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1.
JAMA ; 323(24): 2485-2492, June., 2020. tab., graf.
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1123020

RESUMO

IMPORTANCE Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain. OBJECTIVE To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018. INTERVENTIONS The dexamethasone group (n = 194) received 1mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9%sodium chloride intravenously after anesthesia induction. MAIN OUTCOMES AND MEASURES The primary end pointwas a composite of death, nonfatalmyocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization. RESULTS All of the 394 patients randomized (median age, 6 months; 47.2%boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95%CI, −0.8%to 15.3%; hazard ratio, 0.82; 95%CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group. CONCLUSIONS AND RELEVANCE Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference.


Assuntos
Humanos , Masculino , Feminino , Recém-Nascido , Criança , Ponte Cardiopulmonar , Complicações Cognitivas Pós-Operatórias , Procedimentos Cirúrgicos Cardíacos/mortalidade , Cuidados Intraoperatórios , Dexametasona/efeitos adversos , Método Duplo-Cego , Glucocorticoides/efeitos adversos
2.
Nutrition ; 83: 111057, 2020 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-33360035

RESUMO

OBJECTIVES: The aim of this study was to investigate the relationship between malnutrition and long-term survival in patients who underwent cardiopulmonary bypass (CPB). METHODS: This study analyzed the long-term survival data of a mixed cohort of 1187 cardiac patients previously enrolled in a prospective observational study of nutritional screening in cardiac surgery. Nutritional status was assessed using the Malnutrition Universal Screening Tool (MUST). The mean age of patients was 58.86 ± 10.07 y (95% confidence interval [CI], 58.2-59.4). The median time of follow-up was 73.4 mo (25th-75th percentiles, 18.3-101.3). RESULTS: In all, 449 patients (37.8%) were lost to follow-up after hospitalization. For the remaining participants, the overall 8-y survival was 68% (95% CI, 59-76) and 77% (95% CI, 73-80; log-rank, P = 0.12) in patients with and without malnutrition risk, respectively. Statistically significant differences in survival were found during the 3-y follow-up of patients with heart valve disease: 83% (95% CI, 74-92) with malnutrition versus 93% (95% CI, 90-96) without malnutrition (log-rank, P = 0.03). The final multivariate Cox regression model revealed logistic EuroSCORE (hazard ratio (HR), 1.337; 95% CI, 1.110-1.612), cardiopulmonary bypass time <110.5 min (HR 0.463, 95% CI 0.255-0.842), preoperative albumin (HR 0.799, 95% CI 0.691-0.924), and C-reactive protein (HR, 1.106; 95% CI, 1.018-1.202) as independent predictors of 3-y survival. CONCLUSION: Preoperative malnutrition is not associated with 8-y mortality in a mixed cardiac surgery cohort. However, it may be associated with worse 3-y outcomes in patients with heart valve disease.

5.
Artigo em Inglês | MEDLINE | ID: mdl-33036886

RESUMO

OBJECTIVES: To assess current practice in adult cardiac surgery during cardiopulmonary bypass (CPB) across European and non-European countries. DESIGN: International, multicenter, web-based survey including 28 multiple choice questions addressing hemodynamic and tissue oxygenation parameters, organ protection measures, and the monitoring and usage of anesthetic drugs as part of the anesthetic and perfusion practice during CPB. SETTING: Online survey endorsed by the European Association of Cardiothoracic Anesthesiologists. PARTICIPANTS: Representatives of anesthesiology departments in European and non-European adult cardiac surgical centers. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The survey was distributed via e-mail to European Association of Cardiothoracic Anesthesiologists members (n = 797) and kept open for 1 month. The response rate was 34% (n = 271). After exclusion of responses from the same centers and of incomplete answers, data from 202 cardiac centers in 56 countries, of which 67% of centers were university hospitals, were analyzed. Optimization of pump flows and tissue oxygenation parameters during CPB were applied by the majority of centers, with target flow rates of >2.2 L/min/m2 in 93% (n = 187) of centers and mean arterial blood pressures between 51 and 90 mmHg in 85% (n = 172). Hemoglobin transfusion triggers were either individualized or between 7 and 8 g/dL in 92% (n = 186) of centers. Mixed venous oxyhemoglobin saturations were assessed routinely in 59% (n = 120) and lactate in 88% (n = 178) of cardiac surgery units. Noninvasive cerebral saturation monitoring was used in a subgroup of patients or routinely in 84% (n = 169) of sites, and depth-of-anesthesia monitoring was used routinely in 53% (n = 106). Transesophageal echocardiography and pulmonary artery catheters were used routinely or in subgroups of patients in 97% (n = 195) and 71% (n = 153) of centers, respectively. The preferred site for temperature monitoring was the nasopharynx in 66% (n = 134) of centers. Anesthetic techniques were variable, with 26% of centers (n = 52) using low-tidal-volume ventilation and 28% (n = 57) using continuous positive airway pressure during CPB. Volatile agents were used routinely as the only agent during CPB in 36% sites (n = 73) and propofol in 47% (n = 95). Other drugs routinely administered included magnesium in 45% (n = 91), steroids in 18% (n = 37), tranexamic acid in 88% (n = 177), and aprotinin in 15% (n = 30) of the centers. CONCLUSION: This international CPB survey revealed that techniques for optimization of pump flow and oxygenation during CPB usually were applied. Furthermore, cerebral and hemodynamic monitoring devices were frequently used during CPB. However, most CPB-related anesthetic techniques and medications were more variable. More high-quality randomized controlled trials are needed to assess anesthetic techniques and organ protection.

6.
Artigo em Inglês | MEDLINE | ID: mdl-32718702

RESUMO

OBJECTIVE: Acute kidney injury (AKI) is a serious complication of cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to evaluate the effects of nitric oxide (NO) supplementation to the CPB circuit on the development of cardiac surgery-associated AKI. METHODS: This prospective randomized controlled study included 96 patients with moderate risk of renal complications who underwent elective cardiac surgery with CPB. The study protocol was registered at ClinicalTrials.gov (identifier NCT03527381). Patients were randomly allocated to either NO supplementation to the CPB bypass circuit (NO treatment group; n = 48) or usual care (control group; n = 48). In the NO treatment group, 40-ppm NO was administered during the entire CPB period. The primary outcome was the incidence of AKI. RESULTS: NO treatment was associated with a significant decrease in AKI incidence (10 cases [20.8%] vs 20 cases [41.6%] in the control group; relative risk, 0.5; 95% confidence interval, 0.26-0.95; P = .023) and a higher median urine output during CPB (2.6 mL/kg/h [interquartile range (IQR), 2.1-5.08 mL/kg/h] vs 1.7 mL/kg/h [IQR, 0.80-2.50 mL/kg/h]; P = .0002). The median urinary neutrophil gelatinase-associated lipocalin level at 4 hours after surgery was significantly lower in the NO treatment group (1.12 ng/mL [IQR, 0.75-5.8 ng/mL] vs 4.62 ng/mL [IQR, 2.02-34.55 ng/mL]; P = .005). In the NO treatment group, concentrations of NO metabolites were significantly increased at 5 minutes postclamping, at 5 minutes after declamping, and at the end of the operation. Concentrations of proinflammatory and anti-inflammatory mediators and free plasma hemoglobin did not differ significantly between the 2 groups. CONCLUSIONS: NO administration in patients at moderate risk of renal complications undergoing elective cardiac surgery with CPB was associated with a lower incidence of AKI.

7.
J Cardiothorac Vasc Anesth ; 34(12): 3275-3281, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32532692

RESUMO

OBJECTIVES: To evaluate the dynamics of the cerebral oxygen supply in patients aged ≥65 years, during coronary artery bypass grafting (CABG), and to test the hypothesis that lower intraoperative brain oxygen saturation is associated with postoperative neurological complications. DESIGN: Prospective cohort study. SETTING: The E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia. PARTICIPANTS: The study comprised 200 elderly patients who underwent CABG between April, 2018 and November, 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The regional hemoglobin oxygen saturation (rSO2, %) of the right and left brain hemispheres were assessed during the intraoperative period using bilateral near-infrared spectroscopy. Furthermore, neurological complications during hospitalization were evaluated. At the anesthesia induction stage, the average levels of rSO2 for the right and left hemispheres were within 65% and did not differ significantly at any stage of CABG (p>0.05). The risk of neurological complications was associated with rSO2 decrease during cardiopulmonary bypass (CPB). An increased risk was associated with rSO2 decrease by 20% or more during CPB, relative to the stage of anesthesia induction, which was observed in 19% of patients. CONCLUSIONS: In elderly patients, the decrease in rSO2 during CPB is associated with an increased risk of neurological complications during hospitalization. This risk increases with a decrease in rSO2 by 20% or more during CPB relative to the stage of anesthesia induction, by a 5-fold and 7-fold for the left and right hemispheres, respectively.

8.
JAMA ; 323(24): 2485-2492, 2020 06 23.
Artigo em Inglês | MEDLINE | ID: mdl-32573670

RESUMO

Importance: Corticosteroids are widely used in pediatric cardiac surgery to blunt systemic inflammatory response and to reduce complications; nevertheless, their clinical efficacy is uncertain. Objective: To determine whether intraoperative administration of dexamethasone is more effective than placebo for reducing major complications and mortality during pediatric cardiac surgery. Design, Setting, and Participants: The Intraoperative Dexamethasone in Pediatric Cardiac Surgery was an investigator-initiated, double-blind, multicenter randomized trial that involved 4 centers in China, Brazil, and Russia. A total of 394 infants younger than 12 months, undergoing cardiac surgery with cardiopulmonary bypass were enrolled from December 2015 to October 2018, with follow-up completed in November 2018. Interventions: The dexamethasone group (n = 194) received 1 mg/kg of dexamethasone; the control group (n = 200) received an equivolume of 0.9% sodium chloride intravenously after anesthesia induction. Main Outcomes and Measures: The primary end point was a composite of death, nonfatal myocardial infarction, need for extracorporeal membrane oxygenation, need for cardiopulmonary resuscitation, acute kidney injury, prolonged mechanical ventilation, or neurological complications within 30 days after surgery. There were 17 secondary end points, including the individual components of the primary end point, and duration of mechanical ventilation, inotropic index, intensive care unit stay, readmission to intensive care unit, and length of hospitalization. Results: All of the 394 patients randomized (median age, 6 months; 47.2% boys) completed the trial. The primary end point occurred in 74 patients (38.1%) in the dexamethasone group vs 91 patients (45.5%) in the control group (absolute risk reduction, 7.4%; 95% CI, -0.8% to 15.3%; hazard ratio, 0.82; 95% CI, 0.60 to 1.10; P = .20). Of the 17 prespecified secondary end points, none showed a statistically significant difference between groups. Infections occurred in 4 patients (2.0%) in the dexamethasone group vs 3 patients (1.5%) in the control group. Conclusions and Relevance: Among infants younger than 12 months undergoing cardiac surgery with cardiopulmonary bypass, intraoperative administration of dexamethasone, compared with placebo, did not significantly reduce major complications and mortality at 30 days. However, the study may have been underpowered to detect a clinically important difference. Trial Registration: ClinicalTrials.gov Identifier: NCT02615262.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Dexametasona/uso terapêutico , Glucocorticoides/uso terapêutico , Cardiopatias Congênitas/cirurgia , Cuidados Intraoperatórios , Complicações Cognitivas Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar , Dexametasona/efeitos adversos , Método Duplo-Cego , Feminino , Glucocorticoides/efeitos adversos , Humanos , Lactente , Recém-Nascido , Masculino , Complicações Cognitivas Pós-Operatórias/mortalidade
9.
J Crit Care ; 58: 89-95, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32402931

RESUMO

PURPOSE: Perioperative myocardial dysfunction occurs frequently in cardiac surgery, and is a risk factor for morbidity and mortality. Levosimendan has been suggested to reduce mortality of patients with perioperative myocardial dysfunction. However, long-term outcome data on its efficacy in cardiac surgery are lacking. MATERIALS AND METHODS: Cardiac surgery patients with perioperative myocardial dysfunction were randomized to levosimendan or placebo, in addition to standard inotropic care. One-year mortality data were collected. RESULTS: We randomized 506 patients (248 to levosimendan 258 to placebo). At 1-year follow-up, 41 patients (16.5%) died in the levosimendan group, while 47 (18.3%) died in the placebo group (absolute risk difference -1.8; 95% CI -8.4 to 4.9; P = .60). Female sex, history of chronic obstructive pulmonary disease, previous myocardial infarction, serum creatinine, hematocrit, mean arterial pressure, and duration of cardiopulmonary bypass were independently associated with 1-year mortality. CONCLUSIONS: Levosimendan administration does not improve 1-year survival in cardiac surgery patients with perioperative myocardial dysfunction. One-year mortality in these patients is 17%. Six predictive factors for long-term mortality were identified. STUDY REGISTRATION NUMBER: NCT00994825 (ClinicalTrials.gov).

10.
J Cardiothorac Vasc Anesth ; 34(6): 1622-1635, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32276758

RESUMO

SEPARATION from cardiopulmonary bypass (CPB) after cardiac surgery is a progressive transition from full mechanical circulatory and respiratory support to spontaneous mechanical activity of the lungs and heart. During the separation phase, measurements of cardiac performance with transesophageal echocardiography (TEE) provide the rationale behind the diagnostic and therapeutic decision-making process. In many cases, it is possible to predict a complex separation from CPB, such as when there is known preoperative left or right ventricular dysfunction, bleeding, hypovolemia, vasoplegia, pulmonary hypertension, or owing to technical complications related to the surgery. Prompt diagnosis and therapeutic decisions regarding mechanical or pharmacologic support have to be made within a few minutes. In fact, a complex separation from CPB if not adequately treated leads to a poor outcome in the vast majority of cases. Unfortunately, no specific criteria defining complex separation from CPB and no management guidelines for these patients currently exist. Taking into account the above considerations, the aim of the present review is to describe the most common scenarios associated with a complex CPB separation and to suggest strategies, pharmacologic agents, and para-corporeal mechanical devices that can be adopted to manage patients with complex separation from CPB. The routine management strategies of complex CPB separation of 17 large cardiac centers from 14 countries in 5 continents will also be described.

11.
J Cardiothorac Vasc Anesth ; 34(8): 2111-2115, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32173209

RESUMO

OBJECTIVES: To describe international practices on the use of calcium salts during cardiopulmonary bypass (CPB) weaning in adult cardiac surgery patients. DESIGN: Multiple-choice survey on current practice of CPB weaning. SETTING: Online survey using the SurveyMonkey platform. PARTICIPANTS: Departments of cardiac anesthesiology worldwide. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Out of 112 surveys sent, 100 centers from 32 countries replied. The majority of centers (88 of 100 = 88%) administer calcium salts intraoperatively: 71 of 100 (71%) are using these drugs for CPB weaning and 78 of 100 (78%) for correction of hypocalcemia. Among the 88 centers that use calcium salts intraoperatively, 66% (58 of 88) of respondents use calcium chloride, 22% (19 of 88) use calcium gluconate, and 12% (11 of 88) use both drugs. Calcium salts are routinely used during normal (47 of 71 centers = 66%) and difficult (59 of 71 centers = 83%) weaning from CPB. Doses of 5 to 15 mg/kg during termination of CPB were used by 55 of 71 centers (77%) either by bolus (39 of 71, 55%) or over a time period longer than 1 minute (32 of 71 = 45%). Norepinephrine is the most commonly used first line vasopressor or inotropic agent used to support hemodynamics during termination of CPB in 32 out of 100 centers (32%), and calcium is the second one, used by 23 out of 100 centers (23%). CONCLUSION: This survey demonstrates that the majority of cardiac centers use calcium in adult patients undergoing cardiac surgery, especially during weaning from CPB. There is variability on the type of drug, dose, and modality of drug administration.

12.
Qual Life Res ; 29(8): 2111-2118, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32180099

RESUMO

PURPOSE: To assess the dynamic of various health-related quality of life (HRQoL) parameters 3 years after pulmonary thromboendarterectomy (PTE), and to identify factors affecting HRQoL parameters in patients with chronic thromboembolic pulmonary hypertension (CTEPH) in the long-term follow-up after surgery. METHODS: This prospective cohort study included 128 patients with CTEPH before and after the PTE (3 year follow-up). The HRQoL was examined using the Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS: In patients with CTEPH 3 years after PTE, a significant improvement in all the HRQoL parameters. The summary indicators of the physical and mental components of health remained at the same level as 1 year after the PTE and did not exceed 50 points. The residual pulmonary hypertension was a leading factor limiting parameters of physical and mental health 3 years after a PTE. In addition, the parameters of physical activity were adversely affected by age and the age-adjusted Charlson Comorbidity Index. CONCLUSIONS: In the study group of patients with CTEPH, PTE contributes to a significant improvement in all HRQoL parameters, which observed both 1 year and 3 years after surgery. The leading factor adversely affecting the physical and emotional components of health in the long-term period after PTE was residual pulmonary hypertension recorded in the early postoperative period. In addition, some physical HRQoL parameters are affected by age and age-adjusted Charlson Comorbidity Index.


Assuntos
Hipertensão Pulmonar/cirurgia , Embolia Pulmonar/cirurgia , Adulto , Doença Crônica , Estudos de Coortes , Feminino , Humanos , Hipertensão Pulmonar/psicologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Embolia Pulmonar/psicologia , Qualidade de Vida/psicologia , Resultado do Tratamento
13.
Korean J Anesthesiol ; 73(6): 525-533, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32098012

RESUMO

BACKGROUND: The aim of this study was to test the hypothesis that the use of inhalational anesthesia leads to higher suppression of the cell-mediated immunity compared to total intravenous anesthesia in patients undergoing kidney cancer surgery under combined low thoracic epidural analgesia and general anesthesia. METHODS: Patients were randomly allocated to either propofol-based (intravenous anesthetic) or sevoflurane-based (volatile anesthetic) anesthesia group with 10 patients in each group, along with epidural analgesia in both groups. Amounts of natural killer (NK) cells, total T lymphocytes, and T lymphocyte subpopulations in the blood samples collected from the patients before surgery, at the end of the surgery and postoperative days 1, 3 and 7 were determined by flow cytometric analysis. The NK cell count served as the primary endpoint of the study, whereas the total T lymphocyte count and cell counts for T lymphocyte subpopulations were used as the secondary endpoint. RESULTS: Our study showed that there were no significant differences in the amount of NK cells, total T lymphocytes, regulatory T cells, and T-helper cells, cytotoxic T lymphocytes, and their subpopulations between the propofol- and sevoflurane-based anesthesia groups when the anesthesia was administered in combination with epidural analgesia. CONCLUSIONS: The results of this pilot study did not support the hypothesis that the use of inhalational anesthesia leads to higher suppression of the cell-mediated immunity than that of total intravenous anesthesia in patients undergoing kidney cancer surgery under combined low thoracic epidural analgesia and general anesthesia.

14.
Int J Artif Organs ; 43(7): 476-481, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31894709

RESUMO

INTRODUCTION: The use of volatile agents during cardiopulmonary bypass allows a "single drug anesthesia" and is associated with reduced peak postoperative troponin levels. Connecting the exhaust systems to the oxygenator's gas outlet port is mandatory and allows to prevent operating room (but not atmospheric) pollution by volatile agents. The aim of this study was to create a prototype filter for volatile agents and to test its adsorption efficacy during an ex-vivo simulated conventional cardiopulmonary bypass test. METHODS: We carried out bench tests to conceive a prototype filter that could prevent room and environment pollution without damaging membrane oxygenators. We performed the tests at the Engineering Center for Circulatory Assistance Laboratory, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil. Bench tests included simulation of integral adsorption tests, filter dimensions and design, flow versus pressure curve, sizing, and tightness. RESULTS: Calgon AT 410 was the best kind of activated charcoal granules for adsorption of sevoflurane, isoflurane, and desflurane. Filter dimension tests showed that a chamber of 30-cm width over 10-cm diameter filled with 200 g of the Calgon AT410 granules was the minimum required to fully adsorb sevoflurane for 90 min. Adsorption tests showed that the prototype filter fully adsorbed isoflurane in 100 ± 2.3 min, sevoflurane in 95 ± 3.4 min, and desflurane in 95 ± 4.3 min. CONCLUSION: The new version of our prototype filter adsorbed most of the volatile anesthetics agents during an ex-vivo simulated conventional cardiopulmonary bypass test.


Assuntos
Filtros de Ar , Poluição do Ar/prevenção & controle , Anestésicos Inalatórios , Desflurano , Isoflurano , Sevoflurano , Adsorção , Brasil , Ponte Cardiopulmonar , Desenho de Equipamento , Humanos , Oxigenadores de Membrana
15.
J Cardiothorac Vasc Anesth ; 34(4): 1023-1041, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31839459

RESUMO

Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, ß-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.

16.
J Cardiothorac Vasc Anesth ; 34(3): 594-600, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31558398

RESUMO

OBJECTIVE: To test the feasibility and investigate possible cardiovascular effects of a sustained high-dose intravenous thiamine protocol in patients undergoing combined valvular and coronary artery bypass graft surgery. DESIGN: Randomized, placebo-controlled, pilot feasibility trial. SETTING: Cardiac surgery department of a tertiary hospital. PARTICIPANTS: Forty patients undergoing combined valvular and coronary artery bypass surgery. INTERVENTIONS: Intravenous thiamine (600 mg on the day of surgery, and 400 mg/day on postoperative days 1, 2, and 3) or placebo. MEASUREMENTS AND MAIN RESULTS: The primary feasibility endpoints were recruitment rate and protocol compliance. Secondary endpoints included markers of possible biological and physiological effects. The mean recruitment rate was 8 patients per month and protocol compliance was 97.5%. There were no differences in median peak postoperative lactate (2.7 mmol/L [interquartile range [IQR] 1.4-4.6] for thiamine v 2.5 mmol/L [IQR 1.4-3.6] for placebo; p = 0.53), median peak postoperative creatinine (104 µmol/L [IQR 92.5-129] for thiamine v 99 µmol/L [IQR 86.5-109.5] for placebo; p = 0.53), median nadir postoperative cardiac index (1.8 L/min/m2 [IQR 1.5-2.1] for thiamine v 2.2 L/min/m2 [IQR 1.5-2.5] for placebo; p = 0.25), or the number of patients on vasopressor/inotropic agents (thiamine, 12 [63%]; placebo, 12 [60%]; p = 0.80), or in the total inotrope/vasopressor dose 0.14 µg/kg for thiamine v 0.12 µg/kg for placebo; p = 0.88). CONCLUSIONS: A double-blind trial of sustained high-dose intravenous thiamine supplementation in higher-risk cardiac surgery patients was feasible and appeared to be safe. However, such treatment did not demonstrate evidence of biological or physiological effects.

19.
Ann Vasc Surg ; 62: 356-364, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30802587

RESUMO

BACKGROUND: The aim of this study was to evaluate the long-term outcomes of spinal cord stimulation in patients with critical limb ischemia and to test the hypothesis that the dynamics of clinical changes one year after therapy depend both on the clinical determinants associated with the underlying disease and on factors related to systemic atherosclerosis. METHODS: This prospective cohort study included 56 patients with critical limb ischemia. All patients before and after spinal cord stimulation were examined in terms of the dynamics of their clinical changes using the Rutherford scale and transcutaneous oxygen tension (TcPO2, mm Hg) in the affected foot. The active orthostatic test was used to assess the functional state of peripheral perfusion. RESULTS: One year after spinal cord stimulation, 74% of patients showed positive clinical outcomes. No changes were observed in 9.3% of patients, whereas adverse clinical outcomes were revealed in 16.7% of cases. The TcPO2 values were significantly reduced before spinal cord stimulation: 10.5 (6.4-16.0) mm Hg. The functional status of the peripheral microvasculature was also disturbed. One year after therapy, TcPO2 significantly increased and the adaptive mechanisms of the microvasculature were improved in more than 70% of patients. Logistic regression analysis showed that the initially low TcPO2 values (<10 mm Hg) with a lack of gain in TcPO2 during the orthostatic test are associated with the negative clinical outcomes after spinal cord stimulation. The gain in TcPO2 during the orthostatic test to >10 mm Hg is associated with the positive clinical outcomes after spinal cord stimulation. The age-adjusted Charlson Comorbidity Index >5 and duration of critical ischemic symptoms also had a negative effect on the clinical outcomes after spinal cord stimulation. CONCLUSIONS: The positive clinical outcomes were revealed in most patients with critical limb ischemia one year after spinal cord stimulation. The low values of peripheral tissue metabolism with the disturbed functional status of the microvasculature are associated with the negative clinical outcome. The patients with baseline TcPO2 <10 mm Hg can recover if they still have a sufficient microcirculatory reserve capacity. Duration of critical ischemic symptoms and high comorbidity burden with allowance for age are negative factors affecting the clinical outcome.


Assuntos
Isquemia/terapia , Doença Arterial Periférica/terapia , Estimulação da Medula Espinal , Idoso , Biomarcadores/sangue , Monitorização Transcutânea dos Gases Sanguíneos , Estado Terminal , Feminino , Humanos , Isquemia/sangue , Isquemia/diagnóstico , Isquemia/fisiopatologia , Masculino , Microcirculação , Pessoa de Meia-Idade , Oxigênio/sangue , Doença Arterial Periférica/sangue , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Estudos Prospectivos , Recuperação de Função Fisiológica , Fluxo Sanguíneo Regional , Fatores de Tempo , Resultado do Tratamento
20.
J Cardiothorac Vasc Anesth ; 34(1): 235-244, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31350149

RESUMO

The search for safe and effective patient management strategies during weaning from cardiopulmonary bypass is ongoing; intravenous calcium is occasionally used as a first-line drug. The physiologic role of calcium suggests that it can support the function of the cardiovascular system during this critical period. Patients may be mildly hypocalcemic after cardiopulmonary bypass; however, this degree of hypocalcemia does not significantly impair the cardiovascular system. The transient beneficial effects of calcium administration (increase in arterial blood pressure, systemic vascular resistance, cardiac index, stroke volume, and coronary perfusion pressure) might be helpful in cases of moderate contractility reduction or vasoplegia. Nonetheless, effects on clinically relevant endpoints are unknown, and possible systemic side effects, such as transient reduction in internal mammary artery graft flow, attenuation of the effects of ß-sympathomimetics, "stone heart" phenomenon, and pancreatic cellular injury, may limit the use of calcium salts. Further studies are needed to expand the understanding of the effects of calcium administration on patient outcomes.

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