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1.
Br J Anaesth ; 124(3): e117-e130, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31955857

RESUMO

A systematic literature search was performed to identify studies that reported risk factors for persistent pain after childbirth. Many studies have sought to identify risk factors for post-delivery pain in different populations, using different methodologies and different outcome variables. Studies of several different but interrelated post-partum pain syndromes have been conducted. Factors strongly and specifically associated with persistent incisional scar pain after Caesarean delivery include a coexisting persistent pain problem in another part of the body and severe acute postoperative pain. For persistent vaginal and perineal pain, operative vaginal delivery and the magnitude of perineal trauma have been consistently linked. History of pregnancy-related and pre-pregnancy back pain and heavier body weight are robust risk factors for persistent back pain after pregnancy. Unfortunately, limitations, particularly small samples and lack of a priori sample size calculation designed to detect specific effect sizes for risk of persistent pain outcomes, preclude definitive conclusions about many other predictors and the strength of outcome associations. In future studies, assessments of specific phenotypes using a rigorous analysis with appropriate predetermined sample sizes and validated instruments are needed to allow elucidation of stronger and reliable associations. Interventional studies targeting the most robustly associated, modifiable risk factors, such as acute post-partum pain, may lead to solutions for the prevention and treatment of these common problems that impact a large population.


Assuntos
Cesárea/efeitos adversos , Dor Crônica/etiologia , Parto Obstétrico/efeitos adversos , Analgésicos Opioides/uso terapêutico , Catecol O-Metiltransferase/genética , Dor Crônica/prevenção & controle , Cicatriz/complicações , Feminino , Humanos , Períneo , Gravidez , Receptores Opioides mu/genética , Fatores de Risco
3.
J Anesth ; 32(5): 663-672, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30014234

RESUMO

PURPOSE: To determine whether hypothyroidism is associated with cardiovascular complications and surgical wound infections after cardiac surgery. METHODS: Patients were categorized as: (1) hypothyroid [patients with increased TSH concentrations (≧ 5.5 mIU/L) within 6 months prior to surgery]; (2) corrected hypothyroid [diagnosis of hypothyroidism any time before surgery or on preoperative thyroid supplementation and normal TSH concentration (0.4 [Formula: see text] TSH [Formula: see text] 5.5 mIU/L]; and (3) euthyroid [no hypothyroid diagnosis and not on preoperative thyroid supplementation and normal TSH concentrations (0.4-5.5 mIU/L)]. We conducted pairwise comparisons among the three groups using inverse probability of treatment weighting. We compared the groups on postoperative myocardial infarction, cardiac arrest, atrial fibrillation, and a composite of surgical wound infections and postoperative vasopressor use using multivariable logistic regression models. We compared the groups on ICU and hospital length of stay using Cox proportional hazards regression. RESULTS: Hypothyroidism was associated with a lower risk of atrial fibrillation than euthyroidism, with an estimated relative risk (99.4% CI) of 0.71 (0.56, 0.89); P < 0.001. However, none of the other pairwise comparisons on myocardial infarction, cardiac arrest, and atrial fibrillation were significant. Corrected hypothyroid patients were slightly more likely to be discharged from hospital at any given time than euthyroid patients (hazard ratios (99.6% CI), 1.18 (1.07, 1.30); P < 0.001), but no other pairwise comparisons for secondary outcomes were significant. CONCLUSIONS: Hypothyroidism was associated with lower risk of atrial fibrillation than euthyroidism, and corrected hypothyroidism was associated with a shorter length of stay than euthyroidism.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hipotireoidismo/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Risco , Tireotropina/sangue
4.
Anesthesiology ; 127(4): 684-694, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28926443

RESUMO

BACKGROUND: The majority of parturients in the United States first return for evaluation by their obstetric practitioner 6 weeks after delivery. As such, there is little granular data on the pain experience, analgesic requirements, and functional recovery during the postpartum period. This prospective observational study was performed to evaluate these factors to provide expectations for patients. METHODS: A total of 213 nulliparous women were enrolled and assessed daily until they completed 3 outcomes: (1) pain resolution; (2) opioid cessation; and (3) self-assessed functional recovery from delivery. The primary endpoint, pain- and opioid-free functional recovery, was the time required to reach all three of the endpoints. Pain burden was assessed as the area under the curve created by plotting the daily numerical pain rating scale against the days required to attain pain resolution. Times to attain study endpoints after cesarean delivery and vaginal delivery were compared using survival analysis. RESULTS: After vaginal delivery, days required for pain and opioid-free functional recovery (median [interquartile range (IQR)]) were 19 [11 to 26], for opioid cessation 0 [0 to 2], termination of all analgesic (including nonsteroidal antiinflammatories and acetaminophen) 11 [5 to 17], and pain resolution 14 [7 to 24]. Achievement of these endpoints after cesarean delivery required 27 [19 to 40], 9 [5 to 12], 16 [11 to 24], and 21 [14 to 27] days, respectively. CONCLUSIONS: There is clinically significant variability between healthy nulliparous parturients in the pain experience, opioid use, and functional recovery after childbirth following vaginal and cesarean delivery. Recovery to predelivery function is similar after vaginal and cesarean delivery, and approximately half of the variance was explained by pain burden.


Assuntos
Analgesia Obstétrica/métodos , Analgésicos Opioides/uso terapêutico , Parto Obstétrico/métodos , Dor/tratamento farmacológico , Parto/fisiologia , Recuperação de Função Fisiológica/fisiologia , Adulto , Feminino , Humanos , Paridade , Período Pós-Parto , Gravidez , Estudos Prospectivos
5.
J Anesth ; 31(5): 782-784, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28477229

RESUMO

The head-mounted display (HMD) has the potential to improve the quality of ultrasound-guided procedures. The aim of this non-clinical crossover designed study is to evaluate the feasibility of the HMD for ultrasound-guided nerve block. Eight experienced anesthesiologists performed ultrasound-guided peripheral nerve blocks on a training simulator with a standard approach and with an upside-down approach. Each approach was performed with a control conventional method and with an HMD. The ultrasound image and operating field were recorded by video camera. The procedure time and fractional percentage of time with the needle visible on the ultrasound image were determined. The needle insertion times were 10.4 ± 7.2 s with the control method and 6.8 ± 5.3 s with the HMD method for the standard approach (p = 0.03), and 18.1 ± 10.1 with the control method and 11.8 ± 9.5 s with the HMD method for the upside-down approach (p = 0.002). The fractional percentages of time with the needle visible on the ultrasound image were 34.1 ± 20.9 with the control method and 56.5 ± 13.6% with the HMD method for the standard approach (p < 0.001), and 20.1 ± 13.4 with the control method and 38.2 ± 21.2% with the HMD method for the upside-down approach (p = 0.001). In conclusion, this pilot study using a simulation model indicated that the use of an HMD shortened the procedure time and improved the needle visibility on ultrasound.


Assuntos
Anestesia por Condução , Bloqueio Nervoso/métodos , Ultrassonografia/métodos , Adulto , Estudos Cross-Over , Apresentação de Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Agulhas , Nervos Periféricos , Projetos Piloto , Treinamento por Simulação
6.
Anesthesiology ; 126(5): 799-809, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28207437

RESUMO

BACKGROUND: Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery. METHODS: The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models. RESULTS: Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay. CONCLUSIONS: Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Doenças do Sistema Nervoso/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Transtornos Respiratórios/prevenção & controle , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
7.
J Cardiothorac Vasc Anesth ; 30(6): 1516-1522, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-27554237

RESUMO

OBJECTIVE: To compare incidence of atrial arrhythmia, duration of care, and major complications after cardiac surgery between patients who received etomidate and those who received other induction agents. DESIGN: Retrospective cohort study utilizing propensity score matching. SETTING: A single academic, tertiary care hospital. PARTICIPANTS: Eight thousand nine hundred seventy-eight patients undergoing coronary artery bypass grafting (CABG), valve, or combined valve/CABG surgery requiring cardiopulmonary bypass between January 2005 and December 2010. INTERVENTIONS: Patients were divided into those who received etomidate at anesthetic induction and those who received another induction agent. Patients given etomidate were propensity-score matched to patients given other induction agents in a 2:1 ratio. MEASUREMENTS AND MAIN RESULTS: Of 8,978 patients who underwent CABG, valve, or combined valve/surgery, 6,313 received etomidate and 2,665 received other induction agents. Among these, the authors successfully matched 4,094 etomidate patients with 2,524 non-etomidate patients. The authors did not find a significant association between receiving etomidate and odds of experiencing postoperative atrial arrhythmia (odds ratio [98.3% confidence interval] of 1.07 [0.92, 1.23], p = 0.29). Etomidate was not associated significantly with either intensive care unit or hospital stay. Etomidate was associated significantly with use of packed red blood cells (odds ratio [99.6% confidence interval] of 1.32 [1.02, 1.70], p = 0.002), but not with use of fresh frozen plasma, platelets, or cryoprecipitate. None of the other complications differed significantly between the groups. CONCLUSIONS: Etomidate was not associated with increased incidence of postoperative atrial arrhythmia or increased intensive care unit or hospital stay.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Etomidato , Hipnóticos e Sedativos , Complicações Pós-Operatórias/epidemiologia , Idoso , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pontuação de Propensão , Estudos Retrospectivos , Risco
8.
Anesth Analg ; 121(3): 716-26, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26287300

RESUMO

BACKGROUND: We tested the hypothesis that hypothyroidism, as defined by thyroid-stimulating hormone (TSH) concentration, is associated with a severity-weighted composite of mortality and major cardiovascular and infectious complications after noncardiac surgery. METHODS: In this retrospective cohort study, we evaluated adults at the Cleveland Clinic Main Campus between 2005 and 2012, who had had available TSH concentrations within the 6 months before noncardiac surgery. Patients were categorized as (1) hypothyroid (patients who had diagnosis of hypothyroidism any time prior to surgery and increased TSH value (> 5.5 mIU/L) within 6 months prior to surgery); (2) treated (hypothyroid diagnosis and normal TSH concentrations [0.4-5.5 mIU/L]); and (3) euthyroid (no hypothyroid diagnosis and normal TSH concentrations). We conducted pairwise comparisons among the 3 groups using inverse propensity score weighting to control for observed confounding variables. Average relative effect generalized estimating equation model was used for the primary outcome composite of in-hospital cardiovascular morbidity, surgical wound complication or infection, and mortality. Logistic regression and Cox proportional hazards regression were used for secondary outcomes of intraoperative vasopressor use and duration of hospitalization, respectively. RESULTS: We identified 800 hypothyroid patients (median TSH: 8.6 mIU/L [Q1, Q3: 6.5, 13.0]), 1805 treated patients (2.0 mIU/L [1.1, 3.2]), and 5612 euthyroid patients (1.7 mIU/L [1.1, 2.6]). There were no significant differences among the hypothyroid, treated, and euthyroid patients on the primary composite outcome (all P values ≥0.30). Hypothyroid patients were slightly more likely to receive vasopressor during surgery than either treated (odds ratio, 1.17; 99.2% confidence interval [CI], 1.01-1.36) or euthyroid (odds ratio, 1.12; 99.2% CI, 1.02-1.24) patients. Furthermore, hypothyroid patients were slightly but significantly less likely to be discharged at any given postoperative time than treated patients (hazard ratio, 0.92; 99.2% CI, 0.86-0.99). CONCLUSIONS: Hypothyroidism was not associated with worse postoperative mortality, wound, or cardiovascular outcomes in noncardiac patients. Thus, postponing surgery to initiate thyroid replacement therapy in patients with hypothyroidism seems unnecessary.


Assuntos
Doenças Cardiovasculares/mortalidade , Procedimentos Cirúrgicos Eletivos/mortalidade , Hipotireoidismo/mortalidade , Complicações Pós-Operatórias/mortalidade , Infecção da Ferida Cirúrgica/mortalidade , Adulto , Idoso , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/etiologia , Estudos de Coortes , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/tendências , Registros Eletrônicos de Saúde/tendências , Feminino , Humanos , Hipotireoidismo/diagnóstico , Hipotireoidismo/cirurgia , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Sistema de Registros , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/diagnóstico , Infecção da Ferida Cirúrgica/etiologia
9.
J Anesth ; 29(1): 47-55, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-24957190

RESUMO

PURPOSE: Atrial arrhythmias are common after non-cardiac thoracic surgery. We tested the hypothesis that TEA reduces the risk of new-onset atrial arrhythmias after pulmonary resection. METHODS: We evaluated patients who had pulmonary resection. New-onset atrial arrhythmias detected before hospital discharge was our primary outcome. Secondary outcomes included other cardiovascular complications, pulmonary complications, time-weighted average pain score over 72 h, and duration of hospitalization. Patients with combination of general anesthesia and TEA were matched on propensity scores with patients given general anesthesia only. The matched groups were compared by use of logistic regression, linear regression, or Cox proportional hazards regression, as appropriate. RESULTS: Among 1,236 patients who had pulmonary resections, 937 received a combination of general anesthesia and TEA (TEA) and 299 received general anesthesia only (non-TEA). We successfully matched 311 TEA patients with 132 non-TEA patients. We did not find a significant association between TEA and postoperative atrial arrhythmia (odds ratio (95 % CI) of 1.05 (0.50, 2.19), P = 0.9). TEA was not significantly associated with length of hospital stay or postoperative pulmonary complications (odds ratio (95 % CI) of 0.71 (0.22, 2.29), P = 0.47). TEA patients experienced fewer postoperative cardiovascular complications; although the association was not statistically significant (odds ratio (95 % CI) of 0.30 (0.06, 1.45), P = 0.06). Time-weighted average pain scores were similar in the two groups. CONCLUSION: TEA was not associated with reduced occurrence of postoperative atrial arrhythmia. Although postoperative pulmonary complications were similar with and without TEA, TEA patients tended to experience fewer cardiovascular complications.


Assuntos
Analgesia Epidural/métodos , Arritmias Cardíacas/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Pulmonares/métodos , Idoso , Anestesia Geral/efeitos adversos , Anestesia Geral/métodos , Arritmias Cardíacas/etiologia , Estudos de Coortes , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Razão de Chances , Dor Pós-Operatória/tratamento farmacológico , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Estudos Retrospectivos , Risco
10.
Anesth Analg ; 119(3): 603-12, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25121616

RESUMO

BACKGROUND: Vitamin D deficiency is a global health problem. Epidemiological studies demonstrate that vitamin D is both cardioprotective and neuroprotective. Vitamin D also plays a substantial role in innate and acquired immunity. Our goal was to evaluate the association of serum vitamin D concentration on serious postoperative complications and death in noncardiac surgical patients. METHODS: We retrospectively analyzed the data of 3509 patients who had noncardiac surgery at the Cleveland Clinic Main Campus and had a serum vitamin D measurement. The relationship between serum vitamin D concentration and all-cause in-hospital mortality, in-hospital cardiovascular morbidity, and serious in-hospital infections was assessed as a common effect odds ratio (OR) by using a multivariate generalized estimating equation model with adjustment for demographic, medical history variables, and type and duration of surgery. RESULTS: Higher vitamin D concentrations were associated with decreased odds of in-hospital mortality/morbidity (P = 0.003). There was a linear reduction of the corresponding common effect odds ratio (OR 0.93, 95% confidence interval, 0.88-0.97) for severe in-hospital outcomes for each 5 ng/mL increase in vitamin D concentration over the range from 4 to 44 ng/mL. In addition, we found that the odds versus patients with vitamin D <13 ng/mL (i.e., 1st quintile) were significantly lower in patients with vitamin D 13-20, 20-27, 27-36, and > 36 ng/mL (i.e., 2nd-5th quintiles); the corresponding estimated ORs were 0.65 (99% confidence interval, 0.43-0.98), 0.53 (0.35-0.80), 0.44 (0.28-0.70), and 0.49 (0.31-0.78), respectively. However, there was no statistically significant difference among individual quintiles >13 ng/mL. CONCLUSIONS: Vitamin D concentrations were associated with a composite of in-hospital death, serious infections, and serious cardiovascular events in patients recovering from noncardiac surgery. While causality cannot be determined from our retrospective analysis, the association suggests that a large randomized trial of preoperative vitamin D supplementation and postoperative outcomes is warranted.


Assuntos
Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Vitamina D/sangue , Adulto , Idoso , Pressão Sanguínea/fisiologia , Doenças Cardiovasculares/mortalidade , Comorbidade , Infecção Hospitalar/mortalidade , Feminino , Frequência Cardíaca/fisiologia , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Retrospectivos , Tamanho da Amostra , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento , Resistência Vascular , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/complicações
11.
J Clin Anesth ; 26(6): 432-7, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25172503

RESUMO

STUDY OBJECTIVE: To investigate whether Type O blood group status is associated with increased intraoperative blood loss and requirement of blood transfusion in extensive spine surgery. DESIGN: Retrospective comparative study. SETTING: University-affiliated, non-profit teaching hospital. MEASUREMENTS: Data from 1,050 ASA physical status 1, 2, 3, 4, and 5 patients who underwent spine surgeries involving 4 or more vertebral levels were analyzed. Patients with Type O blood were matched to similar patients with other blood types using propensity scores, which were estimated via demographic and morphometric data, medical history variables, and extent of surgery. Intraoperative estimated blood loss (EBL) was compared among matched patients using a linear regression model; intraoperative transfusion requirement in volume of red blood cells, fresh frozen plasma, platelet, cryoprecipitate, cell salvaged blood, volume of intraoperative infusion of hetastarch, 5% albumin, crystalloids, and hospital length of hospital (LOS) were compared using Wilcoxon rank-sum tests. MAIN RESULTS: Intraoperative EBL and requirement of blood product transfusion were similar in patients with Type O blood group and those with other blood groups. CONCLUSION: There was no association between Type O blood and increased intraoperative blood loss or blood transfusion requirement during extensive spine surgery, with similar hospital LOS in Type O and non-O patients.


Assuntos
Sistema ABO de Grupos Sanguíneos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Coluna Vertebral/cirurgia , Adulto , Idoso , Transfusão de Componentes Sanguíneos/métodos , Suscetibilidade a Doenças/sangue , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco
12.
Anesth Analg ; 117(6): 1329-37, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24257383

RESUMO

BACKGROUND: Because etomidate impairs adrenal function and blunts the cortisol release associated with surgical stimulus, we hypothesized that patients induced with etomidate suffer greater mortality and morbidity than comparable patients induced with propofol. METHODS: We evaluated the electronic records of 31,148 ASA physical status III and IV patients who had noncardiac surgery at the Cleveland Clinic. Among these, anesthesia was induced with etomidate and maintained with volatile anesthetics in 2616 patients whereas 28,532 were given propofol for induction and maintained with volatile anesthetics. Two thousand one hundred forty-four patients given etomidate were propensity matched with 5233 patients given propofol and the groups compared on 30-day postoperative mortality, length of hospital stay, cardiovascular and infectious morbidities, vasopressor requirement, and intraoperative hemodynamics. RESULTS: Patients given etomidate had 2.5 (98% confidence interval [CI], 1.9-3.4) times the odds of dying than those given propofol. Etomidate patients also had significantly greater odds of having cardiovascular morbidity (odds ratio [OR] [98% CI]: 1.5 [1.2-2.0]), and significantly longer hospital stay (hazard ratio [95% CI]: 0.82 [0.78-0.87]). However, infectious morbidity (OR [98% CI]: 1.0 [0.8-1.2]) and intraoperative vasopressor use (OR [95% CI] 0.92: [0.82-1.0]) did not differ between the agents. CONCLUSION: Etomidate was associated with a substantially increased risk for 30-day mortality, cardiovascular morbidity, and prolonged hospital stay. Our conclusions, especially on 30-day mortality, are robust to a strong unmeasured binary confounding variable. Although our study showed only an association between etomidate use and worse patients' outcomes but not causal relationship, clinicians should use etomidate judiciously, considering that improved hemodynamic stability at induction may be accompanied by substantially worse longer-term outcomes.


Assuntos
Anestesia Intravenosa/efeitos adversos , Anestesia Intravenosa/mortalidade , Anestésicos Intravenosos/efeitos adversos , Doenças Cardiovasculares/induzido quimicamente , Doenças Cardiovasculares/mortalidade , Etomidato/efeitos adversos , Propofol/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/terapia , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Ohio , Pontuação de Propensão , Modelos de Riscos Proporcionais , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Vasoconstritores/uso terapêutico
13.
PLoS One ; 8(5): e63831, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23724006

RESUMO

OBJECTIVE: To determine the effect of vitamin D on postoperative outcomes in cardiac surgical patients. DESIGN: Retrospective study. SETTING: Single institution-teaching hospital. PARTICIPANTS: Adult cardiac surgical patients with perioperative 25-hydroxyvitamin D measurements. INTERVENTIONS: None. We gathered information from the Cardiac Anesthesiology Registry that was obtained at the time of the patients' visit/hospitalization. MEASUREMENTS AND MAIN RESULTS: We used data of 18,064 patients from the Cardiac Anesthesiology Registry; 426 patients with 25-hydroxyvitamin D measurements met our inclusion criteria. Association with Vitamin D concentration and composite of 11 cardiac morbidities was done by multivariate (i.e., multiple outcomes per subject) analysis. For other outcomes separate multivariable logistic regressions and adjusting for the potential confounders was used. The observed median vitamin D concentration was 19 [Q1-Q3∶12, 30] ng/mL. Vitamin D concentration was not associated with our primary composite of serious cardiac morbidities (odds ratio [OR], 0.96; 95% CI, 0.86-1.07). Vitamin D concentration was also not associated with any of the secondary outcomes: neurologic morbidity (P = 0.27), surgical (P = 0.26) or systemic infections (P = 0.58), 30-day mortality (P = 0.55), or length of initial intensive care unit (ICU) stay (P = 0.04). CONCLUSIONS: Our analysis suggests that perioperative vitamin D concentration is not associated with clinically important outcomes, likely because the outcomes are overwhelmingly determined by other baseline and surgical factors.


Assuntos
Procedimentos Cirúrgicos Cardíacos/mortalidade , Morbidade , Vitamina D/análogos & derivados , Adulto , Humanos , Resultado do Tratamento , Vitamina D/sangue
14.
Anesth Analg ; 116(2): 319-26, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23302977

RESUMO

BACKGROUND: We have previously shown that red hair is associated with increased desflurane requirement for immobility, compared with dark hair. The effect of red hair on IV anesthetic requirement remains unknown. We tested the hypothesis that the propofol concentration in the effect site associated with half maximal electroencephalogram response, Ce50, is at least 50% higher in subjects with red hair. METHODS: We modeled the propofol concentration versus electroencephalogram response relationship using a 2-step approach in 29 healthy dark- and red-haired volunteers receiving a propofol infusion to produce loss of consciousness. Bispectral Index (BIS) was the measure of drug effect. The parameters of a 3-compartment pharmacokinetic model were fit to measured arterial propofol concentrations. The relationship between effect-site propofol concentration (Ce) and BIS was characterized using a sigmoid Emax model. Model performance and accuracy of the estimated parameters were evaluated using accepted metrics and bootstrap resampling. The effect of hair color on the Ce50 for BIS response in the final model was assessed using a threshold of 6.63 (P<0.01) in reduction of -2 log likelihood. The influence of body weight on the model was also assessed. RESULTS: The inclusion of hair color as a model covariate did not improve either the pharmacokinetic or the pharmacodynamic model. A separate analysis for the dark- and red-haired subjects estimated a median (95% confidence interval) Ce50 BIS of 2.71 µg/mL (2.28-3.36 µg/mL) and 2.57 µg/mL (1.68-3.60 µg/mL), respectively. Body weight was a significant covariate for the CL1 and V1. CONCLUSIONS: Red hair phenotype does not affect the pharmacokinetics or pharmacodynamics of propofol.


Assuntos
Anestésicos Intravenosos/farmacologia , Monitores de Consciência , Cor de Cabelo/fisiologia , Hipnóticos e Sedativos/farmacologia , Propofol/farmacologia , Adulto , Algoritmos , Anestesia Intravenosa , Anestésicos Intravenosos/farmacocinética , Teorema de Bayes , Pressão Sanguínea/efeitos dos fármacos , Peso Corporal/fisiologia , Dióxido de Carbono/sangue , Eletrocardiografia/efeitos dos fármacos , Eletroencefalografia/efeitos dos fármacos , Feminino , Humanos , Hipnóticos e Sedativos/farmacocinética , Masculino , Dinâmica não Linear , Propofol/farmacocinética , Adulto Jovem
15.
Anesth Analg ; 112(4): 868-74, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21385975

RESUMO

BACKGROUND: Tracheal intubation in the lateral position is difficult because the laryngeal view is compromised during direct laryngoscopy. The Airway Scope facilitates intubation even when laryngeal views are poor with direct laryngoscopy, as they often are in the lateral position. We thus compared the efficacy of the Airway Scope in supine patients with those in the left- and right-lateral positions. METHODS: Anesthetized adults were randomly assigned to supine, left-lateral, or right-lateral position (n = 43 for each group). Laryngeal views were obtained in the designated position with a Macintosh laryngoscope, and patients' tracheas were subsequently intubated with the Airway Scope. Specifically, we tested the hypothesis that the time required for intubation in the left- and right-lateral positions is not increased by >10 seconds compared with tracheal intubation in the supine position. RESULTS: Overall intubation success was 100% in the 2 lateral positions, and 98% in the supine position. Intubation times were similar in the left-lateral (24 [5] seconds, mean [SD]), right-lateral (24 [6] seconds), and supine (22 [7] seconds) positions. The numbers of required intubation attempts were similar in the 2 lateral positions and in the supine and left-lateral positions. However, more intubation attempts were required in the supine position than in the right-lateral position (P = 0.004). The incidences of airway complications were similar in each position; no hypoxia, dental injury, or esophageal intubation was observed. Modified Cormack-Lehane and the percentage of glottic opening scores obtained with the Macintosh laryngoscope did not differ between the 2 lateral positions, but the modified Cormack-Lehane and percentage of glottic opening scores were superior in the supine position (all P < 0.001) compared with either of the lateral positions. CONCLUSIONS: Despite worse laryngoscopic views in either lateral position than when patients were supine, intubation with the Airway Scope offered high success rates. Furthermore, intubation time using the Airway Scope in either lateral position was not longer by >10 seconds than in the supine position. The Airway Scope thus seems to be a useful tool when tracheal intubation is required in a laterally positioned patient.


Assuntos
Intubação Intratraqueal/métodos , Laringoscópios , Laringoscopia/métodos , Posicionamento do Paciente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Laringoscopia/instrumentação , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Fatores de Tempo
16.
J Anesth ; 24(6): 869-76, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-20848164

RESUMO

PURPOSE: Conscious sedation with intravenous sedative-hypnotic drugs has the advantage of relaxing patients before invasive procedures. Preoperative anxiety has been suggested to correlate with postoperative comfortableness. In this study, we chose midazolam and droperidol as well-established intravenous sedative-hypnotic drugs. We evaluated the preoperative anxiolytic effect on postoperative memories and emotions up to the first postoperative morning. METHODS: In a prospective, double blind study, 120 patients requiring epidural anesthesia were randomly assigned to one of three groups to receive saline, midazolam (0.04 mg/kg), or droperidol (0.1 mg/kg). Cardiovascular and respiratory measurements, observer's assessment of alertness/sedation scale, level of anxiety and discomfort of the patients, pain during the infiltration of local anesthetics, and incidence of adverse effects were recorded. Amnesia, anxiety, and discomfort during the epidural procedure were re-assessed between 12 and 20 h postsurgery. RESULTS: Patients who received sedatives were significantly more sedated (P < 0.0001), but the pain score was significantly higher in the droperidol group (P = 0.0007) at epidural catheterization. On the first postoperative morning, patients receiving midazolam had a significantly lower pain score (P < 0.0001) with less anxiety and discomfort. Patients in both the midazolam and droperidol groups showed a significant decrease in blood pressure (P < 0.0167), but no respiratory impairment. No adverse effects were experienced throughout the study period. CONCLUSION: Conscious sedation with intravenous midazolam 0.04 mg/kg significantly decreased the anxiety and discomfort scores of the patients on the day following surgery but had no effect on these immediately following the epidural catheterization procedure.


Assuntos
Sedação Consciente , Hipnóticos e Sedativos , Midazolam , Cuidados Pós-Operatórios , Adulto , Idoso , Anestésicos Locais/efeitos adversos , Pressão Sanguínea/efeitos dos fármacos , Eletrocardiografia/efeitos dos fármacos , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Dor/induzido quimicamente , Dor/prevenção & controle , Medição da Dor , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/prevenção & controle , Estudos Prospectivos
17.
Anesth Analg ; 111(2): 427-31, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20529982

RESUMO

BACKGROUND: Direct laryngoscopy of a patient lying on the ground is difficult because the intubator's head is far above the head of the patient, making alignment of the intubator's visual axis with the patient's tracheal axis difficult. The Airway Scope is a laryngoscope designed to facilitate tracheal intubation without requiring alignment of the oral, pharyngeal, and tracheal axes. We thus tested the hypothesis that intubation with the Airway Scope is faster than with the Macintosh laryngoscope in subjects lying on the ground. METHODS: Adult surgical patients were enrolled. After anesthesia induction, direct laryngoscopy was performed and airway characteristics noted. Patients were randomly assigned to tracheal intubation by either the Airway Scope (n = 50) or the Macintosh laryngoscope (n = 50). The intubator performed tracheal intubation from a table positioned at the same height as that of the operating table, thus simulating intubating on the ground. An unblinded observer recorded overall intubation success rate, time required for intubation, the number of attempts required for successful intubation, and airway complications related to intubation. Of these, the primary end point was time required for intubation. RESULTS: Overall intubation success rates were 98% with the Airway Scope and 100% with the Macintosh laryngoscope. Intubation was 17 s faster with the Airway Scope (mean, 18 (SD, 4) seconds) versus the Macintosh laryngoscope (35 (16) seconds). The number of intubation attempts was similar with each device. The incidences of airway complications were similar, with no hypoxia (Spo(2) <95%) occurring in either group. CONCLUSIONS: Both the Airway Scope and the Macintosh laryngoscope offer high success rates in adequately prepared paralyzed patients lying supine at ground level in the hands of a skilled practitioner. However, the Airway Scope facilitated faster tracheal intubation.


Assuntos
Intubação Intratraqueal/instrumentação , Laringoscópios , Laringoscopia , Decúbito Dorsal , Adulto , Idoso , Competência Clínica , Desenho de Equipamento , Feminino , Humanos , Intubação Intratraqueal/efeitos adversos , Laringoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Operatórios , Fatores de Tempo
18.
Masui ; 59(6): 734-7, 2010 Jun.
Artigo em Japonês | MEDLINE | ID: mdl-20560377

RESUMO

We experienced anesthesia of a patient with pheochromocytoma on chronic hemodialysis who developed severe hypotension resistant to vasopressors after induction of general anesthesia. She was presented for spine surgery for destructive arthropathy of the cervical spine. Doxazosin up to 0.5 mg x day(-1) was administered for five days preoperatively for alpha-adrenergic blokade and regular hemodialysis was continued until the day before surgery without change in dry body weight. Blood pressure (BP) was within normal limits preoperatively. After induction of anesthesia with propofol and fentanyl, the patient developed hypotension with systolic BP of 60 mmHg which was resistant to vasopressor treatment with phenylephrine and ephedrine. After 45 minutes of volume replacement and commencement of dopamine and norepinephrine administration via a central venous catheter, BP recovered, and the surgery proceeded without further incident. Hypertension due to pheochromocytoma can be masked by excessive reduction of intravascular volume by preoperative hemodialysis. In a hemodialysed patient harboring pheochromocytoma who undergoes a surgical procedure unrelated to adrenalectomy, preoperative alpha-adrenergic blockade and subsequent intravascular volume expansion by increasing dry weight is required to avoid severe intraoperative hypotension, as for the case of adrenalectomy in the same situation.


Assuntos
Neoplasias das Glândulas Suprarrenais/complicações , Antagonistas Adrenérgicos alfa/administração & dosagem , Anestesia Geral , Doxazossina/administração & dosagem , Hipotensão/prevenção & controle , Complicações Intraoperatórias/prevenção & controle , Falência Renal Crônica/complicações , Feocromocitoma/complicações , Cuidados Pré-Operatórios , Diálise Renal , Vértebras Cervicais/cirurgia , Doença Crônica , Feminino , Humanos , Hipotensão/etiologia , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Procedimentos Ortopédicos
19.
Anesthesiology ; 112(6): 1525-31, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20463580

RESUMO

BACKGROUND: In this study, the authors determined the success and failure rates for interns learning bag-and-mask ventilation and orotracheal intubation. Their goal was to determine the amount of experience needed to perform these procedures correctly. METHODS: The authors recorded 695 bag-and-mask ventilations and 679 orotracheal intubations performed by 15 inexperienced interns during their 3 month-long anesthesia rotations. Learning curves for each procedure for each intern were constructed with both the standard and risk-adjusted cumulative sum methods. The average number of procedures required to attain a failure rate of 20% was estimated for each technique. RESULTS: Fourteen of 15 interns attained acceptable failure rates at bag-and-mask ventilation after 27 +/- 13 procedures, with a median (95% confidence interval) of 25 (15-32) procedures to cross the decision limit when considering all 15 interns. Nine of 15 interns attained acceptable failure rates at orotracheal intubation after 26 +/- 8 procedures, with a median of 29 (22-not estimable) procedures to cross the limit when considering all interns. The proportion of interns who attained acceptable failure rates for mask ventilation was greater than for tracheal intubation (93% vs. 60%, P = 0.025). Overall, our interns achieved a bag-and-mask ventilation failure rate of 20% or better after a median of 25 procedures; approximately 80% of interns achieved the goal after 35 procedures or less. CONCLUSIONS: Participating interns developed mask ventilation skills faster than orotracheal intubation skills, and there was more variability in the rate at which intubation skills developed. A median of 29 procedures was required to achieve an 80% orotracheal intubation success rate.


Assuntos
Competência Clínica/normas , Internato e Residência/normas , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Laringoscopia/métodos , Aprendizagem , Humanos , Internato e Residência/métodos , Máscaras Laríngeas
20.
Masui ; 59(4): 501-3, 2010 Apr.
Artigo em Japonês | MEDLINE | ID: mdl-20420145

RESUMO

We experienced perioperative management of a patient with Quincke's edema who underwent clipping of ruptured intracranial aneurysm. At the time of presentation, he complained of lip and tongue swelling. We administered dl-chlorpheniramine malate and tranexamic acid perioperatively to prevent further edema. Intraoperatively, we avoided contact of objects to the face and the oral cavity which might have caused mechanical stimuli, and infused albumin to maintain plasma osmotic pressure. The patient was kept intubated postoperatively because of significant tongue edema at the end of the procedure. On postoperative day 1, we extubated the trachea after prophylactic administration of methylpredonisolone. Significant upper airway edema was denied by flexible laryngoscopy. Pathophysiological cause of Quincke's edema is increased permeability of capillary vessels due to vasoactive substances. Aside from anti-histaminergic agents and steroids, tranexamic acid, which reduces production of kinin, is specifically effective for this condition. Although there is a reported case of Quincke's edema, eventually diagnosed after development of postoperative upper airway obstruction, there have been no reports of planned perioperative management of this condition. We demonstrated that Quincke's edema could be managed without life-threatening airway compromise by employing adequate pharmacologic interventions and sensible determination of the timing of extubation.


Assuntos
Aneurisma Roto/cirurgia , Angioedema/complicações , Aneurisma Intracraniano/cirurgia , Assistência Perioperatória , Aneurisma Roto/complicações , Angioedema/prevenção & controle , Clorfeniramina/administração & dosagem , Craniotomia , Humanos , Aneurisma Intracraniano/complicações , Intubação Intratraqueal , Masculino , Metilprednisolona/administração & dosagem , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Complicações Pós-Operatórias/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Procedimentos Cirúrgicos Vasculares
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