Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 139
Filtrar
1.
J Clin Monit Comput ; 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33523352

RESUMO

It remains unclear whether reduced myocardial contractility, venous dilation with decreased venous return, or arterial dilation with reduced systemic vascular resistance contribute most to hypotension after induction of general anesthesia. We sought to assess the relative contribution of various hemodynamic mechanisms to hypotension after induction of general anesthesia with sufentanil, propofol, and rocuronium. In this prospective observational study, we continuously recorded hemodynamic variables during anesthetic induction using a finger-cuff method in 92 non-cardiac surgery patients. After sufentanil administration, there was no clinically important change in arterial pressure, but heart rate increased from baseline by 11 (99.89% confidence interval: 7 to 16) bpm (P < 0.001). After administration of propofol, mean arterial pressure decreased by 23 (17 to 28) mmHg and systemic vascular resistance index decreased by 565 (419 to 712) dyn*s*cm-5*m2 (P values < 0.001). Mean arterial pressure was < 65 mmHg in 27 patients (29%). After propofol administration, heart rate returned to baseline, and stroke volume index and cardiac index remained stable. After tracheal intubation, there were no clinically important differences compared to baseline in heart rate, stroke volume index, and cardiac index, but arterial pressure and systemic vascular resistance index remained markedly decreased. Anesthetic induction with sufentanil, propofol, and rocuronium reduced arterial pressure and systemic vascular resistance index. Heart rate, stroke volume index, and cardiac index remained stable. Post-induction hypotension therefore appears to result from arterial dilation with reduced systemic vascular resistance rather than venous dilation or reduced myocardial contractility.

2.
Anesth Analg ; 2021 Jan 15.
Artigo em Inglês | MEDLINE | ID: mdl-33464759

RESUMO

Researchers often convert prediction tools built on statistical regression models into integer scores and risk classification systems in the name of simplicity. However, this workflow discards useful information and reduces prediction accuracy. We, therefore, investigated the impact on prediction accuracy when researchers simplify a regression model into an integer score using a simulation study and an example clinical data set. Simulated independent training and test sets (n = 1000) were randomly generated such that a logistic regression model would perform at a specified target area under the receiver operating characteristic curve (AUC) of 0.7, 0.8, or 0.9. After fitting a logistic regression with continuous covariates to each data set, continuous variables were dichotomized using data-dependent cut points. A logistic regression was refit, and the coefficients were scaled and rounded to create an integer score. A risk classification system was built by stratifying integer scores into low-, intermediate-, and high-risk tertiles. Discrimination and calibration were assessed by calculating the AUC and index of prediction accuracy (IPA) for each model. The optimism in performance between the training set and test set was calculated for both AUC and IPA. The logistic regression model using the continuous form of covariates outperformed all other models. In the simulation study, converting the logistic regression model to an integer score and subsequent risk classification system incurred an average decrease of 0.057-0.094 in AUC, and an absolute 6.2%-17.5% in IPA. The largest decrease in both AUC and IPA occurred in the dichotomization step. The dichotomization and risk stratification steps also increased the optimism of the resulting models, such that they appeared to be able to predict better than they actually would on new data. In the clinical data set, converting the logistic regression with continuous covariates to an integer score incurred a decrease in externally validated AUC of 0.06 and a decrease in externally validated IPA of 13%. Converting a regression model to an integer score decreases model performance considerably. Therefore, we recommend developing a regression model that incorporates all available information to make the most accurate predictions possible, and using the unaltered regression model when making predictions for individual patients. In all cases, researchers should be mindful that they correctly validate the specific model that is intended for clinical use.

3.
Anesth Analg ; 132(3): 866-877, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33433116

RESUMO

BACKGROUND: Anesthesiologists typically care for patients having a broad range of procedures. Outcomes might be improved when care is provided by caregivers experienced in particular types of surgery. We tested the hypothesis that intraoperative care provided by pairs of anesthesia caregivers having significant experience with a particular type of surgery reduces a composite of in-hospital death and 6 serious complications, including bleeding, cardiac, gastrointestinal, infectious, respiratory, and urinary complications, compared to care provided by pairs of anesthesia caregivers with less experience. METHODS: We included patients having surgery lasting at least 30 minutes. Using cluster analysis, attending anesthesiologists, and Certified Registered Nurse Anesthetists (CRNAs) were identified as experienced or inexperienced caregivers for each type of surgery at the case level. We then compared surgeries for which anesthesia was provided by a pair of experienced caregivers versus a pair of inexperienced caregivers on our composite outcome. We estimated the average relative effect (ie, the exponentiated average log odds ratio) of receiving anesthesia from an experienced versus inexperienced caregiver pair across the 7 components of the composite outcome using a generalized estimating equation (GEE) model to adjust for between-component correlation and with inverse propensity score weighing to adjust for potential confounding from a host of variables. RESULTS: A total of 8968 patients who received anesthesia care by an experienced pair were compared with 25,361 patients who received care from an inexperienced pair, adjusting for potential confounding. The incidence of composite complications (ie, any component event) was 7.6% (677/8968) for experienced pairs and 12% (2976/25,361) for inexperienced pairs (P < .001). Care by experienced pairs of caregivers was associated with lower odds of the composite outcome with an estimated average relative effect odds ratio across the individual components of 0.61 (95% confidence interval [CI], 0.54-0.71), P < .001. Among the 7 components of the primary outcome, experienced pairs of providers had significantly lower estimated odds of bleeding, infection, and mortality. CONCLUSIONS: Anesthesia care by experienced pairs was associated with fewer bleeding complications, fewer infections, shorter hospitalization, and reduced in-hospital mortality.

4.
Pain Med ; 21(Suppl 2): S53-S61, 2020 12 12.
Artigo em Inglês | MEDLINE | ID: mdl-33313729

RESUMO

BACKGROUND: Percutaneous peripheral nerve stimulation (PNS) is an analgesic modality involving the insertion of a lead through an introducer needle followed by the delivery of electric current after needle withdrawal. This modality has been used extensively to treat chronic pain, but only small series have been published involving postoperative pain. The ultimate objective of this study is to determine the postoperative effects of percutaneous PNS following moderately to severely painful ambulatory surgery within a real-world clinical practice setting. The primary hypothesis is that surgical pain and opioid consumption during the initial 7 days after surgery will be reduced by percutaneous PNS compared with usual and customary analgesia (dual primary outcome measures). DESIGN: A multicenter pragmatic effectiveness trial. We are randomizing participants having painful orthopedic surgical procedures of the upper and lower extremity to receive 14 days of either 1) electrical stimulation or 2) sham in a double-masked fashion. End points are being assessed at various time points over 12 postoperative months. SUMMARY: The postoperative experience will be much improved if percutaneous PNS provides potent analgesia while concurrently decreasing opioid requirements following painful surgery. Because this modality can be administered for up to 60 days at home, it may provide postoperative analgesia that outlasts surgical pain yet has relatively few risks and, unlike opioids, has no systemic side effects or potential for abuse, addiction, and overdose. Percutaneous PNS has the potential to revolutionize postoperative analgesia as it has been practiced for the past century. This study will inform key stakeholders regarding an evidence-based nonpharmacologic approach to the management of postoperative pain.

5.
Anesth Analg ; 131(5): 1540-1550, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079877

RESUMO

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.


Assuntos
Pressão Arterial , Cateteres , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Área Sob a Curva , Diagnóstico Precoce , Feminino , Humanos , Hipotensão/terapia , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Oscilometria , Sensibilidade e Especificidade , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento
6.
Anesth Analg ; 2020 Oct 06.
Artigo em Inglês | MEDLINE | ID: mdl-33031346

RESUMO

BACKGROUND: Avoiding intraoperative hypotension might serve as a measure of clinician skill. We, therefore, estimated the range of hypotension in patients of nurse anesthetists, and whether observed differences were associated with a composite of serious complications. METHODS: First, we developed a multivariable model to predict the amount of hypotension, defined as minutes of mean arterial pressure (MAP) <65 mm Hg, for noncardiac surgical cases from baseline characteristics excluding nurse anesthetist. Second, we compared observed and predicted amounts of hypotension for each case and summarized "excess" amounts across providers. Third, we estimated the extent to which hypotension on an individual case level was independently associated with a composite of serious complications. Finally, we assessed the range of actual and excess minutes of MAP <65 mm Hg on a provider level, and the extent to which these pressure exposures were associated with complications. RESULTS: We considered 110,391 hours of anesthesia by 99 nurse anesthetists. A total of 69% of 25,702 included cases had at least 1 minute of MAP <65 mm Hg, with a median (quartiles) of 4 (0-15) minutes on the case level. We were unable to explain much variance of intraoperative hypotension from baseline patient characteristics. However, cases in the highest 2 quartiles (>10 and >24 min/case more than predicted) were an estimated 27% (95% confidence interval [CI], 1.1-1.4) and 31% (95% CI, 1.2-1.5) more likely to experience complications compared to those with 0 excess minutes (both P< .001). There was little variation of the average excess minutes <65 mm Hg across the nurse anesthetists, with median (quartiles) of 1.6 (1.2-1.9) min/h. There was no association in confounder-adjusted models on the nurse anesthetist level between average excess hypotension and complications, either for continuous exposure (P = .09) or as quintiles (P = .30). CONCLUSIONS: Hypotension is associated with complications on a case basis. But the average amount of hypotension for nurse anesthetists over hundreds of cases differed only slightly and was insufficient to explain meaningful differences in complications. Avoiding hypotension is a worthy clinical goal, but does not appear to be a useful metric of performance because the range of average amounts per clinician is not meaningfully associated with patient outcomes, at least among nurse anesthetists in 1 tertiary center.

7.
Pain ; 2020 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-33021563

RESUMO

Phantom limb pain is thought to be sustained by reentrant neural pathways which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0-12 weeks. Pretreatment pain scores were similar in both groups, with a median [interquartile range] of 5.0 [4.0, 7.0] for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic versus 4.5 (2.6) in those given placebo (difference (95% CI) 1.3 (0.4, 2.2), P=0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 [0, 5.0] vs. 1.5 [0, 5.0] for the placebo group; there appeared to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.

8.
Anesthesiology ; 133(6): 1214-1222, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32960954

RESUMO

BACKGROUND: The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. METHODS: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg. RESULTS: Among 214 enrolled patients, guidance was provided for 105 (49%) patients randomly assigned to the index guidance group. The median (first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14 (0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0 (-0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than 60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened. CONCLUSIONS: In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment, presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment.

10.
JAMA ; 324(4): 350-358, 2020 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-32721009

RESUMO

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.


Assuntos
Acetaminofen/administração & dosagem , Analgésicos não Entorpecentes/administração & dosagem , Hipóxia/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Falha de Tratamento
14.
Anesth Analg ; 131(1): 24-30, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32343514

RESUMO

BACKGROUND: Health care worker (HCW) safety is of pivotal importance during a pandemic such as coronavirus disease 2019 (COVID-19), and employee health and well-being ensure functionality of health care institutions. This is particularly true for an intensive care unit (ICU), where highly specialized staff cannot be readily replaced. In the light of lacking evidence for optimal staffing models in a pandemic, we hypothesized that staff shortage can be reduced when staff scheduling takes the epidemiology of a disease into account. METHODS: Various staffing models were constructed, and comprehensive statistical modeling was performed. A typical routine staffing model was defined that assumed full-time employment (40 h/wk) in a 40-bed ICU with a 2:1 patient-to-staff ratio. A pandemic model assumed that staff worked 12-hour shifts for 7 days every other week. Potential in-hospital staff infections were simulated for a total period of 120 days, with a probability of 10%, 25%, and 40% being infected per week when at work. Simulations included the probability of infection at work for a given week, of fatality after infection, and the quarantine time, if infected. RESULTS: Pandemic-adjusted staffing significantly reduced workforce shortage, and the effect progressively increased as the probability of infection increased. Maximum effects were observed at week 4 for each infection probability with a 17%, 32%, and 38% staffing reduction for an infection probability of 0.10, 0.25, and 0.40, respectively. CONCLUSIONS: Staffing along epidemiologic considerations may reduce HCW shortage by leveling the nadir of affected workforce. Although this requires considerable efforts and commitment of staff, it may be essential in an effort to best maintain staff health and operational functionality of health care facilities and systems.


Assuntos
Infecções por Coronavirus , Cuidados Críticos/organização & administração , Métodos Epidemiológicos , Pandemias , Admissão e Escalonamento de Pessoal/organização & administração , Pneumonia Viral , Anestesiologia/organização & administração , Simulação por Computador , Mão de Obra em Saúde , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional , Modelos Organizacionais , Quarentena
15.
Anesthesiology ; 133(1): 119-132, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32349070

RESUMO

BACKGROUND: Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers improve cognitive function. The authors therefore tested the primary hypothesis that preoperative use of angiotensin inhibitors is associated with less delirium in critical care patients. Post hoc, the association between postoperative use of angiotensin system inhibitors and delirium was assessed. METHODS: The authors conducted a single-site cohort study of adults admitted to Cleveland Clinic critical care units after noncardiac procedures between 2013 and 2018 who had at least one Confusion Assessment Method delirium assessment. Patients with preexisting dementia, Alzheimer's disease or other cognitive decline, and patients who had neurosurgical procedures were excluded. For the primary analysis, the confounder-adjusted association between preoperative angiotensin inhibitor use and the incidence of postoperative delirium was assessed. Post hoc, the confounder-adjusted association between postoperative angiotensin system inhibitor use and the incidence of delirium was assessed. RESULTS: The incidence of delirium was 39% (551 of 1,396) among patients who were treated preoperatively with angiotensin system inhibitors and 39% (1,344 of 3,468) in patients who were not. The adjusted odds ratio of experiencing delirium during critical care was 0.98 (95% CI, 0.86 to 1.10; P = 0.700) for preoperative use of angiotensin system inhibitors versus control. Delirium was observed in 23% (100 of 440) of patients who used angiotensin system inhibitors postoperatively before intensive care discharge, and in 41% (1,795 of 4,424) of patients who did not (unadjusted P < 0.001). The confounder-adjusted odds ratio for experiencing delirium in patients who used angiotensin system inhibitors postoperatively was 0.55 (95% CI, 0.43 to 0.72; P < 0.001). CONCLUSIONS: Preoperative use of angiotensin system inhibitors is not associated with reduced postoperative delirium. In contrast, treatment during intensive care was associated with lower odds of delirium. Randomized trials of postoperative angiotensin-converting enzymes inhibitors and angiotensin receptor blockers seem justified.


Assuntos
Bloqueadores do Receptor Tipo 1 de Angiotensina II/efeitos adversos , Inibidores da Enzima Conversora de Angiotensina/efeitos adversos , Anti-Hipertensivos/efeitos adversos , Delírio do Despertar/induzido quimicamente , Delírio do Despertar/epidemiologia , Idoso , Benzodiazepinas/efeitos adversos , Estudos de Coortes , Confusão/etiologia , Confusão/psicologia , Cuidados Críticos , Delírio do Despertar/prevenção & controle , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Resultados Negativos , Pontuação de Propensão
18.
Anesthesiology ; 132(5): 1053-1061, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31929326

RESUMO

BACKGROUND: Perioperative acute kidney injury is common. However, it is unclear whether this merely represents a transient increase in creatinine or has prognostic value. Therefore, the long-term clinical importance of mild postoperative acute kidney injury remains unclear. This study assessed whether adults who do and do not experience mild kidney injury after noncardiac surgery are at similar risk for long-term renal injury. METHODS: This study is a retrospective cohort analysis of adults having noncardiac surgery at the Cleveland Clinic who had preoperative, postoperative, and long-term (1 to 2 yr after surgery) plasma creatinine measurements. The exposure (postoperative kidney injury) and outcome (long-term renal injury) were defined and staged according to the Kidney Disease: Improving Global Outcomes (KDIGO) initiative criteria. The primary analysis was for lack of association between postoperative kidney injury (stage I vs. no injury) and long-term renal injury. RESULTS: Among 15,621 patients analyzed, 3% had postoperative stage I kidney injury. Long-term renal outcomes were not similar in patients with and without postoperative stage I injury. Specifically, about 26% of patients with stage I postoperative kidney injury still had mild injury 1 to 2 yr later, and 11% had even more severe injury. A full third (37%) of patients with stage I kidney injury therefore had renal injury 1 to 2 yr after surgery. Patients with postoperative stage I injury had an estimated 2.4 times higher odds of having long-term renal dysfunction (KDIGO stage I, II, or III) compared with patients without postoperative kidney injury (odds ratio [95% CI] of 2.4 [2.0 to 3.0]) after adjustment for potential confounding factors. CONCLUSIONS: In adults recovering from noncardiac surgery, even small postoperative increases in plasma creatinine, corresponding to stage I kidney injury, are associated with renal dysfunction 1 to 2 yr after surgery. Even mild postoperative renal injury should therefore be considered a clinically important perioperative outcome.


Assuntos
Lesão Renal Aguda/etiologia , Lesão Renal Aguda/fisiopatologia , Rim/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Lesão Renal Aguda/diagnóstico , Adulto , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Fatores de Tempo
19.
Anesthesiology ; 132(2): 291-306, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31939844

RESUMO

BACKGROUND: Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. METHODS: The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients' lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. RESULTS: Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. CONCLUSIONS: Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.


Assuntos
Lesão Renal Aguda/fisiopatologia , Pressão Sanguínea/fisiologia , Monitorização Intraoperatória/métodos , Isquemia Miocárdica/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
20.
Anesthesiology ; 132(4): 614-624, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31977517

RESUMO

BACKGROUND: Both saline and lactated Ringer's solutions are commonly given to surgical patients. However, hyperchloremic acidosis consequent to saline administration may provoke complications. The authors therefore tested the primary hypothesis that a composite of in-hospital mortality and major postoperative complications is less common in patients given lactated Ringer's solution than normal saline. METHODS: The authors conducted an alternating cohort controlled trial in which adults having colorectal and orthopedic surgery were given either lactated Ringer's solution or normal saline in 2-week blocks between September 2015 and August 2018. The primary outcome was a composite of in-hospital mortality and major postoperative renal, respiratory, infectious, and hemorrhagic complications. The secondary outcome was postoperative acute kidney injury. RESULTS: Among 8,616 qualifying patients, 4,187 (49%) were assigned to lactated Ringer's solution, and 4,429 (51%) were assigned to saline. Each group received a median 1.9 l of fluid. The primary composite of major complications was observed in 5.8% of lactated Ringer's versus 6.1% of normal saline patients, with estimated average relative risk across the components of the composite of 1.16 (95% CI, 0.89 to 1.52; P = 0.261). The secondary outcome, postoperative acute kidney injury, Acute Kidney Injury Network stage I-III versus 0, occurred in 6.6% of lactated Ringer's patients versus 6.2% of normal saline patients, with an estimated relative risk of 1.18 (99.3% CI, 0.99 to 1.41; P = 0.009, significance criterion of 0.007). Absolute differences between the treatment groups for each outcome were less than 0.5%, an amount that is not clinically meaningful. CONCLUSIONS: In elective orthopedic and colorectal surgery patients, there was no clinically meaningful difference in postoperative complications with lactated Ringer's or saline volume replacement. Clinicians can reasonably use either solution intraoperatively.


Assuntos
Mortalidade Hospitalar/tendências , Cuidados Intraoperatórios/métodos , Complicações Pós-Operatórias/mortalidade , Lactato de Ringer/administração & dosagem , Solução Salina/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Infusões Intravenosas , Cuidados Intraoperatórios/efeitos adversos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/diagnóstico , Lactato de Ringer/efeitos adversos , Solução Salina/efeitos adversos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...