 24 hours of arrival to the ICU. Eighty-three of the patients (1.1%) died, and the proportion did not vary between day and night. In the delayed extubation group, 127 of the 1,639 patients (7.7%) died. Nocturnal extubation was associated with increased mortality only in the patients extubated more than 24 hours after ICU admission (adjusted odds ratio 2.46, 95% confidence interval: 1.45 to 4.16, p = 0.001). This increased risk persisted through all subgroup and sensitivity analyses. CONCLUSIONS: Nocturnal extubation was associated with increased mortality only in the group of patients receiving more than 24 hours of mechanical ventilation.

Extubação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cuidados Críticos , Complicações Pós-Operatórias/mortalidade , Respiração Artificial , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo
Anesthesiology ; 129(6): 1101-1110, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30300157


WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Beta (ß) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume ß blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of ß blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. METHODS: The authors evaluated 8,201 adult ß-blocker users with no previous history of atrial fibrillation who stayed at least two nights after noncardiothoracic and nonvascular surgery as a retrospective observational cohort. After propensity score matching on baseline and intraoperative variables, 1,924 patients who did resume ß blockers by the end of postoperative day 1 were compared with 973 patients who had not resumed by that time on postoperative atrial fibrillation using logistic regression. A secondary matched analysis compared 3,198 patients who resumed ß blockers on the day of surgery with 3,198 who resumed thereafter. RESULTS: Of propensity score-matched patients who resumed ß blockers by end of postoperative day 1, 4.9% (94 of 1,924) developed atrial fibrillation, compared with 7.0% (68 of 973) of those who resumed thereafter (adjusted odds ratio, 0.69; 95% CI, 0.50-0.95; P = 0.026). Patients who resumed ß blockers on day of surgery had an atrial fibrillation incidence of 4.9% versus 5.8% for those who started thereafter (odds ratio, 0.84; 95% CI, 0.67-1.04; P = 0.104). CONCLUSIONS: Resuming ß blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.

Antagonistas Adrenérgicos beta/uso terapêutico , Fibrilação Atrial/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Idoso , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos
J Can Chiropr Assoc ; 48(4): 266-72, 2004 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-17549104


A 50-year-old female presented to a chiropractic clinic with left jaw pain consistent with temporomandibular joint disorder. Examination revealed a large ulcerated mass on the posterolateral margin of the tongue which was later diagnosed as squamous cell carcinoma. Squamous cell carcinoma is the most common of the oral cancers. These cancers are often detected late making treatment more complicated and reducing the chance of survival. In the early stages squamous cell carcinoma can be asymptomatic. Symptoms can be similar to that of temporomandibular joint disorder making examination of the patient's mouth important to rule out oral cancers. Oral cancers should be considered when patients present to a chiropractor with pain in the area of the temporomandibular joint. Risk factors such as chronic tobacco and alcohol use should raise concern in these patients. Suspicious lesions should be referred immediately for further investigation.