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1.
Anesth Analg ; 2020 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-31904632

RESUMO

BACKGROUND: Mechanical ventilation with low tidal volumes appears to provide benefit in patients having noncardiac surgery; however, whether it is beneficial in patients having cardiac surgery is unclear. METHODS: We retrospectively examined patients having elective cardiac surgery requiring cardiopulmonary bypass through a median sternotomy approach who received mechanical ventilation with a single lumen endotracheal tube from January 2010 to mid-August 2016. Time-weighted average tidal volume (milliliter per kilogram predicted body weight [PBW]) during the duration of surgery excluding cardiopulmonary bypass was analyzed. The association between tidal volumes and postoperative oxygenation (measured by arterial partial pressure of oxygen (PaO2)/fraction of inspired oxygen ratio [PaO2/FIO2]), impaired oxygenation (PaO2/FIO2<300), and clinical outcomes were examined. RESULTS: Of 9359 cardiac surgical patients, larger tidal volumes were associated with slightly worse postoperative oxygenation. Postoperative PaO2/FIO2 decreased an estimated 1.05% per 1 mL/kg PBW increase in tidal volume (97.5% confidence interval [CI], -1.74 to -0.37; PBon = .0005). An increase in intraoperative tidal volumes was also associated with increased odds of impaired oxygenation (odds ratio [OR; 97.5% CI]: 1.08 [1.02-1.14] per 1 mL/kg PBW increase in tidal volume; PBon = .0029), slightly longer intubation time (5% per 1 mL/kg increase in tidal volume (hazard ratio [98.33% CI], 0.95 [0.93-0.98] per 1 mL/kg PBW; PBon < .0001), and increased mortality (OR [98.33% CI], 1.34 [1.06-1.70] per 1 mL/kg PBW increase in tidal volume; PHolm = .0144). An increase in intraoperative tidal volumes was also associated with acute postoperative respiratory failure (OR [98.33% CI], 1.16 [1.03-1.32] per 1 mL/kg PBW increase in tidal volume; PHolm = .0146), but not other pulmonary complications. CONCLUSIONS: Lower time-weighted average intraoperative tidal volumes were associated with a very modest improvement in postoperative oxygenation in patients having cardiac surgery.

2.
Artigo em Inglês | MEDLINE | ID: mdl-31813538

RESUMO

BACKGROUND: Although observational studies suggest an association between transfusion of older red blood cell (RBC) units and increased postoperative risk, randomized trials have not supported this. The objective of this randomized trial was to test the effect of RBC storage age on outcomes after cardiac surgery. METHODS: From July 2007 to May 2016, 3835 adults undergoing coronary artery bypass grafting, cardiac valve procedures, or ascending aorta repair, either alone or in combination, were randomized to transfusion of RBCs stored for ≤14 days (younger units) or for ≥20 days (older units) intraoperatively and throughout the postoperative hospitalization. According to protocol, 2448 patients were excluded because they did not receive RBC transfusions. Among the remaining 1387 modified intent-to-treat patients, 701 were randomized to receive younger RBC units (median age, 11 days) and the remaining 686 to receive older units (median age, 25 days). The primary endpoint was composite morbidity and mortality, analyzed using a generalized estimating equation (GEE) model. The trial was discontinued midway owing to enrollment constraints. RESULTS: A total of 5470 RBC units were transfused, including 2783 in the younger RBC storage group and 2687 in the older RBC storage group. The GEE average relative-effect odds ratio was 0.77 (95% confidence interval [CI], 0.50-1.19; P = .083) for the composite morbidity and mortality endpoint. In-hospital mortality was lower for the younger RBC storage group (2.1% [n = 15] vs 3.4% [n = 23]), as was occurrence of other adverse events except for atrial fibrillation, although all CIs crossed 1.0. CONCLUSIONS: This clinical trial, which was stopped at its midpoint owing to enrollment constraints, supports neither the efficacy nor the futility of transfusing either younger or older RBC units. The effects of transfusing RBCs after even more prolonged storage (35-42 days) remains untested.

3.
Artigo em Inglês | MEDLINE | ID: mdl-31558395

RESUMO

OBJECTIVES: Right ventricular failure after left ventricular assist device implantation increases postoperative morbidity and mortality. Whether intraoperative echocardiographic and hemodynamic measurements predict right ventricular failure is unclear. Speckle-tracking-derived tricuspid annulus displacement may provide a useful, effective, and straightforward predictor of severe right ventricular failure in patients having left ventricular device implantation. The aim of this study was to determine if intraoperative tricuspid annulus displacement is a stronger discriminator compared with the global longitudinal strain and modified tricuspid annular plane systolic excursion, the Michigan risk score, and pulmonary artery pulsatility index. DESIGN: Retrospective analysis. SETTING: A tertiary-care referral center. PARTICIPANTS: Patients scheduled for left ventricular assist device implantation from January 2010 to December 2017. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: The authors examined 86 patients undergoing left ventricular assist device implantation with adequate intraoperative echocardiographic images. The analyses did not demonstrate an association between tricuspid annulus displacement and severe right ventricular failure (univariate C-statistics <0.60 for all 4 echocardiographic measures). The discrimination ability was not significantly better than strain (DeLong test p = 0.44) and modified tricuspid annular plane systolic excursion (p = 0.89). The discrimination ability of tricuspid annulus displacement measurements was not better than the Michigan risk score (p = 0.65) and pulmonary artery pulsatility index (p = 0.73). CONCLUSIONS: Intraoperative echocardiographic parameters, including tricuspid annulus displacement, modified tricuspid annular plane systolic excursion, and strain, are poor discriminators of severe right ventricular failure after left ventricular assist device implantation. The preoperative Michigan risk-scoring system and intraoperative pulmonary artery pulsatility index are equally unreliable.

4.
Artigo em Inglês | MEDLINE | ID: mdl-31358329

RESUMO

OBJECTIVE: In the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial, no differences in clinical outcomes were observed between levosimendan and placebo in a broad population of patients undergoing cardiac surgery. In previous studies, the benefits of levosimendan were most clearly evident in patients undergoing isolated coronary artery bypass grafting (CABG) surgery. In a prespecified analysis of LEVO-CTS, we compared treatment-related outcomes and costs across types of cardiac surgical procedures. METHODS: Overall, 563 (66.4%) patients underwent isolated CABG, 97 (11.4%) isolated valve, and 188 (22.2%) combined CABG/valve surgery. Outcomes included the co-primary 4-component composite (30-day mortality, 30-day renal replacement, 5-day myocardial infarction, or 5-day mechanical circulatory support), the 2-component composite (30-day mortality or 5-day mechanical circulatory support), 90-day mortality, low cardiac output syndrome (LCOS), and 30-day medical costs. RESULTS: The 4- and 2-component outcomes were not significantly different with levosimendan and placebo in patients undergoing CABG (15.2% vs 19.3% and 7.8% vs 10.4%), valve (49.0% vs 33.3% and 22.4% vs 2.1%), or combined procedures (39.6% vs 35.9% and 24.0% vs 19.6%). Ninety-day mortality was lower with levosimendan in isolated CABG (2.1% vs 7.9%; hazard ratio [HR], 0.26; 95% confidence interval [CI], 0.11-0.64), but not significantly different in valve (8.3% vs 2.0%; HR, 4.10; 95% CI, 0.46-36.72) or combined procedures (10.4% vs 7.6%; HR, 1.39; 95% CI, 0.53-3.64; interaction P = .011). LCOS (12.0% vs 22.1%; odds ratio, 0.48; 95% CI, 0.30-0.76; interaction P = .118) was significantly lower in levosimendan-treated patients undergoing isolated CABG. Excluding study drug costs, median and mean 30-day costs were $53,707 and $65,852 for levosimendan and $54,636 and $67,122 for placebo, with a 30-day mean difference (levosimendan - placebo) of -$1270 (bootstrap 95% CI, -$8722 to $6165). CONCLUSIONS: Levosimendan was associated with lower 90-day mortality and LCOS in patients undergoing isolated CABG, but not in those undergoing isolated valve or combined CABG/valve procedures.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31133354

RESUMO

OBJECTIVES: Long-axis right ventricular (RV) function, which provides nearly 80% of RV ejection, acutely decreases during cardiac surgery. RV dysfunction increases risk for perioperative morbidity and mortality. Our objective was to characterize the change in perioperative RV long-axis and global function by determining the influence of procedure type, surgical approach, and reoperative status and examining its temporal relationship to pericardiotomy versus cardiopulmonary bypass (CPB) and cardioplegia. METHODS: Standardized transesophageal echocardiographic examinations (TEEs) were prospectively performed in 109 patients undergoing coronary artery bypass grafting, mitral or aortic valve surgery, and/or aortic surgery via full sternotomy, mini-sternotomy, or right thoracotomy. Mid-esophageal, 4-chamber views centered on the RV were recorded at 4 intraoperative time points, following: (1) anesthetic induction; (2) pericardiotomy; (3) CPB; and (4) chest closure. Long-axis RV function was assessed by tricuspid annular plane systolic excursion and 2-dimensional longitudinal RV strain, and global RV function by fractional area change (FAC), calculated off-line from 2-dimensional TEE images. RESULTS: TEE measures of RV function were significantly reduced after CPB compared with baseline (baseline vs after CPB: TAPSE 2.2 [Q1, Q3: 1.8, 2.5] vs 1.5 [1.1, 1.7] mm; RV strain -22 [-24, -18] vs -16 [-20, -14] %; FAC 45 [35, 51] vs 42 [34, 49] %), but not after pericardiotomy. Reduced RV function persisted after chest closure: tricuspid annular plane systolic excursion 1.3 [1.0, 1.6] mm, RV strain -16 [-18, -13]%, FAC 38 [31, 46] %. Reduced function was demonstrated across cardiac surgical procedures, approaches, and primary and reoperative surgery. CONCLUSIONS: Acute intraoperative reduction in RV function occurs following CPB, independent of procedural characteristics and pericardiotomy. Etiology and clinical implications of reduced perioperative RV function remain to be determined.

6.
J Cardiothorac Vasc Anesth ; 33(5): 1315-1322, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30581109

RESUMO

OBJECTIVE: Myocardial strain measured by speckle-tracking echocardiography detects subtle regional and global left ventricular dysfunction. Myocardial strain is measured in the longitudinal, circumferential, and radial dimensions; however, it is unclear which dimension of strain is the best predictor of postoperative outcomes. DESIGN: A secondary analysis of prospectively collected data from a clinical trial (NCT01187329). SETTING: The cardiothoracic surgical operating rooms of an academic tertiary-care center. PARTICIPANTS: Cardiothoracic surgery patients with aortic stenosis having aortic valve replacement (AVR) with or without coronary artery bypass grafting enrolled in a clinical trial. INTERVENTIONS: Myocardial deformation analysis from standardized investigative transesophageal echocardiographic examinations performed after induction of anesthesia. MEASUREMENTS AND MAIN RESULTS: The authors compared the ability of intraoperative global longitudinal strain (GLS), global circumferential strain (GCS), and global radial strain (GRS) strain to predict adverse postoperative outcomes, including prolonged hospitalization and the need for pharmacologic hemodynamic support after cardiac surgery. The association of GLS, GCS, and GRS with prolonged hospitalization (>7 days) and the need for pharmacologic hemodynamic support, with epinephrine or norepinephrine after cardiopulmonary bypass, were assessed using separate multivariable logistic regression models with adjustment for multiple comparisons. Of 100 patients, 86 had acceptable measurements for GLS analysis, 73 for GCS, and 72 for GRS. Worse GLS was associated with prolonged hospitalization [odds ratio [OR] (98.3% confidence interval [CI]) of 1.21 (1.01-1.46) per-unit worsening in strain (p = 0.01, significance criterion <0.0167)] and the need for inotropic support with epinephrine [OR (99.2% CI) of 1.81 (1.10-2.97) per-unit worsening in strain (p = 0.002, significance criterion <0.0083)], but not norepinephrine. GCS and GRS were not associated with adverse outcomes. CONCLUSION: GLS, but not GCS or GRS, predicts prolonged hospitalization and the requirement for inotropic support with epinephrine after AVR.


Assuntos
Procedimentos Cirúrgicos Cardíacos/tendências , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Feminino , Implante de Prótese de Valva Cardíaca/efeitos adversos , Implante de Prótese de Valva Cardíaca/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento , Disfunção Ventricular Esquerda/epidemiologia
10.
Anesthesiology ; 128(6): 1125-1139, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29537981

RESUMO

BACKGROUND: Hyperinsulinemic normoglycemia augments myocardial glucose uptake and utilization. We tested the hypothesis that hyperinsulinemic normoglycemia reduces 30-day mortality and morbidity after cardiac surgery. METHODS: This dual-center, parallel-group, superiority trial randomized cardiac surgical patients between August 2007 and March 2015 at the Cleveland Clinic, Cleveland, Ohio, and Royal Victoria Hospital, Montreal, Canada, to intraoperative glycemic management with (1) hyperinsulinemic normoglycemia, a fixed high-dose insulin and concomitant variable glucose infusion titrated to glucose concentrations of 80 to 110 mg · dl; or (2) standard glycemic management, low-dose insulin infusion targeting glucose greater than 150 mg · dl. The primary outcome was a composite of 30-day mortality, mechanical circulatory support, infection, renal or neurologic morbidity. Interim analyses were planned at each 12.5% enrollment of a maximum 2,790 patients. RESULTS: At the third interim analysis (n = 1,439; hyperinsulinemic normoglycemia, 709, standard glycemic management, 730; 52% of planned maximum), the efficacy boundary was crossed and study stopped per protocol. Time-weighted average glucose concentration (means ± SDs) with hyperinsulinemic normoglycemia was 108 ± 20 versus 150 ± 33 mg · dl with standard glycemic management, P < 0.001. At least one component of the composite outcome occurred in 49 (6.9%) patients receiving hyperinsulinemic normoglycemia versus 82 (11.2%) receiving standard glucose management (P < efficacy boundary 0.0085); estimated relative risk (95% interim-adjusted CI) 0.62 (0.39 to 0.97), P = 0.0043. There was a treatment-by-site interaction (P = 0.063); relative risk for the composite outcome was 0.49 (0.26 to 0.91, P = 0.0007, n = 921) at Royal Victoria Hospital, but 0.96 (0.41 to 2.24, P = 0.89, n = 518) at the Cleveland Clinic. Severe hypoglycemia (less than 40 mg · dl) occurred in 6 (0.9%) patients. CONCLUSIONS: Intraoperative hyperinsulinemic normoglycemia reduced mortality and morbidity after cardiac surgery. Providing exogenous glucose while targeting normoglycemia may be preferable to simply normalizing glucose concentrations.


Assuntos
Glicemia/metabolismo , Procedimentos Cirúrgicos Cardíacos/mortalidade , Hospitalização/tendências , Hiperinsulinismo/mortalidade , Cuidados Intraoperatórios/mortalidade , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/tendências , Feminino , Índice Glicêmico/fisiologia , Humanos , Hiperinsulinismo/sangue , Insulina/sangue , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/tendências , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Complicações Pós-Operatórias/sangue
11.
Anesth Analg ; 126(4): 1121-1123, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29547419
12.
Anesth Analg ; 126(6): 2025-2031, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29533258

RESUMO

BACKGROUND: Patients with obstructive sleep apnea (OSA) experience intermittent hypoxia, hypercarbia, and sympathetic activation during sleep, which increases risk for paroxysmal atrial fibrillation and other cardiac arrhythmias. Whether patients with OSA experience increased episodes of atrial fibrillation after cardiac surgery is unclear. We examined whether patients at increased risk for OSA, assessed by the STOP-BANG (snoring, tired during the day, observed stop breathing during sleep, high blood pressure, body mass index more than 35 kg/m, age more than 50 years, neck circumference more than 40 cm, and male gender) questionnaire, had a higher incidence of new-onset postoperative atrial fibrillation after cardiac surgery. Because both postoperative atrial fibrillation and OSA increase resource utilization, we secondarily examined whether patients at increased OSA risk had longer duration of postoperative mechanical ventilation and intensive care unit (ICU) length of stay. METHODS: With institutional review board approval, this retrospective observational study evaluated adult patients who underwent elective cardiac surgery requiring cardiopulmonary bypass between 2014 and 2015 with preoperative assessment of OSA risk using the STOP-BANG questionnaire. Patients with a history of atrial fibrillation were excluded. The association between the STOP-BANG score and postoperative atrial fibrillation was examined using a multivariable logistic regression model. Secondarily, we estimated the association between the STOP-BANG score and duration of initial intubation using multivariable linear regression and ICU length of stay using Cox proportional hazards regression. We also descriptively summarized the percentage of patients requiring tracheal reintubation for mechanical ventilation. RESULTS: Of 4228 cardiac surgery patients, 1593 met inclusion and exclusion criteria. An increased STOP-BANG score was associated with higher odds of postoperative atrial fibrillation (odds ratio [95% confidence interval {CI}], 1.16 [1.09-1.23] per-point increase in the STOP-BANG score; P < .001). The STOP-BANG score was not associated with ICU length of stay (estimated hazard ratio [97.5% CI], 0.99 [0.96-1.03] per-point increase in the STOP-BANG score; P = .99) or duration of initial intubation (ratio of geometric means [97.5% CI], 1.01 [1.00-1.04]; P = .03; significance criterion [Bonferroni correction] < 0.025). One percent of patients required reintubation. DISCUSSION: Increasing risk for OSA, assessed by STOP-BANG, was associated with higher odds of postoperative atrial fibrillation, but not prolonged duration of mechanical ventilation or ICU length of stay.


Assuntos
Fibrilação Atrial/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/tendências , Complicações Pós-Operatórias/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Adulto , Idoso , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polissonografia/tendências , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Estudos Retrospectivos , Fatores de Risco , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia
13.
Anesthesiology ; 128(3): 675-676, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29438242
15.
Anesth Analg ; 126(5): 1484-1493, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29200066

RESUMO

BACKGROUND: Left ventricular ejection fraction (LVEF) is often preserved in patients with aortic stenosis and thus cannot distinguish between normal myocardial contractile function and subclinical dysfunction. Global longitudinal strain and strain rate (SR), which measure myocardial deformation, are robust indicators of myocardial function and can detect subtle myocardial dysfunction that is not apparent with conventional echocardiographic measures. Strain and SR may better predict postoperative outcomes than LVEF. The primary aim of our investigation was to assess the association between global longitudinal strain and serious postoperative outcomes in patients with aortic stenosis having aortic valve replacement. Secondarily, we also assessed the associations between global longitudinal SR and LVEF and the outcomes. METHODS: In this post hoc analysis of data from a randomized clinical trial (NCT01187329), we examined the association between measures of myocardial function and the following outcomes: (1) need for postoperative inotropic/vasopressor support; (2) prolonged hospitalization (>7 days); and (3) postoperative atrial fibrillation. Standardized transesophageal echocardiographic examinations were performed after anesthetic induction. Myocardial deformation was measured using speckle-tracking echocardiography. Multivariable logistic regression was used to assess associations between measures of myocardial function and outcomes, adjusted for potential confounding factors. The predictive ability of global longitudinal strain, SR, and LVEF was assessed as area under receiver operating characteristics curves (AUCs). RESULTS: Of 100 patients enrolled in the clinical trial, 86 patients with aortic stenosis had acceptable images for global longitudinal strain analysis. Primarily, worse intraoperative global longitudinal strain was associated with prolonged hospitalization (odds ratio [98.3% confidence interval], 1.22 [1.01-1.47] per 1% decrease [absolute value] in strain; P = .012), but not with other outcomes. Secondarily, worse global longitudinal SR was associated with prolonged hospitalization (odds ratio [99.7% confidence interval], 1.68 [1.01-2.79] per 0.1 second(-1) decrease [absolute value] in SR; P = .003), but not other outcomes. LVEF was not associated with any outcomes. Global longitudinal SR was the best predictor for prolonged hospitalization (AUC, 0.72), followed by global longitudinal strain (AUC, 0.67) and LVEF (AUC, 0.62). CONCLUSIONS: Global longitudinal strain and SR are useful predictors of prolonged hospitalization in patients with aortic stenosis having an aortic valve replacement.


Assuntos
Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca/tendências , Hospitalização/tendências , Função Ventricular Esquerda/fisiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/fisiopatologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Volume Sistólico/fisiologia , Fatores de Tempo
17.
J Anesth ; 31(5): 692-702, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28707021

RESUMO

PURPOSE: Trendelenburg positioning is commonly used to temporarily treat intraoperative hypotension. The Trendelenburg position improves cardiac output in normovolemic or anesthetized patients, but not hypovolemic or non-anesthetized patients. Therefore, the response to Trendelenburg positioning may vary depending on patient population or hemodynamic conditions. We thus tested the hypothesis that the effectiveness of the Trendelenburg position, as indicated by an increase in cardiac output, improves after replacement of a stenotic aortic valve. Secondarily, we evaluated whether measurements of left ventricular preload, systolic function, or afterload were associated with the response to Trendelenburg positioning. METHODS: This study is a secondary analysis of a clinical trial which included patients having aortic valve replacement (AVR) who were monitored with pulmonary artery catheters (NCT01187329). We examined changes in thermodilution cardiac output with Trendelenburg positioning before and after AVR. We also examined whether echocardiographic and hemodynamic measurements of preload, afterload, and systolic function were associated with changes in cardiac output during Trendelenburg positioning. RESULTS: Thirty-seven patients were included. The median [IQR] cardiac output change with Trendelenburg positioning was -3% [-10%, 5%] before AVR versus +4% [-4%, 15%] after AVR. Estimated median difference in cardiac output with Trendelenburg was 5% (95% CI 1, 15%, P = 0.04) greater after AVR. The response to Trendelenburg positioning was largely independent of hemodynamic conditions. CONCLUSION: The response to Trendelenburg positioning improved following AVR, but by a clinically unimportant amount. The response to Trendelenburg positioning was independent of hemodynamic conditions.


Assuntos
Estenose da Valva Aórtica/cirurgia , Decúbito Inclinado com Rebaixamento da Cabeça , Implante de Prótese de Valva Cardíaca/métodos , Idoso , Valva Aórtica/cirurgia , Débito Cardíaco/fisiologia , Ecocardiografia , Feminino , Hemodinâmica/fisiologia , Humanos , Hipovolemia , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente , Sístole , Termodiluição , Função Ventricular Esquerda
18.
Anesthesiology ; 126(6): 1065-1076, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28398932

RESUMO

BACKGROUND: Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications. METHODS: The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization. RESULTS: Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality. CONCLUSIONS: Brachial artery cannulation for hemodynamic monitoring during cardiac surgery rarely causes complications.


Assuntos
Pressão Arterial/fisiologia , Artéria Braquial , Procedimentos Cirúrgicos Cardíacos , Cateterismo Periférico/métodos , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/efeitos adversos , Monitorização Intraoperatória/instrumentação
19.
Anesth Analg ; 124(2): 406-418, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-26702865

RESUMO

BACKGROUND: The immediate effect of aortic valve replacement (AVR) for aortic stenosis on perioperative myocardial function is unclear. Left ventricular (LV) function may be impaired by cardioplegia-induced myocardial arrest and ischemia-reperfusion injury, especially in patients with LV hypertrophy. Alternatively, LV function may improve when afterload is reduced after AVR. The right ventricle (RV), however, experiences cardioplegic arrest without benefiting from improved loading conditions. Which of these effects on myocardial function dominate in patients undergoing AVR for aortic stenosis has not been thoroughly explored. Our primary objective is thus to characterize the effect of intraoperative events on LV function during AVR using echocardiographic measures of myocardial deformation. Second, we evaluated RV function. METHODS: In this supplementary analysis of 100 patients enrolled in a clinical trial (NCT01187329), 97 patients underwent AVR for aortic stenosis. Of these patients, 95 had a standardized intraoperative transesophageal echocardiographic examination of systolic and diastolic function performed before surgical incision and repeated after chest closure. Echocardiographic images were analyzed off-line for global longitudinal myocardial strain and strain rate using 2D speckle-tracking echocardiography. Myocardial deformation assessed at the beginning of surgery was compared with the end of surgery using paired t tests corrected for multiple comparisons. RESULTS: LV volumes and arterial blood pressure decreased, and heart rate increased at the end of surgery. Echocardiographic images were acceptable for analysis in 72 patients for LV strain, 67 for LV strain rate, and 54 for RV strain and strain rate. In 72 patients with LV strain images, 9 patients required epinephrine, 22 required norepinephrine, and 2 required both at the end of surgery. LV strain did not change at the end of surgery compared with the beginning of surgery (difference: 0.7 [97.6% confidence interval, -0.2 to 1.5]%; P = 0.07), whereas LV systolic strain rate improved (became more negative) (-0.3 [-0.4 to -0.2] s; P < 0.001). In contrast, RV systolic strain worsened (became less negative) at the end of surgery (difference: 4.6 [3.1 to 6.0]%; P < 0.001) although RV systolic strain rate was unchanged (0.0 [97.6% confidence interval, -0.1 to 0.1]; P = 0.83). CONCLUSIONS: LV function improved after replacement of a stenotic aortic valve demonstrated by improved longitudinal strain rate. In contrast, RV function, assessed by longitudinal strain, was reduced.


Assuntos
Valva Aórtica/cirurgia , Implante de Prótese de Valva Cardíaca , Função Ventricular Esquerda , Função Ventricular Direita , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/cirurgia , Pressão Arterial , Ponte de Artéria Coronária , Ecocardiografia Transesofagiana , Epinefrina/uso terapêutico , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Norepinefrina/uso terapêutico , Vasoconstritores/uso terapêutico
20.
Anesth Analg ; 123(3): 795-6, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27537765
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