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1.
Artigo em Inglês | MEDLINE | ID: mdl-31780265

RESUMO

Saccharomyces cerevisiae yeast, when pretreated with elevated temperatures, undergo adaptive changes that promote survival after an otherwise lethal heat stress. The heat shock response, a cellular stress response variant, mediates these adaptive changes. Ethanol, a low-potency anesthetic, promotes thermotolerance possibly through heat shock response activation. Therefore, we hypothesized other anesthetic compounds, like ethanol, may invoke the heat shock response to promote thermotolerance. To test this hypothesis, we pretreated yeast with a series of non-volatile anesthetic and anesthetic-related compounds and quantified survival following lethal heat shock (52 °C for 5 min). Most compounds invoked thermoprotection and promoted survival with a potency proportional to hydrophobicity: tribromoethanol (5.6 mM, peak survival response), trichloroethanol (17.8 mM), dichloroethanol (100 mM), monochloroethanol (316 mM), trifluoroethanol (177.8 mM), ethanol (1 M), isopropanol (1 M), propofol (316 µM), and carbon tetrabromide (32 µM). Thermoprotection conferred by pretreatment with elevated temperatures was "left shifted" by anesthetic co-treatment from (in °C) 35.3 ± 0.1 to 32.2 ± 0.1 with trifluoroethanol (177.8 mM), to 31.2 ± 0.1 with trichloroethanol (17.8 mM), and to 29.1 ± 0.3 with tribromoethanol (5.6 mM). Yeast in postdiauxic shift growth phase, relative to mid-log, responded with greater heat shock survival; and media supplementation with tryptophan and leucine blocked thermoprotection, perhaps by reversing the amino acid starvation response. Our results suggest S. cerevisase may serve as a model organism for understanding anesthetic toxicity and anesthetic preconditioning, a process by which anesthetics promote tissue survival after hypoxic insult.

2.
Heart ; 105(11): 826-833, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30541757

RESUMO

OBJECTIVE: Recently, daytime variation in perioperative myocardial injury (PMI) has been observed in patients undergoing cardiac surgery. We aim at investigating whether daytime variation also occurs in patients undergoing non-cardiac surgery. METHODS: In a prospective diagnostic study, we evaluated the presence of daytime variation in PMI in patients at increased cardiovascular risk undergoing non-cardiac surgery, as well as its possible impact on the incidence of acute myocardial infarction (AMI), and death during 1-year follow-up in a propensity score-matched cohort. PMI was defined as an absolute increase in high-sensitivity cardiac troponin T (hs-cTnT) concentration of ≥14 ng/L from preoperative to postoperative measurements. RESULTS: Of 1641 patients, propensity score matching defined 630 with similar baseline characteristics, half undergoing non-cardiac surgery in the morning (starting from 8:00 to 11:00) and half in the afternoon (starting from 14:00 to 17:00). There was no difference in PMI incidence between both groups (morning: 50, 15.8% (95% CI 12.3 to 20.3); afternoon: 52, 16.4% (95% CI 12.7 to 20.9), p=0.94), nor if analysing hs-cTnT release as a quantitative variable (median morning group: 3 ng/L (95% CI 1 to 7 ng/L); median afternoon group: 2 ng/L (95% CI 0 to 7 ng/L; p=0.16). During 1-year follow-up, the incidence of AMI was 1.2% (95% CI 0.4% to 3.2%) among morning surgeries versus 4.1% (95% CI 2.3% to 6.9%) among the afternoon surgeries (corrected HR for afternoon surgery 3.44, bootstrapped 95% CI 1.33 to 10.49, p log-rank=0.03), whereas no difference in mortality emerged (p=0.70). CONCLUSIONS: Although there is no daytime variation in PMI in patients undergoing non-cardiac surgery, the incidence of AMI during follow-up is increased in afternoon surgeries and requires further study. CLINICAL TRIAL REGISTRATION: NCT02573532;Results.

3.
World J Surg ; 42(12): 3888-3896, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29978247

RESUMO

BACKGROUND: Surgical site infections (SSI) are a major cause of morbidity and mortality in surgical patients. Postoperative and total hospital length of stay (LOS) are known to be prolonged by the occurrence of SSI. Preoperative LOS may increase the risk of SSI. This study aims at identifying the associations of pre- and postoperative LOS in hospital and intensive care with the occurrence of SSI. METHODS: This observational cohort study includes general, orthopedic trauma and vascular surgery patients at two tertiary referral centers in Switzerland between February 2013 and August 2015. The outcome of interest was the 30-day SSI rate. RESULTS: We included 4596 patients, 234 of whom (5.1%) experienced SSI. Being admitted at least 1 day before surgery compared to same-day surgery was associated with a significant increase in the odds of SSI in univariate analysis (OR 1.65, 95% CI 1.25-2.21, p < 0.001). More than 1 day compared to 1 day of preoperative hospital stay did not further increase the odds of SSI (OR 1.08, 95% CI 0.77-1.50, p = 0.658). Preoperative admission to an intensive care unit (ICU) increased the odds of SSI as compared to hospital admission outside of an ICU (OR 2.19, 95% CI 0.89-4.59, p = 0.057). Adjusting for potential confounders in multivariable analysis weakened the effects of both preoperative admission to hospital (OR 1.38, 95% CI 0.99-1.93, p = 0.061) and to the ICU (OR 1.89, 95% CI 0.73-4.24, p = 0.149). CONCLUSION: There was no significant independent association between preoperative length of stay and risk of SSI while SSI and postoperative LOS were significantly associated.

4.
Psychiatr Prax ; 45(5): 269-272, 2018 07.
Artigo em Alemão | MEDLINE | ID: mdl-29665606

RESUMO

We report on a 54-year-old patient who described a progressive anxiety disorder additionally recurrent sight disorders associated with room-tilt illusions and subjective visual field defects. She also reported disturbances of concentration and attention and of a modified typeface accompanied by difficulty in writing with an increase of grammatical errors. Based on the case, the relevant anamnestic and clinical data, the neuropsychological and neuroimaging findings and also differential diagnosis of the posterior cortical atrophy, a rare neurodegenerative disease, will be discussed.

5.
Circulation ; 137(12): 1221-1232, 2018 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-29203498

RESUMO

BACKGROUND: Perioperative myocardial injury (PMI) seems to be a contributor to mortality after noncardiac surgery. Because the vast majority of PMIs are asymptomatic, PMI usually is missed in the absence of systematic screening. METHODS: We performed a prospective diagnostic study enrolling consecutive patients undergoing noncardiac surgery who had a planned postoperative stay of ≥24 hours and were considered at increased cardiovascular risk. All patients received a systematic screening using serial measurements of high-sensitivity cardiac troponin T in clinical routine. PMI was defined as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. Furthermore, mortality was compared among patients with PMI not fulfilling additional criteria (ischemic symptoms, new ECG changes, or imaging evidence of loss of viable myocardium) required for the diagnosis of spontaneous acute myocardial infarction versus those that did. RESULTS: From 2014 to 2015 we included 2018 consecutive patients undergoing 2546 surgeries. Patients had a median age of 74 years and 42% were women. PMI occurred after 397 of 2546 surgeries (16%; 95% confidence interval, 14%-17%) and was accompanied by typical chest pain in 24 of 397 patients (6%) and any ischemic symptoms in 72 of 397 (18%). Crude 30-day mortality was 8.9% (95% confidence interval [CI], 5.7-12.0) in patients with PMI versus 1.5% (95% CI, 0.9-2.0) in patients without PMI (P<0.001). Multivariable regression analysis showed an adjusted hazard ratio of 2.7 (95% CI, 1.5-4.8) for 30-day mortality. The difference was retained at 1 year with mortality rates of 22.5% (95% CI, 17.6-27.4) versus 9.3% (95% CI, 7.9-10.7). Thirty-day mortality was comparable among patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction (280/397, 71%) versus those with at least 1 additional criterion (10.4%; 95% CI, 6.7-15.7, versus 8.7%; 95% CI, 4.2-16.7; P=0.684). CONCLUSIONS: PMI is a common complication after noncardiac surgery and, despite early detection during routine clinical screening, is associated with substantial short- and long-term mortality. Mortality seems comparable in patients with PMI not fulfilling any other of the additional criteria required for spontaneous acute myocardial infarction versus those patients who do. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

6.
J Vasc Surg ; 66(6): 1826-1835.e1, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-28807383

RESUMO

OBJECTIVE: Predicting cardiac events is essential to provide patients with the best medical care and to assess the risk-benefit ratio of surgical procedures. The aim of our study was to evaluate the performance of the Revised Cardiac Risk Index (Lee) and the Vascular Study Group of New England Cardiac Risk Index (VSG) scores for the prediction of major cardiac events in unselected patients undergoing arterial surgery and to determine whether the inclusion of additional risk factors improved their accuracy. METHODS: The study prospectively enrolled 954 consecutive patients undergoing arterial vascular surgery, and the Lee and VSG scores were calculated. Receiver operating characteristic curves for each cardiac risk score were constructed and the areas under the curve (AUCs) compared. Two logistic regression models were done to determine new variables related to the occurrence of major cardiac events (myocardial infarction, heart failure, arrhythmias, and cardiac arrest). RESULTS: Cardiac events occurred in 120 (12.6%) patients. Both scores underestimated the rate of cardiac events across all risk strata. The VSG score had AUC of 0.63 (95% confidence interval [CI], 0.58-0.68), which was higher than the AUC of the Lee score (0.58; 95% CI, 0.52-0.63; P = .03). Addition of preoperative anemia significantly improved the accuracy of the Lee score to an AUC of 0.61 (95% CI, 0.58-0.67; P = .002) but not that of the VSG score. CONCLUSIONS: The Lee and VSG scores have low accuracy and underestimate the risk of major perioperative cardiac events in unselected patients undergoing vascular surgery. The Lee score's accuracy can be increased by adding preoperative anemia. Underestimation of major cardiac complications may lead to incorrect risk-benefit assessments regarding the planned operation.


Assuntos
Artérias/cirurgia , Técnicas de Apoio para a Decisão , Cardiopatias/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Área Sob a Curva , Brasil , Distribuição de Qui-Quadrado , Feminino , Cardiopatias/diagnóstico , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Curva ROC , Sistema de Registros , Medição de Risco , Fatores de Risco , Suíça , Resultado do Tratamento
7.
Lancet Infect Dis ; 17(6): 605-614, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28385346

RESUMO

BACKGROUND: Based on observational studies, administration of surgical antimicrobial prophylaxis (SAP) for the prevention of surgical site infection (SSI) is recommended within 60 min before incision. However, the precise optimum timing is unknown. This trial compared early versus late administration of SAP before surgery. METHODS: In this phase 3 randomised controlled superiority trial, we included general surgery adult inpatients (age ≥18 years) at two Swiss hospitals in Basel and Aarau. Patients were randomised centrally and stratified by hospital according to a pre-existing computer-generated list in a 1:1 ratio to receive SAP early in the anaesthesia room or late in the operating room. Patients and the outcome assessment team were blinded to group assignment. SAP consisted of single-shot, intravenous infusion of 1·5 g of cefuroxime, a commonly used cephalosporin with a short half-life, over 2-5 min (combined with 500 mg metronidazole in colorectal surgery). The primary endpoint was the occurrence of SSI within 30 days of surgery. The main analyses were by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT01790529. FINDINGS: Between Feb 21, 2013, and Aug 3, 2015, 5580 patients were randomly assigned to receive SAP early (2798 patients) or late (2782 patients). 5175 patients (2589 in the early group and 2586 in the late group) were analysed. Median administration time was 42 min before incision in the early group (IQR 30-55) and 16 min before incision in the late group (IQR 10-25). Inpatient follow-up rate was 100% (5175 of 5175 patients); outpatient 30-day follow-up rate was 88·8% (4596 of 5175), with an overall SSI rate of 5·1% (234 of 4596). Early administration of SAP did not significantly reduce the risk of SSI compared with late administration (odds ratio 0·93, 95% CI 0·72-1·21, p=0·601). INTERPRETATION: Our findings do not support any narrowing of the 60-min window for the administration of a cephalosporin with a short half-life, thereby obviating the need for increasingly challenging SAP timing recommendations. FUNDING: Swiss National Science Foundation, Hospital of Aarau, University of Basel, Gottfried und Julia Bangerter-Rhyner Foundation, Hippocrate Foundation, and Nora van Meeuwen-Häfliger Foundation.


Assuntos
Antibacterianos/uso terapêutico , Cefuroxima/uso terapêutico , Esquema de Medicação , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/prevenção & controle , Adolescente , Adulto , Idoso , Anti-Infecciosos/uso terapêutico , Feminino , Humanos , Masculino , Metronidazol/uso terapêutico , Pessoa de Meia-Idade , Fatores de Risco , Resultado do Tratamento
8.
Eur J Anaesthesiol ; 32(10): 687-96, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26213905

RESUMO

BACKGROUND: The duration of neuromuscular block (NMB) following succinylcholine administration is characterised by a high interindividual variability. However, this has not yet been quantified in a large sample of surgical patients. The significance of underlying clinical factors is unknown. OBJECTIVE: The objective of this study was to profile the variability in NMB duration following a standard dose of succinylcholine and to investigate contributing clinical and genetic factors. DESIGN: A prospective, observational study. SETTING: Tertiary referral centre. PATIENTS: In a total of 1630 surgical patients undergoing a rapid sequence induction and intubation, clinical risk factors for a prolongation in NMB duration following succinylcholine were assessed. In a subset of 202 patients, additional biochemical and molecular genetic investigations of butyrylcholinesterase were performed. INTERVENTION: A standard 1 mg kg dose of succinylcholine after administration of an induction drug and an opioid. MAIN OUTCOME: NMB duration measured as the time between administration of succinylcholine until reappearance of palpable muscular response to supramaximal transcutaneous ulnar nerve stimulation. RESULTS: NMB varied from 80 s to 44 min with a median duration of 7.3 min. Sixteen percent of patients had NMB duration in excess of 10 min. A multivariable survival model identified physical status, sex, age, hepatic disease, pregnancy, history of cancer and use of etomidate or metoclopramide as independent risk factors for a prolonged NMB. Three novel butyrylcholinesterase variants were identified: p.Ile5Thr; p.Val178Ile; and p.Try231Ser. CONCLUSION: Neuromuscular blockade duration in excess of 10 min occurred in 16% of a general surgical population following a single dose of succinylcholine. The multivariable model of clinical risk factors for prolonged NMB revealed a negative predictive value of 87%, thereby indicating that absence of such risk factors may reliably predict a shorter duration of NMB. In patients with clinical risk factors for a prolonged NMB or with butyrylcholinesterase mutations, an alternative to succinylcholine should be considered.


Assuntos
Butirilcolinesterase/genética , Bloqueio Neuromuscular/métodos , Fármacos Neuromusculares Despolarizantes/administração & dosagem , Succinilcolina/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Mutação , Fármacos Neuromusculares Despolarizantes/farmacologia , Valor Preditivo dos Testes , Estudos Prospectivos , Fatores de Risco , Succinilcolina/farmacologia , Fatores de Tempo
9.
Trials ; 15: 188, 2014 May 24.
Artigo em Inglês | MEDLINE | ID: mdl-24885132

RESUMO

BACKGROUND: Surgical site infections are the most common hospital-acquired infections among surgical patients. The administration of surgical antimicrobial prophylaxis reduces the risk of surgical site infections . The optimal timing of this procedure is still a matter of debate. While most studies suggest that it should be given as close to the incision time as possible, others conclude that this may be too late for optimal prevention of surgical site infections. A large observational study suggests that surgical antimicrobial prophylaxis should be administered 74 to 30 minutes before surgery. The aim of this article is to report the design and protocol of a randomized controlled trial investigating the optimal timing of surgical antimicrobial prophylaxis. METHODS/DESIGN: In this bi-center randomized controlled trial conducted at two tertiary referral centers in Switzerland, we plan to include 5,000 patients undergoing general, oncologic, vascular and orthopedic trauma procedures. Patients are randomized in a 1:1 ratio into two groups: one receiving surgical antimicrobial prophylaxis in the anesthesia room (75 to 30 minutes before incision) and the other receiving surgical antimicrobial prophylaxis in the operating room (less than 30 minutes before incision). We expect a significantly lower rate of surgical site infections with surgical antimicrobial prophylaxis administered more than 30 minutes before the scheduled incision. The primary outcome is the occurrence of surgical site infections during a 30-day follow-up period (one year with an implant in place). When assuming a 5% surgical site infection risk with administration of surgical antimicrobial prophylaxis in the operating room, the planned sample size has an 80% power to detect a relative risk reduction for surgical site infections of 33% when administering surgical antimicrobial prophylaxis in the anesthesia room (with a two-sided type I error of 5%). We expect the study to be completed within three years. DISCUSSION: The results of this randomized controlled trial will have an important impact on current international guidelines for infection control strategies in the hospital. Moreover, the results of this randomized controlled trial are of significant interest for patient safety and healthcare economics. TRIAL REGISTRATION: This trial is registered on ClinicalTrials.gov under the identifier NCT01790529.


Assuntos
Antibacterianos/administração & dosagem , Antibioticoprofilaxia/métodos , Projetos de Pesquisa , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Infecção da Ferida Cirúrgica/prevenção & controle , Protocolos Clínicos , Esquema de Medicação , Humanos , Fatores de Risco , Infecção da Ferida Cirúrgica/microbiologia , Suíça , Centros de Atenção Terciária , Fatores de Tempo , Resultado do Tratamento
10.
Br J Nutr ; 107(4): 573-80, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21846430

RESUMO

Loss of body protein and hyperglycaemia represent typical features of the stress response to surgery and anaesthesia. This appears to be particularly pronounced in patients with diabetes mellitus type 2. The aim of the present study was to highlight the greater benefit of amino acids (AA) as represented by positive protein balance and maintenance of blood glucose homoeostasis compared with dextrose (DEX) in diabetic patients after colorectal surgery. A total of thirteen patients underwent a 5 h stable isotope infusion study (2 h fasted, 3 h fed with an infusion of AA (n 6) or DEX (n 7)) on the second post-operative day. Glucose and protein kinetics were assessed by using the stable isotopes l-[1-¹³C]leucine and [6,6-²H2]glucose. The transition from fasted to fed state decreased endogenous glucose production (P < 0·001) in both groups, with a more profound effect in the DEX group (P = 0·031). In contrast, total glucose production was increased by the provision of DEX while being lowered by AA (P = 0·021). Feeding decreased protein oxidation (P = 0·009) and protein synthesis in the AA group, whereas DEX infusion did not affect oxidation and even decreased protein synthesis. Therefore, only AA shifted protein balance to a positive value, while patients in the DEX group remained in a catabolic state (P < 0·001). Parenteral nutritional support with AA rather than with DEX is an effective strategy to achieve a positive protein balance while maintaining normoglycaemia in diabetic patients after colorectal surgery.


Assuntos
Aminoácidos/uso terapêutico , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/metabolismo , Hiperglicemia/prevenção & controle , Hipoglicemia/prevenção & controle , Nutrição Parenteral , Complicações Pós-Operatórias/prevenção & controle , Idoso , Idoso de 80 Anos ou mais , Aminoácidos/administração & dosagem , Cirurgia Colorretal/efeitos adversos , Complicações do Diabetes/cirurgia , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Feminino , Gluconeogênese , Glucose/administração & dosagem , Glucose/metabolismo , Glucose/uso terapêutico , Humanos , Cinética , Estudos Longitudinais , Masculino , Período Pós-Operatório , Biossíntese de Proteínas , Proteínas/metabolismo
11.
Reg Anesth Pain Med ; 35(4): 355-60, 2010 Jul-Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20607877

RESUMO

BACKGROUND: Surgical injury provokes a stress response that is thought to be pronounced in patients with diabetes mellitus type 2 (DM2) leading to intensified catabolism. The aim of this study was to compare the effects of perioperative epidural analgesia (EDA) versus patient controlled analgesia (PCA) and amino acid infusion on postoperative metabolism in patients with and without DM2. METHODS: For this study, 12 nondiabetic patients and 12 diabetic patients undergoing colorectal surgery were randomly assigned to 4 groups (n = 6 per group) receiving either EDA (nondiabetic EDA and diabetic EDA [DEDA group]) or PCA with morphine (nondiabetic PCA and diabetic PCA) for perioperative pain control. Protein and glucose kinetics were measured on the second postoperative day using L-[1-13C]leucine and [6,6-2H2]glucose infusion during a fasted state and a 3-hr fed state with amino acid infusion. RESULTS: The transition from the fasted to fed state suppressed endogenous rate of appearance (Ra) of glucose (P G 0.001) with a distinct effect for the DEDA group (P G 0.001). The Ra of leucine and the endogenous rate of appearance of leucine tended to be lower in the DEDA group(P = 0.056 and P = 0.07). Leucine oxidation was more suppressed in the DEDA group (P = 0.02) and when receiving amino acids(P = 0.001). Diabetic patients achieved a higher protein balance than nondiabetic patients (P = 0.032) and when receiving EDA instead of PCA (P = 0.012) or infusion of amino acids (P = 0.014). CONCLUSIONS: A short-term infusion of amino acids reduced protein breakdown, increased protein synthesis, and rendered protein balance positive. This anabolic effect was pronounced in diabetic patients with EDA compared with nondiabetic patients or PCA, respectively, and prevented an undesirable hyperglycemia.


Assuntos
Aminoácidos/administração & dosagem , Analgesia Epidural , Analgesia Controlada pelo Paciente , Colectomia , Doenças do Colo/cirurgia , Diabetes Mellitus Tipo 2/metabolismo , Proteínas na Dieta/administração & dosagem , Dor Pós-Operatória/prevenção & controle , Idoso , Aminoácidos/farmacocinética , Analgésicos Opioides/administração & dosagem , Anestésicos Locais/administração & dosagem , Glicemia/metabolismo , Bupivacaína/administração & dosagem , Doenças do Colo/complicações , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/complicações , Proteínas na Dieta/farmacocinética , Jejum/sangue , Feminino , Fentanila/administração & dosagem , Glucagon/sangue , Humanos , Hiperglicemia/sangue , Hiperglicemia/etiologia , Hiperglicemia/prevenção & controle , Infusões Parenterais , Insulina/sangue , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Troca Gasosa Pulmonar , Quebeque , Resultado do Tratamento
12.
J Clin Anesth ; 22(1): 13-21, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20206846

RESUMO

STUDY OBJECTIVE: To evaluate the incidence of perioperative minor adverse events and to analyze patient satisfaction based on potential explanatory variables. DESIGN: Structured, face-to-face interview of 25% of all patients undergoing surgery during the period from January 2003 through June 2006. SETTING: Academic university medical center. PATIENTS: 12,276 patients (5,793 men and 6,483 women) from all surgical disciplines: 7,440 patients had general anesthesia, 4,236 patients had regional anesthesia, and 600 patients had a combined general-regional anesthetic technique. MEASUREMENTS: Occurrence of perioperative minor adverse events was assessed during the interview. Patient satisfaction was measured with a 4-point Likert scale. MAIN RESULTS: 3,652 (30%) patients reported at least one perioperative complaint and 737 (6%) patients reported multiple minor adverse events. Overall, a total of 4,475 minor adverse events were reported. Leading adverse events included postoperative nausea and vomiting (1,705 complaints), sore throat (1,228 complaints), and hoarseness (802 complaints). Patient satisfaction with anesthetic care was generally high (97% satisfied or highly satisfied). Patients were significantly more satisfied following regional than general anesthesia (P < 0.001). Patient dissatisfaction was also associated with the occurrence of at least one minor adverse event (P < 0.001) or with increasing ASA physical status (P < 0.001). CONCLUSION: Minor events occur with a surprisingly high incidence and are significantly associated with patient dissatisfaction. Regional anesthesia is associated with fewer patient complaints and significantly higher postoperative patient satisfaction.


Assuntos
Anestesia por Condução , Anestesia Geral , Satisfação do Paciente , Complicações Pós-Operatórias/psicologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos
13.
Eur J Anaesthesiol ; 27(8): 690-5, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20090534

RESUMO

BACKGROUND AND OBJECTIVE: Postoperative cardiac complications pose a substantial risk to patients undergoing orthopaedic surgery. METHODS: B-type natriuretic peptide (BNP) was determined preoperatively in 270 patients undergoing scheduled orthopaedic surgery. The accuracy of BNP to predict the occurrence of in-hospital cardiac events was evaluated as the primary endpoint. Cardiac events at 1 year of follow-up were considered secondary endpoints. RESULTS: Preoperative BNP levels were significantly higher in the four patients experiencing in-hospital cardiac events than in patients without events [median 306 pg ml(-1) (range 123-3958) vs. 35 pg ml(-1) (range 14-2074), P = 0.01]. In a receiver operating characteristic analysis for the prediction of in-hospital cardiac events, the area under the receiver operating characteristic curve for BNP was 0.86 (95% confidence interval 0.74-0.99). The optimal predictive accuracy was achieved with a BNP threshold of 174 pg ml(-1). Importantly, the combination of BNP and the American Society of Anesthesiologists score further improved this accuracy. Additionally, BNP retained a high predictive accuracy in the subgroup of patients with known cardiac diseases [area under the receiver operating characteristic curve 0.85 (95% confidence interval from 0.65 to <1)]. The area under the receiver operating characteristic curve for the prediction of long-term cardiac events by BNP was 0.71 (95% confidence interval 0.57-0.84). CONCLUSION: In patients undergoing orthopaedic surgery, preoperative BNP levels can predict short-term and long-term postoperative cardiac events. Despite the paucity of endpoint events observed in this study, our results are in agreement with all prior investigations. BNP used in addition to an American College of Cardiology/American Heart Association guideline-based risk assessment might, therefore, be a useful tool in the preoperative evaluation of patients undergoing orthopaedic surgery.


Assuntos
Doenças Cardiovasculares/sangue , Peptídeo Natriurético Encefálico/sangue , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Assistência ao Paciente/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Adulto Jovem
14.
Ther Umsch ; 66(7): 503-8, 2009 Jul.
Artigo em Alemão | MEDLINE | ID: mdl-19565444

RESUMO

Anaesthetists often visit their patients in exceptional situations characterised by preoperative anxiety or distress. Therefore, even brief contact with the patient can be considered intense and meaningful. The initial preoperative anaesthetic visit is the beginning of the relationship between patient and anaesthetist, and should help to explain the planned anaesthetic technique. Preoperative anaesthetic visits are intense and last for 20 minutes on average. They should assert a professional approach to the patient's emotions, particularly to preoperative anxiety, and a structured and clear collection of information including the past history of the patient. These visits should also provide information about the anaesthesia itself and instructions for the patient with respect to the perioperative period. Communication about the side effects and risks of anaesthetic techniques, and the discussion of potential alternatives are mandatory. Worldwide, courts of law increasingly require a documented discussion between the anaesthetist and patient based on risk-benefit evidence. Today, there is in general a shift away from decisions made solely by physicians, reflecting an increased respect for the autonomy of the patient towards a model of shared decision-making and informed choice. Ideally, the preoperative visit follows the four key habits of highly effective clinicians, i.e., to rapidly establish a rapport with the patient and provide an agenda for the visit, to explore the patient's perspectives and expectations, to demonstrate empathy, and to focus on the end of the visit with providing information and including the patient in the decision-making process. Visits are then concluded upon obtaining informed consent from the patient.


Assuntos
Anestesia , Comunicação , Indicadores Básicos de Saúde , Educação de Pacientes como Assunto , Cuidados Pré-Operatórios , Anestesia/psicologia , Ansiedade/psicologia , Empatia , Humanos , Consentimento Livre e Esclarecido/psicologia , Anamnese , Participação do Paciente/psicologia , Relações Médico-Paciente , Cuidados Pré-Operatórios/psicologia , Suíça
15.
Eur J Anaesthesiol ; 26(10): 807-20, 2009 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-19494779

RESUMO

General anaesthesia is administered each day to thousands of patients worldwide. Although more than 160 years have passed since the first successful public demonstration of anaesthesia, a detailed understanding of the anaesthetic mechanism of action of these drugs is still lacking. An important early observation was the Meyer-Overton correlation, which associated the potency of an anaesthetic with its lipid solubility. This work focuses attention on the lipid membrane as a likely location for anaesthetic action. With the advent of cellular electrophysiology and molecular biology techniques, tools to dissect the components of the lipid membrane have led, in recent years, to the widespread acceptance of proteins, namely receptors and ion channels, as more likely targets for the anaesthetic effect. Yet these accumulated data have not produced a comprehensive explanation for how these drugs produce central nervous system depression. In this review, we follow the story of anaesthesia mechanisms research from its historical roots to the intensely neurophysiological research regarding it today. We will also describe recent findings that identify specific neuroanatomical locations mediating the actions of some anaesthetic agents.


Assuntos
Anestesia Geral/métodos , Anestésicos Gerais/farmacologia , Sistemas de Liberação de Medicamentos , Anestesia Geral/história , Anestésicos Gerais/química , Anestésicos Gerais/história , Animais , Sistema Nervoso Central/efeitos dos fármacos , Sistema Nervoso Central/metabolismo , Eletrofisiologia , História do Século XVIII , História do Século XIX , História do Século XX , Humanos , Solubilidade
16.
Anesth Analg ; 106(5): 1524-33, table of contents, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18420871

RESUMO

BACKGROUND: The expansion of science has resulted in an increased information flow and in an exponentially growing number of connections between knowledge in different research fields. In this study, we used methods of scientometric analysis to obtain a conceptual network that forms the structure of active scientific research fields in anesthesia. METHODS: We extracted from the Web of Science (Institute for Scientific Information) all original articles (n = 3275) including their references (n = 79,972) that appeared in 2003 in all 23 journals listed in the Institute for Scientific Information Journal Citation Reports under the subject heading "Anesthesiology." After identification of highly cited references (> or = 5), pairs of co-cited references were created and grouped into uniformly structured clusters of documents using a single linkage and variable level clustering method. In addition, for each such cluster of documents, we identified corresponding front papers published in 2003, each of which co-cited at least two documents of the cluster core. Active anesthetic research fields were then named by examining the titles of the documents in both the established clusters and in their corresponding front papers. These research fields were sorted according to the proportion of recent documents in their cluster core (immediacy index) and were further analyzed. RESULTS: Forty-six current anesthetic research fields were identified. The research field named "ProSeal laryngeal mask airway" showed the highest immediacy index (100%) whereas the research fields "Experimental models of neuropathic pain" and "Volatile anesthetic-induced cardioprotection" exhibited the highest level of co-citation strength (level 9). The research field with the largest cluster core, containing 12 homogeneous papers, was "Postoperative nausea and vomiting." The journal Anesthesia & Analgesia published most front papers while Anesthesiology published most of the fundamental documents used as references in the front papers. CONCLUSIONS: Using co-citation analysis, we identified distinct homogenous clusters of highly cited documents representing 46 active current anesthetic research fields and determined multiple nets of knowledge among them.


Assuntos
Anestesia/tendências , Bibliometria , Pesquisa Biomédica/tendências , Bases de Dados Bibliográficas , Publicações Periódicas como Assunto , Animais , Análise por Conglomerados , Humanos
17.
J Clin Anesth ; 19(1): 9-14, 2007 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-17321920

RESUMO

STUDY OBJECTIVE: To evaluate patient acceptability of continued versus divided anesthetic care. DESIGN: Patient satisfaction ratings with continuous and divided anesthetic care were assessed by patient questionnaire. In addition, the effect of training anesthesia personnel in communication regarding divided anesthesia care was examined. SETTING: University medical center. PATIENTS: 654 consecutive patients scheduled for elective surgery. MEASUREMENTS AND MAIN RESULTS: Overall postoperative patient satisfaction was high and not different between patients experiencing continued or divided anesthetic care (P=0.97). Asking patients before their operations about the importance of continued anesthetic care resulted in a highly significant difference between the two groups. In the continued anesthetic care model, patients felt it more important to experience continued care. In contrast, patients who were told that another anesthesiologist would take care of them rated the same question with a lower importance (P<0.001). CONCLUSION: Before their operations, more than half of the patients felt it very important that they were visited and anesthetized by the same physician. Nevertheless, postoperative patient satisfaction was equally high regardless of whether they were anesthetized by the same physician who had visited them preoperatively.


Assuntos
Anestesia Geral , Anestesiologia , Comunicação , Satisfação do Paciente/estatística & dados numéricos , Relações Médico-Paciente , Inquéritos e Questionários , Adulto , Idoso , Análise de Variância , Anestesia Geral/psicologia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Capacitação em Serviço/métodos , Masculino , Pessoa de Meia-Idade
18.
Anesth Analg ; 101(4): 1042-9, table of contents, 2005 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-16192517

RESUMO

UNLABELLED: TRESK (TWIK-related spinal cord K+ channel) is the most recently characterized member of the tandem-pore domain potassium channel (K2P) family. Human TRESK is potently activated by halothane, isoflurane, sevoflurane, and desflurane, making it the most sensitive volatile anesthetic-activated K2P channel yet described. Herein, we compare the anesthetic sensitivity and pharmacologic modulation of rodent versions of TRESK to their human orthologue. Currents passed by mouse and rat TRESK were enhanced by isoflurane at clinical concentrations but with significantly lower efficacy than human TRESK. Unlike human TRESK, the rodent TRESKs are strongly inhibited by acidic extracellular pH in the physiologic range. Zinc inhibited currents passed by both rodent TRESK in the low micromolar range but was without effect on human TRESK. Enantiomers of isoflurane that have stereoselective anesthetic potency in vivo produced stereospecific enhancement of the rodent TRESKs in vitro. Amide local anesthetics inhibited the rodent TRESKs at almost 10-fold smaller concentrations than that which inhibit human TRESK. These results identified interspecies differences and similarities in the pharmacology of TRESK. Further characterization of TRESK expression patterns is needed to understand their role in anesthetic mechanisms. IMPLICATIONS: Mouse and rat TRESK (TWIK-related spinal cord K+ channel) have different pharmacologic responses compared with human TRESK. In particular, we found stereospecific differences in response to isoflurane by the rodent TRESKs but not by human TRESK. TRESK may be a target site for the mechanism of action of volatile anesthetics.


Assuntos
Anestésicos/farmacologia , Canais de Potássio/efeitos dos fármacos , Animais , Concentração de Íons de Hidrogênio , Camundongos , Canais de Potássio/química , Canais de Potássio/genética , Canais de Potássio/fisiologia , Ratos , Especificidade da Espécie , Zinco/farmacologia
19.
Anesth Analg ; 101(3): 715-21, table of contents, 2005 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-16115980

RESUMO

Antagonists of the serotonergic 5-hydroxytryptamine 3A receptor (5-HT(3A)R) and muscle nicotinic acetylcholine receptors (nAChR) are widely used in anesthesia practice. Both 5-HT(3A)R and nAChR are ligand-gated ion channels with known pharmacological overlap between some of their agonists and antagonists. We studied the actions of clinically used 5-HT(3A)R antagonist antiemetics and nondepolarizing muscle blockers on ionic currents elicited by the activation of mammalian 5-HT(3A)R and muscle nAChR, expressed in Xenopus laevis oocytes. Currents were recorded using a whole-cell two-electrode voltage clamp technique. Dolasetron, ondansetron, and granisetron reversibly inhibited 5-HT(3A)R function at nanomolar concentrations with 50% inhibitory concentrations (IC(50)) of 11.8, 6.4, and 0.2 nM; the rank order of inhibition correlated well with their clinical antiemetic potencies. The principal metabolite of dolasetron, hydrodolasetron, was 40 times more potent than the parent compound on 5-HT(3A)R (IC(50) = 0.29 nM). The potency of the nondepolarizing muscle blocker d-tubocurarine in blocking 5-HT(3A)R was similar to that of the antiemetics and significantly more than vecuronium and rapacuronium (IC(50) = 11.4 nM, 18.9 microM, 60.5 microM). Conversely, ondansetron, dolasetron, and granisetron also reversibly inhibited nAChR currents in a dose-dependent manner with IC(50)s of 14.2, 7.8, and 4.4 microM for the adult nAChR and 16.0, 18.6, and 13.9 microM for the embryonic nAChR. Again, hydrodolasetron showed significantly (10 times) more inhibitory potency on the adult nAChR than the parent compound dolasetron. These results indicate that drugs that target specific ligand-gated ion channels may also affect other ion channel types.


Assuntos
Antieméticos/farmacologia , Músculo Esquelético/efeitos dos fármacos , Receptores Nicotínicos/efeitos dos fármacos , Receptores 5-HT3 de Serotonina/efeitos dos fármacos , Antagonistas da Serotonina/farmacologia , Animais , Camundongos , Fármacos Neuromusculares não Despolarizantes/farmacologia , Antagonistas Nicotínicos/farmacologia , Oócitos/metabolismo , RNA Complementar/biossíntese , Receptores Nicotínicos/genética , Receptores 5-HT3 de Serotonina/genética , Serotonina/farmacologia , Tubocurarina/farmacologia , Brometo de Vecurônio/análogos & derivados , Brometo de Vecurônio/farmacologia
20.
Reg Anesth Pain Med ; 30(3): 260-74, 2005 May-Jun.
Artigo em Inglês | MEDLINE | ID: mdl-15898030

RESUMO

Potassium (K+) channels form the largest family of ion channels with more than 70 such genes identified in the human genome. They are organized in 3 superfamilies according to their predicted membrane topology: (1) subunits with 6 membrane-spanning segments and 1-pore domain, (2) subunits with 2 membrane-spanning segments and 1-pore domain, and (3) subunits with 4 membrane-spanning segments and 2-pore domains arrayed in a tandem position. The last family has most recently been identified and comprises the so-called 2-pore domain potassium (K2P) channels, believed responsible for background or leak K+ currents. Despite their recent discovery, interest in them is growing rapidly with more than 270 references in the literature reported (www.ipmc.cnrs.fr/~duprat/2p/ref2p.htm#2P, accessed October 30, 2004). K2P channels are widely expressed in the central nervous system and are involved in the control of the resting membrane potential and the firing pattern of excitable cells. This article will therefore review recent findings on actions of local anesthetics with respect to 2P channels. It begins with an overview of the role of background K+ channels in neuronal excitability and nerve conduction and is followed by a description of the K2P channel family including experimental evidence for the contribution of K2P channels to the mechanism of action and toxicity of local anesthetics.


Assuntos
Anestésicos Locais/farmacologia , Anestésicos Locais/toxicidade , Canais de Potássio de Domínios Poros em Tandem/efeitos dos fármacos , Animais , Humanos , Potenciais da Membrana/efeitos dos fármacos , Condução Nervosa/efeitos dos fármacos , Neurônios/efeitos dos fármacos
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