Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 10 de 10
Filtrar
Mais filtros










Base de dados
Tipo de estudo
Intervalo de ano de publicação
1.
Anesthesiology ; 132(4): 614-624, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31977517

RESUMO

BACKGROUND: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline. METHODS: The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. RESULTS: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. CONCLUSIONS: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively.

3.
Eur J Anaesthesiol ; 34(3): 135-140, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28009637

RESUMO

BACKGROUND: Ultrasound-guided nerve blocks have become the standard when performing regional nerve blocks in anaesthesia. Infiniti Plus (CIVCO Medical Solutions, Kalona, Iowa, USA) is a needle guide that has been recently developed to help clinicians in performing ultrasound-guided nerve blocks. OBJECTIVES: We tested the hypothesis that femoral nerve catheter placement carried out with the Infiniti Plus needle guide will be quicker to perform than without the Infiniti Plus. Secondary aims were to assess whether the Infiniti Plus needle guide decreased the number of block attempts and also whether it improved needle visibility. DESIGN: A randomised, controlled trial. SETTING: Cleveland Clinic, Cleveland, Ohio, USA. PATIENTS: We enrolled adult patients having elective total knee arthroplasty with a femoral nerve block and femoral nerve catheter. Patients, who were pregnant or those who had preexisting neuropathy involving the surgical limb, coagulopathy, infection at the block site or allergy to local anaesthetics were excluded. INTERVENTIONS: Patients were randomised into two groups to receive the ultrasound-guided femoral nerve catheter placement with or without the Infiniti Plus needle guide. MAIN OUTCOME MEASURES: The time taken to place the femoral nerve catheter, the number of attempts, the success rate and needle visibility were recorded. We used an overall α of 0.05 for both the primary and secondary analyses; the secondary analyses were Bonferroni corrected to control for multiple comparisons. RESULT: The median (interquartile range Q1 to Q3) time to perform the femoral nerve catheter placement was 118 (100 to 150) s with Infiniti Plus and 177 (130 to 236) s without Infiniti Plus. Infiniti Plus significantly reduced the time spent performing femoral nerve catheterisation, with estimated ratio of means [(95% confidence interval), P value] of 0.67 [(0.60 to 0.75), P < 0.001] with Infiniti Plus compared with no Infiniti Plus. However, Infiniti Plus had no effect on the odds of a successful femoral nerve catheter placement, number of attempts or percentage of perfect needle visibility. CONCLUSION: We found that the use of Infiniti Plus decreased the median time to successfully place a femoral nerve catheter by 33% compared with not using Infiniti Plus. This difference may be more apparent to clinicians undertaking this procedure less often or by those in training as our team was very experienced, had been trained in the technique and was working in a hospital with a large caseload. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02080481.


Assuntos
Bloqueio Nervoso Autônomo/métodos , Cateterismo/métodos , Nervo Femoral/diagnóstico por imagem , Agulhas , Ultrassonografia de Intervenção/métodos , Idoso , Artroplastia do Joelho/instrumentação , Artroplastia do Joelho/métodos , Bloqueio Nervoso Autônomo/instrumentação , Cateterismo/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Ultrassonografia de Intervenção/instrumentação
4.
A A Case Rep ; 5(7): 107-11, 2015 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-26402020

RESUMO

We present a case of acute postoperative abdominal pain after proctosigmoidectomy and colorectal anastomosis that was treated by bilateral continuous quadratus lumborum block. The block was performed in the lateral position under ultrasound guidance with a 15-mL bolus of 0.5% bupivacaine injected anterior to the quadratus lumborum muscle followed by bilateral catheter placement. Each catheter received a continuous infusion of 0.1% bupivacaine at 8 mL/h and an on-demand bolus 5 mL every 30 minutes. Sensory level was confirmed by insensitivity to cold from T7 through T12. The block was devoid of hemodynamic side effects or motor weakness. This case demonstrates that bilateral continuous quadratus lumborum catheters can provide extended postoperative pain control.


Assuntos
Analgésicos Opioides/efeitos adversos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/terapia , Insuficiência Respiratória/induzido quimicamente , Analgesia Controlada pelo Paciente/efeitos adversos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Bupivacaína/administração & dosagem , Bupivacaína/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Próstata/cirurgia , Neoplasias Retais/cirurgia , Insuficiência Respiratória/tratamento farmacológico , Resultado do Tratamento , Ultrassonografia de Intervenção
5.
Ochsner J ; 15(4): 441-2, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26730230

RESUMO

BACKGROUND: Complex regional pain syndrome, type 1 (CRPS-1) causes severe pain that can be resistant to multiple treatment modalities. Amputation as a form of long-term treatment for therapy-resistant CRPS-1 is controversial. CASE REPORT: We report the case of a 38-year-old man who failed all treatment modalities for CRPS-1, including medication, steroid injections, and spinal cord stimulator implantation. Below-the-knee amputation to relieve intractable foot and ankle pain resulted in a favorable outcome for this patient. CONCLUSION: Select patients with severe CRPS-1 who are unresponsive to all forms of treatment for pain may benefit from amputation as a last option for relief of suffering. Larger studies are needed to prove the efficacy of amputation.

6.
Ochsner J ; 13(2): 256-8, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23789013

RESUMO

BACKGROUND: Myasthenia gravis (MG) is an autoimmune disease involving the formation of antibodies against the nicotinic acetylcholine receptors. Thymectomy is the treatment in MG patients with thymoma. We report a case of an MG patient who developed postthymectomy bilateral pneumothoraces after the placement of a subclavian central venous catheter. CASE REPORT: The 21-year-old patient with MG underwent a thymectomy and, in a later admission, complained of myasthenic crisis symptoms. He was scheduled to receive plasma exchange therapy and electromyography the following day. Plasmapheresis was initiated after the placement of a right subclavian dialysis catheter. Postinsertion chest x-ray revealed bilateral pneumothoraces after a single unilateral attempt to cannulate the right subclavian vein. A right thoracotomy tube was placed with interval resolution of the bilateral pneumothoraces. CONCLUSION: The development of bilateral pneumothoraces in this case was attributed to the possible accidental communication between the 2 pleural spaces, which rarely happens during thymectomy surgery.

7.
Ochsner J ; 13(2): 264-6, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23789015

RESUMO

BACKGROUND: The traditional goals of perioperative management of severe aortic stenosis are based on maintaining a high systemic vascular resistance (SVR) to allow for good coronary perfusion. CASE REPORT: An 87-year-old male presented with septic arthritis of a prosthetic knee joint. Arthroplasty, implant removal, and joint washout were planned as surgical intervention. His comorbidities included severe aortic stenosis (peak/mean gradient 109/60 mmHg, aortic valve area of 0.80 cm(2)), new onset mitral regurgitation secondary to a flail posterior mitral valve leaflet, and a new third-degree conduction block. A nitroprusside infusion was initiated 72 hours preoperatively and continued throughout the intraoperative period and postoperative intensive care stay. This novel use of nitroprusside improved cardiac output and forward flow through the stenotic aortic valve. CONCLUSIONS: To our knowledge, the use of nitroprusside infusion during the intraoperative period in patients with severe aortic stenosis undergoing noncardiac surgery has not been described previously. Although contrary to the traditional goal of maintaining a high SVR, this important pharmacological intervention optimizes cardiac indices during the perioperative period in these patients.

8.
Ochsner J ; 13(2): 267-9, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23789016

RESUMO

INTRODUCTION: Continuous peripheral nerve block achieves good pain control. However, uncontrolled pain despite an effective block in the target areas of the nerve can be an early sign of ischemia. We report a case of iatrogenic injury to the axillary artery during shoulder surgery in a patient who had continuous supraclavicular block and demonstrate how vigilant monitoring helped the diagnosis and resulted in timely management of upper limb ischemia. CASE REPORT: A 58-year-old female underwent total revision surgery of her right shoulder under continuous supraclavicular block. Postoperatively, she complained of pain along the medial side of her forearm despite clinical evidence of nerve block. Continuous neurovascular monitoring and timely angiography confirmed axillary artery injury, and subsequent vascular repair saved the patient's limb. CONCLUSION: Iatrogenic injuries to vessels or nerves sometimes occur during orthopedic surgical procedures. Regional anesthesia can mask and delay the onset of these symptoms. Postoperative monitoring and the ability to differentiate between the effects of local anesthetics and the body's response to ischemia are important for avoiding postoperative complications. This case report aims to improve awareness about the need for vigilant monitoring of the distal pulses after peripheral nerve blocks.

10.
J Cardiothorac Vasc Anesth ; 24(6): 946-51, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20599396

RESUMO

OBJECTIVE: The authors analyzed hospital mortality in adult cardiac surgery patients who required postoperative venoarterial extracorporeal membrane oxygenation (ECMO) support for circulatory failure and identified perioperative patient variables associated with hospital mortality in these patients. DESIGN: A retrospective study. SETTING: A single institution, tertiary academic center. PARTICIPANTS: Adult patients requiring venoarterial ECMO support after cardiac surgery from January 1995 to December 2005 were identified from the Anesthesiology Institute Patient Registry. Twenty-two preselected patient variables were entered into a logistic regression model of hospital death. INTERVENTIONS: None. RESULTS: Two hundred thirty-three of 40,116 (0.58%) adult cardiac surgery patients required postoperative venoarterial ECMO, and among these, 149 (64%) died in the hospital. In an unadjusted analysis, older age, higher preoperative albumin, diabetes history, coronary artery bypass graft surgery, and longer total cardiopulmonary bypass (CPB) time were associated with increased hospital mortality, and a history of cardiogenic shock was associated with decreased mortality. In an adjusted logistic regression analysis, a history of cardiogenic shock and younger age were associated with decreased hospital mortality. The overall use of postoperative venoarterial ECMO in this patient population decreased since its peak in 1996. CONCLUSION: Venoarterial ECMO support after cardiac surgery was required in a small fraction of patients and was associated with very high hospital mortality; but among those requiring ECMO, mortality in these patients was lower in younger, nondiabetic patients with cardiogenic shock who had shorter CPB times. The mortality associated patient variables identified are not easily modifiable and do not appear sufficiently robust to define which patients should be selected for this potentially life-saving therapy.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Oxigenação por Membrana Extracorpórea , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Adulto , Fatores Etários , Idoso , Cuidados Críticos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Análise de Sobrevida , Sobreviventes , Resultado do Tratamento , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA