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1.
Anesthesiology ; 132(4): 692-701, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32022771

RESUMO

BACKGROUND: The authors previously reported that perioperative aspirin and/or clonidine does not prevent a composite of death or myocardial infarction 30 days after noncardiac surgery. Moreover, aspirin increased the risk of major bleeding and clonidine caused hypotension and bradycardia. Whether these complications produce harm at 1 yr remains unknown. METHODS: The authors randomized 10,010 patients with or at risk of atherosclerosis and scheduled for noncardiac surgery in a 1:1:1:1 ratio to clonidine/aspirin, clonidine/aspirin placebo, clonidine placebo/aspirin, or clonidine placebo/aspirin placebo. Patients started taking aspirin or placebo just before surgery; those not previously taking aspirin continued daily for 30 days, and those taking aspirin previously continued for 7 days. Patients were also randomly assigned to receive clonidine or placebo just before surgery, with the study drug continued for 72 h. RESULTS: Neither aspirin nor clonidine had a significant effect on the primary 1-yr outcome, a composite of death or nonfatal myocardial infarction, with a 1-yr hazard ratio for aspirin of 1.00 (95% CI, 0.89 to 1.12; P = 0.948; 586 patients [11.8%] vs. 589 patients [11.8%]) and a hazard ratio for clonidine of 1.07 (95% CI, 0.96 to 1.20; P = 0.218; 608 patients [12.1%] vs. 567 patients [11.3%]), with effect on death or nonfatal infarction. Reduction in death and nonfatal myocardial infarction from aspirin in patients who previously had percutaneous coronary intervention at 30 days persisted at 1 yr. Specifically, the hazard ratio was 0.58 (95% CI, 0.35 to 0.95) in those with previous percutaneous coronary intervention and 1.03 (95% CI, 0.91to 1.16) in those without (interaction P = 0.033). There was no significant effect of either drug on death, cardiovascular complications, cancer, or chronic incisional pain at 1 yr (all P > 0.1). CONCLUSIONS: Neither perioperative aspirin nor clonidine have significant long-term effects after noncardiac surgery. Perioperative aspirin in patients with previous percutaneous coronary intervention showed persistent benefit at 1 yr, a plausible sub-group effect.

5.
Artigo em Inglês | MEDLINE | ID: mdl-31761653

RESUMO

Airway surgery poses a host of unique challenges to both the surgical and anesthesiology teams. Accordingly, there are a variety of surgical, anesthetic, and airway management options to be strategically considered. Management can be challenging during multidisciplinary preoperative planning, during the surgical procedure itself, and during recovery. In this review, emphasis is placed on anesthesia challenges for patients undergoing major tracheal or carinal surgery with specific considerations related to perioperative management.

6.
Semin Cardiothorac Vasc Anesth ; 23(3): 319-323, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30709327

RESUMO

Tracheal laceration during cardiac surgery is a rarely reported form of iatrogenic tracheal injury. During dissection prior to sternotomy, the interclavicular ligament must be divided. This structure overlies the proximal trachea, predisposing the trachea to injury at this location. Challenges related to tracheal laceration in cardiac surgery include patients with already tenuous cardiopulmonary status, surgical positioning that increases the risk of injury, obscured traditional clinical findings causing delayed recognition, increased risk of mediastinitis, and a heightened risk of airway fire. The incidence, mechanism, and ideal management of sternotomy-related tracheal injury, though a life-threatening complication, is rarely described in the literature. Consensus is lacking regarding the necessity and timing of tracheal repair versus conservative management, whether to proceed with the initially planned procedure, and the optimal timing of airway exchange in the event of endotracheal tube cuff rupture. In this article, we present the management of a full-thickness thermal tracheal injury due to electrocautery, resulting in a large air leak treated with delayed endotracheal tube exchange and tracheal repair after cardiopulmonary bypass.


Assuntos
Ponte Cardiopulmonar/métodos , Eletrocoagulação/efeitos adversos , Esternotomia/métodos , Traqueia/lesões , Humanos , Intubação Intratraqueal/métodos , Masculino , Pessoa de Meia-Idade
9.
J Infect Dis ; 218(6): 901-910, 2018 08 14.
Artigo em Inglês | MEDLINE | ID: mdl-29688496

RESUMO

Filoviruses, including Ebola, have the potential to be transmitted via virus-laden droplets deposited onto mucus membranes. Protecting against such emerging pathogens will require understanding how they may transmit at mucosal surfaces and developing strategies to reinforce the airway mucus barrier. Here, we prepared Ebola pseudovirus (with Zaire strain glycoproteins) and used high-resolution multiple-particle tracking to track the motions of hundreds of individual pseudoviruses in fresh and undiluted human airway mucus isolated from extubated endotracheal tubes. We found that Ebola pseudovirus readily penetrates human airway mucus. Addition of ZMapp, a cocktail of Ebola-binding immunoglobulin G antibodies, effectively reduced mobility of Ebola pseudovirus in the same mucus secretions. Topical delivery of ZMapp to the mouse airways also facilitated rapid elimination of Ebola pseudovirus. Our work demonstrates that antibodies can immobilize virions in airway mucus and reduce access to the airway epithelium, highlighting topical delivery of pathogen-specific antibodies to the lungs as a potential prophylactic or therapeutic approach against emerging viruses or biowarfare agents.


Assuntos
Anticorpos Monoclonais/farmacologia , Ebolavirus/fisiologia , Traqueia/virologia , Administração Tópica , Extubação/instrumentação , Animais , Células Cultivadas , Ebolavirus/efeitos dos fármacos , Ebolavirus/isolamento & purificação , Células Epiteliais/citologia , Células Epiteliais/imunologia , Células Epiteliais/virologia , Contaminação de Equipamentos , Humanos , Camundongos , Traqueia/citologia , Traqueia/imunologia
14.
J Cardiothorac Vasc Anesth ; 32(2): 915-927, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29169795

RESUMO

Local anesthetic injected into a wedge-shaped space lateral to the spinal nerves as they emerge from the intervertebral foramina produces somatosensory and sympathetic nerve blockade effective for anesthesia and for managing pain of unilateral origin from the chest and abdomen. Paravertebral blockade (PVB) is versatile and may be applied unilaterally or bilaterally. Unlike thoracic epidural, the PVB technique may be used to avoid contralateral sympathectomy, thereby minimizing hypotension and leading to better preservation of blood pressure. There are no reports on systemic toxicity associated with bilateral PVB despite the need for relatively large doses of local anesthetics. This review includes an important historic background and captures the resurgence of PVB-an almost lost technique. Thoracic PVB provides post-thoracotomy pain relief comparable with thoracic epidural analgesia (TEA) with lower side effects supported by moderate-quality evidence. The feasibility and potential of bilateral thoracic PVB for bilateral thoracic surgery appear practical. However, there is existing controversy in the assumption that thoracic PVB is a satisfactory, safer alternative when anticoagulation status is a contraindication to thoracic epidural placement. During the last 2 decades of systematic reviews and meta-analyses, both TEA and PVB have been deemed appropriate in the management of thoracic surgery. A multimodal approach to analgesia includes regional techniques for thoracic surgery that may reduce the likelihood of the development of postoperative complications and chronic pain. PURPOSE OF THIS REVIEW: The authors evaluated current opinion, clinical practice, new multimodal adjuvants, regional anesthesia, and innovation and technology related PVB in the thoracic surgery patient population. The review focuses on history, techniques, application, ease of placement, and relative safety of this regional technique. For this review, studies and reference lists were retrieved from the Cochrane library, Embase, and Medline from January 1995 through January 2017. SUMMARY: Existing evidence demonstrates noninferiority of thoracic PVB compared with TEA for postoperative analgesia, with fewer side effects for unilateral and bilateral thoracic surgery, including video-assisted thoracoscopy. The determining factors in selecting the regional technique of choice include the following: (1) tolerance of side effects associated with TEA, (2) consensus on best practice or technique, and (3) operator experience. There is no consensus on the optimal approach for thoracic PVB technique or any standardization when comparing the landmark, ultrasound-guided, or stimulation-based PVB approaches. Moreover, the efficacy of TEA compared with PVB in preventing post-thoracotomy chronic pain syndrome has not been investigated thoroughly and requires future clinical trials.


Assuntos
Bloqueio Nervoso/métodos , Procedimentos Cirúrgicos Torácicos/métodos , Analgesia Epidural , Dor Crônica/prevenção & controle , Hemodinâmica , Humanos , Bloqueio Nervoso/efeitos adversos , Dor Pós-Operatória/prevenção & controle , Pneumotórax/etiologia
15.
Ann Intern Med ; 168(4): 237-244, 2018 02 20.
Artigo em Inglês | MEDLINE | ID: mdl-29132159

RESUMO

Background: Uncertainty remains about the effects of aspirin in patients with prior percutaneous coronary intervention (PCI) having noncardiac surgery. Objective: To evaluate benefits and harms of perioperative aspirin in patients with prior PCI. Design: Nonprespecified subgroup analysis of a multicenter factorial trial. Computerized Internet randomization was done between 2010 and 2013. Patients, clinicians, data collectors, and outcome adjudicators were blinded to treatment assignment. (ClinicalTrials.gov: NCT01082874). Setting: 135 centers in 23 countries. Patients: Adults aged 45 years or older who had or were at risk for atherosclerotic disease and were having noncardiac surgery. Exclusions were placement of a bare-metal stent within 6 weeks, placement of a drug-eluting stent within 1 year, or receipt of nonstudy aspirin within 72 hours before surgery. Intervention: Aspirin therapy (overall trial, n = 4998; subgroup, n = 234) or placebo (overall trial, n = 5012; subgroup, n = 236) initiated within 4 hours before surgery and continued throughout the perioperative period. Of the 470 subgroup patients, 99.9% completed follow-up. Measurements: The 30-day primary outcome was death or nonfatal myocardial infarction; bleeding was a secondary outcome. Results: In patients with prior PCI, aspirin reduced the risk for the primary outcome (absolute risk reduction, 5.5% [95% CI, 0.4% to 10.5%]; hazard ratio [HR], 0.50 [CI, 0.26 to 0.95]; P for interaction = 0.036) and for myocardial infarction (absolute risk reduction, 5.9% [CI, 1.0% to 10.8%]; HR, 0.44 [CI, 0.22 to 0.87]; P for interaction = 0.021). The effect on the composite of major and life-threatening bleeding in patients with prior PCI was uncertain (absolute risk increase, 1.3% [CI, -2.6% to 5.2%]). In the overall population, aspirin increased the risk for major bleeding (absolute risk increase, 0.8% [CI, 0.1% to 1.6%]; HR, 1.22 [CI, 1.01 to 1.48]; P for interaction = 0.50). Limitation: Nonprespecified subgroup analysis with small sample. Conclusion: Perioperative aspirin may be more likely to benefit rather than harm patients with prior PCI. Primary Funding Source: Canadian Institutes of Health Research.


Assuntos
Aspirina/uso terapêutico , Intervenção Coronária Percutânea , Inibidores da Agregação de Plaquetas/uso terapêutico , Procedimentos Cirúrgicos Operatórios , Idoso , Anti-Hipertensivos/uso terapêutico , Aspirina/efeitos adversos , Biomarcadores/sangue , Clonidina/uso terapêutico , Esquema de Medicação , Quimioterapia Combinada , Feminino , Hemorragia/induzido quimicamente , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/prevenção & controle , Inibidores da Agregação de Plaquetas/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/prevenção & controle , Resultado do Tratamento
16.
Anesthesiology ; 126(6): 1065-1076, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28398932

RESUMO

BACKGROUND: Brachial arterial catheters better estimate aortic pressure than radial arterial catheters but are used infrequently because complications in a major artery without collateral flow are potentially serious. However, the extent to which brachial artery cannulation promotes complications remains unknown. The authors thus evaluated a large cohort of cardiac surgical patients to estimate the incidence of related serious complications. METHODS: The institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database and Perioperative Health Documentation System Registry of the Cleveland Clinic were used to identify patients who had brachial artery cannulation between 2007 and 2015. Complications within 6 months after surgery were identified by International Classification of Diseases, Ninth Revision diagnostic and procedural codes, Current Procedural Terminology procedure codes, and Society of Thoracic Surgeons variables. The authors reviewed electronic medical records to confirm that putative complications were related plausibly to brachial arterial catheterization. Complications were categorized as (1) vascular, (2) peripheral nerve injury, or (3) infection. The authors evaluated associations between brachial arterial complications and patient comorbidities and between complications and in-hospital mortality and duration of hospitalization. RESULTS: Among 21,597 qualifying patients, 777 had vascular or nerve injuries or local infections, but only 41 (incidence 0.19% [95% CI, 0.14 to 0.26%]) were potentially consequent to brachial arterial cannulation. Vascular complications occurred in 33 patients (0.15% [0.10 to 0.23%]). Definitely or possibly related infection occurred in 8 (0.04% [0.02 to 0.08%]) patients. There were no plausibly related neurologic complications. Peripheral arterial disease was associated with increased risk of complications. Brachial catheter complications were associated with prolonged hospitalization and in-hospital mortality. CONCLUSIONS: Brachial artery cannulation for hemodynamic monitoring during cardiac surgery rarely causes complications.


Assuntos
Pressão Arterial/fisiologia , Artéria Braquial , Procedimentos Cirúrgicos Cardíacos , Cateterismo Periférico/métodos , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Cateterismo Periférico/efeitos adversos , Cateterismo Periférico/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/efeitos adversos , Monitorização Intraoperatória/instrumentação
19.
Semin Cardiothorac Vasc Anesth ; 21(1): 95-98, 2017 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26620136

RESUMO

Although nephrectomy for renal cell carcinoma with inferior vena cava invasion is a common procedure, it is rare to have level IV invasion necessitating cardiopulmonary bypass (CPB). Furthermore, it is exceptionally rare to perform cardiac surgery concomitantly with this resection. We report a case in which an aortic valve replacement was done in the same surgical setting as a level IV thrombectomy. We have demonstrated that although it can be difficult to manage the coagulopathy post-CPB, this can be successfully accomplished with adequate prior preparation and a coordinated team effort.


Assuntos
Carcinoma de Células Renais/complicações , Ponte Cardiopulmonar/métodos , Implante de Prótese de Valva Cardíaca/métodos , Neoplasias Renais/complicações , Trombectomia/métodos , Trombose Venosa/cirurgia , Valva Aórtica/cirurgia , Carcinoma de Células Renais/cirurgia , Ecocardiografia Transesofagiana/métodos , Humanos , Cuidados Intraoperatórios/métodos , Rim/cirurgia , Neoplasias Renais/cirurgia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Trombose Venosa/etiologia
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