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1.
J Clin Monit Comput ; 2018 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-29789999

RESUMO

The pilot balloon palpation (or 'finger-pressure') method is still widely used to assess the endotracheal tube cuff inflation, despite consistent evidence of its poor sensitivity in recognizing cuff overinflation. It was recently speculated that this may be related to the lower wall tension (due to the smaller radius) of the pilot balloon as compared with the cuff, according to Laplace's law. To verify this hypothesis and, secondarily, to assess whether the use of a 'large' pilot balloon (identical to the cuff) increases the reliability of this technique, 62 anesthetists (41 experienced anesthesiologists and 21 residents) were asked to estimate the pressure of a cuff inflated to 88 mmHg into a simulated trachea by feeling both a usual and a modified 'large' pilot balloon. A similar test was repeated at 40 mmHg. After palpation of the usual pilot balloon, only 35% of participants (49% of experienced anesthesiologists and 10% of residents) recognized considerable overinflation (88 mmHg), as compared with 87% of participants (95% of experienced anesthesiologists and 71% of residents) after palpation of the 'large' pilot balloon. Moreover, 89% of participants (85% of experienced anesthesiologists and 95% of residents) believed that pressure was higher in the 'large' balloon than in the normal one. However, only 32% of participants (51% of experienced anesthesiologists and none of residents) recognized slight overinflation (40 mmHg) after feeling the 'large' balloon. The pilot balloon size affects the sensitivity of the 'finger-pressure' technique, but it remains poorly reliable with a larger pilot balloon.

2.
Eur J Cardiothorac Surg ; 52(5): 901-908, 2017 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-28977378

RESUMO

OBJECTIVES: We tested the possible value of routine aggregometry testing for bleeding prediction following coronary artery bypass grafting in patients who received preoperative double antiplatelet therapy. METHODS: In 226 patients undergoing on-pump isolated coronary artery bypass grafting, aggregometry [adenosine diphosphate (ADP) test and ASPI test] was always prospectively performed by Multiplate® analyser immediately before surgery. We assessed the differences in postoperative bleeding according to the type of double antiplatelet therapy [acetylsalicylic acid plus clopidogrel (ASA+C), or plus ticagrelor (ASA+T)], duration of clopidogrel/ticagrelor withdrawal (0-3 days or ≥ 4 days) and results of aggregometry tests. Multivariable predictors of blood losses were sought by linear regressions (drainage amount at 6, 12 and 24 postoperative hours) and logistic regression (increased bleeding: 75th percentile of blood losses at 6 h, i.e. >450 ml). RESULTS: Overall, postoperative blood losses did not significantly differ between treatment groups (median at 6 h: ASA + C = 335 ml, ASA + T = 300 ml, P = 0.21). With longer withdrawal interval, higher rates of patients with normal ADP-related platelet function were observed in both groups (ASA + C: P = 0.04; ASA + T: P = 0.006) but only in the ASA + T group were blood losses significantly smaller at all 3 time points. Bleeders (>450 ml at 6 h) were significantly less frequent among patients with ADP test showing recovered platelet function (ASA + T: P = 0.002; ASA + C: P = 0.053). The correlation between ADP test result and blood losses amount was stronger in the ASA + T group (e.g. at 6 h: r = -0.6; P < 0.001). In multivariable analyses, the ADP test result independently predicted postoperative bleeding in the ASA + T group and the ASPI test in the ASA + C group. CONCLUSIONS: Aggregometry can help in predicting postoperative bleeding in double antiplatelet therapy patients undergoing coronary artery bypass grafting.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Inibidores da Agregação de Plaquetas/efeitos adversos , Testes de Função Plaquetária/estatística & dados numéricos , Hemorragia Pós-Operatória/epidemiologia , Cuidados Pré-Operatórios/métodos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Inibidores da Agregação de Plaquetas/uso terapêutico , Estudos Prospectivos , Fatores de Risco
3.
Am Heart J ; 177: 66-73, 2016 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27297851

RESUMO

OBJECTIVE: Patients undergoing cardiac surgery are at risk of perioperative low cardiac output syndrome due to postoperative myocardial dysfunction. Myocardial dysfunction in patients undergoing cardiac surgery is a potential indication for the use of levosimendan, a calcium sensitizer with 3 beneficial cardiovascular effects (inotropic, vasodilatory, and anti-inflammatory), which appears effective in improving clinically relevant outcomes. DESIGN: Double-blind, placebo-controlled, multicenter randomized trial. SETTING: Tertiary care hospitals. INTERVENTIONS: Cardiac surgery patients (n = 1,000) with postoperative myocardial dysfunction (defined as patients with intraaortic balloon pump and/or high-dose standard inotropic support) will be randomized to receive a continuous infusion of either levosimendan (0.05-0.2 µg/[kg min]) or placebo for 24-48 hours. MEASUREMENTS AND MAIN RESULTS: The primary end point will be 30-day mortality. Secondary end points will be mortality at 1 year, time on mechanical ventilation, acute kidney injury, decision to stop the study drug due to adverse events or to start open-label levosimendan, and length of intensive care unit and hospital stay. We will test the hypothesis that levosimendan reduces 30-day mortality in cardiac surgery patients with postoperative myocardial dysfunction. CONCLUSIONS: This trial is planned to determine whether levosimendan could improve survival in patients with postoperative low cardiac output syndrome. The results of this double-blind, placebo-controlled randomized trial may provide important insights into the management of low cardiac output in cardiac surgery.


Assuntos
Baixo Débito Cardíaco/terapia , Cardiotônicos/uso terapêutico , Hidrazonas/uso terapêutico , Balão Intra-Aórtico , Complicações Pós-Operatórias/terapia , Piridazinas/uso terapêutico , Lesão Renal Aguda/epidemiologia , Baixo Débito Cardíaco/mortalidade , Procedimentos Cirúrgicos Cardíacos/mortalidade , Método Duplo-Cego , Humanos , Infusões Intravenosas , Unidades de Terapia Intensiva , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Respiração Artificial , Simendana
4.
PLoS One ; 10(5): e0120813, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25942400

RESUMO

BACKGROUND AND AIM OF THE STUDY: Implications of Cardiac troponin (cTnI) release after cardiac transplantation are still unclear. This study disclosed risk factors and prognostic implication of cTnI early levels in a single centre cohort operated on between January 1999 and December 2010. METHODS: Data on 362 consecutive recipients (mean age: 47.8±13.7, 20.2% female, 18.2% diabetics, 22.1% with previous cardiac operations, 27.6% hospitalized, 84.9±29.4 ml/min preoperative glomerular filtration rate) were analyzed using multivariable logistic regression modeling. Target outcomes were determinants of troponin release, early graft failure (EGF), acute kidney injury (AKI) and operative death. RESULTS: Mean cTnI release measured 24 hours after transplant was 10.9±11.6 µg/L. Overall hospital mortality was 10.8%, EGF 10.5%, and AKI was 12.2%. cTnI release>10 µg/L proved an independent predictor of EGF (OR 2.2; 95% CI, 1.06-4.6) and AKI (OR 1.031; 95% CI, 1.001-1.064). EGF, in turn, proved a determinant of hospital mortality. Risk factors for cTnI>10 µg/L release were: status 2B (OR 0.35; 95% CI, 0.18-0.69, protective), duration of the ischemic period (OR 1.006; 95% CI, 1.001-1.011), previous cardiac operation (OR 2.9; 95% CI, 1.67-5.0), and left ventricular hypertrophy (OR 3.3; 95% CI, 1.9-5.6). CONCLUSIONS: Myocardial enzyme leakage clearly emerged as an epiphenomenon of more complicated clinical course. The complex interplay between surgical procedure features, graft characteristics and recipient end-organ function highlights cTnI release as a risk marker of graft failure and acute kidney injury. The search for optimal myocardial preservation is still an issue.


Assuntos
Transplante de Coração/efeitos adversos , Troponina/metabolismo , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Adulto , Ecocardiografia , Feminino , Hemodinâmica/fisiologia , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Fatores de Risco
5.
JAMA ; 312(21): 2244-53, 2014 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-25265449

RESUMO

IMPORTANCE: No effective pharmaceutical agents have yet been identified to treat acute kidney injury after cardiac surgery. OBJECTIVE: To determine whether fenoldopam reduces the need for renal replacement therapy in critically ill cardiac surgery patients with acute kidney injury. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized, double-blind, placebo-controlled, parallel-group study from March 2008 to April 2013 in 19 cardiovascular intensive care units in Italy. We randomly assigned 667 patients admitted to intensive care units after cardiac surgery with early acute kidney injury (≥50% increase of serum creatinine level from baseline or oliguria for ≥6 hours) to receive fenoldopam (338 patients) or placebo (329 patients). We used a computer-generated permuted block randomization sequence for treatment allocation. All patients completed their follow-up 30 days after surgery, and data were analyzed according to the intention-to-treat principle. INTERVENTIONS: Continuous infusion of fenoldopam or placebo for up to 4 days with a starting dose of 0.1 µg/kg/min (range, 0.025-0.3 µg/kg/min). MAIN OUTCOMES AND MEASURES: The primary end point was the rate of renal replacement therapy. Secondary end points included mortality (intensive care unit and 30-day mortality) and the rate of hypotension during study drug infusion. RESULTS: The study was stopped for futility as recommended by the safety committee after a planned interim analysis. Sixty-nine of 338 patients (20%) allocated to the fenoldopam group and 60 of 329 patients (18%) allocated to the placebo group received renal replacement therapy (P = .47). Mortality at 30 days was 78 of 338 (23%) in the fenoldopam group and 74 of 329 (22%) in the placebo group (P = .86). Hypotension occurred in 85 (26%) patients in the fenoldopam group and in 49 (15%) patients in the placebo group (P = .001). CONCLUSIONS AND RELEVANCE: Among patients with acute kidney injury after cardiac surgery, fenoldopam infusion, compared with placebo, did not reduce the need for renal replacement therapy or risk of 30-day mortality but was associated with an increased rate of hypotension. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00621790.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Fenoldopam/uso terapêutico , Terapia de Substituição Renal/métodos , Vasodilatadores/uso terapêutico , Lesão Renal Aguda , Idoso , Creatinina , Estado Terminal , Método Duplo-Cego , Feminino , Fenoldopam/efeitos adversos , Humanos , Hipotensão/induzido quimicamente , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Estados Unidos , Vasodilatadores/efeitos adversos
6.
Clin Transplant ; 28(7): 837-43, 2014 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-24828060

RESUMO

Unresponsive pulmonary hypertension (PH) implies poor posttransplant outcomes. Data on late adaptation of the right ventricle (RV) are still few. This study evaluated three-yr RV function and remodeling, exercise capacity, and hemodynamic data in a selected group of patients initially disqualified because of PH. Between May 2005 and December 2009, 31 consecutive patients were qualified for oral sildenafil because of unresponsive PH at baseline right heart catheterization (RHC). After a 12-wk trial, RHC disclosed PH reversibility (mean PVR: 5.41 ± 3 Wood units, mean TPG 14.5 ± 5.6 mmHg, and mean systolic PAP 68.9 ± 15.1 mmHg), allowing listing even though as high-risk procedures. All patients underwent heart transplantation. RV failure developed in three patients (9.6%), and hospital mortality was 3.2%. Protocol RHC disclosed pulmonary hemodynamic profile normalization within the third postoperative month, allowing weaning from sildenafil in the 30 hospital survivors. One- and three-yr RHCs confirmed stable PH reversal (n = 26, all three-yr survivors). Parameters of late RV function and remodeling proved satisfactory. Parameters of functional capacity (Vo2 peak 19.7 ± 3.6 mL/kg/min and slope VE/Vco2 34.8 ± 2.7) proved homogeneous to those measured in transplant recipients with normal preoperative pulmonary artery pressure. Oral sildenafil is effective in allowing candidacy, safe transplantation, and long-term survival in PH recipients initially disqualified.


Assuntos
Tolerância ao Exercício/efeitos dos fármacos , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Hipertensão Pulmonar/tratamento farmacológico , Piperazinas/administração & dosagem , Sulfonas/administração & dosagem , Vasodilatadores/administração & dosagem , Função Ventricular Direita/efeitos dos fármacos , Administração Oral , Aloenxertos , Cateterismo Cardíaco , Feminino , Seguimentos , Insuficiência Cardíaca/complicações , Hemodinâmica/efeitos dos fármacos , Humanos , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prognóstico , Estudos Prospectivos , Purinas/administração & dosagem , Fatores de Risco , Citrato de Sildenafila , Transplantados
7.
Clin Infect Dis ; 57(3): 349-58, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23616495

RESUMO

BACKGROUND: Extensively drug-resistant (XDR) Acinetobacter baumannii may cause serious infections in critically ill patients. Colistin often remains the only therapeutic option. Addition of rifampicin to colistin may be synergistic in vitro. In this study, we assessed whether the combination of colistin and rifampicin reduced the mortality of XDR A. baumannii infections compared to colistin alone. METHODS: This multicenter, parallel, randomized, open-label clinical trial enrolled 210 patients with life-threatening infections due to XDR A. baumannii from intensive care units of 5 tertiary care hospitals. Patients were randomly allocated (1:1) to either colistin alone, 2 MU every 8 hours intravenously, or colistin (as above), plus rifampicin 600 mg every 12 hours intravenously. The primary end point was overall 30-day mortality. Secondary end points were infection-related death, microbiologic eradication, and hospitalization length. RESULTS: Death within 30 days from randomization occurred in 90 (43%) subjects, without difference between treatment arms (P = .95). This was confirmed by multivariable analysis (odds ratio, 0.88 [95% confidence interval, .46-1.69], P = .71). A significant increase of microbiologic eradication rate was observed in the colistin plus rifampicin arm (P = .034). No difference was observed for infection-related death and length of hospitalization. CONCLUSIONS: In serious XDR A. baumannii infections, 30-day mortality is not reduced by addition of rifampicin to colistin. These results indicate that, at present, rifampicin should not be routinely combined with colistin in clinical practice. The increased rate of A. baumannii eradication with combination treatment could still imply a clinical benefit. CLINICAL TRIALS REGISTRATION: NCT01577862.


Assuntos
Infecções por Acinetobacter/tratamento farmacológico , Acinetobacter baumannii/efeitos dos fármacos , Antibacterianos/uso terapêutico , Colistina/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Rifampina/uso terapêutico , Infecções por Acinetobacter/mortalidade , Acinetobacter baumannii/isolamento & purificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Estado Terminal , Quimioterapia Combinada/métodos , Feminino , Humanos , Unidades de Terapia Intensiva , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise de Sobrevida , Centros de Atenção Terciária , Resultado do Tratamento
8.
Eur J Cardiothorac Surg ; 42(5): 864-9; discussion 869-70, 2012 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-22402452

RESUMO

OBJECTIVES: Unresponsive pulmonary hypertension (PH) may contraindicate heart transplant since it implies poor early outcomes. The present study reports the effectiveness of oral perioperative sildenafil in allowing heart transplant candidacy and surgery in a selected group of patients initially deemed ineligible because of PH. METHODS: Between May 2005 and December 2009, 31 consecutive patients (5 females, 9 with a history of idiopatic cardiomyopathy and 16 with a history of coronary artery disease, 10 with previous sternotomies, 71.42 ± 27.69 ml/min/m(2) mean preoperative epidermal growth factor receptor) were qualified for oral sildenafil because of unresponsive PH at baseline right heart catheterization (RHC). After a 12-week trial, RHC disclosed PH reversibility (mean pulmonary vascular resistance index: 9.57 ± 4.07 WU, mean transpulmonary gradient 14.47 ± 5.66 mmHg and mean systolic pulmonary artery pressure: 68.96 ± 15.15 mmHg), allowing listing despite a higher risk for early post-transplant RV failure. Transplant protocol included donor/recipient size matching ≥ 0.8 and inhaled nitric oxide in the early postoperative period followed by reinstitution of oral sildenafil. RESULTS: All patients underwent heart transplantation. Mean overall graft ischaemic time was 179 ± 47 min; mean donor recipient weight ratio was 1.04 ± 0.17. Right ventricular failure developed in three patients (9.6%) and hospital mortality was 3.2%. Protocol RHC disclosed pulmonary haemodynamic profile normalization within the third postoperative month allowing weaning from sildenafil in the 30 hospital survivors. One-year RHC confirmed PH reversal (n = 29 patients, all who survived up to 1 year). CONCLUSIONS: This pilot prospective uncontrolled trial suggests that oral sildenafil is effective in allowing candidacy, safe transplantation and postoperative pulmonary profile normalization in potential recipients initially disqualified because of PH.


Assuntos
Insuficiência Cardíaca/cirurgia , Transplante de Coração , Hipertensão Pulmonar/tratamento farmacológico , Inibidores da Fosfodiesterase 5/uso terapêutico , Piperazinas/uso terapêutico , Sulfonas/uso terapêutico , Administração Oral , Adulto , Cateterismo Cardíaco , Contraindicações , Esquema de Medicação , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/mortalidade , Transplante de Coração/mortalidade , Humanos , Hipertensão Pulmonar/diagnóstico , Hipertensão Pulmonar/etiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Purinas/uso terapêutico , Índice de Gravidade de Doença , Citrato de Sildenafila , Resultado do Tratamento
9.
J Thorac Cardiovasc Surg ; 140(1): 188-95, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20416894

RESUMO

OBJECTIVE: Leukocytes in allogeneic blood transfusions cause several immunomodulatory events. This before-and-after cohort study evaluated clinical outcomes after adoption of prestorage leukoreduction program for blood transfusions, with particular focus on acute kidney injury. METHODS: One thousand thirty-four consecutive patients who underwent on-pump coronary artery bypass grafting between January 2004 and December 2007 were included. Propensity score analysis for transfusion was performed in the whole population; patients who were actually transfused were then divided according to leukoreduction. From these 2 groups, 147 pairs matched for propensity score were considered to evaluate with bivariate and multivariable analyses the effects of leukoreduction, with all-cause in-hospital mortality and morbidity as main outcomes. RESULTS: Unadjusted in-hospital mortalities were 6.6% for the entire cohort and 44.2% for those with acute kidney injury. In the matched population, after introduction of leukoreduction, mortality rates decreased to 5.4% (vs 11.4%) and acute kidney injury (RIFLE [Risk, Injury, Failure, Loss of function, End-stage renal disease] class R or greater) dropped from 51.7% to 41.5% (relative risk -20%, P < .045). No difference emerged regarding other major complications. At multivariable analysis, intra-aortic balloon pump, RIFLE score, and propensity score for transfusion proved independent predictors of in-hospital mortality. Intra-aortic balloon pump and nonleukodepleted transfusion emerged as independent predictors of acute kidney injury. Multivariable analysis on the overall cohort of transfused patients confirmed that nonleukodepleted transfusion was an independent predictor of acute kidney injury. CONCLUSIONS: Leukoreduction of allogeneic blood products is associated with decreased acute kidney injury and mortality in highly transfused patients.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/mortalidade , Transfusão de Eritrócitos/efeitos adversos , Transfusão de Eritrócitos/mortalidade , Nefropatias/mortalidade , Nefropatias/prevenção & controle , Procedimentos de Redução de Leucócitos , Resultado do Tratamento , Centros Médicos Acadêmicos , Doença Aguda , Idoso , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Itália , Nefropatias/etiologia , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Prospectivos , Análise de Regressão , Medição de Risco , Fatores de Risco
10.
J Heart Valve Dis ; 19(1): 139-47; discussion 148, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20329500

RESUMO

BACKGROUND AND AIM OF THE STUDY: The RIFLE classification, which defines three grades of increasing severity of acute kidney injury--risk (RIFLE R), injury (RIFLE I) and failure (RIFLE F), and two outcome classes (L, loss) and E (end-stage kidney disease)--represents a valuable method for evaluating acute renal failure. Risk factors for acute kidney injury (AKI) according to the RIFLE criteria and for operative mortality were identified in patients undergoing valvular procedures. METHODS: A single-center prospective cohort study of 1424 patients who were not receiving renal replacement therapy preoperatively was conducted between January 2004 and December 2007. A total of 100 variables was collected from each patient. RESULTS: The main features were: mean age 61.9 +/- 12.9 years (range: 15-88 years), 47% females, 6% endocarditis, 11% redo surgery, 8% urgent/emergent surgery, 30% combined procedures, 5% complex, and 16% associated coronary artery bypass grafting (CABG). The overall AKI prevalence was 10%, with RIFLE scores of I or F being detected in 8% and continuous veno-venous hemofiltration being required in 5%. Risk factors for AKI were age (OR 1.03; 95% CI 1.14-4.15), time of extracorporeal circulation (ECC) (OR 1.09; 95% CI 1.005-1.013), redo procedure (OR 2.35; 95% CI 1.42-3.8), chronic kidney disease (OR 3.2; 95% CI 1.6-6.1), and blood transfusion (OR 3.8; 95% CI 2.5-6.5). The transfusion of leukodepleted blood exerted a protective effect on AKI development (OR 0.6; 95% CI 0.4-0.9). The average overall hospital mortality was 4.8%. Risk factors for operative mortality included: ECC time (OR 1; 95% CI 1.002-1.014), age (OR 1.043; 95% CI 1.01-1.07), chronic kidney disease (OR 4.8; 95% CI 2.2-10.6), blood transfusion (OR 6.43; 95% CI 2.8-14.7), surgical priority (OR 6.5; 95% CI 2.8-14.7), RIFLE class I (OR 11.9; 95% CI 5.5-25.7), and RIFLE class F (OR 30; 95% CI 8.1-111.7). Mortality increased with each RIFLE stratification (Normal 1.7%, RIFLE R = 4.1%, RR = 2.5; RIFLE I = 27.6%, RR = 16.2; and RIFLE F = 43.8% RR = 25.8). CONCLUSION: AKI is a highly prevalent and prognostically important complication, for which the majority of risk factors that have been identified are not modifiable. The transfusion of leukodepleted blood products was seen to exert a preventive effect.


Assuntos
Lesão Renal Aguda/classificação , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Transfusão de Sangue/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Doenças das Valvas Cardíacas/cirurgia , Hematócrito , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Avaliação de Resultados (Cuidados de Saúde) , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Reoperação/estatística & dados numéricos , Fatores de Risco , Adulto Jovem
11.
J Thorac Cardiovasc Surg ; 137(2): 342-6, 2009 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-19185148

RESUMO

OBJECTIVE: Extubation failure is a serious complication after cardiac surgery. The role of noninvasive positive-pressure ventilation for acute respiratory failure in patients undergoing cardiac surgery is unknown. This study aimed to assess the safety of implementing noninvasive positive-pressure ventilation in this setting and its impact on lung function and operative outcomes. METHODS: In a 6-month pilot prospective survey, the study population comprised 43 patients (32 were male with a mean age of 65.73 +/- 9 years; 3 heart transplantations, 18 coronary artery bypass grafts, 5 aortic dissections, and 17 valvular procedures; 34 active smokers, 25 with medically treated chronic obstructive pulmonary disease, 21 emergency/urgency procedures) who required noninvasive positive-pressure ventilation for acute respiratory failure after initial weaning from a respirator. The cause of acute respiratory failure (classified as post-cardiopulmonary bypass lung injury in 48.8% [21 patients], cardiogenic edema in 30.2% [13 patients], and pneumonia in 21% [9 patients]), length of noninvasive positive-pressure ventilation support, respiratory ratios (arterial oxygen tension/fraction of inspired oxygen assessed immediately before noninvasive positive-pressure ventilation, and every 6 hours after institution of pressure ventilation), and need for reintubation along with a set of predefined safety parameters were recorded. RESULTS: The mean length of noninvasive positive-pressure ventilation support was 33.8 +/- 24.04 hours. Plotting respiratory ratios with length of noninvasive positive-pressure ventilation supports a significant improvement was already evident within the first 6-hour frame (133.6 +/- 39.5 vs 205 +/- 65.7; P < .001) for all causes. Noninvasive positive-pressure ventilation prevented intubation in 74.4% of the patients, with satisfactory recovery for post-cardiopulmonary bypass lung injury and cardiogenic dysfunction (90.5% and 69.2%, respectively) and poor results (55% reintubated) in those treated for pneumonia. Noninvasive positive-pressure ventilation safety approached 97.7%. CONCLUSION: In appropriate candidates, noninvasive positive-pressure ventilation exerts favorable effects on lung function, preventing reintubation. The cost-effectiveness of its systematic use in this setting should be assessed.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Respiração com Pressão Positiva , Insuficiência Respiratória/terapia , Idoso , Feminino , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Retratamento
12.
Eur J Cardiothorac Surg ; 33(4): 666-72, 2008 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-18261917

RESUMO

OBJECTIVE: The aim of this study was to prospectively evaluate frequency, characteristics, and predictors of nosocomial infections (NI) in a tertiary care centre. METHODS: Study population included 925 patients (mean age 62.3+/-12.5, 32.3% females, 22.9% diabetics, 6.8% with previous cardiac procedures) operated on between June 2005 and December 2006 (CABG 48.72%, valvular procedures 30.05%, thoracic aortic 10.9%, heart transplantations 3.78% and miscellanea 6.55%, procedure status: elective 72.9%, urgent 15.9% and emergent 11.2%). The study population was divided in two groups according to development of NI. Primary endpoints were multiorgan failure (MOF) and hospital mortality in the two groups. Secondary endpoints were length of intubation, intensive care unit (ICU) stay and overall hospitalisation. Univariate and multivariate analysis of NI predictors was conducted between 115 perioperative variables. RESULTS: Eighty-three patients (9%) developed a NI. Infections affected respiratory tract in 51.8%, blood stream in 20.5 and wound infection in 27.7 (13.3% deep wound). Staphylococcal species (60.6%) predominated in blood stream and surgical wound infections while Gram-negative species predominated in respiratory infections. Patients affected by NI experienced significantly higher incidence of MOF (12% vs 0.8%) and hospital mortality (24.1 vs 6.9%). Development of NI significantly lengthened all the steps of postoperative process of care (length of intubation: 49.9+/-73 h vs 19.1+/-35.2; ICU stay: 10.4+/-12.8 days vs 3.4+/-4.6 and hospitalisation 20.7+/-15.3 vs 10.6+/-7). Independent predictors of NI were immunosuppressive therapy [OR 12.9 (CI 5.07-31.2)], reintubation [OR 10.3 (CI 4.6-2.3)], stroke [OR 9.5 (CI 1.8-49)], resternotomy for bleeding [OR 6.7 (CI 1.9-23.6)], emergent/urgent status [OR 3.6 (CI 1.5-8.4)], CVVH [OR 3.2 (CI 1.4-7.5)] and length of intubation [OR 1.03 (CI 1.01-1.1)]. CONCLUSIONS: NI still represents a serious complication. Presence of identified determinants of NI should prompt modification of management algorithms.


Assuntos
Infecção Hospitalar/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Infecção Hospitalar/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/microbiologia , Estudos Prospectivos , Procedimentos Cirúrgicos Torácicos/mortalidade
13.
J Cardiovasc Med (Hagerstown) ; 8(11): 950-2, 2007 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-17906484

RESUMO

Pulmonary arterial hypertension represents an absolute contraindication for heart transplantation. We report the case of a 30-year-old man with end-stage heart failure due to restrictive cardiomyopathy and pulmonary arterial hypertension. A complex multidrug therapy improved pulmonary haemodynamics to the point that orthotopic heart transplantation could be carried out. At 18-month follow-up after heart transplantation, the patient's cardiac function made a full recovery. Larger prospective studies are warranted to support these results.


Assuntos
Anti-Hipertensivos/administração & dosagem , Epoprostenol/administração & dosagem , Insuficiência Cardíaca/cirurgia , Transplante de Coração , Hipertensão Pulmonar/tratamento farmacológico , Sulfonamidas/administração & dosagem , Adulto , Bosentana , Cateterismo Cardíaco , Cardiomiopatia Restritiva/complicações , Cardiomiopatia Restritiva/fisiopatologia , Contraindicações , Quimioterapia Combinada , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertensão Pulmonar/complicações , Hipertensão Pulmonar/fisiopatologia , Masculino
14.
J Cardiothorac Vasc Anesth ; 18(4): 409-14, 2004 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-15365919

RESUMO

OBJECTIVE: To assess whether routine postoperative enoximone infusion compared with dobutamine improved clinical and biochemical results after coronary artery bypass grafting with cardiopulmonary bypass. DESIGN: Prospective nonrandomized study. Data collection was blinded to the choice of inotrope. SETTING: Double-institutional clinical investigation. PARTICIPANTS: Two hundred sixteen consecutive patients undergoing myocardial revascularization between May 2000 and December 2002. INTERVENTIONS: Seventy-two patients underwent myocardial revascularization and were treated with enoximone, 5 microg/kg/min (group A). They were compared in a ratio of 1:2 to 144 patients treated with dobutamine at the same dose (group B) after aortic cross-clamp removal. The groups proved to be homogenous in preoperative and intraoperative characteristics. MEASUREMENTS AND MAIN RESULTS: Hospital outcome, electrocardiogram, echocardiography, further inotropic support, and biochemical markers of ischemia were compared. Subsets of patients with comorbidities and total arterial revascularization were analyzed. Perioperative myocardial infarction, postoperative low-output syndrome, intra-aortic balloon pump, atrial fibrillation, ST-segment changes, postoperative echocardiographic findings, and intensive care and hospital durations were similar between groups. In the postoperative course, more patients belonging to group A maintained low-dose inotropic support, whereas more patients belonging to group B required higher doses. Troponin I and creatine kinase-MB values were higher in patients of group B, especially when subgroups with diabetes, left ventricular hypertrophy, or total arterial revascularization were included. CONCLUSION: Postoperative enoximone reduced troponin I release and need for inotropic support in patients undergoing on-pump myocardial revascularization. Subgroup data were confirmed in diabetes, left ventricular hypertrophy, and total arterial revascularization.


Assuntos
Cardiotônicos/administração & dosagem , Ponte de Artéria Coronária , Enoximona/administração & dosagem , Miocárdio/enzimologia , Ponte Cardiopulmonar , Creatina Quinase/sangue , Creatina Quinase Forma MB , Dobutamina/administração & dosagem , Eletrocardiografia , Feminino , Humanos , Infusões Intravenosas , Isoenzimas/sangue , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Troponina I/sangue
15.
J Thorac Cardiovasc Surg ; 126(3): 826-31, 2003 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-14502161

RESUMO

OBJECTIVE: Postoperative respiratory failure is a frequent and serious complication in patients with type A acute aortic dissection operated on with deep systemic hypothermia. Interaction between neutrophils and pulmonary endothelium along with ischemic insult and reperfusion are the major determinants of lung injury. The aim of this prospective study was to evaluate the effect of continuous pulmonary perfusion during retrograde cerebral perfusion on lung function. METHODS: Twenty-two patients referred for acute type A aortic dissection, who were free from preoperative respiratory dysfunction, were assigned prospectively and alternately to one of 2 treatment groups. Pulmonary perfusion was performed during retrograde cerebral perfusion in group B (11 patients), whereas the conventional Ueda technique was applied in group A (11 patients). Lung function was evaluated on the basis of intubation time, scoring of chest radiographs at 12 hours after cardiopulmonary bypass, and Pao(2)/fraction of inspired oxygen ratio assessed from immediately before the operation to 72 hours after termination of cardiopulmonary bypass. RESULTS: Study groups were homogeneous for age, sex, interval between symptom onset and surgical operation, previous aortic surgery, preoperative ejection fraction and pulmonary gas exchange function, extent of aortic repair, and concomitant procedures. Cardiopulmonary bypass time, length of retrograde cerebral perfusion, operation time, need for blood substitutes, and surgical revision for bleeding did not differ between treatment groups. Postoperative Pao(2)/fraction of inspired oxygen ratios were higher in group B than in group A, and the difference remained statistically significant throughout the study period. The incidence of prolonged ventilator support (>72 hours) and the severity of the radiographic pulmonary infiltrate score were lower in the perfused group (18.2% vs 72.7% [P =.015] and 0.81 +/- 0.75 vs 1.8 +/- 0.78 [P =.028], respectively). CONCLUSIONS: Continuous pulmonary perfusion provided a better preservation of lung function in patients operated on with deep systemic hypothermia.


Assuntos
Aneurisma Dissecante/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Encefalopatias/prevenção & controle , Encéfalo , Pneumopatias/prevenção & controle , Pulmão , Perfusão/métodos , Complicações Pós-Operatórias/prevenção & controle , Doença Aguda , Adulto , Idoso , Aneurisma Dissecante/classificação , Aneurisma da Aorta Torácica/classificação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
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