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1.
N. Engl. j. med. ; 380(13): 1214-1225, Mar. 2019. gráfico, tabela
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1024163

RESUMO

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.). (AU)


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Ponte de Artéria Coronária , Anestésicos Inalatórios , Anestesia Geral , Anestesia Intravenosa
2.
N Engl J Med ; 380(13): 1214-1225, 2019 03 28.
Artigo em Inglês | MEDLINE | ID: mdl-30888743

RESUMO

BACKGROUND: Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG). METHODS: We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year. RESULTS: A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction. CONCLUSIONS: Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).


Assuntos
Anestesia Intravenosa , Anestésicos Gerais/farmacologia , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Administração por Inalação , Idoso , Anestesia Geral , Anestésicos Intravenosos , Doença da Artéria Coronariana/mortalidade , Doença da Artéria Coronariana/fisiopatologia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Método Simples-Cego , Volume Sistólico
3.
Interact Cardiovasc Thorac Surg ; 28(6): 845-851, 2019 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-30689873

RESUMO

OBJECTIVES: Usefulness of immature granulocyte percentage (IG%) to discriminate between postoperative non-infective systemic inflammatory response syndrome (SIRS) and sepsis was tested in cardiac surgical patients. METHODS: A retrospective analysis of 124 patients who developed non-infective SIRS and sepsis after elective cardiac surgery was performed. Predictive ability of IG% to predict sepsis was compared to procalcitonin (PCT), white blood cell count, temperature and different biomarker combinations using receiver operating characteristic and logistic regression analysis. The optimal cut-off points, diagnosis sensitivity and specificity were calculated. RESULTS: There were 44 patients diagnosed with sepsis and 80 patients with non-infective SIRS. In receiver operating characteristic analysis, area under the curve was higher for IG% (0.71) and PCT (0.72) compared to white blood cell count (0.62) and temperature (0.58). The best cut-off value for IG% was 1.45% (sensitivity 70.5%, specificity 60%) and 1.43 µg/l for PCT (sensitivity 65.9%, specificity 75%). The combination of IG% and PCT provided the best sepsis prediction (area under the curve of 0.8, sensitivity 63.6% and specificity 88.8%). CONCLUSIONS: In cardiac surgical patients, IG% is a helpful marker with the moderate ability to discriminate between sepsis and non-infective SIRS, comparable to serum PCT. A combination of these parameters increased the test's overall predictive ability by improving its specificity.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Granulócitos/patologia , Pró-Calcitonina/sangue , Sepse/diagnóstico , Idoso , Biomarcadores/sangue , Feminino , Humanos , Contagem de Leucócitos , Masculino , Prognóstico , Curva ROC , Estudos Retrospectivos , Sepse/etiologia
4.
Eur J Heart Fail ; 19 Suppl 2: 97-103, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28470920

RESUMO

AIMS: Ventricular septal rupture (VSR) became a rare mechanical complication of myocardial infarction in the era of percutaneous coronary interventions but is associated with extreme mortality in patients who present with cardiogenic shock (CS). Promising outcomes have been reported with the use of circulatory support allowing haemodynamic stabilization, followed by delayed repair. Therefore, we analysed our experience with an early use of Veno-Arterial Extracorporeal Membrane Oxygenation (V-A ECMO) for postinfarction VSR. METHODS AND RESULTS: We conducted a retrospective search of institutional database for patients presenting with postinfarction VSR from January 2007 to June 2016. Data from 31 consecutive patients (mean age 69.5 ± 9.1 years) who were admitted to hospital were analysed. Seven out of 31 patients with VSR who were in refractory CS received V-A ECMO support preoperatively. ECMO improved end-organ perfusion with decreased lactate levels 24 hours after implantation (7.9 mmol/L vs. 1.6 mmol/L, p = 0.01), normalized arterial pH (7.25 vs. 7.40, p < 0.04), improved mean arterial pressure (64 mmHg vs. 83 mmHg, p < 0.01) and lowered heart rate (115/min vs. 68/min, p < 0.01). Mean duration of ECMO support was 12 days, 5 out of 7 patients underwent surgical repair, 4 were weaned from ECMO, 3 survived 30 days and 2 survived more than 1 year. The most frequent complication (5 patients) and the cause of death (3 patients) was bleeding. CONCLUSIONS: Our experience suggests that early V-A ECMO in patients with VSR and refractory CS might prevent irreversible multiorgan failure by improved end-organ perfusion. Bleeding complications remain an important limitation of this approach.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Choque Cardiogênico/terapia , Ruptura do Septo Ventricular/complicações , Idoso , Angiografia , Feminino , Seguimentos , Hemodinâmica/fisiologia , Humanos , Masculino , Estudos Retrospectivos , Fatores de Risco , Choque Cardiogênico/etiologia , Choque Cardiogênico/fisiopatologia , Resultado do Tratamento , Ruptura do Septo Ventricular/diagnóstico , Ruptura do Septo Ventricular/fisiopatologia
5.
Ann Thorac Cardiovasc Surg ; 23(4): 188-195, 2017 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-28539544

RESUMO

PURPOSE: Cardiac surgery in octogenarians with severely deteriorated functional status is increasingly common, but outcome data are still limited. The aim of this study was to compare postoperative outcome, survival, and quality of life of low-, medium-, and high-risk octogenarians undergoing cardiac surgery. METHODS: In all, 285 Czech octogenarians who underwent any cardiac surgical procedure between January 2011 and December 2012 were included in the study. Five out of all twelve national adult cardiac surgical centers participated in the study, representing almost half of all octogenarians operated in our country in that period. Patients' perioperative data were analyzed retrospectively. Follow-up was performed by interviewing patients by telephone. RESULTS: There was higher 30-day mortality (20% vs. 6.4% vs. 5.2%, respectively, p <0.001), lower 2-year survival (60% vs. 84.0% vs. 85.4%, respectively, p <0.05), and lower Karnofsky score (44.4 vs. 70.1 vs. 70.6, respectively, p <0.001) in high-risk group compared with medium- and low-risk groups, respectively. Greater improvement in New York Heart Association (NYHA) status was noted in high- and medium-risk groups compared with low-risk group (51% vs. 45% vs. 24%, respectively, p <0.05). CONCLUSION: High perioperative mortality, poor 2-year survival, and low postoperative quality of life have been observed in high-risk octogenarians undergoing cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Fatores Etários , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos/mortalidade , República Tcheca , Feminino , Humanos , Estimativa de Kaplan-Meier , Avaliação de Estado de Karnofsky , Masculino , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Modelos de Riscos Proporcionais , Qualidade de Vida , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
6.
Contemp Clin Trials ; 59: 38-43, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28533194

RESUMO

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


Assuntos
Anestesia em Procedimentos Cardíacos , Anestésicos Inalatórios , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Complicações Pós-Operatórias , Adulto , Anestesia em Procedimentos Cardíacos/efeitos adversos , Anestesia em Procedimentos Cardíacos/métodos , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/química , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/métodos , Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Feminino , Humanos , Masculino , Avaliação de Processos e Resultados (Cuidados de Saúde) , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Análise de Sobrevida , Volatilização
7.
Prague Med Rep ; 118(4): 139-146, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29324221

RESUMO

A massive left ventricular thrombosis represents a rare however, catastrophic complication of a central veno-arterial extra-corporeal membrane oxygenation. We report a case of such complication in a patient with severe left ventricular dysfunction after cardiac surgery. Its management and preventive measures are described and discussed.


Assuntos
Trombose Coronária/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Choque Cardiogênico/etiologia , Disfunção Ventricular Esquerda/etiologia , Obstrução do Fluxo Ventricular Externo/etiologia , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Trombose Coronária/fisiopatologia , Evolução Fatal , Humanos , Masculino , Choque Cardiogênico/fisiopatologia , Disfunção Ventricular Esquerda/fisiopatologia
8.
Contemp Clin Trials ; 59: 38-43, 2017. tab
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: ses-37191

RESUMO

Objective: There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless,small Randomized Controlled Trials have failed to demonstrate a survival advantage. Thus, whethervolatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable.Design: Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio.Setting: Tertiary and University hospitals. (AU)


Assuntos
Humanos , Masculino , Feminino , Adulto , Anestesia , Mortalidade , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos
9.
J Cardiothorac Vasc Anesth ; 30(5): 1386-95, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-27499346

RESUMO

OBJECTIVES: Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. DESIGN AND SETTING: A systematic review of literature followed by web-based voting on findings of a consensus conference. PARTICIPANTS: A total of 555 clinicians from 61 countries. INTERVENTIONS: The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated. MEASUREMENTS AND MAIN RESULTS: According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement. CONCLUSIONS: Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.


Assuntos
Cuidados Críticos/métodos , Medicina Baseada em Evidências/métodos , Mortalidade Hospitalar , Internacionalidade , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Estado Terminal , Humanos , Médicos
10.
Springerplus ; 5(1): 799, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-27390640

RESUMO

BACKGROUND: Thoracic epidural anesthesia (TEA) has been proposed to improve and facilitate early postoperative outcome in cardiac surgery. The aim of our study was to analyze early postoperative outcome data of patients undergoing cardiac surgery under general anesthesia (GA) with comparison to patients receiving combined TEA and GA. METHODS: Medical records data from 288 patients who underwent elective on-pump cardiac surgery were retrieved and analyzed. Patients were divided into two study groups according to the type of anesthesia used: GA group (n = 141) and TEA group (n = 147). Early postoperative outcome data including quality of analgesia and major organ outcome parameters were compared between the study groups. RESULTS: There was no major difference in early postoperative outcome data between the study groups, except for shorter time to extubation (6.0 ± 10.0 vs. 6.9 ± 8.8 h, respectively, P < 0.05) and hospital stay (10.7 ± 5.9 vs. 12.9 ± 8.8 days, respectively, P < 0.05) in TEA group compared to GA group. Also TEA group as compared to GA group had lower pain numeric rating scale scores (1 ± 1.1 vs. 1.4 ± 1.5 at 24 h, respectively, P < 0.05) and morphine requirements during the first 24 h after surgery (148.2 vs. 193 ± 85.4 µg/kg, respectively, P < 0.05). CONCLUSION: Both anesthetic methods were equivalent in most postoperative outcome measures. Thoracic epidural analgesia provided superior pain relief, shorter time to extubation and earlier hospital discharge.

11.
J Clin Endocrinol Metab ; 100(8): 3081-9, 2015 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26079777

RESUMO

CONTEXT: Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE: The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN: This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS: The setting was an academic tertiary hospital. PARTICIPANTS: Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION: Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES: Adverse events from any cause during postoperative hospital stay were compared. RESULTS: In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS: Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.


Assuntos
Glicemia/metabolismo , Procedimentos Cirúrgicos Cardíacos/métodos , Glucose/uso terapêutico , Insulina/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Glicemia/efeitos dos fármacos , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Glucose/administração & dosagem , Cardiopatias/epidemiologia , Cardiopatias/cirurgia , Humanos , Infusões Intravenosas , Insulina/administração & dosagem , Pessoa de Meia-Idade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Método Simples-Cego , Adulto Jovem
12.
Prague Med Rep ; 116(1): 57-63, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25923972

RESUMO

A young patient with streptococcal sepsis due to the phlegmon of his left thigh was admitted to the general intensive care unit. He developed a multi-organ failure and septic cardiomyopathy with subsequent cardiogenic shock. This resulted in hemodynamic instability unresponsive to conservative medical treatment. We report a successful application of veno-arterial extra-corporeal membrane oxygenation, which was used to overcome the period of critically low cardiac output caused by severe septic myocardial dysfunction.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Choque Séptico/terapia , Infecções Estreptocócicas/terapia , Adulto , Humanos , Masculino , Choque Séptico/microbiologia , Infecções Estreptocócicas/microbiologia
14.
Eur J Anaesthesiol ; 31(9): 452-6, 2014 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-25077896

RESUMO

BACKGROUND: Regular endotracheal tube cuff monitoring may prevent silent aspiration. OBJECTIVES: We hypothesised that active management of the cuff of the tracheal tube during deep hypothermic cardiac arrest would reduce silent subglottic aspiration. We also determined to study its effect on postoperative mechanical ventilation and the incidence of postoperative positive tracheal cultures. DESIGN: A randomised clinical trial. SETTING: The study was conducted in a University Teaching Hospital from September 2008 to November 2009. PATIENTS: Twenty-four patients undergoing elective pulmonary endarterectomy were included in the study. INTERVENTION: After induction of general anaesthesia and tracheal intubation, the cuff of the tracheal tube was inflated to 25 cmH2O. Following this, 1 ml of methylene blue dye diluted in 2 ml of physiological saline was injected into the hypopharynx. Patients were randomly assigned to active cuff management during cooling and warming (where cuff pressure was monitored and the cuff was reinflated if it dropped below 20 cmH2O, or deflated if pressure exceeded 30 cmH2O) or passive monitoring (where cuff pressure was monitored but volume was not altered). Before weaning from cardiopulmonary bypass, fibreoptic bronchoscopy was performed. Silent aspiration was then diagnosed if blue dye was seen in the trachea below the cuff of the tube. MAIN OUTCOME MEASURES: The primary aim of this study was to determine the incidence of silent aspiration. Secondary outcomes included duration of postoperative mechanical ventilation of the lungs and incidence of positive culture of tracheal aspirate. RESULTS: Active cuff management patients were younger than controls (51.2 ±â€Š11.6 vs. 63.2 ±â€Š9 years, P = 0.028), but otherwise the two groups were similar. The primary endpoint was reached because we showed that silent aspiration was significantly less frequent in the study group (0/12 vs. 8/12 patients, P = 0.001). Significantly lower intracuff pressures were measured in the control group patients at several timepoints during cooling, just before hypothermic arrest and at all timepoints during rewarming. CONCLUSION: We recommend that the cuff of the tracheal tube should be checked regularly during surgery under deep hypothermia, and the cuff pressure adjusted as required.


Assuntos
Parada Circulatória Induzida por Hipotermia Profunda/métodos , Intubação Intratraqueal/métodos , Pneumonia Aspirativa/prevenção & controle , Respiração Artificial/métodos , Adulto , Fatores Etários , Idoso , Anestesia Geral/métodos , Broncoscopia , Feminino , Seguimentos , Hospitais Universitários , Humanos , Incidência , Intubação Intratraqueal/instrumentação , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Pressão , Fatores de Tempo , Traqueia
15.
J Transl Med ; 10: 163, 2012 Aug 10.
Artigo em Inglês | MEDLINE | ID: mdl-22883307

RESUMO

BACKGROUND: Out of hospital cardiac arrest (OHCA) has a poor outcome. Recent non-randomized studies of ECLS (extracorporeal life support) in OHCA suggested further prospective multicenter studies to define population that would benefit from ECLS. We aim to perform a prospective randomized study comparing prehospital intraarrest hypothermia combined with mechanical chest compression device, intrahospital ECLS and early invasive investigation and treatment in all patients with OHCA of presumed cardiac origin compared to a standard of care. METHODS: This paper describes methodology and design of the proposed trial. Patients with witnessed OHCA without ROSC (return of spontaneous circulation) after a minimum of 5 minutes of ACLS (advanced cardiac life support) by emergency medical service (EMS) team and after performance of all initial procedures (defibrillation, airway management, intravenous access establishment) will be randomized to standard vs. hyperinvasive arm. In hyperinvasive arm, mechanical compression device together with intranasal evaporative cooling will be instituted and patients will be transferred directly to cardiac center under ongoing CPR (cardiopulmonary resuscitation). After admission, ECLS inclusion/exclusion criteria will be evaluated and if achieved, veno-arterial ECLS will be started. Invasive investigation and standard post resuscitation care will follow. Patients in standard arm will be managed on scene. When ROSC achieved, they will be transferred to cardiac center and further treated as per recent guidelines. PRIMARY OUTCOME: 6 months survival with good neurological outcome (Cerebral Performance Category 1-2). Secondary outcomes will include 30 day neurological and cardiac recovery. DISCUSSION: Authors introduce and offer a protocol of a proposed randomized study comparing a combined "hyperinvasive approach" to a standard of care in refractory OHCA. The protocol is opened for sharing by other cardiac centers with available ECLS and cathlab teams trained to admit patients with refractory cardiac arrest under ongoing CPR. A prove of concept study will be started soon. The aim of the authors is to establish a net of centers for a multicenter trial initiation in future. ETHICS AND REGISTRATION: The protocol has been approved by an Institutional Review Board, will be supported by a research grant from Internal Grant Agency of the Ministry of Health, Czech Republic NT 13225-4/2012 and has been registered under ClinicalTrials.gov identifier: NCT01511666.


Assuntos
Reanimação Cardiopulmonar/instrumentação , Serviços Médicos de Emergência/organização & administração , Parada Cardíaca/terapia , Hipertermia Induzida , Humanos
16.
Eur J Cardiothorac Surg ; 39(2): 195-200, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20615721

RESUMO

OBJECTIVE: Pulmonary endarterectomy (PEA) is an effective and potentially curative treatment for chronic thrombo-embolic pulmonary hypertension (CTEPH). The postoperative course after PEA is accompanied by a number of complications, which contribute to the high rate of early postoperative mortality. Markers allowing the early detection of infectious complication during the postoperative period may be of major clinical importance. The aim of the prospective study was to analyse a predictive value of five inflammatory markers to recognise inflammatory complications accompanying PEA before the first clinical signs of infection. METHODS: Eighty-two patients with CTEPH, who underwent PEA using cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), were included into the study. Procalcitonin (PCT), tumour necrosis factor-α, interleukin (IL)-6, IL-8 and C-reactive protein arterial concentrations were measured before sternotomy and repeatedly up to 72h after the end of surgery. Haemodynamic parameters, infectious and non-infectious complications were recorded. RESULTS: Postoperative course was uncomplicated in 59/82 patients (group 1). Fourteen out of 82 patients (group 2) developed an infection in the first 3 days after surgery (bronchopneumonia, n = 9; bacterial sepsis, n = 5). Nine out of 82 patients (group 3) developed non-infectious complications in the same period. PCT and IL-6 were the only significant independent predictors of infection in days 1-3 after PEA. The area under receiver operating characteristic (ROC) curve calculated for PCT to predict postoperative infection was 0.83 (95% confidence interval (CI): 0.74-0.92) compared with 0.74 (95% CI: 0.68-0.81) for IL-6. With the cut-off 2.3 ng ml(-1), the test characteristics of PCT were as follows: sensitivity, 86%; specificity, 83%; negative predictive value, 92%; and positive predictive value, 84%. CONCLUSIONS: The increase in PCT and IL-6 may allow patients at increased risk of infection after PEA to be identified, allowing earlier institution of antibiotic treatment. These changes that occur before infection can be detected clinically. This finding may make the daily monitoring of PCT post-PEA useful.


Assuntos
Infecções Bacterianas/diagnóstico , Endarterectomia/métodos , Hipertensão Pulmonar/cirurgia , Complicações Pós-Operatórias/diagnóstico , Artéria Pulmonar/cirurgia , Embolia Pulmonar/cirurgia , Idoso , Infecções Bacterianas/sangue , Infecções Bacterianas/etiologia , Biomarcadores/sangue , Proteína C-Reativa/metabolismo , Calcitonina/sangue , Peptídeo Relacionado com Gene de Calcitonina , Ponte Cardiopulmonar , Diagnóstico Precoce , Métodos Epidemiológicos , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Mediadores da Inflamação/sangue , Interleucina-6/sangue , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/sangue , Precursores de Proteínas/sangue , Embolia Pulmonar/complicações
17.
J Invasive Cardiol ; 22(8): 365-9, 2010 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-20679672

RESUMO

Extracorporeal membrane oxygenation (ECMO) is an effective rescue method for severe respiratory and cardiac failure. Right ventricular (RV) failure with cardiogenic shock is a critical condition with generally poor prognosis unless aggressive therapeutical measures are undertaken. Authors report on their initial experience with ECMO support in severe RV failure with cardiogenic shock caused by an obstructive hemodynamic pattern. Four patients with cardiogenic shock due to severe RV failure related to pulmonary arterial hypertension (2 patients), congenital heart disease with Eisenmenger physiology (1 subject) and massive pulmonary embolism (1 patient) were supported with emergency veno-arterial ECMO. ECMO circuit was instituted using peripheral cannulation in all subjects. Immediate hemodynamic and ventilatory improvement was observed in all patients. The mean support duration was 11 days (range 5-16 days), 2 (50%) patients were successfully weaned off ECMO and survived to hospital discharge. The other 2 patients were considered by mutual consensus to have irreversible organ damage, the ECMO support was withdrawn and the patients died. Bleeding complications were the main complications observed. As per initial experience, veno-arterial ECMO allows bypassing of the pulmonary bed, therefore, relieves the RV pressure overload and does not cause further elevation of the pulmonary pressures in contrary to RV assist devices. This aggressive management approach requires further clinical evaluation in order to establish its definite role in critical RV failure.


Assuntos
Complexo de Eisenmenger/terapia , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Hipertensão Pulmonar/terapia , Circulação Pulmonar/fisiologia , Adulto , Arteriopatias Oclusivas/fisiopatologia , Arteriopatias Oclusivas/terapia , Complexo de Eisenmenger/fisiopatologia , Feminino , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque Cardiogênico/fisiopatologia , Choque Cardiogênico/terapia , Resultado do Tratamento
18.
Diabetes Care ; 32(5): 757-61, 2009 May.
Artigo em Inglês | MEDLINE | ID: mdl-19196894

RESUMO

OBJECTIVE: We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS: A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1- to 4-h intervals as requested by the protocols. RESULTS: The eMPC algorithm gave the best performance as assessed by time to target (8.8 +/- 2.2 vs. 10.9 +/- 1.0 vs. 12.3 +/- 1.9 h; eMPC vs. Matias vs. Bath, respectively; P < 0.05), average blood glucose after reaching the target (5.2 +/- 0.1 vs. 6.2 +/- 0.1 vs. 5.8 +/- 0.1 mmol/l; P < 0.01), time in target (62.8 +/- 4.4 vs. 48.4 +/- 3.28 vs. 55.5 +/- 3.2%; P < 0.05), time in hyperglycemia >8.3 mmol/l (1.3 +/- 1.2 vs. 12.8 +/- 2.2 vs. 6.5 +/- 2.0%; P < 0.05), and sampling interval (2.3 +/- 0.1 vs. 2.1 +/- 0.1 vs. 1.8 +/- 0.1 h; P < 0.05). However, time in hypoglycemia risk range (2.9-4.3 mmol/l) in the eMPC group was the longest (22.2 +/- 1.9 vs. 10.9 +/- 1.5 vs. 13.1 +/- 1.6; P < 0.05). No severe hypoglycemic episode (<2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group. CONCLUSIONS: The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients.


Assuntos
Glicemia/metabolismo , Procedimentos Cirúrgicos Cardíacos , Cuidados Pós-Operatórios , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Glicemia/efeitos dos fármacos , Cuidados Críticos/métodos , Homeostase , Humanos , Hiperglicemia/epidemiologia , Hiperglicemia/prevenção & controle , Hipoglicemia/epidemiologia , Hipoglicemia/prevenção & controle , Infusões Intravenosas , Insulina/administração & dosagem , Insulina/uso terapêutico , Unidades de Terapia Intensiva/normas , Pessoa de Meia-Idade , Adulto Jovem
19.
Heart Surg Forum ; 11(4): E202-8, 2008.
Artigo em Inglês | MEDLINE | ID: mdl-18782697

RESUMO

BACKGROUND: The suitability of combined high-thoracic epidural anesthesia for pulmonary endarterectomy was studied. METHODS: A prospective randomized clinical study was conducted in a university medical center from November 2005 to December 2006. The primary endpoint of this study was to evaluate perioperative hemodynamic data; secondary endpoints were to evaluate the duration of artificial ventilation, length of stay in the intensive care unit, and the impact on postoperative morbidity and mortality. RESULTS: The 16 patients in the study group received high-thoracic epidural anesthesia plus general anesthesia; the 16 control patients received total intravenous anesthesia alone. Hemodynamic parameters and drug use, as well as the time to extubation, rate of complications, postoperative pain, the length of intensive care unit stay, and mortality, were recorded. The 2 groups were comparable with respect to hemodynamic stability during induction of anesthesia. The study group patients had significantly lower sufentanil consumption (mean +/- SD, 2.1 +/- 0.7 microg/kg versus 9.1 +/- 3.1 microg/kg; P <.001), a shorter period of artificial ventilation (34 +/- 35 hours versus 52 +/- 49 hours; P = .0318), and lower postoperative pain scores at 3 hours (0.10 +/- 0.26 versus 0.93 +/- 1.38; P = .015), 12 hours (0.14 +/- 0.53 versus 0.93 +/- 0.79; P = .002), and 24 hours (0.35 +/- 0.49 versus 1.33 +/- 1.04; P = .007). CONCLUSIONS: This study has shown that combined epidural and general anesthesia is a suitable anesthetic option in patients who are selected for pulmonary endarterectomy. It provides hemodynamic stability and reduces the duration of tracheal intubation postoperatively and improves postoperative pain relief, although this option has not been shown to decrease either the length of the intensive care unit stay or mortality.


Assuntos
Analgesia Epidural/métodos , Endarterectomia , Artéria Pulmonar/cirurgia , Adulto , Idoso , Analgésicos Opioides/administração & dosagem , Anestesia Geral , Relação Dose-Resposta a Droga , Endarterectomia/métodos , Endarterectomia/mortalidade , Estudos de Viabilidade , Feminino , Hemodinâmica , Humanos , Unidades de Terapia Intensiva , Intubação Intratraqueal/estatística & dados numéricos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/fisiopatologia , Período Pós-Operatório , Estudos Prospectivos , Respiração Artificial , Sufentanil/administração & dosagem , Tórax , Fatores de Tempo
20.
Interact Cardiovasc Thorac Surg ; 7(3): 435-6, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-18258652

RESUMO

We report an unusual source of intra-operative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of an oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear.


Assuntos
Valva Aórtica/cirurgia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hemoperitônio/etiologia , Fígado/lesões , Esterno/cirurgia , Valva Tricúspide/cirurgia , Ferimentos não Penetrantes/complicações , Transfusão de Sangue , Ponte Cardiopulmonar , Feminino , Hematócrito , Hemoperitônio/sangue , Hemoperitônio/terapia , Hemostáticos/uso terapêutico , Humanos , Laparotomia , Pessoa de Meia-Idade , Reoperação , Resultado do Tratamento , Ferimentos não Penetrantes/sangue , Ferimentos não Penetrantes/etiologia , Ferimentos não Penetrantes/cirurgia
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