Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 59
Filtrar
Mais filtros










Intervalo de ano de publicação
2.
J Cardiovasc Pharmacol ; 73(5): 301-306, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30855406

RESUMO

OBJECTIVE: International guidelines recommend the introduction of sacubitril/valsartan (Entresto) in patients with heart failure (HF) and reduced ejection fraction (EF), who remain symptomatic, despite optimal uptitrated therapy. The purpose of the following analysis is to verify the real-life eligibility for sacubitril/valsartan in a population of patients suffering from chronic HF, regularly monitored in a single HF clinic and treated according to guideline-directed medical therapy (GDMT). METHODS: From a total of 1070 patients regularly monitored in our HF Clinic between January 2011 and September 2017, the clinical records of 224 patients with HF and reduced EF on optimized GDMT were retrospectively analyzed. RESULTS: Of 224 analyzed patients, 75 improved their EF or were asymptomatic after uptitration of GDMT during follow-up; 50 were not on angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for different reasons; 13 patients had systolic blood pressure ≤100 mm Hg, so they were not eligible for sacubitril/valsartan introduction. The remaining patients were still symptomatic (NYHA ≥2), and therefore, sacubitril/valsartan introduction was indicated in these 86 patients (38.4%) of 224 enrolled. CONCLUSION: In patients with HF and reduced EF, where GDMT is appropriately achieved, indication to sacubitril/valsartan treatment is around 38%.

3.
Int J Colorectal Dis ; 34(5): 915-921, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30927065

RESUMO

PURPOSE: A well-controlled pain is one of the most important targets of enhanced recovery after surgery (ERAS) protocols. Recent studies questioned the role of TEA (thoracic epidural analgesia) in support of less invasive techniques, in particular in laparoscopic mini-invasive surgery. The aim of this study is to compare patients undergoing laparoscopic mini-invasive colorectal surgery and receiving different analgesic techniques. METHODS: Prospectively collected data entered in the electronic registry of POIS (Perioperative Italian Society) specifically designed for ERAS were reviewed. Patients undergoing colorectal laparoscopic surgery were divided in two groups according to TEA or parenteral opioid administration. In comparing TEA and opioid groups, propensity score weights were obtained. Postoperative pain control and time to readiness for discharge (TRD) were considered as primary endpoints of the study. Secondary endpoints were postoperative morbidity, PONV (postoperative nausea and vomiting), hours of mobilization, length of hospital stay (LOS), timing of fluid and solid re-assumption, and recovery of bowel function. RESULTS: Fourteen Italian hospitals reported data on 560 patients (283 TEA, 277 opioid group). Patients of the opioid group were able to mobilize for a longer period than TEA group patients but presented a higher incidence of PONV. Pain intensity and TRD were similar in both groups. LOS was significantly reduced in TEA patients; also, this result was clinically irrelevant (5.7 ± 3.21 days TEA group vs 5.8 ± 2.92 opioid group). CONCLUSION: In patients undergoing laparoscopic colorectal surgery, TEA was not associated to a better pain control or to an improvement in postoperative outcome compared with opioid administration.


Assuntos
Analgesia Epidural , Analgésicos Opioides/uso terapêutico , Cirurgia Colorretal , Laparoscopia , Idoso , Feminino , Fidelidade a Diretrizes , Humanos , Masculino , Período Pós-Operatório
4.
Pituitary ; 22(2): 187-194, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30826981

RESUMO

PURPOSE: Acromegaly may be associated with an increased risk of complex intraoperative management and anesthetic complications. No study addressed whether pretreatment with somatostatin receptor ligands (SRLs) affects anesthesiologic management. METHODS: We studied 211 consecutive acromegalic patients who had a recorded intraoperative computerized anesthetic record (ICAR) available for analysis. Ninety-six (45.5%) patients were SRL-pretreated while 115 patients were treatment naïve. RESULTS: Treatment with SRLs reduced mean basal growth hormone level from 23.8 ± 4.2 to 5.9 ± 1.3 µg/L. Normalization of insulin-like growth factor-1 was achieved in 26 patients (27.1%). The frequency of comorbidities at surgery was similar in the two groups. Five patients with difficult intubation were naïve (4.3%) as compared with 5 SRL-pretreated patients (5.2%; P = 1.0). ICAR registration did not show any significant change of intraoperative vital parameters in the two groups of patients as well as in the intraoperative utilization of drugs. Total duration of anesthesia and surgery were similar in the two groups. Four patients with an intraoperative adverse event were naïve (3.5%) as compared with 4 SRL-pretreated patients (4.2%; P = 1.00). Remission of disease occurred in 83 of 114 naïve patients (72.8%) and in 57 of 93 SRL-pretreated patients (61.3%; P = 0.11). CONCLUSIONS: SRL-pretreatment of patients with acromegaly had no significant impact on intraoperative anesthesiologic management. Despite a better Cormack-Lehane score in SRL-pretreated than in naïve patients, the rate of difficult intubation was similar in both groups. SRL-pretreatment did not affect the rate of surgical remission or complications as well.


Assuntos
Anestesia/métodos , Neoplasias Hipofisárias/tratamento farmacológico , Somatostatina/análogos & derivados , Somatostatina/uso terapêutico , Acromegalia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Neoplasias Hipofisárias/metabolismo , Receptores de Somatostatina/metabolismo , Estudos Retrospectivos
5.
Contemp Clin Trials ; 78: 126-132, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30739002

RESUMO

OBJECTIVE: Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. DESIGN: Pragmatic, parallel group, randomized, controlled, multicenter trial. SETTING: Non-intensive care wards of tertiary centers. PATIENTS: Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. INTERVENTIONS: Patients will be randomized to receive or not receive NIV in addition to best available care. MEASUREMENTS AND MAIN RESULTS: We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. CONCLUSIONS: This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.

6.
Minerva Anestesiol ; 2018 May 11.
Artigo em Inglês | MEDLINE | ID: mdl-29756695

RESUMO

BACKGROUND: This study was aimed to investigate whether stimulating catheters for continuous lumbar plexus block reduce local anesthetic consumption after hip arthroplasty if compared with traditional non-stimulating catheters. METHODS: Seventy-two ASA I-III, 18-82 year-old, undergoing primary hip replacement (THA) for osteoarthritis with spinal anesthesia were randomized into two groups: Stim group (stimulating catheter, n=36) and Nonstim group (non-stimulating catheter, n=36). After surgery, 15 ml of mepivacaine 1% were administered in both groups through the catheter. An electronic pump was connected to deliver ropivacaine 0.2% (3 ml/h, bolus 3 ml, lock out 15 min) for the first 72h. Patients were given ketorolac 30 mg i.v. every 8h, acetaminophen 1g i.v. every 8h and oxycodone 10 mg per os for rescue analgesia. Primary outcome was postoperative local anesthetic consumption. Numerical Rating Scale (NRS), complications, both quadriceps and obturator strength measurements, and opioid requirement were also registered. Mixed effect models (random intercept) were built for repeated measures over time. A difference between groups was considered statistically significant if p< 0.05. RESULTS: Local anesthetic consumption and NRS were comparable between groups. Patients in the Nonstim group required significant more rescue opioid analgesia compared with the Stim group during the first 36h (p = 0.002). Quadriceps and adductor muscle strength was equally preserved in the two groups. CONCLUSIONS: The study showed comparable local anesthetic consumption, pain scores and muscle strength preservation between the two groups. The stimulating catheter allowed a significant, although underpowered, reduction in opioid consumption.

7.
Anesthesiology ; 129(2): 241-248, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29762181

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Both extra- and intraneural sciatic injection resulted in significant axonal nerve damage. This study aimed to establish the minimum effective volume of intraneural ropivacaine 1% for complete sensory-motor sciatic nerve block in 90% of patients, and related electrophysiologic variations. METHODS: Forty-seven consecutive American Society of Anesthesiologists physical status I-II patients received an ultrasound-guided popliteal intraneural nerve block following the up-and-down biased coin design. The starting volume was 15 ml. Baseline, 5-week, and 6-month electrophysiologic tests were performed. Amplitude, latency, and velocity were evaluated. A follow-up telephone call at 6 months was also performed. RESULTS: The minimum effective volume of ropivacaine 1% in 90% of patients for complete sensory-motor sciatic nerve block resulted in 6.6 ml (95% CI, 6.4 to 6.7) with an onset time of 19 ± 12 min. Success rate was 98%. Baseline amplitude of action potential (mV) at ankle, fibula, malleolus, and popliteus were 8.4 ± 2.3, 7.1 ± 2.0, 15.4 ± 6.5, and 11.7 ± 5.1 respectively. They were significantly reduced at the fifth week (4.3 ± 2.1, 3.5 ± 1.8, 6.9 ± 3.7, and 5.2 ± 3.0) and at the sixth month (5.9 ± 2.3, 5.1 ± 2.1, 10.3 ± 4.0, and 7.5 ± 2.7) (P < 0.001 in all cases). Latency and velocity did not change from the baseline. No patient reported neurologic symptoms at 6-month follow-up. CONCLUSIONS: The intraneural ultrasound-guided popliteal local anesthetic injection significantly reduces the local anesthetic dose to achieve an effective sensory-motor block, decreasing the risk of systemic toxicity. Persistent electrophysiologic changes suggest possible axonal damage that will require further investigation.

8.
J Cardiovasc Med (Hagerstown) ; 19(7): 351-356, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29762337

RESUMO

: Ivabradine is a selective and specific inhibitor of If current. With its pure negative chronotropic action, it is recommended by European Society of Cardiology and American College of Cardiology/American Heart Association guidelines in symptomatic heart failure patients (NYHA ≥ 2) with ejection fraction 35% or less, sinus rhythm and heart rate (HR) at least 70 bpm, despite maximally titrated ß-blocker therapy. Data supporting this indication mainly derive from the SHIFT study, in which ivabradine reduced the combined endpoint of mortality and hospitalization, despite the fact that only 26% of patients enrolled were on optimal ß-blocker doses. The aim of the present analysis is to establish the real-life eligibility for ivabradine in a population of patients with systolic heart failure, regularly attending a single heart failure clinic and treated according to guideline-directed medical therapy (GDMT). The clinical cards of 308 patients with heart failure with reduced ejection fraction (HFrEF) through a 68-month period of observation were retrospectively analyzed. GDMT, including ß-blocker up-titration to maximal tolerated dose, was implemented during consecutive visits at variable intervals. Demographic, clinical and echocardiographic data were collected at each visit, together with 12-leads ECG and N-terminal pro-B-type natriuretic peptide levels. Out of 308 analyzed HFrEF patients, 220 (71%) were on effective ß-blocker therapy, up-titrated to effective/maximal tolerated dose (55 ±â€Š28% of maximal dose) (HR 67 ±â€Š10 bpm). Among the remaining 88 patients, 10 (3.2%) were on maximally tolerated ß blocker and ivabradine; 21 patients (6.8%), despite being on maximal tolerated ß-blocker dose, had still HR ≥70 bpm, ejection fraction 35% or less and were symptomatic NYHA ≥2, being therefore eligible for ivabradine treatment. The remaining 57 (18%) patients were not on ß blocker due to either intolerance or major contraindications. Among them, 13 (4%) were taking ivabradine alone. Of the final 44 (14%) patients, 27 (9%) showed an inadequate HR control (74 ±â€Š6 bpm). Of these, only eight (3%) patients resulted to be eligible for ivabradine introduction according to HR and ejection fraction parameters. Overall ivabradine was indicated in 52 patients (16.8%) out of 308 enrolled.In conclusion, in a carefully managed population of patients with moderate and stable HFrEF, in which optimal GDMT is properly attained, indication to ivabradine treatment is around 17%.

9.
PLoS One ; 13(5): e0196858, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29723285

RESUMO

BACKGROUND: Chromogranin A (CgA) is a plasma biomarker widely used in the follow-up of patients with neuroendocrine neoplasms (NENs). However, its accuracy as a tumor biomarker is relatively low because plasma CgA can increase also in patients with other diseases or in subjects treated with proton-pump inhibitors (PPIs), a class of widely-used drugs. METHODS: In the attempt to identify a more reliable biomarker for NENs, we investigated, by ELISA, the circulating levels of full-length CgA (CgA1-439) and of various CgA-derived fragments in 17 patients with ileal or pancreatic NENs, 10 healthy controls, and 21 healthy volunteers before and after treatment with PPIs. RESULTS: Patients with ileal or pancreatic NENs showed increased plasma levels of total-CgA and CgA1-76 fragment (vasostatin-1, VS-1) compared to controls [median (25th-75th-percentiles); total-CgA: 1.85 nM (1.01-4.28) vs 0.75 nM (0.52-0.89), p = 0.004; VS-1: 2.76 nM (1.09-7.10) vs 0.29 nM (0.26-0.32), p<0.001, respectively], but not of CgA1-439 or CgA1-373 fragment. VS-1 positively correlated with total-CgA (r = 0.65, p<0.001). The Receiver Operating Characteristic area under the curve was 0.9935 for VS-1 and 0.8824 for total-CgA (p = 0.067). Treatment of patients with somatostatin analogues decreased both total-CgA and VS-1. In contrast, administration of PPIs increased the plasma levels of total-CgA, but not of VS-1. CONCLUSION: These findings suggest that plasma VS-1 is a novel biomarker for ileal and pancreatic NENs. Considering that VS-1 is a well-defined fragment not induced by proton-pump inhibitors, this polypeptide might represent a biomarker for NENs diagnosis and follow-up more accurate and easier to standardize than CgA.


Assuntos
Biomarcadores Tumorais/sangue , Cromogranina A/sangue , Neoplasias do Íleo/diagnóstico , Tumores Neuroendócrinos/diagnóstico , Neoplasias Pancreáticas/diagnóstico , Fragmentos de Peptídeos/sangue , 2-Piridinilmetilsulfinilbenzimidazóis/administração & dosagem , Idoso , Antineoplásicos/uso terapêutico , Área Sob a Curva , Biomarcadores Tumorais/genética , Estudos de Casos e Controles , Cromogranina A/genética , Feminino , Expressão Gênica , Humanos , Neoplasias do Íleo/sangue , Neoplasias do Íleo/genética , Neoplasias do Íleo/patologia , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/sangue , Tumores Neuroendócrinos/genética , Tumores Neuroendócrinos/patologia , Octreotida/uso terapêutico , Neoplasias Pancreáticas/sangue , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/patologia , Pantoprazol , Fragmentos de Peptídeos/genética , Prognóstico , Inibidores da Bomba de Prótons/administração & dosagem , Curva ROC , Somatostatina/administração & dosagem , Somatostatina/análogos & derivados
10.
Clin Nutr ESPEN ; 25: 139-144, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29779809

RESUMO

BACKGROUND & AIMS: The Enhanced Recovery After Surgery (ERAS) pathway represents an optimal approach in patients undergoing colorectal surgery but complexity in implementing its items could limit its application. The aim of this study is to identify possible core items within an ERAS pathway following elective colorectal resection. METHODS: This is a retrospective review of data prospectively collected between January 2014 and September 2015 by 14 Italian Hospitals in an electronic registry dedicated to an ERAS protocol. 722 patients undergoing elective colorectal surgery within an ERAS protocol have been included in the study. Adherence to ERAS items was assessed in all patients. A secondary analysis was restricted to pre- and intraoperative ERAS items. Time to readiness for discharge (TRD) was the primary endpoint of the study. Postoperative overall morbidity was the secondary endpoint. RESULTS: Multivariate analyses showed that active intraoperative warming (p = 0.008), early stop of intravenous fluids (p = 0.0001), and early removal of urinary catheter (p = 0.0001) were associated to a shorter TRD, while early stop of intravenous fluids (p < 0.001) also reduced morbidity. When the analysis was restricted to pre- and intraoperative items, removal of NGT at the end of surgery had an independent role to shorten TRD (p < 0.001) and to reduce overall morbidity (p = 0.019), while the absence of oral bowel preparation reduced postoperative overall morbidity (p = 0.021). CONCLUSIONS: In implementing an ERAS pathway, hospitals could initially focus on active intraoperative warming, early stop of intravenous fluids, early removal of urinary catheter, removal of NGT at the end of surgery, and absence of oral bowel preparation, keeping on continuous effort to apply the complete ERAS protocol.

11.
J Neurosurg Anesthesiol ; 30(3): 246-250, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28671879

RESUMO

BACKGROUND: Traditional ventilation approaches, providing high tidal volumes (Vt), produce excessive alveolar distention and lung injury. Protective ventilation, employing lower Vt and positive end-expiratory pressure (PEEP), is an attractive alternative also for neuroanesthesia, when prolonged mechanical ventilation is needed. Nevertheless, protective ventilation during intracranial surgery may exert dangerous effects on intracranial pressure (ICP). We tested the feasibility of a protective ventilation strategy in neurosurgery. MATERIALS AND METHODS: Our monocentric, double-blind, 1:1 randomized, 2×2 crossover study aimed at studying the effect size and variability of ICP in patients undergoing elective supratentorial brain tumor removal and alternatively ventilated with Vt 9 mL/kg-PEEP 0 mm Hg and Vt 7 mL/kg-PEEP 5 mm Hg. Respiratory rate was adjusted to maintain comparable end-tidal carbon dioxide between ventilation modes. ICP was measured through a subdural catheter inserted before dural opening. RESULTS: Forty patients were enrolled; 8 (15%) were excluded after enrollment. ICP did not differ between traditional and protective ventilation (11.28±5.37, 11 [7 to 14.5] vs. 11.90±5.86, 11 [8 to 15] mm Hg; P=0.541). End-tidal carbon dioxide (28.91±2.28, 29 [28 to 30] vs. 28.00±2.17, 28 [27 to 29] mm Hg; P<0.001). Peak airway pressure (17.25±1.97, 17 [16 to 18.5] vs. 15.81±2.87, 15.5 [14 to 17] mm Hg; P<0.001) and plateau airway pressure (16.06±2.30, 16 [14.5 to 17] vs. 14.19±2.82, 14 [12.5 to 16] mm Hg; P<0.001) were higher during protective ventilation. Blood pressure, heart rate, and body temperature did not differ between ventilation modes. Dural tension was "acceptable for surgery" in all cases. ICP differences between ventilation modes were not affected by ICP values under traditional ventilation (coefficient=0.067; 95% confidence interval, -0.278 to 0.144; P=0.523). CONCLUSIONS: Protective ventilation is a feasible alternative to traditional ventilation during elective neurosurgery.


Assuntos
Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/prevenção & controle , Pulmão/fisiopatologia , Procedimentos Neurocirúrgicos , Respiração Artificial/métodos , Idoso , Estudos Cross-Over , Método Duplo-Cego , Estudos de Viabilidade , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade
12.
Neurocrit Care ; 28(3): 370-378, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28875429

RESUMO

BACKGROUND: Cardiac arrest is an important cause of morbidity and mortality. Brain injury severity and prognosis of cardiac arrest patients are related to the cerebral areas affected. To this aim, we evaluated the variability and the distribution of brain glucose metabolism after cardiac arrest and resuscitation in an adult rat model. METHODS: Ten rats underwent 8-min cardiac arrest, induced with a mixture of potassium and esmolol, and resuscitation, performed with chest compressions and epinephrine. Eight sham animals received anesthesia and experimental procedures identical to the ischemic group except cardiac arrest induction. Brain metabolism was assessed using [18F]FDG autoradiography and small animal-dedicated positron emission tomography. RESULTS: The absolute glucose metabolism measured with [18F]FDG autoradiography 2 h after cardiac arrest and resuscitation was lower in the frontal, parietal, occipital, and temporal cortices of cardiac arrest animals, showing, respectively, a 36% (p = 0.006), 32% (p = 0.016), 36% (p = 0.009), and 32% (p = 0.013) decrease compared to sham group. Striatum, hippocampus, thalamus, brainstem, and cerebellum showed no significant changes. Relative regional metabolism indicated a redistribution of metabolism from cortical area to brainstem and cerebellum. CONCLUSIONS: Our data suggest that cerebral regions have different susceptibility to moderate global ischemia in terms of glucose metabolism. The neocortex showed a higher sensibility to hypoxia-ischemia than other regions. Other subcortical regions, in particular brainstem and cerebellum, showed no significant change compared to non-ischemic rats.

13.
Eur J Anaesthesiol ; 34(10): 665-672, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28767456

RESUMO

BACKGROUND: Perioperative regional anaesthesia may protect from persistent postsurgical pain (PPSP) and improve outcome after total knee arthroplasty (TKA). OBJECTIVES: Aim of this study was to evaluate the impact of regional anaesthesia on PPSP and long-term functional outcome after TKA. DESIGN: A web-based prospective observational registry. SETTING: Five Italian Private and University Hospitals from 2012 to 2015. PATIENTS: Undergoing primary unilateral TKA, aged more than 18 years, informed consent, American Society of Anesthesiologists (ASA) physical status classes 1 to 3, no previous knee surgery. INTERVENTION(S): Personal data (age, sex, BMI and ASA class), preoperative pain assessed by numerical rating scale (NRS) score, and risk factors for PPSP were registered preoperatively. Data on anaesthetic and analgesic techniques were collected. Postoperative pain (NRS), analgesic consumption, major complications and patient satisfaction were registered up to the time of discharge. PPSP was assessed by a blinded investigator during a phone call after 1, 3 and 6 months, together with patient satisfaction, quality of life (QOL) and walking ability. MAIN OUTCOME MEASURES: Experience of PPSP according to the type of peri-operative analgesia. RESULTS: Five hundred sixty-three patients completed the follow-up. At 6 months, 21.6% of patients experienced PPSP, whereas autonomy was improved only in 56.3%; QOL was worsened or unchanged in 30.7% of patients and improved in 69.3%. Patients receiving continuous regional anaesthesia (epidural or peripheral nerve block) showed a lower NRS through the whole peri-operative period up to 1 month compared with both single shot peripheral nerve block and those who did not receive any type of regional anaesthesia. No difference was found between these latter two groups. Differences in PPSP at 3 or 6 months were not significantly affected by the type of anaesthesia or postoperative analgesia. A higher NRS score at 1 month, younger age, history of anxiety or depression, pro-inflammatory status, higher BMI and a lower ASA physical status were associated with a higher incidence of PPSP and worsened QOL at 6 months. CONCLUSION: Continuous regional anaesthesia provides analgesic benefit for up to 1 month after surgery, but did not influence PPSP at 6 months. Better pain control at 1 month was associated with reduced PPSP. Patients with higher expectations from surgery, enhanced basal inflammation and a pessimistic outlook are more prone to develop PPSP. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02147730.


Assuntos
Analgesia/métodos , Anestesia/métodos , Artroplastia do Joelho/efeitos adversos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Satisfação do Paciente , Analgesia/psicologia , Analgesia/tendências , Analgesia Controlada pelo Paciente/métodos , Analgesia Controlada pelo Paciente/psicologia , Analgesia Controlada pelo Paciente/tendências , Anestesia/psicologia , Anestesia/tendências , Artroplastia do Joelho/psicologia , Artroplastia do Joelho/tendências , Feminino , Seguimentos , Humanos , Itália/epidemiologia , Masculino , Manejo da Dor/psicologia , Manejo da Dor/tendências , Dor Pós-Operatória/psicologia , Estudos Prospectivos , Método Simples-Cego , Fatores de Tempo , Resultado do Tratamento
14.
Contemp Clin Trials ; 59: 38-43, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28533194

RESUMO

OBJECTIVE: There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless, small randomized controlled trials have failed to demonstrate a survival advantage. Thus, whether volatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable. DESIGN: Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio. SETTING: Tertiary and University hospitals. INTERVENTIONS: Patients (n=10,600) undergoing coronary artery bypass graft will be randomized to receive either volatile anesthetic as part of the anesthetic plan, or total intravenous anesthesia. MEASUREMENTS AND MAIN RESULTS: The primary end point of the study will be one-year mortality (any cause). Secondary endpoints will be 30-day mortality; 30-day death or non-fatal myocardial infarction (composite endpoint); cardiac mortality at 30day and at one year; incidence of hospital re-admission during the one year follow-up period and duration of intensive care unit, and hospital stay. The sample size is based on the hypothesis that volatile anesthetics will reduce 1-year unadjusted mortality from 3% to 2%, using a two-sided alpha error of 0.05, and a power of 0.9. CONCLUSIONS: The trial will determine whether the simple intervention of adding a volatile anesthetic, an intervention that can be implemented by all anesthesiologists, can improve one-year survival in patients undergoing coronary artery bypass graft surgery.


Assuntos
Anestesia em Procedimentos Cardíacos , Anestésicos Inalatórios , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Complicações Pós-Operatórias , Adulto , Anestesia em Procedimentos Cardíacos/efeitos adversos , Anestesia em Procedimentos Cardíacos/métodos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/química , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Avaliação de Processos e Resultados (Cuidados de Saúde) , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Análise de Sobrevida , Volatilização
15.
J Cardiothorac Vasc Anesth ; 31(4): 1210-1217, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28283250

RESUMO

OBJECTIVE: Adequate maintenance of hypnosis during anesthesia throughout surgery using sevoflurane alone was investigated. In addition, sevoflurane pharmacokinetics during cardiopulmonary bypass were analyzed. DESIGN: This was a pilot pharmacokinetic study. SETTING: Tertiary care university hospital. PARTICIPANTS: The study comprised 10 patients aged between 18 and 75 years who underwent elective mitral valve surgery. INTERVENTIONS: The end-tidal and sevoflurane plasma concentrations were measured throughout cardiac surgery procedures involving cardiopulmonary bypass. The sevoflurane plasma concentration was measured using gas chromatography. In addition, the ratio between sevoflurane alveolar concentration and inspired concentration over time (FA/FI) was analyzed to describe wash-in and wash-out curves. MEASUREMENTS AND MAIN RESULTS: Hypnosis was maintained adequately throughout surgery using sevoflurane alone. The bispectral index was maintained between 40 and 60 during cardiopulmonary bypass. The end-tidal sevoflurane was significantly different before and during cardiopulmonary bypass (1.86%±0.54% v 1.30%±0.58%, respectively; p<0.001). However, the sevoflurane plasma concentration was not significantly different before and after cardiopulmonary bypass start-up (40.55 µg/mL [76.62-125.33] before cardiopulmonary bypass and 36.24 µg/mL [56.49-81-42] during cardiopulmonary bypass). This mismatch possibly can be explained by changes that occured after cardiopulmonary bypass start-up, such as reductions of body temperature (36.33°C±0.46°C v 32.98°C±2.38°C, respectively; p<0.001) and hematocrit (35.62%±3.98% v 25.5%±3.08%, respectively; p<0.001). The sevoflurane alveolar concentration varied according to sevoflurane plasma concentration and bispectral index values. No adverse events regarding sevoflurane administration during cardiopulmonary bypass were observed. CONCLUSIONS: Sevoflurane end-tidal values were reliable indicators of adequate anesthesia during all cardiac surgery procedures involving cardiopulmonary bypass.


Assuntos
Anestesia Geral/métodos , Anestésicos Inalatórios/sangue , Ponte Cardiopulmonar/métodos , Éteres Metílicos/sangue , Adulto , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/farmacocinética , Estudos de Viabilidade , Feminino , Humanos , Masculino , Éteres Metílicos/administração & dosagem , Éteres Metílicos/farmacocinética , Pessoa de Meia-Idade , Projetos Piloto , Sevoflurano
16.
J Clin Monit Comput ; 31(3): 651, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28124227
17.
Minerva Anestesiol ; 83(6): 638-651, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28094478

RESUMO

Fluid administration is a powerful tool for hemodynamic stabilization as it increases preload and improves cardiac function in fluid-responsive patients. However, there are various types of fluid to choose from. The use of colloids and crystalloids in non-cardiac Intensive Care Units (ICU) has been reported, showing controversial results. Many trials on sepsis in a non-cardiac ICU setting show that colloids, in particular hydroxyethyl starches and gelatins, might have a detrimental effect on kidney function, and on major outcomes such as mortality. Many small randomized clinical trials focusing on coagulation and bleeding show controversial results regarding fluid safety during the perioperative period in cardiac surgery, and in the cardiac ICU. No definitive data are available on the superiority of one fluid compared with another for fluid replacement after cardiac surgery. Only few data are available regarding the impact of fluids on kidney function in the cardiac ICU. On the other hand, there is much evidence showing that fluid administration requires strict protocols and close monitoring. Improved clinical outcomes are evident in protocols for goal-directed therapy. In conclusion, the application of a close monitoring and a pre-defined goal-directed protocol are far more important than the choice of a single fluid. This review examines the available evidence on fluid management in cardiac surgery and in the ICU, and analyzes the key steps of fluid strategy in these settings.

18.
Endocrine ; 58(2): 303-311, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28005257

RESUMO

PURPOSE: Patients affected by Cushing's disease often have important comorbidities directly linked to hypercortisolism that might enhance the operative risk. We report the safety of transsphenoidal surgery in patients affected by Cushing's disease as compared with patients with nonfunctioning pituitary adenoma. METHODS: We have retrospectively analyzed 142 patients with Cushing's disease and 299 patients with nonfunctioning pituitary adenoma who underwent transsphenoidal surgery performed by a single experienced neurosurgeon between September 2007 and December 2014. For all of them, an intraoperative computerized anesthetic record for the automatic storage of data was available. RESULTS: The intraoperative vital parameters and the frequency of drugs administered during anesthesia were comparable between Cushing's disease and nonfunctioning pituitary adenoma groups. The duration of surgery was similar between the two groups (41.2 ± 11.8 vs. 42.9 ± 15.6 min), while the duration of anesthesia was slightly shorter in Cushing's disease patients (97.6 ± 18.1 min) than in nonfunctioning pituitary adenoma patients (101.6 ± 20.6 min, p = 0.04). The total perioperative mortality rate was 0.2% (0% in Cushing's disease vs. 0.3% in nonfunctioning pituitary adenoma). Cushing's disease patients had surgical and medical complication rates of 3.5% each, not different from those occurring in nonfunctioning pituitary adenoma. The postoperative incidence of diabetes insipidus (10.6%) and isolated hyponatremia (10.6%) in Cushing's disease patients was significantly higher than in nonfunctioning pituitary adenoma patients (4.4 and 4.1%; p = 0.02 and p = 0.01, respectively). CONCLUSIONS: In a large series of unselected and consecutive patients with Cushing's disease, transsphenoidal surgery performed by one dedicated experienced neurosurgeon had a reasonably low risk of complications. In particular, despite the higher burden of comorbidities typically associated with hypercortisolism, medical complications are rare and no more frequent than in patients with nonfunctioning pituitary adenoma.


Assuntos
Adenoma Hipofisário Secretor de ACT/cirurgia , Adenoma/cirurgia , Hipersecreção Hipofisária de ACTH/cirurgia , Seio Esfenoidal/cirurgia , Microcirurgia Endoscópica Transanal/efeitos adversos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Microcirurgia Endoscópica Transanal/métodos , Adulto Jovem
19.
J Physiol ; 595(1): 321-339, 2017 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-27416731

RESUMO

KEY POINTS: The mechanisms of action of anaesthetics on the living brain are still poorly understood. In this respect, the analysis of the differential effects of anaesthetics on spontaneous and sensory-evoked cortical activity might provide important and novel cues. Here we show that the anaesthetic sevoflurane strongly silences the brain but potentiates in a dose- and frequency-dependent manner the cortical visual response. Such enhancement arises from a linear scaling by sevoflurane of the power-law relation between light intensity and the cortical response. The fingerprint of sevoflurane action suggests that circuit silencing can boost linearly synaptic responsiveness presumably by scaling the number of responding units and/or their correlation following a sensory stimulation. ABSTRACT: General anaesthetics, which are expected to silence brain activity, often spare sensory responses. To evaluate differential effects of anaesthetics on spontaneous and sensory-evoked cortical activity, we characterized their modulation by sevoflurane and propofol. Power spectra and the bust-suppression ratio from EEG data were used to evaluate anaesthesia depth. ON and OFF cortical responses were elicited by light pulses of variable intensity, duration and frequency, during light and deep states of anaesthesia. Both anaesthetics reduced spontaneous cortical activity but sevoflurane greatly enhanced while propofol diminished the ON visual response. Interestingly, the large potentiation of the ON visual response by sevoflurane was found to represent a linear scaling of the encoding mechanism for light intensity. To the contrary, the OFF cortical visual response was depressed by both anaesthetics. The selective depression of the OFF component by sevoflurane could be converted into a robust potentiation by the pharmacological blockade of the ON pathway, suggesting that the temporal order of ON and OFF responses leads to a depression of the latter. This hypothesis agrees with the finding that the enhancement of the ON response was converted into a depression by increasing the frequency of light-pulse stimulation from 0.1 to 1 Hz. Overall, our results support the view that inactivity-dependent modulation of cortical circuits produces an increase in their responsiveness. Among the implications of our findings, the silencing of cortical circuits can boost linearly the cortical responsiveness but with negative impact on their frequency transfer and with a loss of the information content of the sensory signal.


Assuntos
Anestésicos Inalatórios/farmacologia , Éteres Metílicos/farmacologia , Córtex Visual/efeitos dos fármacos , Animais , Eletroencefalografia , Potenciais Evocados Visuais/efeitos dos fármacos , Masculino , Estimulação Luminosa , Propofol/farmacologia , Ratos Sprague-Dawley , Sevoflurano , Córtex Visual/fisiologia
20.
World Neurosurg ; 98: 60-72, 2017 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-27777157

RESUMO

OBJECTIVE: Complete removal of vestibular schwannomas (VS) is not always achievable without any risk of disabling postoperative complications, especially in terms of facial nerve function. Moreover, even after gross total removal, a relevant rate of recurrence has been reported. The aim of this study is to validate Gamma Knife radiosurgery (GKRS) as an effective strategy to treat tumor regrowth after previous surgery. METHODS: Ninety patients treated with GKRS for VS after previous microsurgery were included in the present study. GKRS was performed at a median of 31 months (range, 4-174 months) postoperatively. Mean tumor volume was 3.35 cm3 (median, 2.5 cm3; range, 0.027-13 cm3) and median marginal dose was 13 Gy. RESULTS: At a mean follow-up of 77.2 months, tumor control was achieved in 90% of patients: 2 patients underwent repeated GKRS, and 7 patients underwent further microsurgery. Tumor shrinkage at last follow-up was recorded in 80.3% of cases. The complication rate was low and many consisted of a transient worsening of preexisting symptoms. The overall incidence of persisting facial nerve deficit and trigeminal nerve impairment was, in both cases, 3.3%. Two of 5 patients (40%) preserved functional hearing at last follow-up. One patient (1.1%) underwent ventriculoperitoneal shunting 12 months after GKRS. CONCLUSIONS: GKRS is a safe and effective treatment for growing residual and recurrent VSs, with tumor control obtained in 90% of cases and a low morbidity rate. Moreover, the possibility of treating patients with major medical comorbidities constitutes a significant advantage over repeated surgery.


Assuntos
Recidiva Local de Neoplasia/cirurgia , Neuroma Acústico/cirurgia , Radiocirurgia/métodos , Resultado do Tratamento , Adolescente , Adulto , Idoso , Bases de Dados Bibliográficas/estatística & dados numéricos , Feminino , Humanos , Modelos Logísticos , Estudos Longitudinais , Imagem por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Neuroma Acústico/diagnóstico por imagem , Reoperação , Estudos Retrospectivos , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA