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Anesthesiology ; 126(1): 16-27, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27775997


BACKGROUND: The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. METHODS: In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. RESULTS: Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. CONCLUSIONS: Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

Antagonistas de Receptores de Angiotensina/administração & dosagem , Inibidores da Enzima Conversora de Angiotensina/administração & dosagem , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios , Suspensão de Tratamento/estatística & dados numéricos , Idoso , Estudos de Coortes , Feminino , Humanos , Hipotensão/epidemiologia , Internacionalidade , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
CJEM ; 17(1): 89-93, 2015 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25781387


Although penetrating neck injuries (PNIs) represent a small subset of patients presenting to the emergency department (ED), they can result in significant morbidity and mortality. The approach to airway management in PNI varies widely according to clinical presentation and local practice, such that global management statements are lacking. Although rapid sequence intubation (RSI) may be safe in most patients with PNI, the high-risk subset (10%) of patients with laryngotracheal injury require particularly judicious airway management. It is not known if RSI is safe in such patients, nor has there been reported use of videolaryngoscopy in patients with open PNI. Established principles of airway management in patients with an open airway injury include the avoidance of both positive pressure bag-mask ventilation and blind tube passage and the early consideration of a surgical airway. Because this high-risk subset may not be clinically apparent on initial presentation in the ED, such guiding principles apply to all patients with PNI until the nature of the injury is more accurately defined. In this report, we present the case of a patient who presented to the ED with a zone II open PNI, which occurred as a result of a stab wound.

Manuseio das Vias Aéreas/métodos , Serviço Hospitalar de Emergência , Intubação Intratraqueal/métodos , Lesões do Pescoço/cirurgia , Ferimentos Perfurantes/cirurgia , Humanos , Laringoscopia , Masculino
Ergonomics ; 56(10): 1525-34, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-24024596


UNLABELLED: In this study, principles of Cognitive Systems Engineering are used to better understand the human-machine interaction manifesting in the use of anaesthesia alarms. The hypothesis is that the design of the machine incorporates built-in assumptions of the user that are discrepant with the anaesthesiologist's self-assessment, creating 'user image mismatch'. Mismatch was interpreted by focusing on the 'user image' as described from the perspectives of both machine and user. The machine-embedded image was interpreted through document analysis. The user-described image was interpreted through user (anaesthesiologist) interviews. Finally, an analysis was conducted in which the machine-embedded and user-described images were contrasted to identify user image mismatch. It is concluded that analysing user image mismatch expands the focus of attention towards macro-elements in the interaction between man and machine. User image mismatch is interpreted to arise from complexity of algorithm design and incongruity between alarm design and tenets of anaesthesia practice. PRACTITIONER SUMMARY: Cognitive system engineering principles are applied to enhance the understanding of the interaction between anaesthesiologist and alarm. The 'user image' is interpreted and contrasted from the perspectives of machine as well as the user. Apparent machine-user mismatch is explored pertaining to specific design features.

Anestesiologia/instrumentação , Alarmes Clínicos , Ergonomia , Sistemas Homem-Máquina , Desenho de Equipamento , Feminino , Humanos , Entrevistas como Assunto , Masculino
Ergonomics ; 55(12): 1487-501, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23009678


UNLABELLED: The development of physiologic monitors has contributed to the decline in morbidity and mortality in patients undergoing anaesthesia. Diverse factors (physiologic, technical, historical and medico-legal) create challenges for monitor alarm designers. Indeed, a growing body of literature suggests that alarms function sub-optimally in supporting the human operator. Despite existing technology that could allow more appropriate design, most anaesthesia alarms still operate on simple, pre-set thresholds. Arguing that more alarms do not necessarily make for safer alarms is difficult in a litigious medico-legal environment and a competitive marketplace. The resultant commitment to the status quo exposes the risks that a lack of an evidence-based theoretical framework for anaesthesia alarm design presents. In this review, two specific theoretical foundations with relevance to anaesthesia alarms are summarised. The potential significance that signal detection theory and cognitive systems engineering could have in improving anaesthesia alarm design is outlined and future research directions are suggested. PRACTITIONER SUMMARY: The development of physiologic monitors has increased safety for patients undergoing anaesthesia. Evidence suggests that the full potential of the alarms embedded within those monitors is not being realised. In this review article, the authors propose a theoretical framework that could lead to the development of more ergonomic anaesthesia alarms.

Anestesiologia/instrumentação , Alarmes Clínicos , Monitorização Fisiológica/instrumentação , Desenho de Equipamento , Ergonomia , Humanos , Segurança do Paciente