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1.
Artigo em Inglês | MEDLINE | ID: mdl-31702586

RESUMO

BACKGROUND: Despite advances in perioperative neuroscience, there is low interest among anesthesiology trainees to pursue subspecialty training in neuroanesthesiology. We conducted a pilot survey to assess attitudes about neuroanesthesiology fellowship training. MATERIALS AND METHODS: A confidential survey was distributed to an international cohort of anesthesiology attendings and trainees between January 15, 2017 and February 26, 2017. RESULTS: A total of 463 responses were received. Overall, 309 (67%), 30 (6%), 116 (25%), and 8 (2%) of respondents identified themselves as attendings, fellows, residents, and "other," respectively. In total, 390 (84%) of respondents were from the United States. Individuals typically pursue anesthesiology fellowship training because of interest in the subspecialty, acquisition of a special skill set, and the role of fellowship training in career planning and advancement. Overall, 64% of attendings, 56% of fellows, and 55% of residents favored accreditation of neuroanesthesiology fellowships, although opinion was divided regarding the role of accreditation in increasing interest in the specialty. Respondents believe that increased opportunities for research and greater exposure to neurocritical care and neurological monitoring methods would increase interest in neuroanesthesiology fellowship training. Perceived barriers to neuroanesthesiology fellowship training were perceptions that residency provides adequate training in neuroanesthesiology, that a unique skill set is not acquired, and that there are limited job opportunities available to those with neuroanesthesiology fellowship training. CONCLUSIONS: In this pilot survey, we identified several factors that trainees consider when deciding to undertake subspecialty training and barriers that might limit interest in pursuing neuroanesthesiology subspecialty training. Our findings may be used to guide curricular development and identify factors that might increase interest among trainees in pursuing neuroanesthesiology fellowship training.

3.
J Neurosurg ; : 1-9, 2019 Jan 25.
Artigo em Inglês | MEDLINE | ID: mdl-30684941

RESUMO

OBJECTIVECurrent management of gliomas involves a multidisciplinary approach, including a combination of maximal safe resection, radiotherapy, and chemotherapy. The use of intraoperative MRI (iMRI) helps to maximize extent of resection (EOR), and use of awake functional mapping supports preservation of eloquent areas of the brain. This study reports on the combined use of these surgical adjuncts.METHODSThe authors performed a retrospective review of patients with gliomas who underwent minimal access craniotomy in their iMRI suite (IMRIS) with awake functional mapping between 2010 and 2017. Patient demographics, tumor characteristics, intraoperative and postoperative adverse events, and treatment details were obtained. Volumetric analysis of preoperative tumor volume as well as intraoperative and postoperative residual volumes was performed.RESULTSA total of 61 patients requiring 62 tumor resections met the inclusion criteria. Of the tumors resected, 45.9% were WHO grade I or II and 54.1% were WHO grade III or IV. Intraoperative neurophysiological monitoring modalities included speech alone in 23 cases (37.1%), motor alone in 24 (38.7%), and both speech and motor in 15 (24.2%). Intraoperative MRI demonstrated residual tumor in 48 cases (77.4%), 41 (85.4%) of whom underwent further resection. Median EOR on iMRI and postoperative MRI was 86.0% and 98.5%, respectively, with a mean difference of 10% and a median difference of 10.5% (p < 0.001). Seventeen of 62 cases achieved an increased EOR > 15% related to use of iMRI. Seventeen (60.7%) of 28 low-grade gliomas and 10 (30.3%) of 33 high-grade gliomas achieved complete resection. Significant intraoperative events included at least temporary new or worsened speech alteration in 7 of 38 cases who underwent speech mapping (18.4%), new or worsened weakness in 7 of 39 cases who underwent motor mapping (18.0%), numbness in 2 cases (3.2%), agitation in 2 (3.2%), and seizures in 2 (3.2%). Among the patients with new intraoperative deficits, 2 had residual speech difficulty, and 2 had weakness postoperatively, which improved to baseline strength by 6 months.CONCLUSIONSIn this retrospective case series, the combined use of iMRI and awake functional mapping was demonstrated to be safe and feasible. This combined approach allows one to achieve the dual goals of maximal tumor removal and minimal functional consequences in patients undergoing glioma resection.

4.
J Neurosurg Anesthesiol ; 31(1): 7-17, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30334936

RESUMO

Cognitive aids and evidence-based checklists are frequently utilized in complex situations across many disciplines and sectors. The purpose of such aids is not simply to provide instruction so as to fulfill a task, but rather to ensure that all contingencies related to the emergency are considered and accounted for and that the task at hand is completed fully, despite possible distractions. Furthermore, utilization of a checklist enhances communication to all team members by allowing all stakeholders to know and understand exactly what is occurring, what has been accomplished, and what remains to be done. Here we present a set of evidence-based critical event cognitive aids for neuroanesthesia emergencies developed by the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) Education Committee.


Assuntos
Anestesiologia/métodos , Lista de Checagem/métodos , Técnicas de Apoio para a Decisão , Tratamento de Emergência/métodos , Neurocirurgia , Cognição , Consenso , Cuidados Críticos , Emergências , Humanos , Neurociências , Sociedades Médicas
5.
J Cardiothorac Vasc Anesth ; 33(4): 993-1000, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30149982

RESUMO

OBJECTIVE: Cerebrospinal fluid drainage catheter-related complications can be reduced by following strict guidelines during their introduction, maintenance, and removal. The authors therefore aimed to determine whether simulation-based learning would improve senior anesthesiology residents' patient care performance during the insertion and management of these catheters compared to interactive problem-based learning (PBL) using the Anaesthetists' Non-Technical Skills global rating scale (ANTS). DESIGN: Prospective randomized trial. SETTING: Vascular or hybrid operating rooms in a large academic tertiary care center. PARTICIPANTS: Senior anesthesia (categorical anesthesia-3) residents rotating through the vascular rotation at the Cleveland Clinic main campus in the period between December 2014 and June 2017. INTERVENTION: Simulation-based learning versus PBL. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the composite score (ANTS global rating scale) achieved by participating residents as evaluated by their supervising anesthesiologists. Out of 28 residents who completed the study, N = 13 were randomized to simulation-based learning and N = 15 residents to the PBL approach. The median (first quartile, third quartile) composite score was 16 (14, 16) and 16 (13, 16) for the simulation-based learning and PBL groups, respectively. There was no significant difference in staff evaluation of the 2 study groups (p = 0.48) with an estimated odds (95% confidence interval) of getting a better staff evaluation score of 1.9 (0.3-10.6) times higher comparing simulation versus traditional training groups. CONCLUSION: Compared to interactive PBL, simulation-based learning does not result in a statistically significant improvement in anesthesia resident performance during insertion and management of cerebrospinal fluid drainage catheters.


Assuntos
Centros Médicos Acadêmicos/métodos , Anestesiologia/métodos , Cateterismo/métodos , Internato e Residência/métodos , Aprendizagem Baseada em Problemas/métodos , Treinamento por Simulação/métodos , Centros Médicos Acadêmicos/normas , Anestesiologia/educação , Anestesiologia/normas , Cateterismo/normas , Vazamento de Líquido Cefalorraquidiano/prevenção & controle , Competência Clínica/normas , Avaliação Educacional/métodos , Avaliação Educacional/normas , Feminino , Humanos , Internato e Residência/normas , Masculino , Aprendizagem Baseada em Problemas/normas , Estudos Prospectivos , Treinamento por Simulação/normas
6.
Anesthesiology ; 126(5): 799-809, 2017 05.
Artigo em Inglês | MEDLINE | ID: mdl-28207437

RESUMO

BACKGROUND: Statins may reduce the risk of pulmonary and neurologic complications after cardiac surgery. METHODS: The authors acquired data for adults who had coronary artery bypass graft, valve surgery, or combined procedures. The authors matched patients who took statins preoperatively to patients who did not. First, the authors assessed the association between preoperative statin use and the primary outcomes of prolonged ventilation (more than 24 h), pneumonia (positive cultures of sputum, transtracheal fluid, bronchial washings, and/or clinical findings consistent with the diagnosis of pneumonia), and in-hospital all-cause mortality, using logistic regressions. Second, the authors analyzed the collapsed composite of neurologic complications using logistic regression. Intensive care unit and hospital length of stay were evaluated with Cox proportional hazard models. RESULTS: Among 14,129 eligible patients, 6,642 patients were successfully matched. There was no significant association between preoperative statin use and prolonged ventilation (statin: 408/3,321 [12.3%] vs. nonstatin: 389/3,321 [11.7%]), pneumonia (44/3,321 [1.3%] vs. 54/3,321 [1.6%]), and in-hospital mortality (52/3,321 [1.6%] vs. 43/3,321 [1.3%]). The estimated odds ratio was 1.06 (98.3% CI, 0.88 to 1.27) for prolonged ventilation, 0.81 (0.50 to 1.32) for pneumonia, and 1.21 (0.74 to 1.99) for in-hospital mortality. Neurologic outcomes were not associated with preoperative statin use (53/3,321 [1.6%] vs. 56/3,321 [1.7%]), with an odds ratio of 0.95 (0.60 to 1.50). The length of intensive care unit and hospital stay was also not associated with preoperative statin use, with a hazard ratio of 1.04 (0.98 to 1.10) for length of hospital stay and 1.00 (0.94 to 1.06) for length of intensive care unit stay. CONCLUSIONS: Preoperative statin use did not reduce pulmonary or neurologic complications after cardiac surgery.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Doenças do Sistema Nervoso/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Transtornos Respiratórios/prevenção & controle , Idoso , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Respiração Artificial/estatística & dados numéricos , Fatores de Risco , Resultado do Tratamento
7.
World Neurosurg ; 95: 40-45, 2016 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-27452968

RESUMO

BACKGROUND: We evaluated blood pressure management associated with implantable pulse generator (IPG) procedure on same day (SD) versus different day (DD) from deep brain stimulation (DBS) placement. METHODS: A retrospective chart review of 99 records for vasopressors given during IPG using a negative binomial regression model was performed. An association between SD versus DD, cumulative vasopressor dose, and minimum and maximum mean arterial pressure (MAP) were sought. RESULTS: No significant association between SD versus DD DBS and the number of times vasopressors were given during stage II, estimated ratio of means (CI) of 1.8 (0.9-3.5); P = 0.07. Day of stage II had no association with the cumulative dose of vasopressor given during stage II, with an estimated difference in means (CI) of 2.4 (-0.4 to 5.3). The SD group had a significantly lower mean of minimum stage II MAP compared with DD, with an estimated difference in means (CI) of -10.5 (-17.4 to -3.5; P < 0.001). There was no association with maximum stage II MAP, with an estimated difference in means (CI) of -2.8 (-17.6 to 12.0; P = 0.63). CONCLUSION: No difference in intraoperative vasopressor use was found between SD versus DD IPG placement, but the SD group had a significantly lower minimum MAP.


Assuntos
Estimulação Encefálica Profunda , Hipotensão/epidemiologia , Complicações Intraoperatórias/epidemiologia , Procedimentos Neurocirúrgicos/métodos , Doença de Parkinson/terapia , Implantação de Prótese/métodos , Idoso , Pressão Arterial , Feminino , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Vasoconstritores/uso terapêutico
8.
J Clin Anesth ; 28: 4-11, 2016 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-26796607

RESUMO

STUDY OBJECTIVE: Simulation-based learning is emerging as an alternative educational tool in this era of a relative shortfall of teaching anesthesiologists. The objective of the study is to assess whether screen-based (interactive computer simulated) case scenarios are more effective than problem-based learning discussions (PBLDs) in improving test scores 4 and 8 weeks after these interventions in anesthesia residents during their first neuroanesthesia rotation. DESIGN: Prospective, nonblinded quasi-crossover study. SETTING: Cleveland Clinic. PATIENTS: Anesthesiology residents. INTERVENTIONS: Two case scenarios were delivered from the Anesoft software as screen-based sessions, and parallel scripts were developed for 2 PBLDs. Each resident underwent both types of training sessions, starting with the PBLD session, and the 2 cases were alternated each month (ie, in 1 month, the screen-based intervention used case 1 and the PBLD used case 2, and vice versa for the next month). MEASUREMENTS: Test scores before the rotation (baseline), immediately after the rotation (4 weeks after the start of the rotation), and 8 weeks after the start of rotation were collected on each topic from each resident. The effect of training method on improvement in test scores was assessed using a linear mixed-effects model. MAIN RESULTS: Compared to the departmental standard of PBLD, the simulation method did not improve either the 4- or 8-week mean test scores (P = .41 and P = .40 for training method effect on 4- and 8-week scores, respectively). Resident satisfaction with the simulation module on a 5-point Likert scale showed subjective evidence of a positive impact on resident education. CONCLUSIONS: Screen-based simulators were not more effective than PBLD for education during the neuroanesthesia rotation in anesthesia residency.


Assuntos
Anestesiologia/educação , Internato e Residência/métodos , Simulação de Paciente , Aprendizagem Baseada em Problemas , Competência Clínica , Estudos de Coortes , Estudos Cross-Over , Avaliação Educacional , Humanos , Modelos Lineares , Estudos Prospectivos
9.
J Neurosurg Anesthesiol ; 28(4): 282-90, 2016 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26325514

RESUMO

BACKGROUND: Anesthesia for craniotomies should blunt responses to noxious stimuli, whereas subsequently leaving patients sufficiently alert for early neurological evaluation. The aim was to compare postoperative blood pressure control, pain, and opioid requirement after anesthesia with dexmedetomidine versus remifentanil. We therefore tested 2 primary hypotheses: (1) intraoperative administration of dexmedetomidine provides better control of postoperative blood pressure than remifentanil; and (2) patients given dexmedetomidine have less postoperative pain and use less opioid. MATERIALS AND METHODS: Adults having elective brain tumor excisions under balanced general anesthesia with endotracheal intubation were randomized to an infusion of remifentanil (0.08 to 0.15 µg/kg/min, n=71) or dexmedetomidine (0.2 to 0.7 µg/kg/h, n=68). Patients also received propofol, rocuronium, fentanyl, and sevoflurane. The mean arterial pressure (MAP) and pain were recorded at 15, 30, 45, 60, and 90 postoperative minutes. Outcomes were assessed with joint hypothesis testing, evaluating noninferiority and superiority. RESULTS: Compared with remifentanil, the use of dexmedetomidine was associated with reduced postoperative MAP (88±12 vs. 98±11 mm Hg), with estimated mean difference (97.5% confidence interval) of -10 (-13, -4) mm Hg, P<0.001, and mean visual analog pain score (2.9±2.6 vs. 5.1±2.4 points), with estimated mean difference of -5 (-10, -3) points, P<0.001, and required less median opioid consumption (5 [0, 10] vs. 10 [7, 15] mg morphine equivalents), with estimated median difference of -5 (-10, -3) mg, P<0.001. Dexmedetomidine was both noninferior and superior to remifentanil in maintaining postoperative hemodynamics and providing improved pain control. CONCLUSIONS: Intraoperative dexmedetomidine better controlled postoperative MAP and provided superior analgesia in patients undergoing craniotomy.


Assuntos
Analgesia/estatística & dados numéricos , Craniotomia , Dexmedetomidina/farmacologia , Hemodinâmica/efeitos dos fármacos , Piperidinas/farmacologia , Complicações Pós-Operatórias/prevenção & controle , Feminino , Humanos , Hipnóticos e Sedativos/farmacologia , Masculino , Pessoa de Meia-Idade , Remifentanil
10.
A A Case Rep ; 4(5): 58-60, 2015 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-25730411

RESUMO

Retrograde type A aortic dissection that arises immediately after open replacement of the thoracoabdominal aorta is a rare and potentially lethal complication that has only been reported twice previously. A 74-year-old man with a history of expanding Crawford type I thoracoabdominal aortic aneurysm presented for open surgical repair. The intraoperative course was unremarkable. However, intraoperative transesophageal echocardiography after the repair revealed type A aortic dissection extending up to the sinotubular junction. Subsequently, emergent aortic arch repair was performed under deep hypothermic circulatory arrest. Early diagnosis with transesophageal echocardiography and optimal cerebral protection were instrumental in the successful outcome of this repair.


Assuntos
Aneurisma Dissecante/diagnóstico por imagem , Aorta Torácica/cirurgia , Aneurisma da Aorta Torácica/cirurgia , Ecocardiografia Transesofagiana/métodos , Idoso , Aneurisma Dissecante/etiologia , Aorta Torácica/diagnóstico por imagem , Circulação Cerebrovascular , Parada Circulatória Induzida por Hipotermia Profunda/métodos , Diagnóstico Precoce , Humanos , Complicações Intraoperatórias , Masculino , Monitorização Intraoperatória , Procedimentos Cirúrgicos Vasculares/efeitos adversos
11.
J Clin Neurosci ; 21(10): 1790-5, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24915957

RESUMO

Hypertension is common in deep brain stimulator (DBS) placement predisposing to intracranial hemorrhage. This retrospective review evaluates factors predicting incremental antihypertensive use intraoperatively. Medical records of Parkinson's disease (PD) patients undergoing DBS procedure between 2008-2011 were reviewed after Institutional Review Board approval. Anesthesia medication, preoperative levodopa dose, age, preoperative use of antihypertensive medications, diabetes mellitus, anxiety, motor part of the Unified Parkinson's Disease Rating Scale score and PD duration were collected. Univariate and multivariate analysis was done between each patient characteristic and the number of antihypertensive boluses. From the 136 patients included 60 were hypertensive, of whom 32 were on angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), told to hold on the morning of surgery. Antihypertensive medications were given to 130 patients intraoperatively. Age (relative risk [RR] 1.01; 95% confidence interval [CI] 1.00-1.02; p=0.005), high Joint National Committee (JNC) class (p<0.0001), diabetes mellitus (RR 1.4; 95%CI 1.2-17; p<0.0001) and duration of PD >10 years (RR 1.2; 95%CI 1.1-1.3; p=0.001) were independent predictors for antihypertensive use. No difference was noted in the mean dose of levodopa (p=0.1) and levodopa equivalent dose (p=0.4) between the low (I/II) and high severity (III/IV) JNC groups. Addition of dexmedetomidine to propofol did not influence antihypertensive boluses required (p=0.38). Intraoperative hypertension during DBS surgery is associated with higher age group, hypertensive, diabetic patients and longer duration of PD. Withholding ACEI or ARB is an independent predictor of hypertension requiring more aggressive therapy. Levodopa withdrawal and choice of anesthetic agent is not associated with higher intraoperative antihypertensive medications.


Assuntos
Anti-Hipertensivos/administração & dosagem , Estimulação Encefálica Profunda , Cuidados Intraoperatórios/métodos , Procedimentos Neurocirúrgicos/métodos , Doença de Parkinson/terapia , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestésicos/uso terapêutico , Antiparkinsonianos/uso terapêutico , Pressão Sanguínea , Complicações do Diabetes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Doença de Parkinson/complicações , Estudos Retrospectivos
12.
J Clin Neurosci ; 20(8): 1068-73, 2013 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-23453156

RESUMO

The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47 mmHg versus 102.9 mmHg, p < 0.05 and emergence 84.85 mmHg versus 105 mmHg, p < 0.05). Patients in the AW group required less vasopressors intraoperatively (AW = 43% versus AS = 69%, p < 0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen.


Assuntos
Anestesia Geral/métodos , Craniotomia/métodos , Complicações Intraoperatórias/etiologia , Complicações Pós-Operatórias/etiologia , Neoplasias Supratentoriais/cirurgia , Adulto , Anestesia Geral/efeitos adversos , Craniotomia/efeitos adversos , Craniotomia/classificação , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Estudos Retrospectivos
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