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1.
Anesth Analg ; 2020 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-32175948

RESUMO

BACKGROUND: Two-thirds of the US population is considered obese and about 8% morbidly obese. Obese patients may present a unique challenge to anesthesia clinicians in airway management. Videolaryngoscopes may provide better airway visualization, which theoretically improves intubation success. However, previous work in morbidly obese patients was limited. We therefore tested the primary hypothesis that the use of McGrath video laryngoscope improves visualization of the vocal cords versus Macintosh direct laryngoscopy (Teleflex, Morrisville, NC) in morbidly obese patients. METHODS: We enrolled 130 surgical patients, aged 18-99 years, with a body mass index ≥40 kg/m and American Society of Anaesthesiologists (ASA) physical status I-III. Patients were randomly allocated 1:1-stratified for patient's body mass index ≥50 kg/m-to McGrath video laryngoscope versus direct laryngoscopy with a Macintosh blade. The study groups were compared on glottis visualization, defined as improved Cormack and Lehane classification, with proportional odds logistic regression model. RESULTS: McGrath video laryngoscope provided significantly better glottis visualization than Macintosh direct laryngoscopy with an estimated odds ratio of 4.6 (95% confidence interval [CI], 2.2-9.8; P < .01). We did not observe any evidence that number of intubation attempts and failed intubations increased or decreased. CONCLUSIONS: McGrath video laryngoscope improves glottis visualization versus Macintosh direct laryngoscopy in morbidly obese patients. Large clinical trials are needed to determine whether improved airway visualization with videolaryngoscopy reduces intubation attempts and failures.

5.
J Thorac Dis ; 11(7): 3156-3170, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31463144

RESUMO

The advent of advanced diagnostic bronchoscopy has shown an increased demand for anesthesiologists to administer anesthesia in the bronchoscopy suite. Procedures such as navigational bronchoscopy, airway stenting and advanced therapeutic procedures often require the presence of an anesthesiologist to manage these more complex patients and procedures. In this review we describe the various bronchoscopic procedures and anesthetic management and complications of these procedures at our institution The Cleveland Clinic, Cleveland Ohio.

6.
Curr Pharm Des ; 25(19): 2140-2148, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31272347

RESUMO

Sugammadex is a reversal agent that was engineered to reverse the effects of aminosteroid muscle relaxants. It is a modified gamma-cyclodextrin, i.e. a large glucose molecule bound in a ring-like structure. Sugammadex, when injected intravenously, creates a concentration gradient favoring the movement of aminosteroid muscle relaxants from the neuromuscular junction back into the plasma, and then encapsulates the aminosteroid muscle relaxants within its inner structure by forming tight water-soluble complexes. The dissociation of the aminosteroidal muscle relaxant from the post-synaptic acetylcholine receptors is responsible for the termination of neuromuscular blockade. This review article presents the current indication, mechanism of action, limitations, side effects and contraindications of sugammadex. An overview of monitoring of the adequacy of reversal of aminosteroid muscle relaxants with sugammadex is presented. Moreover, the use of sugammadex in special situations, including "cannot intubate cannot oxygenate" scenarios is also described.

8.
PLoS One ; 14(2): e0212704, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30811470

RESUMO

BACKGROUND: High-quality chest compressions are imperative for Cardio-Pulmonary-Resuscitation (CPR). International CPR guidelines advocate, that chest compressions should not be interrupted for ventilation once a patient's trachea is intubated or a supraglottic-airway-device positioned. Supraglottic-airway-devices offer limited protection against pulmonary aspiration. Simultaneous chest compressions and positive pressure ventilation both increase intrathoracic pressure and potentially enhances the risk of pulmonary aspiration. The hypothesis was, that regurgitation and pulmonary aspiration is more common during continuous versus interrupted chest compressions in human cadavers ventilated with a laryngeal tube airway. METHODS: Twenty suitable cadavers were included, and were positioned supine, the stomach was emptied, 500 ml of methylene-blue-solution instilled and laryngeal tube inserted. Cadavers were randomly assigned to: 1) continuous chest compressions; or, 2) interrupted chest compressions for ventilation breaths. After 14 minutes of the initial designated CPR strategy, pulmonary aspiration was assessed with a flexible bronchoscope. The methylene-blue-solution was replaced by 500 ml barium-sulfate radiopaque suspension. 14 minutes of CPR with the second designated ventilation strategy was performed. Pulmonary aspiration was then assessed with a conventional chest X-ray. RESULTS: Two cadavers were excluded for technical reasons, leaving 18 cadavers for statistical analysis. Pulmonary aspiration was observed in 9 (50%) cadavers with continuous chest compressions, and 7 (39%) with interrupted chest compressions (P = 0.75). CONCLUSION: Our pilot study indicate, that incidence of pulmonary aspiration is generally high in patients undergoing CPR when a laryngeal tube is used for ventilation. Our study was not powered to identify potentially important differences in regurgitation or aspiration between ongoing vs. interrupted chest compression. Our results nonetheless suggest that interrupted chest compressions might better protect against pulmonary aspiration when a laryngeal tube is used for ventilation.


Assuntos
Reanimação Cardiopulmonar/efeitos adversos , Parada Cardíaca/terapia , Refluxo Laringofaríngeo/epidemiologia , Respiração com Pressão Positiva/efeitos adversos , Aspiração Respiratória de Conteúdos Gástricos/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Cadáver , Reanimação Cardiopulmonar/instrumentação , Reanimação Cardiopulmonar/métodos , Estudos Cross-Over , Feminino , Humanos , Incidência , Máscaras Laríngeas/efeitos adversos , Refluxo Laringofaríngeo/etiologia , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Respiração com Pressão Positiva/instrumentação , Distribuição Aleatória , Aspiração Respiratória de Conteúdos Gástricos/diagnóstico por imagem , Aspiração Respiratória de Conteúdos Gástricos/etiologia
10.
Anesth Analg ; 127(2): 424-431, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29916861

RESUMO

BACKGROUND: Intraoperative hypotension is associated with postoperative mortality. Early detection of hypotension by continuous hemodynamic monitoring might prompt timely therapy, thereby reducing intraoperative hypotension. We tested the hypothesis that continuous noninvasive blood pressure monitoring reduces intraoperative hypotension. METHODS: Patients ≥45 years old with American Society of Anesthesiologists physical status III or IV having moderate-to-high-risk noncardiac surgery with general anesthesia were included. All participating patients had continuous noninvasive hemodynamic monitoring using a finger cuff (ClearSight, Edwards Lifesciences, Irvine, CA) and a standard oscillometric cuff. In half the patients, randomly assigned, clinicians were blinded to the continuous values, whereas the others (unblinded) had access to continuous blood pressure readings. Continuous pressures in both groups were used for analysis. Time-weighted average for mean arterial pressure <65 mm Hg was compared using 2-sample Wilcoxon rank-sum tests and Hodges Lehmann estimation of location shift with corresponding asymptotic 95% CI. RESULTS: Among 320 randomized patients, 316 were included in the intention-to-treat analysis. With 158 patients in each group, those assigned to continuous blood pressure monitoring had significantly lower time-weighted average mean arterial pressure <65 mm Hg, 0.05 [0.00, 0.22] mm Hg, versus intermittent blood pressure monitoring, 0.11 [0.00, 0.54] mm Hg (P = .039, significance criteria P < .048). CONCLUSIONS: Continuous noninvasive hemodynamic monitoring nearly halved the amount of intraoperative hypotension. Hypotension reduction with continuous monitoring, while statistically significant, is currently of uncertain clinical importance.


Assuntos
Determinação da Pressão Arterial/métodos , Pressão Sanguínea , Monitorização Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios , Idoso , Anestesia Geral , Anestesiologia/métodos , Pressão Arterial , Feminino , Hemodinâmica , Humanos , Hipotensão/diagnóstico , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Oscilometria , Reprodutibilidade dos Testes , Resultado do Tratamento
16.
Anesthesiology ; 127(3): 457-465, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28816783

RESUMO

BACKGROUND: Whether patients on testosterone replacement therapy undergoing noncardiac surgery have an increased risk of postoperative in-hospital mortality and cardiovascular events remains unknown. We therefore sought to identify the impact of testosterone replacement on the incidence of a composite of postoperative in-hospital mortality and cardiovascular events in men undergoing noncardiac surgery. METHODS: Data from male American Society of Anesthesiologists I through IV patients 40 yr or older who underwent noncardiac surgery between May 2005 and December 2015 at the Cleveland Clinic (Cleveland, Ohio) main campus were included. The primary exposure was preoperative testosterone use. The primary outcome was a composite of postoperative in-hospital mortality and cardiovascular events. We compared patients who received testosterone and those who did not using propensity score matching within surgical procedure matches. RESULTS: Among 49,273 patients who met inclusion and exclusion criteria, 947 patients on testosterone were matched to 4,598 nontestosterone patients. The incidence of in-hospital mortality was 1.3% in the testosterone group and 1.1% in the nontestosterone group, giving an odds ratio of 1.17 (99% CI, 0.51 to 2.68; P = 0.63). The incidence of myocardial infarction was 0.2% in the testosterone group and 0.6% in the nontestosterone group (odds ratio = 0.34; 99% CI, 0.05 to 2.28; P = 0.15). Similarly, no significant difference was found in stroke (testosterone vs. nontestosterone: 2.0% vs. 2.1%), pulmonary embolism (0.5% vs. 0.7%), or deep venous thrombosis (2.0% vs. 1.7%). CONCLUSIONS: Preoperative testosterone is not associated with an increased incidence of a composite of postoperative in-hospital mortality and cardiovascular events.


Assuntos
Doenças Cardiovasculares/epidemiologia , Terapia de Reposição Hormonal/efeitos adversos , Mortalidade Hospitalar , Procedimentos Cirúrgicos Operatórios , Testosterona/uso terapêutico , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ohio/epidemiologia , Pontuação de Propensão
17.
Ann Card Anaesth ; 20(2): 193-199, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28393780

RESUMO

OBJECTIVE: Poor sleep quality is emerging as high prevalence among the patients suffering from cardiometabolic disturbances. The vascular polypeptide endothelin 1 (ET-1) is involved in many of the health disorders. However, its potential involvement in patients having poor sleep quality along with cardiovascular problem is limited. The present study was formulated to conduct a prospective analysis of the relationship between ET-1 and in hospital outcome in sleep disorder patients undergoing routine coronary artery bypass grafting (CABG). METHODS: A total of 156 patients were enrolled and divided into two groups based on the Pittsburg Sleep Quality Index (PSQI) of ≤5 (Group I, n = 101) or >5 (Group II, n = 55). Blood sample was collected before anesthesia induction (ET-1a) and at 48 h (ET-1b) to analyze the plasma ET-1 and blood sugar level. The patients were monitored for any intraoperative adverse events and postoperative complications during their hospital stay. RESULTS: Both groups were comparable in relation to age, sex, incidence of smoking and alcohol consumption. The distribution of comorbid conditions was also similar in both groups. The ET-1 level was higher in Group II than Group I before anesthesia induction as well as 48 h postoperatively (4.5 ± 1.75 vs. 10.61 ± 9.3, P = 0.001; 2.08 ± 1.3 vs. 8.3 ± 9.86, P = 0.0001, respectively). The Group II patients had a longer duration of mechanical ventilation (14.6 ± 12.05 vs. 10.1 ± 8.19, P = 0.001), Intensive Care Unit stay (2.08 ± 0.95 vs. 2.7 ± 1.45, P = 0016) and hospital stay (5.98 ± 1.73 vs. 7.8 ± 3.66, P = 0.0001, respectively). The high number of patients from Group II required inotrope and intra-aortic balloon pump support while compared with Group I (P ≤ 0.05 in each). The overall postoperative complication rate was significantly higher among patients with PSQI of >5 (Group II) except the rate of infection and neurological complications which was similar among both group of patients. The postoperative in hospital mortality was nil in Group I and 3.6% in Group II (P = 0.05). There was a strong relationship between PSQI and ET-1 at both the time points. CONCLUSION: Poor sleep quality associated with a higher incidence of adverse perioperative events in patients undergoing elective CABG. There exists a potential link between poor sleep quality and ET-1 in these groups of patients.


Assuntos
Ponte de Artéria Coronária , Endotelina-1/sangue , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Transtornos do Sono-Vigília/sangue , Transtornos do Sono-Vigília/epidemiologia , Comorbidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
18.
J Trauma Acute Care Surg ; 74(4): 1102-7, 2013 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-23511151

RESUMO

BACKGROUND: A variety of radiologic screening protocols exist for evaluation of pediatric trauma patients with potential cervical spine (c-spine) injuries. The purpose of this study was to describe findings on c-spine magnetic resonance imaging (MRI) after previously normal c-spine computed tomographic (CT) scan findings at a Level 1 trauma center. METHODS: A retrospective chart review of trauma patients evaluated at Rady Children's Hospital, San Diego, between January 2000 and February 2010 was conducted. Trauma patients who were younger than 18 years, placed in c-spine precautions, had a normal c-spine CT scan, who subsequently had a c-spine MRI were included. The sample was subdivided into patients who underwent CT scans between January 1, 2000 to July 31, 2005 (early group), and August 1, 2005 to February 28, 2010 (late group), to compare results between different CT scan resolutions. RESULTS: A total of 173 patients met inclusion criteria. With 100% of patients demonstrating normal c-spine CT scan findings, 83% of c-spine MRI findings were also negative (p < 0.001). Thirty patients (17%) demonstrated significant abnormalities on MRI. Of the 30, 5 (2.9%) required operative c-spine stabilization. Eighty-five patients underwent CT scan in the early group, and 88 in the late group. All 5 patients with unstable injuries not discovered on CT scan were from the early group, compared with none in the late group (p = 0.027). CONCLUSION: Our results suggest that high-resolution CT scan with sagittal and coronal reconstructions may be comparable with MRI for the detection of unstable c-spine injuries in pediatric trauma patients. Although minimizing CT scan radiation exposure remains essential, high-resolution c-spine CT scan may allow for earlier c-spine clearance with reduction of associated hard collar comorbidities in centers where MRI is not available or in situations where the patient's clinical stability precludes obtaining MRI. LEVEL OF EVIDENCE: Diagnostic study, level III.


Assuntos
Vértebras Cervicais/lesões , Imagem por Ressonância Magnética/métodos , Traumatismos da Coluna Vertebral/diagnóstico , Tomografia Computadorizada por Raios X/métodos , Centros de Traumatologia , Ferimentos não Penetrantes/diagnóstico , Adolescente , Vértebras Cervicais/diagnóstico por imagem , Vértebras Cervicais/patologia , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Índices de Gravidade do Trauma
19.
Pain Pract ; 12(1): 23-32, 2012 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-21615855

RESUMO

Patients with advanced gastrointestinal and pelvic malignancies commonly present with pain of varying severity. In a majority of these patients, pain can be effectively managed using an integrated systemic pharmacological approach with oral morphine being the cornerstone of treatment. However, with escalating doses, intolerable side effects of oral morphine may lead to patient dissatisfaction. When oral pharmacotherapy fails to adequately address the issue of pain or leads to insufferable side effects, neurolytic blocks of the sympathetic axis are usually used for pain alleviation. As these blocks may reduce oral analgesic requirement, a reevaluation of their timing is merited. This article presents our hospital-based in-patient palliative care unit experience with early ultrasonography-guided neurolysis of celiac plexus, superior hypogastric plexus and ganglion impar. Of the 44 patients we studied, 20 underwent celiac plexus neurolysis, 18 superior hypogastric plexus neurolysis, and 6 ganglion impar neurolysis. Their pain was being managed with oral morphine before neurolysis, but only 11.4% patients required oral morphine for satisfactory pain control, 2 months after neurolysis. The mean Visual Analog Scale score before block placement was 5.64 ± 0.69 and fell to 2.25 ± 1.33 at 2 months post neurolysis (P < 0.001). We suggest that bedside ultrasonography-guided sympathetic axis neurolysis may be employed early in patients with incurable abdominal or pelvic cancer. Its use as a first-line intervention for achieving pain control with minimal complications warrants further consideration and investigation.


Assuntos
Bloqueio Nervoso Autônomo/métodos , Plexo Celíaco/diagnóstico por imagem , Dor/tratamento farmacológico , Ultrassonografia/métodos , Adulto , Analgésicos/administração & dosagem , Plexo Celíaco/efeitos dos fármacos , Feminino , Neoplasias Gastrointestinais/complicações , Humanos , Índia , Masculino , Pessoa de Meia-Idade , Dor/etiologia , Neoplasias Pélvicas/complicações
20.
Crit Care Med ; 39(1): 187-9, 2011 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-20959781

RESUMO

OBJECTIVE: Dexmedetomidine (DEX; Precedex) is an alpha-2 adrenergic receptor agonist that produces anxiolysis and sleep-like sedation without narcosis or respiratory depression and has relatively few cardiovascular side effects. Given its favorable sedative properties combined with its limited effects on hemodynamic and respiratory function, it is widely used in pediatric intensive care and anesthesia settings. DESIGN: Case report. SETTING: Pediatric intensive care unit. PATIENT: A three-yr-old girl was admitted after mitral valve replacement for persistent severe mitral insufficiency. Her prior history was significant for tetralogy of Fallot which was repaired at nine months of age. A year later the patient developed mitral and tricuspid valve insufficiency and subsequently underwent mitral and tricuspid valve repair, pulmonary valve replacement, and a maze procedure (the latter was performed for persistent atrial flutter). Following that operation she developed sinus node dysfunction and had a permanent epicardial dual-chamber pacemaker implanted. Due to remaining severe mitral insufficiency the patient had increasing pulmonary symptoms, necessitating the most recent surgery to replace her mitral valve. INTERVENTIONS: On postoperative day two the patient was hemodynamically stable and weaning off mechanical ventilation. Tracheal extubation was anticipated to occur within the next 24 hrs. A DEX infusion of 0.6 mcg/kg/hr was initiated. A pacemaker interrogation performed on postoperative day three, 21 hrs after the initiation of DEX, revealed unsuccessful atrial capture. MEASUREMENTS AND MAIN RESULTS: Dexmedetomidine was subsequently discontinued and the patient's pacemaker was reinterrogated. The interrogation findings were similar to those seen prior to the initiation of DEX. CONCLUSION: As a result of these findings, caution is warranted in the administration of DEX to patients with predisposing conduction abnormalities and patients who are pacemaker-dependent.


Assuntos
Bloqueio Atrioventricular/induzido quimicamente , Dexmedetomidina/efeitos adversos , Implante de Prótese de Valva Cardíaca/métodos , Hipnóticos e Sedativos/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Bloqueio Atrioventricular/terapia , Pré-Escolar , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Dexmedetomidina/administração & dosagem , Feminino , Seguimentos , Átrios do Coração/efeitos dos fármacos , Cardiopatias Congênitas/diagnóstico , Cardiopatias Congênitas/cirurgia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Unidades de Terapia Intensiva Pediátrica , Insuficiência da Valva Mitral/diagnóstico , Marca-Passo Artificial , Cuidados Pós-Operatórios/métodos , Medição de Risco , Fatores de Tempo , Resultado do Tratamento
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