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A A Pract ; 13(5): 188-189, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31180907


We report the case of a 55-year-old woman who required extracorporeal membrane oxygenation for extreme respiratory distress after a liver transplant and eventually died. As is so often the case, this patient's values and wishes were not documented before she had a risky surgical procedure. Anesthesiologists, in partnership with surgeons, can participate in preoperative discussions exploring wishes and values and document them in advance directives which will help clinicians respect patients' preferences.

Crit Care Med ; 47(7): 910-917, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30985388


OBJECTIVES: Hypotension thresholds that provoke renal injury, myocardial injury, and mortality in critical care patients remain unknown. We primarily sought to determine the relationship between hypotension and a composite of myocardial injury (troponin T ≥ 0.03 ng/mL without nonischemic cause) and death up to 7 postoperative days. Secondarily, we considered acute kidney injury (creatinine concentration ≥ 0.3 mg/dL or 1.5 times baseline). DESIGN: Retrospective cohort. SETTING: Surgical ICU at an academic medical center. PATIENTS: Two-thousand eight-hundred thirty-three postoperative patients admitted to the surgical ICU. INTERVENTIONS: A Cox proportional hazard survival model was used to assess the association between lowest mean arterial pressure on each intensive care day, considered as a time-varying covariate, and outcomes. In sensitivity analyses hypotension defined as pressures less than 80 mm Hg and 70 mm Hg were also considered. MEASUREMENTS AND MAIN RESULTS: There was a strong nonlinear (quadratic) association between the lowest mean arterial pressure and the primary outcome of myocardial injury after noncardiac surgery or mortality, with estimated risk increasing at lower pressures. The risk of myocardial injury after noncardiac surgery or mortality was an estimated 23% higher at the 25th percentile (78 mm Hg) of lowest mean arterial pressure compared with at the median of 87 mm Hg, with adjusted hazard ratio (95% CI) of 1.23 (1.12-1.355; p < 0.001). Overall results were generally similar in sensitivity analyses based on every hour of mean arterial pressure less than 80 mm Hg and any mean arterial pressure less than 70 mm Hg. Post hoc analyses showed that the relationship between ICU hypotension and outcomes depended on the amount of intraoperative hypotension. The risk of acute kidney injury increased over a range of minimum daily pressures from 110 mm Hg to 50 mm Hg, with an adjusted hazard ratio of 1.27 (95% CI, 1.18-1.37; p < 0.001). CONCLUSIONS: Increasing amounts of hypotension (defined by lowest mean arterial pressures per day) were strongly associated with myocardial injury, mortality, and renal injury in postoperative critical care patients.

Anesth Analg ; 123(3): 795-6, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27537765
Anesth Analg ; 122(4): 1081-8, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-26991618


BACKGROUND: Severe primary graft dysfunction (PGD) is a major cause of early morbidity and mortality in patients after lung transplantation. The etiology and pathophysiology of PGD is not fully characterized and whether intraoperative fluid administration increases the risk for PGD remains unclear from previous studies. Therefore, we tested the hypothesis that increased total intraoperative fluid volume during lung transplantation is associated with the development of grade-3 PGD. METHODS: This retrospective cohort analysis included patients who had lung transplantation at the Cleveland Clinic between January 2009 and June 2013. We used multivariable logistic regression with adjustment for donor, recipient, and perioperative confounding factors to examine the association between total intraoperative fluid administration and development of grade-3 PGD in the initial 72 postoperative hours. Secondary outcomes included time to initial extubation and intensive care unit length of stay. RESULTS: Grade-3 PGD occurred in 123 of 494 patients (25%) who had lung transplantation. Patients with grade-3 PGD received a larger volume of intraoperative fluid (median 5.0 [3.8, 7.5] L) than those without grade-3 PGD (3.9 [2.8, 5.2] L). Each intraoperative liter of fluid increased the odds of grade-3 PGD by approximately 22% (adjusted odds ratio, 1.22; 95% confidence interval [CI], 1.12-1.34; P <0.001). The volume of transfused red blood cell concentrate was associated with grade-3 PGD (1.1 [0.0, 1.8] L for PGD-3 vs 0.4 [0.0, 1.1 for nongrade-3 PGD] L; adjusted odds ratio, 1.7; 95% CI, 1.08-2.7; P = 0.002). Increased fluid administration was associated with longer intensive care unit stay (adjusted hazard ratio, 0.92; 97.5% CI, 0.88-0.97; P < 0.001) but not with time to initial tracheal extubation (hazard ratio, 0.97; 97.5% CI, 0.93-1.02; P = 0.17). CONCLUSIONS: Increased intraoperative fluid volume is associated with the most severe form of PGD after lung transplant surgery. Limiting fluid administration may reduce the risk for development of grade-3 PGD and thus improve early postoperative morbidity and mortality after lung transplantation.

Hidratação/efeitos adversos , Cuidados Intraoperatórios/efeitos adversos , Transplante de Pulmão/efeitos adversos , Disfunção Primária do Enxerto/induzido quimicamente , Disfunção Primária do Enxerto/diagnóstico , Índice de Gravidade de Doença , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Adulto Jovem
Prog Transplant ; 24(1): 106-12, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24598573


CONTEXT: Hyperglycemia is common in deceased donors, and provokes numerous adverse events in hepatocytic mitochondria. OBJECTIVE: To determine whether hyperglycemia in deceased donors is associated with graft dysfunction after orthotopic liver transplant. METHODS: Charts on 572 liver transplants performed at the Cleveland Clinic between January 2005 and October 2010 were reviewed. The primary measure was time-weighted averages of donors' glucose measurements. Liver graft dysfunction was defined as (1) primary nonfunction as indicated by death or retransplant or (2) liver graft dysfunction as indicated by an aspartate amino transferase level greater than 2000 U/L or prothrombin time greater than 16 seconds during the first postoperative week. The relationship of interest was estimated by using a multivariable logistic regression. RESULTS: The incidence of graft dysfunction was 25%. No significant relationship was found between the range of donor glucose measurements and liver graft dysfunction after donor characteristics were adjusted for (P= .14, Wald test, adjusted odds ratio [95% CI] for liver graft dysfunction corresponding to a relative doubling in time-weighted average for donor glucose of 1.43 [0.89-2.30]). The results thus do not suggest that strict glucose control in donors is likely to improve graft quality.

Hiperglicemia/complicações , Hepatopatias/etiologia , Transplante de Fígado , Doadores de Tecidos , Feminino , Rejeição de Enxerto , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Risco
Liver Transpl ; 19(8): 907-15, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23744721


Obesity is among the great health problems facing Americans today. More than 32% of the US population is considered obese on the basis of a body mass index (BMI) exceeding 30 kg/m(2) . Obesity increases the risk for numerous perioperative complications, but how obesity affects the outcome of liver transplantation remains unclear. We compared graft/patient survival after orthotopic liver transplantation performed at the Cleveland Clinic between April 2005 and June 2011 in 2 groups: obese patients with a BMI ≥ 38 kg/m(2) and lean patients with a BMI between 20 and 26 kg/m(2) . We included 47 obese patients and 183 lean patients, whose demographics and baseline characteristics were well balanced after weighting with the inverse propensity score. After we controlled for observed confounding, no significant differences were observed in graft/patient survival between obese and lean patients (P = 0.30). The estimated hazard ratio for obese patients to experience graft failure or death was 1.19 [95% confidence interval (CI) = 0.85-1.67]. There were 134 patients who had follow-up for more than 3 years, and they included 27 obese patients and 107 lean patients. Within this subset, the odds of having metabolic syndrome were significantly greater for obese patients (46%) versus lean patients (21%; odds ratio = 4.76, 99.5% CI = 1.66-13.7, P < 0.001). However, no significant association between obesity and any other long-term adverse outcomes was found. In conclusion, this study shows that transplant outcomes were comparable for lean and obese recipients. We thus recommend that even morbid obesity per se should not exclude patients from consideration for transplantation.

Sobrevivência de Enxerto , Falência Hepática/complicações , Falência Hepática/terapia , Obesidade/complicações , Idoso , Índice de Massa Corporal , Feminino , Humanos , Unidades de Terapia Intensiva , Falência Hepática/mortalidade , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Razão de Chances , Complicações Pós-Operatórias/mortalidade , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Risco , Resultado do Tratamento