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1.
J Shoulder Elbow Surg ; 29(1): 20-26, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31619355

RESUMO

BACKGROUND: The utility of next-generation sequencing (NGS) in differentiating between active infection and contaminant or baseline flora remains unclear. The purpose of this study is to compare NGS with culture-based methods in primary shoulder arthroplasty. METHODS: A prospective series of primary shoulder arthroplasty patients with no history of infection or antibiotic use within 60 days of surgery was enrolled. All patients received standard perioperative antibiotics. After skin incision, a 10 × 3-mm sample of the medial skin edge was excised. A 2 × 2-cm synovial tissue biopsy was taken from the rotator interval after subscapularis takedown. Each sample set was halved and sent for NGS and standard cultures. RESULTS: Samples from 25 patients were analyzed. Standard aerobic/anaerobic cultures were positive in 10 skin samples (40%, 95% confidence interval [CI] 20%-60%) and 3 deep tissue samples (12%, 90% CI 1%-23%]). NGS detected ≥1 bacterial species in 17 of the skin samples (68%, 95% CI 49%-87%) and 7 deep tissue samples (28%, 95% CI 9%-47%). There was a significant difference (P < .03) in the mean number of bacterial species detected with NGS between the positive standard culture (1.6 species) and the negative standard culture groups (5.7 species). CONCLUSION: NGS identified bacteria at higher rates in skin and deep tissue samples than standard culture did in native, uninfected patients undergoing primary procedures. Further research is needed to determine which NGS results are clinically relevant and which are false positives before NGS can be reliably used in orthopedic cases.

2.
Anesth Analg ; 2019 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-31490816

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.

3.
J Clin Anesth ; 53: 56-63, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30326379

RESUMO

STUDY OBJECTIVE: Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN: Retrospective cost effectiveness analysis. SETTING: Operating room. PATIENTS: We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS: A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS: A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS: From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS: This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.


Assuntos
Analgesia Epidural/economia , Analgesia Controlada pelo Paciente/economia , Analgésicos Opioides/economia , Bupivacaína/economia , Bloqueio Nervoso/economia , Dor Pós-Operatória/terapia , Músculos Abdominais/inervação , Adulto , Idoso , Analgesia Epidural/métodos , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Bupivacaína/administração & dosagem , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Bloqueio Nervoso/métodos , Manejo da Dor/economia , Manejo da Dor/métodos , Medição da Dor , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/etiologia , Estudos Retrospectivos , Resultado do Tratamento
4.
Artigo em Inglês | MEDLINE | ID: mdl-31899092

RESUMO

BACKGROUND: Biomechanical studies show that inlay glenoid components in total shoulder arthroplasty (TSA) can reduce edge loading and opposite-edge lift-off forces with humeral translation compared with onlay glenoids. However, clinical data for these implants are lacking. We report clinical outcomes and return to activities after anatomic TSA with an inlay glenoid component and a stemless ovoid humeral head in an active, young patient population. METHODS: A retrospective review of TSA with an inlay glenoid component and an ovoid humeral head component was performed for 27 shoulders. Patients were evaluated with patient-reported outcome measures, range of motion, and radiographs. Return to occupational and sporting activity, complications, and reoperations were analyzed. RESULTS: A total of 27 shoulders were available for minimum 2-year follow-up. Age averaged 52.1 years, and 92.6% of shoulders were in male patients. The preoperative Walch grade was A1 or A2 in 15 shoulders (55%), B1 in 8 (30%), and B2 in 4 (15%). Patients showed significant improvements in patient-reported outcome measures, active forward flexion, and external rotation (P < .001) with no reoperations. At an average of 3.7 months, the rate of return to work was 92.6%, with 76.0% of those patients returning to their preoperative occupational demand level. At an average of 9.1 months, 75% of patients who responded to our custom survey returned to sport, with 50% achieving the same level or a higher level of sporting activity. Annual postoperative radiographs revealed no inlay component loosening. CONCLUSION: Anatomic TSA with an inlay glenoid coupled with a stemless ovoid humeral head in an active population resulted in improved clinical outcomes, no reoperations or radiographic loosening, and a high rate of return to activity at shorter-term follow-up.

5.
Anesthesiology ; 129(6): 1101-1110, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30300157

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Beta (ß) blockers reduce the risk of postoperative atrial fibrillation and should be restarted after surgery, but it remains unclear when best to resume ß blockers postoperatively. The authors thus evaluated the relationship between timing of resumption of ß blockers and atrial fibrillation in patients recovering from noncardiothoracic and nonvascular surgery. METHODS: The authors evaluated 8,201 adult ß-blocker users with no previous history of atrial fibrillation who stayed at least two nights after noncardiothoracic and nonvascular surgery as a retrospective observational cohort. After propensity score matching on baseline and intraoperative variables, 1,924 patients who did resume ß blockers by the end of postoperative day 1 were compared with 973 patients who had not resumed by that time on postoperative atrial fibrillation using logistic regression. A secondary matched analysis compared 3,198 patients who resumed ß blockers on the day of surgery with 3,198 who resumed thereafter. RESULTS: Of propensity score-matched patients who resumed ß blockers by end of postoperative day 1, 4.9% (94 of 1,924) developed atrial fibrillation, compared with 7.0% (68 of 973) of those who resumed thereafter (adjusted odds ratio, 0.69; 95% CI, 0.50-0.95; P = 0.026). Patients who resumed ß blockers on day of surgery had an atrial fibrillation incidence of 4.9% versus 5.8% for those who started thereafter (odds ratio, 0.84; 95% CI, 0.67-1.04; P = 0.104). CONCLUSIONS: Resuming ß blockers in chronic users by the end of the first postoperative day may be associated with lower odds of in-hospital atrial fibrillation. However, there seems to be little advantage to restarting on the day of surgery itself.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Fibrilação Atrial/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios , Idoso , Fibrilação Atrial/epidemiologia , Estudos de Coortes , Feminino , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Estudos Retrospectivos
6.
Anesth Analg ; 127(4): 897-903, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29505442

RESUMO

BACKGROUND: Laboratory testing is a common component of preanesthesia evaluation and is designed to identify medical abnormalities that might otherwise remain undetected. While blood testing might optimally be performed shortly before surgery, it is often done earlier for practical reasons. We tested the hypothesis that longer periods between preoperative laboratory testing and surgery are associated with increased odds of having a composite of 30-day morbidity and mortality. METHODS: We obtained preoperative data from 2,320,920 patients in the American College of Surgeons National Surgical Quality Improvement Program who were treated between 2005 and 2012. Our analysis was restricted to relatively healthy patients with American Society of Anesthesiology physical status I-II who had elective surgery and normal blood test results (n = 235,010). The primary relationship of interest was the odds of 30-day morbidity and mortality as a function of delay between preoperative testing and surgery. A multivariable logistic regression model was used for the 10 pairwise comparisons among the 5 laboratory timing groups (laboratory blood tests within 1 week of surgery; 1-2 weeks; 2-4 weeks; 1-2 months; and 2-3 months) on 30-day morbidity, adjusting for any imbalanced baseline covariables and type of surgery. RESULTS: A total of 4082 patients (1.74%) had at least one of the component morbidities or died within 30-days after surgery. The observed incidence (unadjusted) was 1.7% when the most recent laboratory blood tests measured within 1 week of surgery, 1.7% when it was within 1-2 weeks, 1.8% when it was within 2-4 weeks, 1.7% when it was between 1 and 2 months, and 2.0% for patients with most recent laboratory blood tests measured 2-3 months before surgery. None of the values within 2 months differed significantly: estimated odds ratios for patients within blood tested within 1 week were 1.00 (99.5% confidence interval, 0.89-1.12) as compared to 1-2 weeks, 0.88 (0.77-1.00) for 2-4 weeks, and 0.95 (0.79-1.14) for 1-2 months, respectively. The estimated odds ratio comparing 1-2 weeks to each of 2-4 weeks and 1-2 months were 0.88 (0.76-1.03) and 0.95 (0.78-1.16), respectively. Blood testing 2-3 months before surgery was associated with increased odds of outcome compared to patients whose most recent test was within 1 week (P = .002) and 1-2 weeks of the date of surgery. CONCLUSIONS: In American Society of Anesthesiologists physical status I and II patients, risk of 30-day morbidity and mortality was not different with blood testing up to 2 months before surgery, suggesting that it is unnecessary to retest patients shortly before surgery.


Assuntos
Testes Hematológicos , Complicações Pós-Operatórias/epidemiologia , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Idoso , Bases de Dados Factuais , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologia
7.
Anesth Analg ; 123(6): 1471-1479, 2016 12.
Artigo em Inglês | MEDLINE | ID: mdl-27607476

RESUMO

BACKGROUND: Opioids can contribute to postoperative desaturation. Short-acting opioids, titrated to need, may cause less desaturation than longer-acting opioids. We thus tested the primary hypothesis that long-acting patient-controlled intravenous opioids are associated with more hypoxemia (defined as an integrated area under a postoperative oxyhemoglobin saturation of 95%) than short-acting opioids. METHODS: This analysis was a substudy of VISION, a prospective cohort study focused on perioperative cardiovascular events (NCT00512109). After excluding for predefined criteria, 191 patients were included in our final analysis, with 75 (39%) patients being given fentanyl (short-acting opioid group) and 116 (61%) patients being given morphine and/or hydromorphone (long-acting opioid group). The difference in the median areas under a postoperative oxyhemoglobin saturation of 95% between short-acting and long-acting opioids was compared using multivariable median quantile regression. RESULTS: The short-acting opioid median area under a postoperative oxyhemoglobin saturation of 95% per hour was 1.08 (q1, q3: 0.62, 2.26) %-h, whereas the long-acting opioid median was 1.28 (0.50, 2.23) %-h. No significant association was detected between long-acting and short-acting opioids and median area under a postoperative oxyhemoglobin saturation of 95% per hour (P = .66) with estimated change in the medians of -0.14 (95% CI, -0.75, 0.47) %-h for the patients given long-acting versus short-acting IV patient-controlled analgesia opioids. CONCLUSIONS: Long-acting patient-controlled opioids were not associated with the increased hypoxemia during the first 2 postoperative days.


Assuntos
Analgesia Controlada pelo Paciente/efeitos adversos , Analgésicos Opioides/efeitos adversos , Hipóxia/induzido quimicamente , Oxigênio/sangue , Dor Pós-Operatória/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Administração Intravenosa , Idoso , Analgesia Controlada pelo Paciente/métodos , Analgésicos Opioides/administração & dosagem , Biomarcadores/sangue , Feminino , Humanos , Hipóxia/sangue , Análise dos Mínimos Quadrados , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Oxiemoglobinas/metabolismo , Dor Pós-Operatória/etiologia , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
8.
J Anesth ; 30(5): 864-72, 2016 10.
Artigo em Inglês | MEDLINE | ID: mdl-27518727

RESUMO

PURPOSE: Sciatic nerve block (SNB) is commonly performed in combination with femoral nerve block (FNB) for postoperative analgesia following total knee arthroplasty (TKA). Despite the fact that 10-20 % of TKA patients require SNB for postoperative posterior knee pain, there are no existing studies that suggest a model to predict the need for SNB. The aim of our study was to develop a prediction tool to measure the likelihood of patients undergoing TKA surgery requiring a postoperative SNB. METHODS: With institutional review board approval, we obtained data from the electronic medical record of patients who underwent TKA at the Cleveland Clinic. A multivariable logistic regression was used to estimate the probability of requiring a postoperative SNB. Clinicians selected potential predictors to create a model, and the potential nonlinear association between continuous predictors and SNB was assessed using the restricted cubic spline model. RESULTS: In total 6279 TKA cases involving 2329 patients with complete datasets were used for building the prediction model, including 276 (12 %) patients who received a postoperative SNB and 2053 (88 %) patients who did not. The estimated C statistic of the prediction model was 0.64. The nomogram is used by first locating the patient position on each predictor variable scale, which has corresponding prognostic points. The cut-off of 11.6 % jointly maximizes the sensitivity and specificity. CONCLUSION: This is the first study to be published on SNB prediction after TKA. Our nomogram may prove to be a useful tool for guiding physicians in terms of their decisions regarding SNB.


Assuntos
Artroplastia do Joelho/métodos , Bloqueio Nervoso/métodos , Nervo Isquiático , Idoso , Algoritmos , Bases de Dados Factuais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nomogramas , Dor Pós-Operatória/epidemiologia , Dor Pós-Operatória/prevenção & controle , Valor Preditivo dos Testes , Sensibilidade e Especificidade
9.
Anesth Analg ; 123(3): 749-57, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27537762

RESUMO

BACKGROUND: Clonidine is an α2-adrenoceptor agonist, which has analgesic properties. However, the analgesic efficacy of perioperative clonidine remains unclear. We, therefore, tested the hypothesis that clonidine reduces both pain scores and cumulative opioid consumption during the initial 72 hours after noncardiac surgery. METHODS: Six hundred twenty-four patients undergoing elective noncardiac surgery under general and spinal anesthesia were included in this substudy of the PeriOperative ISchemia Evaluation-2 trial. Patients were randomly assigned to 0.2 mg oral clonidine or placebo 2 to 4 hours before surgery, followed by 0.2 mg/d transdermal clonidine patch or placebo patch, which was maintained until 72 hours after surgery. Postoperative pain scores and opioid consumption were assessed for 72 hours after surgery. RESULTS: Clonidine had no effect on opioid consumption compared with placebo, with an estimated ratio of means of 0.98 (95% confidence interval, 0.70-1.38); P = 0.92. Median (Q1, Q3) opioid consumption was 63 (30, 154) mg morphine equivalents in the clonidine group, which was similar to 60 (30, 128) mg morphine equivalents in the placebo group. Furthermore, there was no significant effect on pain scores, with an estimated difference in means of 0.12 (95% confidence interval, -0.02 to 0.26); 11-point scale; P = 0.10. Mean pain scores per patient were 3.6 ± 1.8 for clonidine patients and 3.6 ± 1.8 for placebo patients. CONCLUSIONS: Clonidine does not reduce opioid consumption or pain scores in patients recovering from noncardiac surgery.


Assuntos
Analgésicos Opioides/administração & dosagem , Clonidina/administração & dosagem , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Manejo da Dor/métodos , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Idoso , Analgésicos/administração & dosagem , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Adesivo Transdérmico
10.
Anesth Analg ; 121(3): 709-15, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26287299

RESUMO

BACKGROUND: The incidence, severity, and duration of postoperative oxygen desaturation in the general surgical population are poorly characterized. We therefore used continuous pulse oximetry to quantify arterial oxygen saturation (SpO2) in a cross-section of patients having noncardiac surgery. METHODS: Oxygen saturation, blinded to clinicians, was recorded at 1-minute intervals in patients >45 years old for up to 48 hours after noncardiac surgery in 1250 patients from Cleveland Clinic Main Campus and 250 patients from the Juravinski Hospital. We determined (1) the cumulative minutes of raw minute-by-minute values below various hypoxemic thresholds; and (2) the contiguous duration of kernel-smoothed (sliding window) values below various hypoxemic thresholds. Finally, we compared our blinded continuous values with saturations recorded during routine nursing care. RESULTS: Eight hundred thirty-three patients had sufficient data for analyses. Twenty-one percent had ≥10 min/h with raw SpO2 values <90% averaged over the entire recording duration; 8% averaged ≥20 min/h <90%; and 8% averaged ≥5 min/h <85%. Prolonged hypoxemic episodes were common, with 37% of patients having at least 1 (smoothed) SpO2 <90% for an hour or more; 11% experienced at least 1 episode lasting ≥6 hours; and 3% had saturations <80% for at least 30 minutes. Clinical hypoxemia, according to nursing records, measured only in Cleveland Clinic patients (n = 594), occurred in 5% of the monitored patients. The nurses missed 90% of smoothed hypoxemic episodes in which saturation was <90% for at least one hour. CONCLUSIONS: Hypoxemia was common and prolonged in hospitalized patients recovering from noncardiac surgery. The SpO2 values recorded in medical records seriously underestimated the severity of postoperative hypoxemia.


Assuntos
Hipóxia/diagnóstico , Oximetria/tendências , Complicações Pós-Operatórias/diagnóstico , Idoso , Estudos Transversais , Feminino , Humanos , Hipóxia/sangue , Masculino , Pessoa de Meia-Idade , Oximetria/métodos , Complicações Pós-Operatórias/sangue , Estudos Prospectivos , Método Simples-Cego
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