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1.
BMC Med Inform Decis Mak ; 20(1): 26, 2020 Feb 10.
Artigo em Inglês | MEDLINE | ID: mdl-32041584

RESUMO

BACKGROUND: Maintaining adequate situation awareness is crucial for patient safety. Previous studies found that the use of avatar-based monitoring (Visual Patient Technology) improved the perception of vital signs compared to conventional monitoring showing numerical and waveform data; and was further associated with a reduction of perceived workload. In this study, we aimed to evaluate the effectiveness of Visual Patient Technology on perceptive performance and perceived workload when monitoring multiple patients at the same time, such as in central station monitors in intensive care units or operating rooms. METHODS: A prospective, within-subject, computer-based laboratory study was performed in two tertiary care hospitals in Switzerland in 2018. Thirty-eight physician and nurse anesthetists volunteered for the study. The participants were shown four different central monitor scenarios in sequence, where each scenario displayed two critical and four healthy patients simultaneously for 10 or 30 s. After each scenario, participants had to recall the vital signs of the critical patients. Perceived workload was assessed with the National Aeronautics and Space Administration Task-Load-Index (NASA TLX) questionnaire. RESULTS: In the 10-s scenarios, the median number of remembered vital signs significantly improved from 7 to 11 using avatar-based versus conventional monitoring with a mean of differences of 4 vital signs, 95% confidence interval (CI) 2 to 6, p < 0.001. At the same time, the median NASA TLX scores were significantly lower for avatar-based monitoring (67 vs. 77) with a mean of differences of 6 points, 95% CI 0.5 to 11, p = 0.034. In the 30-s scenarios, vital sign perception and workload did not differ significantly. CONCLUSIONS: In central monitor multiple patient monitoring, we found a significant improvement of vital sign perception and reduction of perceived workload using Visual Patient Technology, compared to conventional monitoring. The technology enabled improved assessment of patient status and may, thereby, help to increase situation awareness and enhance patient safety.

2.
A A Pract ; 13(12): 468-472, 2019 Dec 15.
Artigo em Inglês | MEDLINE | ID: mdl-31688028

RESUMO

Here we present the case of a 76-year-old woman with pancreatic cancer receiving epidural analgesia for chronic cancer pain treatment. Attempts of running the epidural catheter sequentially resulted in unexpected and extensive sensory block together with sympathicolysis but insufficient pain control. Finally, after 3 failed attempts of epidural catheter placements with insufficient pain control and uncommon neurological signs, a magnetic resonance imaging (MRI) scan of the spine was ordered. The MRI showed subdural catheter displacement with extensive liquid accumulation in the subdural space and consequent significant spinal cord compression. Findings normalized after removing the subdural catheter.

3.
J Clin Monit Comput ; 2019 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-31768924

RESUMO

Patient monitoring requires constant attention and may be particularly vulnerable to distractions, which frequently occur during perioperative work. In this study, we compared anesthesia providers' perceptive performance and perceived workload under distraction for conventional and avatar-based monitoring, a situation awareness-based technology that displays patient status as an animated patient model. In this prospective, multicenter study with a within-subject design, 38 participants evaluated scenarios of 3- and 10-s durations using conventional and avatar-based monitoring, under standardized distraction in the form of a simple calculation task. We quantified perceptual performance as the number of vital signs correctly remembered out of the total of 11 vital signs shown. We quantified perceived workload using the National Aeronautics and Space Administration Task Load Index score. Anesthesia providers remembered more vital signs under distraction using the avatar monitoring technology in the 3-s scenario: 6 (interquartile range [IQR] 5-7) vs. 3 (IQR 2-4), p < 0.001, mean of differences (MoD): 3 (95% confidence interval [95% CI] 1 to 4), and in the 10-s monitoring task: 6 (IQR 5-8) vs. 4 (IQR 2-7), p = 0.028, MoD: 1 (95% CI 0.2 to 3). Participants rated perceived workload lower under distraction with the avatar in the 3-s scenario: 65 (IQR 40-79) vs. 75 (IQR 51-88), p = 0.007, MoD: 9 (95% CI 3 to 15), and in the 10-s scenario: 68 (IQR 50-80) vs. 75 (IQR 65-86), p = 0.019, MoD: 10 (95% CI 2 to 18). Avatar-based monitoring improved anesthesia providers' perceptive performance under distraction and reduced perceived workload. This technology could help to improve caregivers' situation awareness, especially in high-workload situations.

4.
J Med Internet Res ; 21(7): e13041, 2019 07 17.
Artigo em Inglês | MEDLINE | ID: mdl-31317870

RESUMO

BACKGROUND: Continuous patient monitoring has been described by the World Health Organization as extremely important and is widely used in anesthesia, intensive care medicine, and emergency medicine. However, current state-of-the-art number- and waveform-based monitoring does not ideally support human users in acquiring quick, confident interpretations with low cognitive effort, and there are additional problematic aspects such as alarm fatigue. We developed a visualization technology (Visual Patient), specifically designed to help caregivers gain situation awareness quickly, which presents vital sign information in the form of an animated avatar of the monitored patient. We suspected that because of the way it displays the information as large, colorful, moving graphic objects, caregivers might be able to perform patient monitoring using their peripheral vision, which may facilitate quicker detection of anomalies, independently of acoustic alarms. OBJECTIVE: In this study, we tested the hypothesis that avatar-based monitoring, when observed with peripheral vision only, increases the number of perceptible changes in patient status as well as caregivers' perceived diagnostic confidence compared with a high-fidelity simulation of conventional monitoring, when observed with peripheral vision only. METHODS: We conducted a multicenter comparative study with a within-participant design in which anesthesiologists with their peripheral field of vision looked at 2 patient-monitoring scenarios and tried to identify changes in patient status. To ensure the best possible experimental conditions, we used an eye tracker, which recorded the eye movements of the participants and confirmed that they only looked at the monitoring scenarios with their peripheral vision. RESULTS: Overall, 30 participants evaluated 18 different patient status changes with each technology (avatar and conventional patient monitoring). With conventional patient monitoring, participants could only detect those 3 changes in patient status that are associated with a change in the auditory pulse tone display, that is, tachycardia (faster beeping), bradycardia (slower beeping), and desaturation (lower pitch of beeping). With the avatar, the median number of detected vital sign changes quadrupled from 3 to 12 (P<.001) in scenario 1, and more than doubled from 3 to 8 (P<.001) in scenario 2. Median perceived diagnostic confidence was confident for both scenarios with the avatar and unconfident in scenario 1 (P<.001), and very unconfident in scenario 2 (P=.024) with conventional monitoring. CONCLUSIONS: This study introduces the concept of peripheral vision monitoring. The test performed showed clearly that an avatar-based display is superior to a standard numeric display for peripheral vision. Avatar-based monitoring could potentially make much more of the patient monitoring information available to caregivers for longer time periods per case. Our results indicate that the optimal information transmission would consist of a combination of auditory and avatar-based monitoring.

5.
BMC Anesthesiol ; 18(1): 55, 2018 05 22.
Artigo em Inglês | MEDLINE | ID: mdl-29788919

RESUMO

BACKGROUND: Functional hemodynamic parameters such as stroke volume and pulse pressure variation (SVV and PPV) have been shown to be reliable predictors of fluid responsiveness in mechanically ventilated patients. Today, different minimally- and non-invasive hemodynamic monitoring systems measure functional hemodynamic parameters. Although some of these parameters are described by the same name, they differ in their measurement technique and thus may provide different results. We aimed to test the performance of seven functional hemodynamic parameters simultaneously in the same clinical setting. METHODS: Hemodynamic measurements were done in 30 cardiac surgery patients that were mechanically ventilated. Before and after a standardized intravenous fluid bolus, hemodynamics were measured by the following monitoring systems: PiCCOplus (SVVPiCCO, PPVPiCCO), LiDCOrapid (SVVLiDCO, PPVLiDCO), FloTrac (SVVFloTrac), Philips Intellivue (PPVPhilips) and Masimo pulse oximeter (pleth variability index, PVI). Prediction of fluid responsiveness was tested by calculation of receiver operating characteristic (ROC) curves including a gray zone approach and compared using Fisher's Z-Test. RESULTS: Fluid administration resulted in an increase in cardiac output, while all functional hemodynamic parameters decreased. A wide range of areas under the ROC-curve (AUC's) was observed: AUC-SVVPiCCO = 0.91, AUC-PPVPiCCO = 0.88, AUC-SVVLiDCO = 0.78, AUC-PPVLiDCO = 0.89, AUC-SVVFloTrac = 0.87, AUC-PPVPhilips = 0.92 and AUC-PVI = 0.68. Optimal threshold values for prediction of fluid responsiveness ranged between 9.5 and 17.5%. Lowest threshold values were observed for SVVLiDCO, highest for PVI. CONCLUSION: All functional hemodynamic parameters tested except for PVI showed that their use allows a reliable identification of potential fluid responders. PVI however, may not be suitable after cardiac surgery to predict fluid responsiveness. TRIAL REGISTRATION: NCT02571465 , registered on October 7th, 2015 (retrospectively registered).


Assuntos
Procedimentos Cirúrgicos Cardíacos , Hidratação , Hemodinâmica/fisiologia , Monitorização Fisiológica/métodos , Respiração Artificial , Equilíbrio Hidroeletrolítico/fisiologia , Humanos , Reprodutibilidade dos Testes
7.
8.
J Cardiothorac Vasc Anesth ; 32(2): 715-722, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29217236

RESUMO

OBJECTIVE: The aim of this study was to analyze the accuracy, precision, and trending ability of the following 4 pulse wave analysis devices to measure continuous cardiac output: PiCCO2 ([PCCO]; Pulsion Medical System, Munich, Germany); LiDCORapid ([LCCO]; LiDCO Ltd, London, UK); FloTrac/Vigileo ([FCCO]; Edwards Lifesciences, Irvine, CA); and Nexfin ([NCCO]; BMEYE, Amsterdam, The Netherlands). DESIGN: Prospective, observational clinical study. SETTING: Intensive care unit of a single-center, teaching hospital. PARTICIPANTS: The study comprised 22 adult patients after elective coronary artery bypass surgery. INTERVENTIONS: Three measurement cycles were performed in all patient durings their immediate postoperative intensive care stay before and after fluid loading. Hemodynamic measurements were performed 5 minutes before and immediately after the administration of 500 mL colloidal fluid over 20 minutes. MEASUREMENTS AND MAIN RESULTS: PCCO, LCCO, FCCO, and NCCO were assessed and compared with cardiac output derived from intermittent transpulmonary thermodilution (ICO). One hundred thirty-two matched sets of data were available for analysis. Bland-Altman analysis using linear mixed effects models with random effects for patient and trial revealed a mean bias ±2 standard deviation (%error) of -0.86 ± 1.41 L/min (34.9%) for PCCO-ICO, -0.26 ± 2.81 L/min (46.3%) for LCCO-ICO, -0.28 ± 2.39 L/min (43.7%) for FCCO-ICO, and -0.93 ± 2.25 L/min (34.6%) for NCCO-ICO. Bland-Altman plots without adjustment for repeated measurements and replicates yielded considerably larger limits of agreement. Trend analysis for all techniques did not meet criteria for acceptable performance. CONCLUSIONS: All 4 tested devices using pulse wave analysis for measuring cardiac output failed to meet current criteria for meaningful and adequate accuracy, precision, and trending ability in cardiac output monitoring.


Assuntos
Débito Cardíaco/fisiologia , Unidades de Terapia Intensiva/normas , Monitorização Fisiológica/normas , Cuidados Pós-Operatórios/normas , Análise de Onda de Pulso/normas , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Cuidados Pós-Operatórios/métodos , Período Pós-Operatório , Estudos Prospectivos , Análise de Onda de Pulso/métodos
9.
Anesthesiology ; 127(2): 307-316, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28570294

RESUMO

BACKGROUND: Supraglottic airway devices commonly are used for securing the airway during general anesthesia. Occasionally, intubation with an endotracheal tube through a supraglottic airway is indicated. Reported success rates for blind intubation range from 15 to 97%. The authors thus investigated as their primary outcome the fraction of patients who could be intubated blindly with an Air-Qsp supraglottic airway device (Mercury Medical, USA). Second, the authors investigated the influence of muscle relaxation on air leakage pressure, predictors for failed blind intubation, and associated complications of using the supraglottic airway device. METHODS: The authors enrolled 1,000 adults having elective surgery with endotracheal intubation. After routine induction of general anesthesia, a supraglottic airway device was inserted and patients were ventilated intermittently. Air leak pressure was measured before and after full muscle relaxation. Up to two blind intubation attempts were performed. RESULTS: The supraglottic airway provided adequate ventilation and oxygenation in 99% of cases. Blind intubation succeeded in 78% of all patients (95% CI, 75 to 81%). However, the success rate was inconsistent among the three centers (P < 0.001): 80% (95% CI, 75 to 85%) at the Institute of Anesthesia and Pain Therapy, Kantonsspital Winterthur, Winterthur, Switzerland; 41% (95% CI, 29 to 53%) at the Department of Anesthesiology and Intensive Therapy, Medical University of Lodz, Lodz, Poland; and 84% (95% CI, 80 to 88%) at the Institute of Anesthesiology, University Hospital Zurich, Zurich, Switzerland. Leak pressure before relaxation correlated reasonably well with air leak pressure after relaxation. CONCLUSIONS: The supraglottic airway device reliably provided a good airway and allowed blind intubation in nearly 80% of patients. It is thus a reasonable initial approach to airway control. Muscle relaxation can be used safely when unparalyzed leak pressure is adequate.


Assuntos
Equipamentos Descartáveis , Intubação Intratraqueal/instrumentação , Máscaras Laríngeas , Adulto , Idoso , Estudos de Coortes , Desenho de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polônia , Estudos Prospectivos , Suíça
10.
Anesth Analg ; 124(3): 925-933, 2017 03.
Artigo em Inglês | MEDLINE | ID: mdl-28067701

RESUMO

BACKGROUND: Pharmacologic pre- and postconditioning with sevoflurane compared with total IV anesthesia in patients undergoing liver surgery reduced complication rates as shown in 2 recent randomized controlled trials. However, the potential health economic consequences of these different anesthesia regimens have not yet been assessed. METHODS: An expostcost analysis of these 2 trials in 129 patients treated between 2006 and 2010 was performed. We analyzed direct medical costs for in-hospital stay and compared pharmacologic pre- and postconditioning with sevoflurane (intervention) with total IV anesthesia (control) from the perspective of a Swiss university hospital. Year 2015 costs, converted to US dollars, were derived from hospital cost accounting data and compared with a multivariable regression analysis adjusting for relevant covariables. Costs with negative prefix indicate savings and costs with positive prefix represent higher spending in our analysis. RESULTS: Treatment-related costs per patient showed a nonsignificant change by -12,697 US dollars (95% confidence interval [CI], 10,956 to -36,352; P = .29) with preconditioning and by -6139 US dollars (95% CI, 6723 to -19,000; P = .35) with postconditioning compared with the control group. Results were robust in our sensitivity analysis. For both procedures (control and intervention) together, major complications led to a significant increase in costs by 86,018 US dollars (95% CI, 13,839-158,198; P = .02) per patient compared with patients with no major complications. CONCLUSIONS: In this cost analysis, reduced in-hospital costs by pharmacologic conditioning with sevoflurane in patients undergoing liver surgery are suggested. This possible difference in costs compared with total IV anesthesia is the result of reduced complication rates with pharmacologic conditioning, because major complications have significant cost implications.


Assuntos
Anestesia Intravenosa/economia , Análise Custo-Benefício , Hepatopatias/economia , Hepatopatias/cirurgia , Éteres Metílicos/administração & dosagem , Éteres Metílicos/economia , Adulto , Idoso , Anestesia Intravenosa/métodos , Análise Custo-Benefício/métodos , Feminino , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Hepatopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Sevoflurano , Suíça/epidemiologia
11.
Clin Appl Thromb Hemost ; 23(1): 20-26, 2017 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-27233748

RESUMO

BACKGROUND: Sonoclot is used to measure kaolin-based activated clotting time (kACT) for heparin management. Apart from measuring kACT, the device assesses the patient's coagulation status by glass bead-activated tests (gbACTs; measuring also clot rate [CR] and platelet function [PF]). Recently, a new version of the Sonoclot has been released, and the redesign may result in performance changes. The aim of this study was to evaluate and compare the performance of the new (S2) and the previous (S1) Sonoclot. METHODS: The S1 was used in the routine management of 30 patients undergoing elective cardiac surgery. Blood samples were taken at baseline (T1), after heparin administration (200 U/kg, 100 U/kg; T2 and T3), during cardiopulmonary bypass (T4), after protamine infusion (T5), and before intensive care unit transfer (T6). Kaolin-based activated clotting time and gbACTs were measured in duplicate by both the old and the new device and performance compared by Bland-Altman analysis and percentage error calculation. RESULTS: A total of 300 kACT and 180 gbACTs were available. Bland-Altman analysis for kACT revealed that S2 consistently reported results in shorter time compared to S1 (overall = -14.7%). Comparing S2 and S1, the glass bead-activated tests showed mean percentage differences of -18.9% (gbACTs), +37.4% (CR), and -3.7% (PF). CONCLUSION: Since clotting is faster in the new S2 compared to S1, shorter clotting times have to be considered in clinical practice. The use of S2 kACT in heparin management will result in higher heparin and protamine dosing unless heparin kACT target values are adjusted to correct for the differences in results between S1 and S2.


Assuntos
Testes de Coagulação Sanguínea/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Heparina/uso terapêutico , Idoso , Feminino , Heparina/administração & dosagem , Humanos , Masculino , Testes Imediatos
12.
Eur J Emerg Med ; 23(5): 370-4, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-25794114

RESUMO

BACKGROUND: There is only limited information on patient satisfaction with emergency medical services (EMS). The aim of this multicentre survey was to evaluate patient satisfaction in five out-of-hospital physician-based EMS in Austria and Switzerland. METHODS: The psychometrically tested and standardized questionnaire 'patient satisfaction in out-of-hospital emergency care' was used for this survey. The recruitment of the patients was carried out on the basis of inclusion and exclusion criteria. All questionnaires were sent together with an invitation letter and a prepaid return envelope, followed by a reminder 2 weeks later. The descriptive statistical analysis was carried out by an external organization to maintain anonymity. RESULTS: The response rate of all EMS was 46.7%. High satisfaction rates were achieved for the four quality scales 'emergency call, emergency treatment, transport and hospital admission'. A significant difference was found between the Swiss and the Austrian dispatch centres in the judgement of the call takers' social skills. Patient satisfaction with the emergency treatment, for example, reduction of pain, was high in all EMS, independent of whether the EMS is physician (Austria) or physician and emergency medical assistant based (Switzerland). Lowest satisfaction rates were found for items of social skills. CONCLUSION: Patient satisfaction in out-of-hospital physician-based EMS is generally high. There is room for improvement in areas such as the social skills of dispatchers and EMS-team members and the comfort of the patients during transport. A checklist should be developed for basic articles that patients should take along to hospital and for questions on responsibilities for children, dependent people or pets.


Assuntos
Serviços Médicos de Emergência/métodos , Satisfação do Paciente , Adulto , Áustria , Serviços Médicos de Emergência/normas , Feminino , Humanos , Masculino , Satisfação do Paciente/estatística & dados numéricos , Inquéritos e Questionários , Suíça
13.
J Clin Monit Comput ; 30(1): 13-22, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25721853

RESUMO

Septic shock is a serious medical condition. With increased concerns about invasive techniques, a number of non-invasive and semi-invasive devices measuring cardiac output (CO) have become commercially available. The aim of the present study was to determine the accuracy, precision and trending abilities of the FloTrac and the continuous pulmonary artery catheter thermodilution technique determining CO in septic shock patients. Consecutive septic shock patients were included in two centres and CO was measured every 4 h up to 48 h by FloTrac (APCO) and by pulmonary artery catheter (PAC) using the continuous (CCO) and intermittent (ICO) technique. Forty-seven septic shock patients with 326 matched sets of APCO, CCO and ICO data were available for analysis. Bland and Altman analysis revealed a mean bias ±2 SD of 0.0 ± 2.14 L min(-1) for APCO-ICO (%error = 34.5 %) and 0.23 ± 2.55 L min(-1) for CCO-ICO (%error = 40.4 %). Trend analysis showed a concordance of 85 and 81 % for APCO and CCO, respectively. In contrast to CCO, APCO was influenced by systemic vascular resistance and by mean arterial pressure. In septic shock patients, APCO measurements assessed by FloTrac but also the established CCO measurements using the PAC did not meet the currently accepted statistical criteria indicating acceptable clinical performance.


Assuntos
Débito Cardíaco , Diagnóstico por Computador/métodos , Pressão Propulsora Pulmonar , Análise de Onda de Pulso/instrumentação , Choque Séptico/diagnóstico , Software , Calibragem , Cateterismo Periférico/instrumentação , Cateterismo Periférico/métodos , Diagnóstico por Computador/instrumentação , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Testes de Função Cardíaca/instrumentação , Testes de Função Cardíaca/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Análise de Onda de Pulso/métodos , Reprodutibilidade dos Testes , Arábia Saudita , Sensibilidade e Especificidade , Suíça , Termodiluição/métodos
14.
J Cardiothorac Vasc Anesth ; 29(3): 715-22, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25864405

RESUMO

OBJECTIVES: The aim of the study was to determine if Sonoclot with its sensitive glass bead-activated, viscoelastic test can predict postoperative bleeding in patients undergoing cardiac surgery at predefined time points. DESIGN: A prospective, observational clinical study. SETTING: A teaching hospital, single center. PARTICIPANTS: Consecutive patients undergoing cardiac surgery (N = 300). INTERVENTIONS: Besides routine laboratory coagulation studies and heparin management with standard (kaolin) activated clotting time, additional native blood samples were analyzed on a Sonoclot using glass bead-activated tests. Glass bead-activated clotting time, clot rate, and platelet function were recorded immediately before anesthesia induction and at the end of surgery after heparin reversal but before chest closure. MEASUREMENTS AND MAIN RESULTS: Primary outcome was postoperative blood loss (chest tube drainage at 4, 8, and 12 hours postoperatively). Secondary outcome parameters were transfusion requirements, need for surgical re-exploration, time of mechanical ventilation, length of intensive care unit and hospital stay, and hospital morbidity and mortality. Patients were categorized into "bleeders" and "nonbleeders." Patient characteristics, operations, preoperative standard laboratory parameters, and procedural times were comparable between bleeders and nonbleeders except for sex and age. Bleeders had higher rates of transfusions, surgical re-explorations, and complications. Only glass bead measurements by Sonoclot after heparin reversal before chest closure but not preoperatively were predictive for increased postoperative bleeding. CONCLUSIONS: Sonoclot with its glass bead-activated tests may predict the risk for postoperative bleeding in patients undergoing cardiac surgery at the end of surgery after heparin reversal but before chest closure.


Assuntos
Anticoagulantes/uso terapêutico , Coagulação Sanguínea/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Antagonistas de Heparina/uso terapêutico , Heparina/uso terapêutico , Hemorragia Pós-Operatória/diagnóstico , Idoso , Anticoagulantes/efeitos adversos , Coagulação Sanguínea/fisiologia , Testes de Coagulação Sanguínea/métodos , Feminino , Heparina/efeitos adversos , Antagonistas de Heparina/farmacologia , Humanos , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/sangue , Hemorragia Pós-Operatória/etiologia , Valor Preditivo dos Testes , Estudos Prospectivos
15.
Transplantation ; 99(8): 1606-12, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-25769076

RESUMO

BACKGROUND: During times of organ scarcity and extended use of liver grafts, protective strategies in transplantation are gaining importance. We demonstrated in the past that volatile anesthetics such as sevoflurane attenuate ischemia-reperfusion injury during liver resection. In this randomized study, we examined if volatile anesthetics have an effect on acute graft injury and clinical outcomes after liver transplantation. METHODS: Cadaveric liver transplant recipients were enrolled from January 2009 to September 2012 at 3 University Centers (Zurich/Sao Paulo/Ghent). Recipients were randomly assigned to propofol (control group) or sevoflurane anesthesia. Postoperative peak of aspartate transaminase was defined as primary endpoint, secondary endpoints were early allograft dysfunction, in-hospital complications, intensive care unit, and hospital stay. RESULTS: Ninety-eight recipients were randomized to propofol (n = 48) or sevoflurane (n = 50). Median peak aspartate transaminase after transplantation was 925 (interquartile range, 512-3274) in the propofol and 1097 (interquartile range, 540-2633) in the sevoflurane group. In the propofol arm, 11 patients (23%) experienced early allograft dysfunction, 7 (14%) in the sevoflurane one (odds ratio, 0.64 (0.20 to 2.02, P = 0.45). There were 4 mortalities (8.3%) in the propofol and 2 (4.0%) in the sevoflurane group. Overall and major complication rates were not different. An effect on clinical outcomes was observed favoring the sevoflurane group (less severe complications), but without significance. CONCLUSIONS: This first multicenter trial comparing propofol with sevoflurane anesthesia in liver transplantation shows no difference in biochemical markers of acute organ injury and clinical outcomes between the 2 regimens. Sevoflurane has no significant added beneficial effect on ischemia-reperfusion injury compared to propofol.


Assuntos
Anestésicos Inalatórios/uso terapêutico , Anestésicos Intravenosos/uso terapêutico , Transplante de Fígado/métodos , Éteres Metílicos/uso terapêutico , Disfunção Primária do Enxerto/prevenção & controle , Propofol/uso terapêutico , Condicionamento Pré-Transplante/métodos , Adulto , Idoso , Anestésicos Inalatórios/efeitos adversos , Anestésicos Intravenosos/efeitos adversos , Aspartato Aminotransferases/sangue , Bélgica , Biomarcadores/sangue , Brasil , Feminino , Mortalidade Hospitalar , Humanos , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Masculino , Éteres Metílicos/efeitos adversos , Pessoa de Meia-Idade , Razão de Chances , Disfunção Primária do Enxerto/diagnóstico , Disfunção Primária do Enxerto/etiologia , Disfunção Primária do Enxerto/mortalidade , Propofol/efeitos adversos , Fatores de Risco , Sevoflurano , Suíça , Fatores de Tempo , Condicionamento Pré-Transplante/efeitos adversos , Condicionamento Pré-Transplante/mortalidade , Resultado do Tratamento
16.
Perioper Med (Lond) ; 3(1): 10, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-25485103

RESUMO

BACKGROUND: The benefit of the post-anaesthesia care unit (PACU) with respect to an early detection of postoperative complications is beyond dispute. From a patient perspective, prevention and optimal management of pain, nausea and vomiting (PONV) are also of utmost importance. The aims of the study were therefore to prospectively measure pain and PONV on arrival to the PACU and before discharge and to determine the relationship of pain and PONV to the length of stay in the PACU. METHODS: Postoperative pain was assessed over 30 months using a numeric rating scale on admittance to the PACU and before discharge; in addition, PONV was recorded. Statistical analysis was done considering gender, age, American Society of Anesthesiologists (ASA) classification, surgical speciality, anaesthesia technique, duration of anaesthesia, intensity of nursing and length of stay. RESULTS: Data of 12,179 patients were available for analysis. The average length of stay in the PACU was 5.7 ± 5.9 h, whereas regular PACU patients stayed for 3.2 ± 1.9 h and more complex IMC patients stayed for 15.1 ± 6.0 h. On admittance, 27% of patients were in pain and the number decreased to 13% before discharge; 3% experienced PONV. Risk factors for increased pain determined by multivariate analysis were female gender; higher ASA classification; general, cardiac and orthopaedic surgery and prolonged case duration. In more complex IMC patients, pain scores were higher on arrival but dropped to similar levels before discharge compared to regular PACU patients. Female gender and postoperative pain were risk factors for postoperative vomiting. Pain and PONV on arrival correlated with length of stay in the PACU. Pain- or PONV-free patients stayed almost half of the time in the PACU compared to patients with severe pain or vomiting on arrival. CONCLUSIONS: The majority of PACU patients had good pain control, both on admittance and before discharge, and the overall incidence of PONV was low. Managing patients in the PACU could achieve a significant reduction of pain and PONV. The level of pain and presence of PONV on admittance to the PACU correlate with and act as predictors for increased length of PACU stay.

17.
Curr Opin Anaesthesiol ; 27(1): 28-35, 2014 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24304864

RESUMO

PURPOSE OF REVIEW: Advanced hemodynamic monitoring is indispensable for adequate management of patients undergoing major surgery. This article will summarize minimally invasive hemodynamic monitoring technologies and their potential use in thoracic anesthesia. RECENT FINDINGS: According to their inherent principle, currently available technologies can be classified into four groups: bioimpedance and bioreactance, applied Fick's principle, pulse wave analysis and Doppler. All devices measure stroke volume and cardiac output. Functional hemodynamic variables and volumetric parameters have been integrated in some devices. Two major indications can be identified: the 'hemodynamically unstable' patient and the patient 'at risk' for hemodynamic instability. Although there is evidence for the first indication, pre-emptive hemodynamic therapy or perioperative hemodynamic optimization for the patient 'at risk' is still an issue of ongoing debate. There is a growing body of evidence that this approach can positively influence patients' outcome with less postoperative complications in selected patient groups. SUMMARY: Many different minimally invasive hemodynamic monitoring devices have been developed and clinically introduced in the last years. They offer the advantage of being less invasive and easier to use. However, these techniques have several limitations and data are scarce in patients undergoing thoracic anesthesia, preventing their widespread use so far.


Assuntos
Anestesia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Monitorização Intraoperatória/métodos , Procedimentos Cirúrgicos Torácicos/métodos , Débito Cardíaco/fisiologia , Hemodinâmica/fisiologia , Humanos , Ácido Láctico/sangue , Oxigênio/sangue
18.
A A Case Rep ; 2(3): 34-6, 2014 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-25611155

RESUMO

In this case report, we describe a healthy urological patient who suffered severe intraoperative anaphylaxis to chlorhexidine, an ingredient contained in frequently used lubricants (Instillagel, Endosgel). Chlorhexidine is a well-known skin disinfectant and antiseptic component in mouthwash or other over the counter antiseptic pharmaceuticals. There is little awareness that commonly used lubricants may contain hidden chlorhexidine. After severe intraoperative anaphylaxis, it is important to investigate all potential (including hidden) agents that might have caused this life-threatening reaction.

19.
Expert Rev Med Devices ; 7(5): 625-37, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20822386

RESUMO

Platelets play a central role in primary hemostasis. Analysis of platelet function is therefore a cornerstone in the global assessment of the coagulation status in the perioperative setting, primarily in patients receiving antiplatelet medication, such as cyclooxygenase-1 inhibitors, adenosine diphosphate antagonists and glycoprotein IIb/IIIa inhibitors. In these patients, knowledge of residual platelet function is highly warranted in order to maintain an optimal and individual balance perioperatively between platelet function and inhibition - that is, bleeding and thrombosis. Traditional laboratory-based assays, such as light-transmission aggregometry and flow cytometry, are the clinical standards of platelet function testing today. Light-transmission aggregometry is one of the most widely used tests to identify and diagnose defects in platelet function. The majority of the conventional laboratory-based techniques are labor intensive, costly and time consuming, and require a high degree of experience and expertise to perform and interpret. Therefore, new automated technologies have been developed to measure platelet function more rapidly and easily, and several techniques can be used at the bedside, including whole blood aggregometry, high shear-induced platelet function assessment or viscoelastic measurement techniques. All methods assessing platelet function are summarized and their limitations are discussed in this article, emphasizing their perioperative use.


Assuntos
Assistência Perioperatória , Inibidores da Agregação de Plaquetas/uso terapêutico , Humanos , Testes de Função Plaquetária
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