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1.
Eur J Anaesthesiol ; 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33186306

RESUMO

BACKGROUND: The effectiveness of prophylactic continuous positive pressure ventilation (CPAP) after thoracic surgery is not clearly established. OBJECTIVE: The aim of this study was to assess the effectiveness of CPAP immediately after lung resection either by thoracotomy or thoracoscopy in preventing atelectasis and pneumonia. DESIGN: A multicentre, randomised, controlled, open-label trial. SETTINGS: Four large University hospitals at Madrid (Spain) from March 2014 to December 2016. PATIENTS: Immunocompetent patients scheduled for lung resection, without previous diagnosis of sleep-apnoea syndrome or severe bullous emphysema. Four hundred and sixty-four patients were assessed, 426 were randomised and 422 were finally analysed. INTERVENTION: Six hours of continuous CPAP through a Boussignac system versus standard care. MAIN OUTCOME MEASURES: Primary outcome: incidence of the composite endpoint 'atelectasis + pneumonia'. Secondary outcome: incidence of the composite endpoint 'persistent air leak + pneumothorax'. RESULTS: The primary outcome occurred in 35 patients (17%) of the CPAP group and in 58 (27%) of the control group [adjusted relative risk (ARR) 0.53, 95% CI 0.30 to 0.93]. The secondary outcome occurred in 33 patients (16%) of the CPAP group and in 29 (14%) of the control group [ARR 0.92, 95% CI 0.51 to 1.65]. CONCLUSION: Prophylactic CPAP decreased the incidence of the composite endpoint 'postoperative atelectasis + pneumonia' without increasing the incidence of the endpoint 'postoperative persistent air leaks + pneumothorax'.

2.
J Bone Joint Surg Am ; 102(10): 880-888, 2020 May 20.
Artigo em Inglês | MEDLINE | ID: mdl-32118652

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is common and of prognostic importance. Little is known about MINS in orthopaedic surgery. The diagnostic criterion for MINS was a level of ≥0.03 ng/mL on a non-high-sensitivity troponin T (TnT) assay due to myocardial ischemia. METHODS: We undertook an international, prospective study of 15,103 patients ≥45 years of age who had inpatient noncardiac surgery; 3,092 underwent orthopaedic surgery. Non-high-sensitivity TnT assays were performed on postoperative days 0, 1, 2, and 3. Among orthopaedic patients, we determined (1) the prognostic relevance of the MINS diagnostic criteria, (2) the 30-day mortality rate for those with and without MINS, and (3) the probable proportion of MINS cases that would go undetected without troponin monitoring because of a lack of an ischemic symptom. RESULTS: Three hundred and sixty-seven orthopaedic patients (11.9%) had MINS. MINS was associated independently with 30-day mortality including among those who had had orthopaedic surgery. Orthopaedic patients without and with MINS had a 30-day mortality rate of 1.0% and 9.8%, respectively (odds ratio [OR], 11.28; 95% confidence interval [CI], 6.72 to 18.92). The 30-day mortality rate was increased for patients with MINS who had an ischemic feature (i.e., symptoms, or evidence of ischemia on electrocardiography or imaging) (OR, 18.25; 95% CI, 10.06 to 33.10) and for those who did not have an ischemic feature (OR, 7.35; 95% CI, 3.37 to 16.01). The proportion of orthopaedic patients with MINS who were asymptomatic and in whom the myocardial injury would have probably gone undetected without TnT monitoring was 81.3% (95% CI, 76.3% to 85.4%). CONCLUSIONS: One in 8 orthopaedic patients in our study had MINS, and MINS was associated with a higher mortality rate regardless of symptoms. Troponin levels should be measured after surgery in at-risk patients because most MINS cases (>80%) are asymptomatic and would go undetected without routine measurements. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

3.
Eur J Anaesthesiol ; 37(3): 203-211, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32028288

RESUMO

BACKGROUND: In intermediate-to-high-risk patients, major abdominal surgery is associated with a high incidence of postoperative complications, mainly pulmonary. Neuromuscular blocking drugs have been suggested as a contributing factor, but this remains unproven. OBJECTIVE: To define the relationship of neuromuscular blockade management (reversal) with postoperative pulmonary complications (PPCs). DESIGN: The individualised PeRioperative Open-lung approach Versus standard protectivE ventilation in abdominal surgery study was a prospective, multicentre, four-arm, randomised controlled trial. This is a secondary analysis of the data. SETTING: Twenty-one teaching hospitals in Spain. The study was conducted between 2 January 2015, and 18 May 2016. PATIENTS: Age more than 18 years with an intermediate-to-high risk for PPCs, scheduled for major abdominal surgery lasting more than 2 h. Exclusion criteria included pregnancy or breastfeeding, and moderate-to-severe organ diseases. INTERVENTIONS: The mode of reversal of neuromuscular blockade determined two patient groups: pharmacological reversal versus spontaneous recovery. MAIN OUTCOME MEASURES: The primary outcome was a composite of PPCs during the first 30 postoperative days. The association between categorical variables and PPCs within 30 days was studied. Univariate and multivariable logistic regression modelling and propensity score analyses were performed. RESULTS: From the 923 patients included, 596 (64.6%) presented with PPCs within 30 days after surgery. Patients who developed these complications were older with a higher BMI, a lower pre-operative SpO2, a higher ASA physical status score and a higher incidence of arterial hypertension, diabetes mellitus or chronic obstructive pulmonary disease. Pharmacological neuromuscular blockade reversal was associated with a lower incidence of PPCs (odds ratio 0.62, 95% CI 0.47 to 0.82). CONCLUSION: Spontaneous recovery of neuromuscular blockade was an independent risk factor for PPCs in patients with intermediate-to-high risk, undergoing abdominal surgery. We suggest this factor should be included in future studies on PPCs. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT02158923.

4.
Liver Transpl ; 26(5): 681-692, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31944566

RESUMO

Intraoperative factors implicated in postoperative mortality after liver transplantation (LT) are poorly understood. Because LT is a particularly demanding procedure, we hypothesized that intraoperative myocardial injury may be frequent and independently associated with early postoperative outcomes. We aimed to determine the association between intraoperative high-sensitivity troponin (hsTn) elevation during LT and 30-day postoperative mortality. A total of 203 adult patients undergoing LT were prospectively included in the cohort and followed during 1 year. Advanced hemodynamic parameters and serial high-sensitivity troponin T (hsTnT) measurements were assessed at 6 intraoperative time points. The optimal hsTnT cutoff level for intraoperative troponin elevation (ITE) was identified. Patients were classified into 2 groups according to the presence of ITE. Independent impact of ITE on survival was assessed through survival curves and multivariate Cox regression analysis. Intraoperative cardiac function was compared between groups. Troponin levels increased early during surgery in the ITE group. Troponin values at abdominal closure were associated with 30-day mortality (area under the receiver operating caracteristic curve, [AUROC], 0.73; P = 0.005). Patients with ITE showing values of hsTnT ≥61 ng/L at abdominal closure presented higher 30-day mortality (29.6% versus 3.4%; P < 0.001). ITE was independently associated with 30-day mortality (hazard ratio, 3.8; 95% confidence interval, 1.1-13.8; P = 0.04) and with worse overall intraoperative cardiac function. The hsTnT upper reference limit showed no discriminant capacity during LT. Intraoperative myocardial injury identified by hsTn elevation is frequently observed during LT, and it is associated with myocardial dysfunction and short-term mortality. Determinations of hsTn may serve as a valuable intraoperative monitoring tool during LT.

5.
Br J Anaesth ; 124(1): 110-120, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31767144

RESUMO

BACKGROUND: We aimed to examine whether using a high fraction of inspired oxygen (FIO2) in the context of an individualised intra- and postoperative open-lung ventilation approach could decrease surgical site infection (SSI) in patients scheduled for abdominal surgery. METHODS: We performed a multicentre, randomised controlled clinical trial in a network of 21 university hospitals from June 6, 2017 to July 19, 2018. Patients undergoing abdominal surgery were randomly assigned to receive a high (0.80) or conventional (0.3) FIO2 during the intraoperative period and during the first 3 postoperative hours. All patients were mechanically ventilated with an open-lung strategy, which included recruitment manoeuvres and individualised positive end-expiratory pressure for the best respiratory-system compliance, and individualised continuous postoperative airway pressure for adequate peripheral oxyhaemoglobin saturation. The primary outcome was the prevalence of SSI within the first 7 postoperative days. The secondary outcomes were composites of systemic complications, length of intensive care and hospital stay, and 6-month mortality. RESULTS: We enrolled 740 subjects: 371 in the high FIO2 group and 369 in the low FIO2 group. Data from 717 subjects were available for final analysis. The rate of SSI during the first postoperative week did not differ between high (8.9%) and low (9.4%) FIO2 groups (relative risk [RR]: 0.94; 95% confidence interval [CI]: 0.59-1.50; P=0.90]). Secondary outcomes, such as atelectasis (7.7% vs 9.8%; RR: 0.77; 95% CI: 0.48-1.25; P=0.38) and myocardial ischaemia (0.6% [n=2] vs 0% [n=0]; P=0.47) did not differ between groups. CONCLUSIONS: An oxygenation strategy using high FIO2 compared with conventional FIO2 did not reduce postoperative SSIs in abdominal surgery. No differences in secondary outcomes or adverse events were found. CLINICAL TRIAL REGISTRATION: NCT02776046.


Assuntos
Oxigênio/uso terapêutico , Respiração Artificial/métodos , Infecção da Ferida Cirúrgica/prevenção & controle , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Oxiemoglobinas/análise , Oxiemoglobinas/metabolismo , Assistência Perioperatória , Respiração com Pressão Positiva , Medicina de Precisão , Atelectasia Pulmonar/epidemiologia , Atelectasia Pulmonar/etiologia , Resultado do Tratamento
6.
Minerva Anestesiol ; 86(4): 404-415, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31808662

RESUMO

BACKGROUND: Postoperative pulmonary complications (PPCs) negatively affect morbidity, healthcare costs and postsurgical survival. Preoperative and intraoperative peripheral oxyhemoglobin saturation (SpO2) levels are independent risk factors for postoperative pulmonary complications (PPCs). The air-test assesses the value of SpO2 while breathing room-air. We aimed at building a clinical score that includes the air-test for predicting the risk for PPCs. METHODS: This is a development and validation study in patients -randomly divided into two cohorts- from a large randomized clinical trial (iPROVE) that enrolled 964 intermediate-to-high risk patients scheduled for abdominal surgery. Arterial oxygenation was assessed on room-air in the preoperative period (preoperative air-test) and 3h after admission to the postoperative care unit (postoperative air-test). The air-test was defined as positive or negative if SpO2 was ≤96% or >96%, respectively. Positive air-tests were stratified into weak (93-96%) or strong (<93%). The primary outcome was a composite of moderate-to-severe PPCs during the first seven postoperative days. RESULTS: A total of 902 patients were included in the final analysis (542 in the development cohort and 360 in the validation cohort). Regression analysis identified five independent risk factors for PPC: age, type of surgery, pre- and postoperative air-test, and atelectasis. The area under the receiver operating characteristic curve (AUC) was 0.79 (95% CI: 0.75-0.82) when including these five independent predictors. We built a simplified score termed "air-test score" by using only the pre- and postoperative SpO2, resulting in an AUC of 0.72 (95% CI: 0.67-0.76) for the derivation and 0.72 (95% CI: 0.66-0.78) for the validation cohort, respectively. The air-test score stratified patients into four levels of risk, with PPCs ranging from <15% to >75%. CONCLUSIONS: The simple, non-invasive and inexpensive bedside air-test score, evaluating pre- and postoperatively SpO2 measured on room-air, helps to predict the risk for PPCs.

7.
Trials ; 20(1): 622, 2019 Nov 06.
Artigo em Inglês | MEDLINE | ID: mdl-31694684

RESUMO

BACKGROUND: Use of minimally invasive surgical techniques for lung resection surgery (LRS), such as video-assisted thoracoscopy (VATS), has increased in recent years. However, there is little information about the best anesthetic technique in this context. This surgical approach is associated with a lower intensity of postoperative pain, and its use has been proposed in programs for enhanced recovery after surgery (ERAS). This study compares the severity of postoperative complications in patients undergoing LRS who have received lidocaine intraoperatively either intravenously or via paravertebral administration versus saline. METHODS/DESIGN: We will conduct a single-center randomized controlled trial involving 153 patients undergoing LRS through a thoracoscopic approach. The patients will be randomly assigned to one of the following study groups: intravenous lidocaine with more paravertebral thoracic (PVT) saline, PVT lidocaine with more intravenous saline, or intravenous remifentanil with more PVT saline. The primary outcome will be the comparison of the postoperative course through Clavien-Dindo classification. Furthermore, we will compare the perioperative pulmonary and systemic inflammatory response by monitoring biomarkers in the bronchoalveolar lavage fluid and blood, as well as postoperative analgesic consumption between the three groups of patients. We will use an ANOVA to compare quantitative variables and a chi-squared test to compare qualitative variables. DISCUSSION: The development of less invasive surgical techniques means that anesthesiologists must adapt their perioperative management protocols and look for anesthetic techniques that provide good analgesic quality and allow rapid rehabilitation of the patient, as proposed in the ERAS protocols. The administration of a continuous infusion of intravenous lidocaine has proven to be useful and safe for the management of other types of surgery, as demonstrated in colorectal cancer. We want to know whether the continuous administration of lidocaine by a paravertebral route can be substituted with the intravenous administration of this local anesthetic in a safe and effective way while avoiding the risks inherent in the use of regional anesthetic techniques. In this way, this technique could be used in a safe and effective way in ERAS programs for pulmonary resection. TRIAL REGISTRATION: EudraCT, 2016-004271-52; ClinicalTrials.gov, NCT03905837 . Protocol number IGGFGG-2016 version 4.0, 27th April 2017.


Assuntos
Anestésicos Locais/administração & dosagem , Lidocaína/administração & dosagem , Pneumonectomia/métodos , Complicações Pós-Operatórias/epidemiologia , Método Duplo-Cego , Recuperação Pós-Cirúrgica Melhorada , Humanos , Infusões Intravenosas , Assistência Perioperatória , Toracoscopia
8.
CMAJ ; 191(30): E830-E837, 2019 07 29.
Artigo em Inglês | MEDLINE | ID: mdl-31358597

RESUMO

BACKGROUND: Among adults undergoing contemporary noncardiac surgery, little is known about the frequency and timing of death and the associations between perioperative complications and mortality. We aimed to establish the frequency and timing of death and its association with perioperative complications. METHODS: We conducted a prospective cohort study of patients aged 45 years and older who underwent inpatient noncardiac surgery at 28 centres in 14 countries. We monitored patients for complications until 30 days after surgery and determined the relation between these complications and 30-day mortality using a Cox proportional hazards model. RESULTS: We included 40 004 patients. Of those, 715 patients (1.8%) died within 30 days of surgery. Five deaths (0.7%) occurred in the operating room, 500 deaths (69.9%) occurred after surgery during the index admission to hospital and 210 deaths (29.4%) occurred after discharge from the hospital. Eight complications were independently associated with 30-day mortality. The 3 complications with the largest attributable fractions (AF; i.e., potential proportion of deaths attributable to these complications) were major bleeding (6238 patients, 15.6%; adjusted hazard ratio [HR] 2.6, 95% confidence interval [CI] 2.2-3.1; AF 17.0%); myocardial injury after noncardiac surgery [MINS] (5191 patients, 13.0%; adjusted HR 2.2, 95% CI 1.9-2.6; AF 15.9%); and sepsis (1783 patients, 4.5%; adjusted HR 5.6, 95% CI 4.6-6.8; AF 12.0%). INTERPRETATION: Among adults undergoing noncardiac surgery, 99.3% of deaths occurred after the procedure and 44.9% of deaths were associated with 3 complications: major bleeding, MINS and sepsis. Given these findings, focusing on the prevention, early identification and management of these 3 complications holds promise for reducing perioperative mortality. Study registration: ClinicalTrials.gov, no. NCT00512109.


Assuntos
Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Hemorragia Pós-Operatória/mortalidade , Estudos Prospectivos , Sepse/mortalidade
9.
Rev. bras. anestesiol ; 69(3): 242-252, May-June 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-1013413

RESUMO

Abstract Background and objectives: Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. Methods: We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation periods. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. acute kidney injury was diagnosed within 48 h of surgery based on acute kidney injury criteria. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. Results: The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6 h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89 pg.mL-1). Conclusions: Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.


Resumo Justificativa e objetivos: Os pacientes submetidos à cirurgia de ressecção pulmonar apresentam risco de desenvolver lesão renal aguda pós-operatória. A determinação dos níveis de citocinas permite detectar uma resposta inflamatória precoce. Investigamos a relação temporal entre o estado inflamatório perioperatório e o desenvolvimento de lesão renal aguda após cirurgia de ressecção pulmonar. Além disso, avaliamos o impacto da lesão renal aguda no desfecho e analisamos a viabilidade das citocinas para prever este tipo de lesão. Métodos: No total, foram analisados prospectivamente 174 pacientes agendados para cirurgia eletiva de ressecção pulmonar com períodos intraoperatórios de ventilação monopulmonar. Lavado bronco-alveolar com fibra óptica foi realizado em cada pulmão antes e após os períodos de ventilação monopulmonar para análise das citocinas. Os níveis de citocina foram medidos a partir de amostras de sangue arterial em cinco momentos. A lesão renal aguda foi diagnosticada dentro de 48 horas após a cirurgia, com base nos critérios para sua verificação. Analisamos a associação entre lesão renal aguda e complicações cardiopulmonares, tempo de internação em unidade de terapia intensiva e de internação hospitalar, reinternação em unidade de terapia intensiva e mortalidade a curto e longo prazos. Resultados: A incidência de lesão renal aguda no estudo foi de 6,9% (12/174). Os pacientes com lesão renal aguda apresentaram níveis mais altos de citocinas plasmáticas após a cirurgia, mas não foram detectadas diferenças nas citocinas alveolares. Embora nenhum paciente tenha precisado de terapia renal substitutiva, os com lesão renal aguda apresentaram maior incidência de complicações cardiopulmonares e aumento da mortalidade geral. A interleucina-6 plasmática em seis horas foi a citocina mais preditiva de lesão renal aguda (ponto de corte em 4,89 pg.mL-1). Conclusões: O aumento dos níveis plasmáticos de citocinas no pós-operatório está associado à lesão renal aguda após cirurgia de ressecção pulmonar no estudo, o que piora o prognóstico. A interleucina-6 plasmática pode ser usada como um indicador precoce para pacientes com risco de desenvolver lesão renal aguda após cirurgia de ressecção pulmonar.


Assuntos
Humanos , Masculino , Feminino , Idoso , Complicações Pós-Operatórias/diagnóstico , Procedimentos Cirúrgicos Pulmonares/efeitos adversos , Citocinas/sangue , Lesão Renal Aguda/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Pulmonares/métodos , Incidência , Valor Preditivo dos Testes , Estudos Prospectivos , Lavagem Broncoalveolar , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/epidemiologia , Ventilação Monopulmonar , Pessoa de Meia-Idade
10.
Rev Bras Anestesiol ; 69(3): 242-252, 2019.
Artigo em Português | MEDLINE | ID: mdl-31133282

RESUMO

BACKGROUND AND OBJECTIVES: Patients undergoing lung resection surgery are at risk of developing postoperative acute kidney injury. Determination of cytokine levels allows the detection of an early inflammatory response. We investigated any temporal relationship among perioperative inflammatory status and development of acute kidney injury after lung resection surgery. Furthermore, we evaluated the impact of acute kidney injury on outcome and analyzed the feasibility of cytokines to predict acute kidney injury. METHODS: We prospectively analyzed 174 patients scheduled for elective lung resection surgery with intra-operative periods of one-lung ventilation. Fiberoptic broncho-alveolar lavage was performed in each lung before and after one-lung ventilation periods for cytokine analysis. As well, cytokine levels were measured from arterial blood samples at five time points. Acute kidney injury was diagnosed within 48h of surgery based estabilished criteria for its diagnosis. We analyzed the association between acute kidney injury and cardiopulmonary complications, length of intensive care unit and hospital stays, intensive care unit re-admission, and short-term and long-term mortality. RESULTS: The incidence of acute kidney injury in our study was 6.9% (12/174). Acute kidney injury patients showed higher plasma cytokine levels after surgery, but differences in alveolar cytokines were not detected. Although no patient required renal replacement therapy, acute kidney injury patients had higher incidence of cardiopulmonary complications and increased overall mortality. Plasma interleukin-6 at 6h was the most predictive cytokine of acute kidney injury (cut-off point at 4.89pg.mL-1). CONCLUSIONS: Increased postoperative plasma cytokine levels are associated with acute kidney injury after lung resection surgery in our study, which worsens the prognosis. Plasma interleukin-6 may be used as an early indicator for patients at risk of developing acute kidney injury after lung resection surgery.


Assuntos
Lesão Renal Aguda/diagnóstico , Citocinas/sangue , Complicações Pós-Operatórias/diagnóstico , Procedimentos Cirúrgicos Pulmonares/efeitos adversos , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Idoso , Lavagem Broncoalveolar , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ventilação Monopulmonar , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Estudos Prospectivos , Procedimentos Cirúrgicos Pulmonares/métodos
11.
J Cardiothorac Vasc Anesth ; 33(9): 2492-2502, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30928294

RESUMO

OBJECTIVE: The aim of this clinical trial is to examine whether it is possible to reduce postoperative complications using an individualized perioperative ventilatory strategy versus using a standard lung-protective ventilation strategy in patients scheduled for thoracic surgery requiring one-lung ventilation. DESIGN: International, multicenter, prospective, randomized controlled clinical trial. SETTING: A network of university hospitals. PARTICIPANTS: The study comprises 1,380 patients scheduled for thoracic surgery. INTERVENTIONS: The individualized group will receive intraoperative recruitment maneuvers followed by individualized positive end-expiratory pressure (open lung approach) during the intraoperative period plus postoperative ventilatory support with high-flow nasal cannula, whereas the control group will be managed with conventional lung-protective ventilation. MEASUREMENTS AND MAIN RESULTS: Individual and total number of postoperative complications, including atelectasis, pneumothorax, pleural effusion, pneumonia, acute lung injury; unplanned readmission and reintubation; length of stay and death in the critical care unit and in the hospital will be analyzed for both groups. The authors hypothesize that the intraoperative application of an open lung approach followed by an individual indication of high-flow nasal cannula in the postoperative period will reduce pulmonary complications and length of hospital stay in high-risk surgical patients.


Assuntos
Internacionalidade , Ventilação Monopulmonar/métodos , Assistência Perioperatória/métodos , Respiração com Pressão Positiva/métodos , Medicina de Precisão/métodos , Cirurgia Torácica Vídeoassistida/métodos , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Método Simples-Cego , Cirurgia Torácica Vídeoassistida/efeitos adversos
12.
J Clin Monit Comput ; 33(6): 1043-1054, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30656507

RESUMO

Early detection of patients with a high risk of postoperative pulmonary complications (PPCs) could improve postoperative strategies. We investigated the role of monitoring systemic and lung inflammatory biomarkers during surgery and the early postoperative period to detect patients at high risk of PPCs after lung resection surgery (LRS). This is a substudy of a randomized control trial on the inflammatory effects of anaesthetic drugs during LRS. We classified patients into two groups, depending on whether or not they developed PPCs. We constructed three multivariate logistic regression models to analyse the power of the biomarkers to predict PPCs. Model 1 only included the usual clinical variables; Model 2 included lung and systemic inflammatory biomarkers; and Model 3 combined Models 1 and 2. Comparisons between mathematical models were based on the area under the receiver operating characteristic curve (AUROC) and tests of integrated discrimination improvement (IDI). Statistical significance was set at p < 0.05. PPCs were detected in 37 (21.3%) patients during admission. The AUROC for Models 1, 2, and 3 was 0.79 (95% CI 0.71-0.87), 0.80 (95% CI 0.72-0.88), and 0.93 (95% CI 0.88-0.97), respectively. Comparison of the AUROC between Models 1 and 2 did not reveal statistically significant values (p = 0.79). However, Model 3 was superior to Model 1 (p < 0.001). Model 3 had had an IDI of 0.29 (p < 0.001) and a net reclassification index of 0.28 (p = 0.007). A mathematical model combining inflammation biomarkers with clinical variables predicts PPCs after LRS better than a model that includes only clinical data. Clinical registration number Clinical Trial Registration NCT02168751; EudraCT 2011-002294-29.


Assuntos
Pulmão/cirurgia , Complicações Pós-Operatórias/diagnóstico , Idoso , Anestesia/métodos , Área Sob a Curva , Biomarcadores/metabolismo , Líquido da Lavagem Broncoalveolar , Citocinas/metabolismo , Feminino , Volume Expiratório Forçado , Hemodinâmica , Humanos , Inflamação , Pulmão/metabolismo , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Análise Multivariada , Probabilidade , Estudos Prospectivos , Curva ROC , Fatores de Risco , Cirurgia Torácica
13.
Surg Laparosc Endosc Percutan Tech ; 29(2): 101-108, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30601429

RESUMO

It is well known that surgery provokes an inflammatory response. However, the induced inflammatory response to laparoscopic compared with open surgery under combined anesthesia has never been compared following colorectal cancer surgery. We hypothesize that laparoscopic technique under general anesthesia results in a decreased proinflammatory state. We compared cytokines plasma secretion after laparoscopic technique under general anesthesia (LG), open surgery under combined anesthesia (thoracic epidural and general anesthesia) (OGE), and open surgery under general anesthesia as the control group (OG). Proinflammatory cytokines measured postoperatively were significantly increased in the OG group (n=19), compared with the LG (n=18) and OGE (n=20) groups. Post hoc analysis showed that CCL2 levels were significantly lower in LG at all times postoperatively (P<0.01), while interleukin-4, an anti-inflammatory cytokine, was increased in the OGE group (P<0.01). Laparoscopic technique blunts the postoperative proinflammatory response from the very early stages of the inflammatory cascade, whereas combined anesthesia is a more anti-inflammatory approach.


Assuntos
Quimiocina CCL2/metabolismo , Neoplasias Colorretais/cirurgia , Laparoscopia , Idoso , Proteína C-Reativa/metabolismo , Feminino , Humanos , Hidrocortisona/metabolismo , Leucócitos/fisiologia , Masculino , Metaloproteinase 3 da Matriz/metabolismo , Pró-Calcitonina/metabolismo , Estudos Prospectivos , Fator A de Crescimento do Endotélio Vascular/metabolismo
14.
Rev. bras. anestesiol ; 69(1): 48-57, Jan.-Feb. 2019. tab, graf
Artigo em Inglês | LILACS | ID: biblio-977418

RESUMO

Abstract Background: Anesthetic pre-conditioning attenuates inflammatory response during ischemia-reperfusion lung injury. The molecular mechanisms to explain it are not fully understood. The aim of our investigation was to analyze the molecular mechanism that explain the anti-inflammatory effects of anesthetic pre-conditioning with sevoflurane focusing on its effects on MAPKs (mitogen-activated protein kinases), NF-κB (nuclear factor kappa beta) pathways, and apoptosis in an experimental lung autotransplant model. Methods: Twenty large white pigs undergoing pneumonectomy plus lung autotransplant were divided into two 10-member groups on the basis of the anesthetic received (propofol or sevoflurane). Anesthetic pre-conditioning group received sevoflurane 3% after anesthesia induction and it stopped when one-lung ventilation get started. Control group did not receive sevoflurane in any moment during the whole study period. Intracellular signal-transduction pathways (MAPK family), transcription factor (NF-κB), and apoptosis (caspases 3 and 9) were analyzed during experiment. Results: Pigs that received anesthetic pre-conditioning with sevoflurane have shown significant lower values of MAPK-p38, MAPK-P-p38, JNK (c-Jun N-terminal kinases), NF-κB p50 intranuclear, and caspases (p < 0.05) than pigs anesthetized with intravenous propofol. Conclusions: Lung protection of anesthetic pre-conditioning with sevoflurane during experimental lung autotransplant is, at least, partially associated with MAPKs and NF κB pathways attenuation, and antiapoptotic effects.


Resumo Justificativa: O pré-condicionamento anestésico atenua a resposta inflamatória durante a lesão de isquemia-reperfusão do pulmão. Os mecanismos moleculares para explicá-lo não são totalmente compreendidos. O objetivo de nossa investigação foi analisar o mecanismo molecular que explica os efeitos anti-inflamatórios do pré-condicionamento anestésico com sevoflurano, enfocar seus efeitos sobre as proteínas quinases ativadas por mitógenos (MAPKs), o fator nuclear kappa beta (NF-κB) e a apoptose em modelo experimental de autotransplante pulmonar. Métodos: Vinte porcos Large White submetidos à pneumonectomia e autoimplante de pulmão foram divididos em dois grupos de 10 membros com base no anestésico recebido (propofol ou sevoflurano). O grupo de pré-condicionamento anestésico recebeu sevoflurano a 3% após a indução da anestesia, que foi descontinuado quando a ventilação monopulmonar foi iniciada. O grupo controle não recebeu sevoflurano em qualquer momento durante todo o período do estudo. As vias de transdução de sinal intracelular (família MAPK), o fator de transcrição (NF-κB) e a apoptose (caspases 3 e 9) foram analisados durante o experimento. Resultados: Os suínos que receberam pré-condicionamento anestésico com sevoflurano apresentaram valores mais baixos de MAPK-p38, MAPK-P-p38, c-Jun N-terminal quinases (JNK), NF-κB p50 intranuclear e caspases (p < 0,05) do que os suínos anestesiados com propofol intravenoso. Conclusões: A proteção pulmonar do pré-condicionamento anestésico com sevoflurano durante o autotransplante pulmonar experimental está, pelo menos, parcialmente associada à atenuação das vias de MAPKs e NF κB e aos efeitos antiapoptóticos.


Assuntos
Animais , Transdução de Sinais/efeitos dos fármacos , Transplante de Pulmão , Apoptose/efeitos dos fármacos , Anestésicos Inalatórios/farmacologia , Sevoflurano/farmacologia , Anestesia/métodos , Suínos , Transplante Autólogo , Modelos Teóricos
15.
Rev Bras Anestesiol ; 69(1): 48-57, 2019.
Artigo em Português | MEDLINE | ID: mdl-30459087

RESUMO

BACKGROUND: Anesthetic pre-conditioning attenuates inflammatory response during ischemia-reperfusion lung injury. The molecular mechanisms to explain it are not fully understood. The aim of our investigation was to analyze the molecular mechanism that explain the anti-inflammatory effects of anesthetic pre-conditioning with sevoflurane focusing on its effects on MAPKs (mitogen-activated protein kinases), NF-κB (nuclear factor kappa beta) pathways, and apoptosis in an experimental lung autotransplant model. METHODS: Twenty large white pigs undergoing pneumonectomy plus lung autotransplant were divided into two 10-member groups on the basis of the anesthetic received (propofol or sevoflurane). Anesthetic pre-conditioning group received sevoflurane 3% after anesthesia induction and it stopped when one-lung ventilation get started. Control group did not receive sevoflurane in any moment during the whole study period. Intracellular signal-transduction pathways (MAPK family), transcription factor (NF-κB), and apoptosis (caspases 3 and 9) were analyzed during experiment. RESULTS: Pigs that received anesthetic pre-conditioning with sevoflurane have shown significant lower values of MAPK-p38, MAPK-P-p38, JNK (c-Jun N-terminal kinases), NF-κB p50 intranuclear, and caspases (p<0.05) than pigs anesthetized with intravenous propofol. CONCLUSIONS: Lung protection of anesthetic pre-conditioning with sevoflurane during experimental lung autotransplant is, at least, partially associated with MAPKs and NF κB pathways attenuation, and antiapoptotic effects.


Assuntos
Anestesia/métodos , Anestésicos Inalatórios/farmacologia , Apoptose/efeitos dos fármacos , Transplante de Pulmão , Sevoflurano/farmacologia , Transdução de Sinais/efeitos dos fármacos , Animais , Modelos Teóricos , Suínos , Transplante Autólogo
16.
Anesth Analg ; 128(1): 168-175, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30234542

RESUMO

BACKGROUND: Lung resection surgery (LRS) is associated with systemic and pulmonary inflammation, which can affect postoperative outcomes. Activation of ß-adrenergic receptors increases the expression of proinflammatory and anti-inflammatory mediators, and their blockade may attenuate the systemic inflammatory response. The aim of this study was to analyze the effect of a continuous perioperative intravenous perfusion of esmolol on postoperative pulmonary edema in an experimental model of LRS requiring periods of one-lung ventilation (OLV). METHODS: Twenty-four large white pigs were randomly assigned to 3 groups: control (CON), esmolol (ESM), and sham. The ESM group received an intravenous esmolol bolus (0.5 mg/kg) and then an esmolol infusion (0.05 mg·kg·minute) throughout the procedure. The CON group received the same volume of 0.9% saline solution as the ESM group plus a continual infusion of saline. The sham group underwent a left thoracotomy without LRS or OLV. At the end of the LRS, the animals were awakened, and after 24 hours, they underwent general anesthesia again. Lung biopsies and plasma samples were obtained to analyze the levels and expression of inflammatory mediators, and the animals also received a bronchoalveolar lavage. RESULTS: At 24 hours after the operation, the ESM group had less lung edema and lower expression of the proinflammatory biomarkers tumor necrosis factor (TNF) and interleukin (IL)-1 compared to the CON group for both lung lobes. For the mediastinal lobe biopsies, the mean difference and 95% confidence interval (CI) between the groups for edema, TNF, and IL-1 were 14.3 (95% CI, 5.6-23.1), P = .002; 0.19 (95% CI, 0.07-0.32), P = .002; and 0.13 (95% CI, 0.04-0.22), P = .006, respectively. In the left upper lobe, the mean differences for edema, TNF, and IL-1 were 12.4 (95% CI, 4.2-20.6), P = .003; 0.25 (95% CI, 0.12-0.37), P < .001; and 0.3 (95% CI, 0.08-0.53), P = .009. CONCLUSIONS: Our results suggest that esmolol reduces lung edema and inflammatory responses in the intraoperative and postoperative periods in animals that underwent LRS with OLV.


Assuntos
Antagonistas de Receptores Adrenérgicos beta 1/administração & dosagem , Anti-Inflamatórios/administração & dosagem , Mediadores da Inflamação/sangue , Cuidados Intraoperatórios/métodos , Pulmão/efeitos dos fármacos , Pulmão/cirurgia , Pneumonectomia/efeitos adversos , Pneumonia/prevenção & controle , Propanolaminas/administração & dosagem , Edema Pulmonar/prevenção & controle , Animais , Biomarcadores/sangue , Líquido da Lavagem Broncoalveolar/química , Modelos Animais de Doenças , Esquema de Medicação , Infusões Intravenosas , Interleucina-1/sangue , Pulmão/metabolismo , Pulmão/patologia , Pneumonia/sangue , Pneumonia/etiologia , Pneumonia/patologia , Edema Pulmonar/sangue , Edema Pulmonar/etiologia , Sus scrofa , Fatores de Tempo , Fator de Necrose Tumoral alfa/sangue
17.
Eur Surg Res ; 59(3-4): 115-125, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30089286

RESUMO

PURPOSE: Ischaemia-reperfusion injury (IRI) is a main cause of morbidity after pulmonary resection surgery. The degradation of glycocalyx, a dynamic layer of macromolecules at the luminal surface of the endothelium, seems to participate in tissue dysfunction after IRI. Lidocaine has a proven anti-inflammatory activity in several tissues but its modulation of glycocalyx has not been investigated. This work aimed to investigate the potential involvement of glycocalyx in lung IRI in a lung auto-transplantation model and the possible effect of lidocaine in modulating IRI. METHODS: Three groups (sham-operated, control, and lidocaine), each consisting of 6 Large White pigs, were subjected to lung auto-transplantation. All groups received the same anaesthesia. In addition, the lidocaine group received a continuous IV administration of lidocaine (1.5 mg/kg/h). Lung tissue and plasma samples were taken before pulmonary artery clamp, before reperfusion, and 30 and 60 min post-reperfusion in order to analyse pulmonary oedema, glycocalyx components, adhesion molecules, and myeloperoxidase level. RESULTS: Ischaemia caused pulmonary oedema, which was greater after reperfusion. This effect was accompanied by decreased levels of syndecan-1 and heparan sulphate in the lung samples, together with increased levels of both glycocalyx components in the plasma samples. After reperfusion, neutrophil activation and the expression of adhesion molecules were increased. All these alterations were significantly lower or absent in the lidocaine group. CONCLUSION: Lung IRI caused glycocalyx degradation that contributed to neutrophil activation and adhesion. The administration of lidocaine was able to protect the lung from glycocalyx degradation.


Assuntos
Glicocálix/metabolismo , Transplante de Pulmão/efeitos adversos , Traumatismo por Reperfusão/etiologia , Animais , Adesão Celular , Heparitina Sulfato/análise , Lidocaína/farmacologia , Masculino , Ativação de Neutrófilo , Suínos
18.
Rev. bras. anestesiol ; 68(3): 225-230, May-June 2018. tab, graf
Artigo em Inglês | LILACS-Express | LILACS | ID: biblio-958304

RESUMO

Abstract Introduction: In last few years, emphasis was placed in goal-directed therapy in order to optimize patient's hemodynamic status and improve their prognosis. Parameters based on the interaction between heart and lungs have been questioned in situations like low tidal volume and open chest surgery. The goal of the study was to analyze the changes that one-lung ventilation can produce over stroke volume variation and to assess the possible impact of airway pressures and lung compliance over stroke volume variation. Methods: Prospective observational study, 112 patients undergoing lung resection surgery with one-lung ventilation periods were included. Intravenous fluid therapy with crystalloids was set at 2 mL.g-1. Hypotension episodes were treated with vasoconstrictive drugs. Two-lung Ventilation was implemented with a TV of 8 mL.g-1 and one-lung ventilation was managed with a TV of 6 mL.g-1. Invasive blood pressure was monitored. We recorded the following cardiorespiratory values: heart rate, mean arterial pressure, cardiac index, stroke volume index, airway peak pressure, airway plateau pressure and static lung compliance at 3 different times during surgery: immediately after lung collapse, 30 min after initiating one-lung ventilation and after restoration of two-lung ventilation. Results: Stroke volume variation values were influenced by lung collapse (before lung collapse 14.6 (DS) vs. OLV 9.9% (DS), p < 0.0001); or after restoring two-lung ventilation (11.01 (DS), p < 0.0001). During two-lung Ventilation there was a significant correlation between airway pressures and stroke volume variation, however this correlation lacks during one-lung ventilation. Conclusion: The decrease of stroke volume variation values during one-lung ventilation with protective ventilatory strategies advices not to use the same threshold values to determine fluid responsiveness.


Resumo Introdução: Nos últimos anos, a importância da terapia alvo-dirigida foi enfatizada para aprimorar o estado hemodinâmico do paciente e melhorar seu prognóstico. Os parâmetros baseados na interação entre o coração e os pulmões foram questionados em situações como baixo volume corrente e cirurgia aberta do tórax. O objetivo do estudo foi analisar as alterações que a ventilação monopulmonar pode produzir na variação do volume sistólico e avaliar o possível impacto das pressões da via aérea e da complacência pulmonar sobre a variação do volume sistólico. Métodos: Estudo observacional prospectivo, no qual 112 pacientes submetidos à cirurgia de ressecção pulmonar com períodos de ventilação monopulmonar foram incluídos. A terapia de fluídos intravenosos com cristaloides foi ajustada a 2 mL.kg-1.h-1. Os episódios de hipotensão foram tratados com vasoconstritores. A ventilação dos dois pulmões (VDP) foi implantada com volume corrente de 8 mL.kg-1 e a ventilação monopulmonar foi controlada com volume corrente de 6 mL.kg-1. Foi monitorada a pressão arterial invasiva. Registramos os seguintes valores cardiorrespiratórios: frequência cardíaca, pressão arterial média, índice cardíaco, índice de volume sistólico, pressão de pico das vias aéreas, pressão de platô das vias aéreas e complacência pulmonar estática em três tempos durante a cirurgia: imediatamente após o colapso do pulmão, 30 minutos após o início da ventilação monopulmonar e após a restauração da ventilação dos dois pulmões. Resultados: Os valores de variação do volume sistólico foram influenciados pelo colapso pulmonar (antes do colapso pulmonar 14,6 [DS] vs. ventilação monopulmonar 9,9% [DS], p < 0,0001), ou após o restabelecimento da ventilação dos dois pulmões (11,01 [DS], p < 0,0001). Durante a ventilação dos dois pulmões houve uma correlação significativa entre as pressões das vias aéreas e a variação do volume sistólico, porém, essa correlação não existe durante a ventilação monopulmonar. Conclusão: A diminuição dos valores da variação do volume sistólico durante a ventilação monopulmonar com estratégias ventilatórias protetoras sugere não usar os mesmos valores de limiar para determinar a responsividade aos fluídos.

19.
J Cardiothorac Vasc Anesth ; 32(6): 2665-2672, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29709437

RESUMO

OBJECTIVE: Thoracic surgical procedures are associated with an increased risk of postoperative pulmonary complications (PPCs), which seem to be related directly to intraoperative driving pressure. The authors conducted this study to describe the incidence of PPCs in patients in whom an individualized open-lung approach was applied during one-lung ventilation. DESIGN: This was a prospective, multicenter, national descriptive study. SETTING: Thoracic surgery patients undergoing one-lung ventilation. PARTICIPANTS: Eligible participants were included consecutively from October 1, 2016, to September 30, 2017. A total of 690 patients were included. INTERVENTIONS: An individualized open-lung approach that consisted of an alveolar recruitment maneuver followed by a positive end-expiratory pressure adjusted to best respiratory system compliance was performed in all patients. MEASUREMENTS AND MAIN RESULTS: Preoperative and intraoperative data were recorded; the primary outcome was a description of the incidence of PPCs in these patients during the first 7 postoperative days. The patients were mainly male, and half of them had a high risk of PPCs (ARISCAT score exceeding 44). Eleven percent of participants developed a PPC within the first postoperative week. The mean open lung positive end-expiratory pressure was 8 ± 3 cmH2O. When compared with pre-open lung approach values, the open-lung approach significantly decreased the driving pressure (14 ± 4 cmH2O v 11 ± 3 cmH2O; p < 0.001) and increased dynamic compliance (30 ± 10 mL/cmH2O v 43 ±15 mL/cmH2O; p < 0.001). CONCLUSIONS: The low incidence of PPCs in patients who underwent an open-lung approach during one-lung ventilation compared with that reported for other thoracic surgery series and the decrease in the driving pressure in these patients justify an additional randomized controlled trial to compare the open-lung approach with the standard protective strategy of low tidal volume and low positive end-expiratory pressure.


Assuntos
Pneumopatias/prevenção & controle , Ventilação Monopulmonar/métodos , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Torácicos/métodos , Idoso , Feminino , Humanos , Pneumopatias/diagnóstico , Pneumopatias/epidemiologia , Masculino , Pessoa de Meia-Idade , Ventilação Monopulmonar/efeitos adversos , Ventilação Monopulmonar/tendências , Respiração com Pressão Positiva/efeitos adversos , Respiração com Pressão Positiva/tendências , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Procedimentos Cirúrgicos Torácicos/efeitos adversos , Procedimentos Cirúrgicos Torácicos/tendências , Resultado do Tratamento
20.
Can J Surg ; 61(3): 185-194, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29806816

RESUMO

BACKGROUND: Myocardial injury after noncardiac surgery (MINS) is a mostly asymptomatic condition that is strongly associated with 30-day mortality; however, it remains mostly undetected without systematic troponin T monitoring. We evaluated the cost and consequences of postoperative troponin T monitoring to detect MINS. METHODS: We conducted a model-based cost-consequence analysis to compare the impact of routine troponin T monitoring versus standard care (troponin T measurement triggered by ischemic symptoms) on the incidence of MINS detection. Model inputs were based on Canadian patients enrolled in the Vascular Events in Noncardiac Surgery Patients Cohort Evaluation (VISION) study, which enrolled patients aged 45 years or older undergoing inpatient noncardiac surgery. We conducted probability analyses with 10 000 iterations and extensive sensitivity analyses. RESULTS: The data were based on 6021 patients (48% men, mean age 65 [standard deviation 12] yr). The 30-day mortality rate for MINS was 9.6%. We determined the incremental cost to avoid missing a MINS event as $1632 (2015 Canadian dollars). The cost-effectiveness of troponin monitoring was higher in patient subgroups at higher risk for MINS, e.g., those aged 65 years or more, or with a history of atherosclerosis or diabetes ($1309). CONCLUSION: The costs associated with a troponin T monitoring program to detect MINS were moderate. Based on the estimated incremental cost per health gain, implementation of postoperative troponin T monitoring seems appealing, particularly in patients at high risk for MINS.


Assuntos
Análise Custo-Benefício , Isquemia Miocárdica , Avaliação de Resultados em Cuidados de Saúde , Cuidados Pós-Operatórios , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Troponina T/sangue , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/sangue , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/economia , Isquemia Miocárdica/mortalidade , Avaliação de Resultados em Cuidados de Saúde/economia , Cuidados Pós-Operatórios/economia , Cuidados Pós-Operatórios/métodos , Cuidados Pós-Operatórios/normas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Risco
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