Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 102
Filtrar
1.
Trials ; 21(1): 1005, 2020 Dec 09.
Artigo em Inglês | MEDLINE | ID: mdl-33298149

RESUMO

BACKGROUND: The peak of the global COVID-19 pandemic has not yet been reached, and many countries face the prospect of a second wave of infections before effective vaccinations will be available. After an initial phase of viral replication, some patients develop a second illness phase in which the host thrombotic and inflammatory responses seem to drive complications. Severe COVID-19 disease is linked to high mortality, hyperinflammation, and a remarkably high incidence of thrombotic events. We hypothesize a crucial pathophysiological role for the contact pathway of coagulation and the kallikrein-bradykinin pathway. Therefore, drugs that modulate this excessive thromboinflammatory response should be investigated in severe COVID-19. METHODS: In this adaptive, open-label multicenter randomized clinical trial, we compare low molecular weight heparins at 50 IU anti-Xa/kg twice daily-or 75 IU anti-Xa twice daily for intensive care (ICU) patients-in combination with aprotinin to standard thromboprophylaxis in hospitalized COVID-19 patients. In the case of hyperinflammation, the interleukin-1 receptor antagonist anakinra will be added on top of the drugs in the interventional arm. In a pilot phase, the effect of the intervention on thrombotic markers (D-dimer) will be assessed. In the full trial, the primary outcome is defined as the effect of the interventional drugs on clinical status as defined by the WHO ordinal scale for clinical improvement. DISCUSSION: In this trial, we target the thromboinflammatory response at multiple levels. We intensify the dose of low molecular weight heparins to reduce thrombotic complications. Aprotinin is a potent kallikrein pathway inhibitor that reduces fibrinolysis, activation of the contact pathway of coagulation, and local inflammatory response. Additionally, aprotinin has shown in vitro inhibitory effects on SARS-CoV-2 cellular entry. Because the excessive thromboinflammatory response is one of the most adverse prognostic factors in COVID-19, we will add anakinra, a recombinant interleukin-1 receptor antagonist, to the regimen in case of severely increased inflammatory parameters. This way, we hope to modulate the systemic response to SARS-CoV-2 and avoid disease progressions with a potentially fatal outcome. TRIAL REGISTRATION: The EU Clinical Trials Register 2020-001739-28 . Registered on April 10, 2020.

2.
Anaesthesia ; 75(12): 1626-1634, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32506561

RESUMO

Target-controlled infusion systems are increasingly used to administer intravenous anaesthetic drugs to achieve a user-specified plasma or effect-site target concentration. While several studies have investigated the ability of the underlying pharmacokinetic-dynamic models to predict plasma concentrations, there are no data on their performance in predicting drug concentrations in the human brain. We assessed the predictive performance of the Marsh propofol model and Minto remifentanil model for plasma and brain tissue concentrations. Plasma samples were obtained during neurosurgery from 38 patients, and brain tissue samples from nine patients. Propofol and remifentanil concentrations were measured using gas chromatography mass spectrometry and liquid chromatography tandem mass spectrometry. Data were analysed from the nine patients in whom both plasma and brain samples were simultaneously obtained. For the Minto model (five patients), the median performance error was 72% for plasma and -14% for brain tissue concentration predictions. The model tended to underestimate plasma remifentanil concentrations, and to overestimate brain tissue remifentanil concentrations. For the Marsh model (five patients), the median prediction errors for plasma and brain tissue concentrations were 12% and 81%, respectively. However, when the data from all blood propofol assays (36 patients) were analysed, the median prediction error was 11%, with overprediction in 15 (42%) patients and underprediction in 21 (58%). These findings confirm earlier reports demonstrating inaccuracy for commonly used pharmacokinetic-dynamic models for plasma concentrations and extend these findings to the prediction of effect-site concentrations.


Assuntos
Encéfalo/metabolismo , Sistemas de Liberação de Medicamentos , Propofol/administração & dosagem , Remifentanil/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Infusões Intravenosas/métodos , Masculino , Pessoa de Meia-Idade , Modelos Biológicos , Propofol/farmacocinética , Propofol/farmacologia , Estudos Prospectivos , Remifentanil/farmacocinética , Remifentanil/farmacologia
3.
Anaesthesia ; 75(12): 1635-1642, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32530518

RESUMO

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml-1 . The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.


Assuntos
Analgesia Epidural/métodos , Analgesia Obstétrica/métodos , Analgesia Controlada pelo Paciente/métodos , Adulto , Método Duplo-Cego , Feminino , Humanos , Gravidez
4.
Int J Obstet Anesth ; 39: 74-81, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30772120

RESUMO

INTRODUCTION: This retrospective, matched case-control cohort study describes the incidence, indications, anesthesia techniques and outcomes of pregnancies complicated by surgery in a single tertiary-referral hospital. METHODS: Retrospective review of the hospital records of 171 patients who had non-obstetric surgery in the current pregnancy, between 2001 and 2016. Pregnancy outcomes of these women were firstly compared with all contemporary non-exposed patients (n=35 411), and secondly with 684 non-exposed control patients, matched for age, time of delivery and parity. RESULTS: The incidence of non-obstetric surgery during pregnancy was 0.48%, mostly performed during the second trimester (44%) and under general anesthesia (81%). Intra-abdominal surgery (44%) was the most commonly performed procedure, predominantly using laparoscopy (79%). Women undergoing surgery delivered earlier and more frequently preterm (25% vs. 17%, P=0.018); and birth weight was significantly lower [median (95% CI) 3.16 (3.06 to 3.26) vs. 3.27 (3.22 to 3.32) kg, P=0.044]. When surgery was performed under general anesthesia, low birth weight was more frequent (22% vs 6%, P=0.046). Overall pregnancy outcomes were neither influenced by trimester nor location (intra- vs extra-abdominal) of surgery. However, preterm birth rate secondary to surgery was higher for interventions during the third trimester, compared with other trimesters (10% vs 0, P <0.001). CONCLUSION: Pregnant women who underwent surgery delivered preterm more frequently and their babies had lower birth weights. Laparoscopic surgery did not increase the incidence of adverse pregnancy outcomes. General anesthesia was associated with low birth weight. Whether these associations suggest causation or reflect the severity of the underlying condition remains speculative.


Assuntos
Anestesia Geral/métodos , Complicações na Gravidez/cirurgia , Encaminhamento e Consulta , Peso ao Nascer , Feminino , Humanos , Recém-Nascido , Gravidez , Resultado da Gravidez , Estudos Retrospectivos , Centros de Atenção Terciária , Fatores de Tempo
6.
Br J Surg ; 105(8): 1051-1060, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29603122

RESUMO

BACKGROUND: Ischaemia-reperfusion injury is inevitable during renal transplantation and can lead to delayed graft function and primary non-function. Preconditioning, reconditioning and postconditioning with argon and xenon protects against renal ischaemia-reperfusion injury in rodent models. The hypothesis that postconditioning with argon or xenon inhalation would improve graft function in a porcine renal autotransplant model was tested. METHODS: Pigs (n = 6 per group) underwent left nephrectomy after 60 min of warm ischaemia (renal artery and vein clamping). The procured kidney was autotransplanted in a separate procedure after 18 h of cold storage, immediately after a right nephrectomy. Upon reperfusion, pigs were randomized to inhalation of control gas (70 per cent nitrogen and 30 per cent oxygen), argon (70 per cent and 30 per cent oxygen) or xenon (70 per cent and 30 per cent oxygen) for 2 h. The primary outcome parameter was peak plasma creatinine; secondary outcome parameters included further markers of graft function (creatinine course, urine output), graft injury (aspartate aminotransferase, heart-type fatty acid-binding protein, histology), apoptosis and autophagy (western blot, terminal deoxynucleotidyl transferase dUTP nick-end labelling (TUNEL) staining), inflammatory mediators and markers of cell survival/growth (mRNA and tissue protein quantification), and animal survival. Results are presented as median (i.q.r.). ANOVA and Kruskal-Wallis tests were used where indicated. RESULTS: Peak plasma creatinine levels were similar between the groups: control 20·8 (16·4-23·1) mg/dl, argon 21·4 (17·1-24·9) mg/dl and xenon 19·4 (17·5-21·0) mg/dl (P = 0·607). Xenon was associated with an increase in autophagy and proapoptotic markers. Creatinine course, urine output, injury markers, histology, survival and inflammatory mediators were not affected by the intervention. CONCLUSION: Postconditioning with argon or xenon did not improve kidney graft function in this experimental model. Surgical relevance Ischaemia-reperfusion injury is inevitable during renal transplantation and can lead to delayed graft function and primary non-function. Based on mainly small animal experiments, noble gases (argon and xenon) have been proposed to minimize this ischaemia-reperfusion injury and improve outcomes after transplantation. The hypothesis that postconditioning with argon or xenon inhalation would improve graft function was tested in a porcine kidney autotransplantation model. The peak plasma creatinine concentration was similar in the control, argon and xenon groups. No other secondary outcome parameters, including animal survival, were affected by the intervention. Xenon was associated with an increase in autophagy and proapoptotic markers. Despite promising results in small animal models, postconditioning with argon or xenon in a translational model of kidney autotransplantation was not beneficial. Clinical trials would require better results.


Assuntos
Argônio/farmacologia , Sobrevivência de Enxerto/efeitos dos fármacos , Pós-Condicionamento Isquêmico/métodos , Transplante de Rim/efeitos adversos , Xenônio/farmacologia , Animais , Apoptose/efeitos dos fármacos , Biomarcadores/metabolismo , Feminino , Pós-Condicionamento Isquêmico/efeitos adversos , Rim/fisiopatologia , Rim/cirurgia , Testes de Função Renal/métodos , Transplante de Rim/métodos , Modelos Animais , Reação em Cadeia da Polimerase em Tempo Real , Traumatismo por Reperfusão/prevenção & controle , Taxa de Sobrevida , Suínos , Transplante Autólogo/efeitos adversos , Transplante Autólogo/métodos
7.
Br J Anaesth ; 120(1): 127-137, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29397119

RESUMO

BACKGROUND: Postoperative delirium occurs frequently in elderly hip fracture surgery patients and is associated with poorer overall outcomes. Because xenon anaesthesia has neuroprotective properties, we evaluated its effect on the incidence of delirium and other outcomes after hip fracture surgery. METHODS: This was a phase II, multicentre, randomized, double-blind, parallel-group, controlled clinical trial conducted in hospitals in six European countries (September 2010 to October 2014). Elderly (≥75yr-old) and mentally functional hip fracture patients were randomly assigned 1:1 to receive either xenon- or sevoflurane-based general anaesthesia during surgery. The primary outcome was postoperative delirium diagnosed through postoperative day 4. Secondary outcomes were delirium diagnosed anytime after surgery, postoperative sequential organ failure assessment (SOFA) scores, and adverse events (AEs). RESULTS: Of 256 enrolled patients, 124 were treated with xenon and 132 with sevoflurane. The incidence of delirium with xenon (9.7% [95% CI: 4.5 -14.9]) or with sevoflurane (13.6% [95% CI: 7.8 -19.5]) were not significantly different (P=0.33). Overall SOFA scores were significantly lower with xenon (least-squares mean difference: -0.33 [95% CI: -0.60 to -0.06]; P=0.017). For xenon and sevoflurane, the incidence of serious AEs and fatal AEs was 8.0% vs 15.9% (P=0.05) and 0% vs 3.8% (P=0.06), respectively. CONCLUSIONS: Xenon anaesthesia did not significantly reduce the incidence of postoperative delirium after hip fracture surgery. Nevertheless, exploratory observations concerning postoperative SOFA-scores, serious AEs, and deaths warrant further study of the potential benefits of xenon anaesthesia in elderly hip fracture surgery patients. CLINICAL TRIAL REGISTRATION: EudraCT 2009-017153-35; ClinicalTrials.gov NCT01199276.


Assuntos
Anestésicos Inalatórios , Delírio do Despertar/psicologia , Fraturas do Quadril/cirurgia , Xenônio , Idoso , Idoso de 80 Anos ou mais , Anestesia por Inalação , Delírio do Despertar/epidemiologia , Feminino , Fraturas do Quadril/mortalidade , Humanos , Incidência , Masculino , Procedimentos Ortopédicos/efeitos adversos , Procedimentos Ortopédicos/mortalidade , Estudos Prospectivos , Sevoflurano , Resultado do Tratamento
8.
Br J Anaesth ; 120(1): 156-163, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29397124

RESUMO

BACKGROUND: Poor adherence to guidelines aimed at reducing the incidence of postoperative nausea and vomiting (PONV) is well known. In a before-and-after study, we tested the effectiveness of a simplified algorithm for PONV prophylaxis on the incidence of PONV. METHODS: In the first audit, we examined the adherence to our institutional guidelines for PONV prevention. In response to the results of this audit, we introduced a simplified algorithm for PONV prevention [female patients receiving triple prophylaxis (dexamethasone and ondansetron plus either a target-controlled infusion with propofol or droperidol) and male patients receiving double prophylaxis, dexamethasone, and ondansetron]. The impact of the simplification of the PONV algorithm was evaluated in a second audit. In both audits, we reviewed the medical records of all adult patients undergoing elective non-cardiac non-day-case surgery under general anaesthesia and being admitted to our post-anaesthesia care unit during two arbitrarily chosen weeks. We assessed the incidence of nausea, vomiting, and PONV after 1 and 24 h, and the compliance with the departmental algorithm for PONV prophylaxis. RESULTS: After simplification of the PONV algorithm, the overall incidence of PONV within 24 h after surgery was significantly lower than before the implementation of the simplified PONV algorithm (22% vs 33%, P=0.02). The PONV incidence within 1 h was comparable between the audits (11% vs 14%, P=0.45). The adherence to departmental guidelines for PONV prophylaxis was significantly higher after the implementation of the simplified PONV algorithm (46% vs 18%, P=0.0001). CONCLUSIONS: A simplified algorithm for PONV prophylaxis resulted in a significant reduction in the PONV incidence and better compliance with the PONV algorithm.


Assuntos
Algoritmos , Náusea e Vômito Pós-Operatórios/prevenção & controle , Idoso , Anestesia Geral , Antieméticos/uso terapêutico , Dexametasona/uso terapêutico , Droperidol/uso terapêutico , Quimioterapia Combinada , Feminino , Fidelidade a Diretrizes , Humanos , Hipnóticos e Sedativos/uso terapêutico , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Ondansetron/uso terapêutico , Propofol/uso terapêutico , Resultado do Tratamento
9.
Otolaryngol Head Neck Surg ; 158(1): 144-150, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28849699

RESUMO

Objectives (1) Evaluate hearing outcomes of patients after planned malleus removal during ossicular chain reconstruction. (2) Analyze hearing results for titanium (Ti) and hydroxyapatite (HA) total ossicular prostheses (TOPs) and partial ossicular prostheses (POPs). (3) Compare Ti and HA partial prostheses. Study Design Retrospective case series with chart review. Setting Tertiary health care organization. Subjects and Methods A chart review was conducted of 139 consecutive patients who presented with chronic otitis media with perforation (with or without cholesteatoma) and were treated with initial-stage tympanoplasty (with or without mastoidectomy) and managed with TOP (n = 22) or POP (n = 117) between July 2010 and July 2015. The malleus was completely removed in all cases. Hearing was assessed via bone and air conduction pretone averages (0.5, 1, 2 kHz) pre- and postoperatively. Air-bone gap (ABG) and change in ABG (ΔABG) were analyzed. Pre- and postoperative values were compared. Results The overall mean ABG decreased from 29.4 ± 12.3 dB to 18.2 ± 11.4 dB postoperatively ( P < .001) with a mean ΔABG of 14.5 dB (95% CI, 12.793-16.203). Overall success was achieved by 69.1%. The POP group achieved higher success (70.9%) than the TOP group (59.1%; P = .0001). Mean ABG decreased significantly within surgical groups (TOP and POP) and prosthesis material groups (Ti and HA; all P < .001). Ti had statistically higher success than HA in both techniques: POP ( P = .0478) and TOP ( P = .0251). There was a 98% graft take rate. Conclusion Planned malleus removal during ossicular chain reconstruction, regardless of disease extent, allows for simpler reconstruction and comparable favorable results to preservation of the malleus and should be considered during surgical planning.


Assuntos
Colesteatoma da Orelha Média/cirurgia , Audição , Martelo/cirurgia , Prótese Ossicular , Substituição Ossicular/métodos , Otite Média/cirurgia , Adolescente , Adulto , Idoso , Condução Óssea , Criança , Durapatita , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Desenho de Prótese , Estudos Retrospectivos , Titânio , Resultado do Tratamento , Timpanoplastia
10.
Br J Anaesth ; 118(4): 576-585, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28403408

RESUMO

Background.: It is inconclusive whether the perioperative administration of systemic lidocaine provides effective postoperative analgesia and enhances recovery in major orthopaedic surgery. We hypothesised that in adolescent and adult patients undergoing posterior spinal arthrodesis, a perioperative lidocaine infusion would reduce opioid requirements during the first 24 postoperative h. Methods.: 70 patients undergoing posterior arthrodesis were enrolled in this prospective, randomised, double-blind, placebo-controlled clinical trial. Patients received total i.v. anaesthesia with propofol and remifentanil and were randomized to an adjuvant therapy with either lidocaine [i.v.-bolus injection of 1.5 mg kg -1 at induction of anaesthesia, followed by an infusion of 1.5 mg kg -1 h -1 which was continued until six h after arrival at the post-anaesthesia care unit] or placebo (equal volumes of saline). Postoperative pain was treated with patient-controlled i.v. morphine. Primary endpoints of this study were morphine requirements in the first postoperative 24 h. Results.: Systemic lidocaine did not decrease morphine requirements in the first 24 postoperative h [lidocaine-group: 48 (23) mg (mean( sd )) vs placebo-group: 51(19) mg, P = 0.22]. Likewise, groups were not different with respect to the severity of postoperative pain, morphine consumption after 48 and 72 h, incidence of postoperative nausea and vomiting, perioperative inflammation, time to recovery of intestinal function, hospital length of stay, and quality of life (assessed preoperatively and one month postoperatively using the SF-12 physical and mental composite scores). Conclusions.: In our study, systemic lidocaine had no analgesic benefits in posterior arthrodesis when added to an opioid-based anaesthetic regimen. Clinical trial registration.: Eudra CT 2012-005264-98.


Assuntos
Analgésicos Opioides/uso terapêutico , Anestésicos Locais/uso terapêutico , Artrodese/psicologia , Lidocaína/uso terapêutico , Morfina/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Coluna Vertebral/cirurgia , Adolescente , Adulto , Analgesia Controlada pelo Paciente , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Método Duplo-Cego , Feminino , Humanos , Injeções Intravenosas , Tempo de Internação , Lidocaína/administração & dosagem , Lidocaína/efeitos adversos , Masculino , Pessoa de Meia-Idade , Resultados Negativos , Dor Pós-Operatória/psicologia , Náusea e Vômito Pós-Operatórios/tratamento farmacológico , Estudos Prospectivos , Qualidade de Vida , Adulto Jovem
11.
Acta Anaesthesiol Belg ; 67(4): 175-181, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-29873987

RESUMO

PURPOSE: Adenotonsillectomy is a frequently performed procedure in pediatric day-case surgery causing significant pain for which adequate analgesia is required. Our aim was to investigate if the intraoperative administration of IV tramadol decreases the need for postoperative pain medication in children. Because tramadol has well-known pro-emetic effects, we also assessed the incidence of postoperative nausea and vomiting (PONV). METHODS: We performed a retrospective observational study in 314 children aged 1-13 years undergoing elective adenotonsillectomy. We identified 160 children who had received standard pain medication consisting of IV paracetamol and ketorolac and compared them with a group of 154 children who had received in addition a perioperative infusion of tramadol. RESULTS: 32.5% of the patients in the tramadol group versus 83.8% of the patients in the standard group required postoperative administration of piritramide (p < 0.0001). Groups did not differ with respect to the postoperative need for anti-emetics but in the tramadol group more patients had received prophylactic therapy with odansetron or dexamethasone (P < 0.0001). CONCLUSION: The results of this retrospective study indicate that intraoperative tramadol administration in combination with prophylactic antiemetic therapy decreases the need for piritramide in the immediate postoperative period without increasing the incidence of PONV after tonsillectomy in children.


Assuntos
Adenoidectomia/efeitos adversos , Analgésicos Opioides/uso terapêutico , Cuidados Intraoperatórios/métodos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , Pirinitramida/uso terapêutico , Tonsilectomia/efeitos adversos , Tramadol/uso terapêutico , Adolescente , Analgésicos Opioides/administração & dosagem , Antieméticos/uso terapêutico , Criança , Pré-Escolar , Dexametasona/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Lactente , Masculino , Ondansetron/uso terapêutico , Pirinitramida/administração & dosagem , Náusea e Vômito Pós-Operatórios/epidemiologia , Estudos Retrospectivos , Tramadol/administração & dosagem , Resultado do Tratamento
12.
Curr Pharm Des ; 22(13): 1868-78, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-26642777

RESUMO

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is becoming a valuable alternative to surgical aortic valve replacement in patients with severe aortic stenosis that are at high surgical risk or deemed inoperable. The optimal anesthesia technique for TAVI is still undecided. We performed a systematic review and metaanalysis to compare the safety of locoregional anesthesia (LRA) with or without conscious sedation and general anesthesia (GA) for the TAVI-procedure. METHODS: We searched PUBMED, MEDLINE, EMBASE and the Cochrane central register of controlled trials from January 1st 2002 to February 15th 2015. The primary outcome parameters searched were 30-days mortality, hospital length of stay, procedure time, use of adrenergic support, stroke rate, incidence of myocardial infarction, incidence of acute kidney injury, rate of procedural succes. RESULTS: Ten studies, including 5919 patients, fulfilled the inclusion criteria. None of these studies was randomized resulting in a considerable risk of bias. The choice for a specific anesthesia technique did neither affect the average 30-day mortality rate [RR 0.91 (95% CI: 0.53 to 1.56), p=0.72] nor a wide variety of safety endpoints. LRA for TAVI was associated with a significantly shorter procedure time when compared to GA, and a reduction in hospital length of stay. However, LRA significantly increased the risk for implantation of a permanent pacemaker (RR 1.23, p=0.02) and for paravalvular leakage (RR 1.31, p=0.006.). CONCLUSION: Neither mortality nor the incidence of major adverse cardiac and cerebrovascular events after TAVI is affected by the choice for either LRA or GA.


Assuntos
Anestesia Geral , Anestesia Local , Estenose da Valva Aórtica/cirurgia , Substituição da Valva Aórtica Transcateter , Humanos
14.
Br J Anaesth ; 115(4): 550-9, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26385664

RESUMO

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements. METHODS: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile. RESULTS: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100ß and erythropoietin. CONCLUSIONS: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12).


Assuntos
Anestésicos Inalatórios/farmacologia , Ponte de Artéria Coronária sem Circulação Extracorpórea , Hemodinâmica/efeitos dos fármacos , Xenônio/farmacologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Éteres Metílicos/farmacologia , Pessoa de Meia-Idade , Norepinefrina/administração & dosagem , Estudos Prospectivos , Sevoflurano , Método Simples-Cego , Vasoconstritores/administração & dosagem
16.
Anaesth Intensive Care ; 43(3): 357-60, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25943610

RESUMO

The aim of this study was to assess the relationship between superior vena cava (SVC) diameter, collapsibility and central venous pressure (CVP) in cardiac surgical patients. SVC maximum and minimum diameters, plus collapsibility with ventilation, were measured with transoesophageal echocardiography in the mid-oesophageal bicaval view with M-mode. Simultaneously, CVP was measured via the right atrial port of a pulmonary artery catheter. Measurements were possible in 91 out of 92 patients. The median CVP was 10 mmHg with a range of 2 to 19 mmHg. There was a weak, but statistically significant, correlation between CVP and SVC collapsibility index (r=-0.21, P=0.049). There was no statistically significant correlation between maximum SVC diameter and CVP. Maximum SVC diameter was statistically significantly correlated with weight (Pearson's r=0.28, P=0.008). There was no statistically significant correlation between CVP and age or body dimensions. Our findings indicate that SVC diameter and collapsibility are easily measured with transoesophageal echocardiography but do not reliably reflect CVP in anaesthetised cardiac surgical patients.


Assuntos
Pesos e Medidas Corporais/métodos , Pressão Venosa Central/fisiologia , Veia Cava Superior/diagnóstico por imagem , Veia Cava Superior/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos , Cateterismo de Swan-Ganz/métodos , Ecocardiografia Transesofagiana/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
17.
Int J Cardiol ; 184: 323-36, 2015 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-25734940

RESUMO

In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hidrazonas/uso terapêutico , Assistência Perioperatória/métodos , Cuidados Pré-Operatórios/métodos , Piridazinas/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiotônicos/uso terapêutico , Doenças Cardiovasculares/tratamento farmacológico , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/cirurgia , Ensaios Clínicos como Assunto/métodos , Europa (Continente)/epidemiologia , Humanos , Simendana
18.
Anaesthesia ; 70(3): 258-63, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25388528

RESUMO

With the reduction in use of the pulmonary artery catheter, alternative methods of pulmonary pressure estimation are required. The use of echocardiographically-derived right ventricular systolic pressure has recently been questioned, but this technique has not been validated in anaesthetised surgical patients with transoesophageal echocardiography. One hundred measurements of right ventricular systolic pressure with transoesophageal echocardiography were compared with the pulmonary artery systolic pressure obtained simultaneously from a pulmonary artery catheter in patients undergoing cardiac surgery. Simultaneous right ventricular systolic pressure and pulmonary artery systolic pressure measurements were possible in all patients, and these measurements were strongly correlated (r = 0.98, p < 0.001), with minimal bias and narrow limits of agreement (approximately -5 to +5 mmHg), across a broad range of pulmonary pressures. Measurement of right ventricular systolic pressure using tranoesophageal echocardiography is readily achievable and closely correlates with pulmonary artery systolic pressure, with minimal bias, in cardiac surgical patients undergoing general anaesthesia and positive pressure mechanical ventilation of the lungs.


Assuntos
Pressão Sanguínea/fisiologia , Ecocardiografia Transesofagiana/métodos , Ventrículos do Coração/diagnóstico por imagem , Monitorização Intraoperatória/métodos , Função Ventricular Direita/fisiologia , Idoso , Determinação da Pressão Arterial/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Estudos de Viabilidade , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Artéria Pulmonar/fisiopatologia , Reprodutibilidade dos Testes , Sístole
19.
Acta Anaesthesiol Belg ; 65(1): 9-22, 2014.
Artigo em Inglês | MEDLINE | ID: mdl-24988823

RESUMO

Several randomized controlled trials have raised alarming concerns about the safety of hydroxyethyl starches (HES) for the hemodynamic stabilization of critically ill patients. It has been repeatedly demonstrated that the use of HES in patients treated in an intensive care unit was associated with an increased occurrence of serious adverse events, including a higher incidence of renal injury or failure, a higher need for renal replacement therapy (RRT), and (in one study) increased mortality. HES solutions are also widely used in the perioperative period, although high-level evidence on both the efficacy and safety of HES in patients undergoing surgery is sparse. It is unknown to which extent the concerning findings in critically ill patients can be extrapolated to the perioperative setting, where a variety of distinct patient populations is encountered. However, caution and an increased awareness for possible adverse effects of HES solutions in the perioperative setting are warranted. In 2013, the European Medicines Agency (EMA) concluded that the benefits of HES solutions no longer outweigh their risks, and therefore recommended that the marketing authorizations for these medicines be suspended (1). Upon request of some of the marketing-authorization holders (MAH), the EMA re-analyzed its recommendation. After a thorough review of the available data, the Pharmacovigilance Risk Assessment Committee (PRAC) concluded, on November 11th, that the increased risk of mortality and RRT or renal failure associated with the use of hydroxyethyl starch containing medicinal products outweighs their limited clinical benefits in the approved indications, and in any patient population. In June 2013, the U.S. Food and Drug Administration also communicated a serious warning with respect to the use of HES (2). The present (non-systematic) review summarizes the evidence upon which these remarkable recommendations are based. Moreover, current guidelines on the use of HES are quoted.


Assuntos
Derivados de Hidroxietil Amido/uso terapêutico , Período Perioperatório/métodos , Estado Terminal , Relação Dose-Resposta a Droga , Hemodinâmica/efeitos dos fármacos , Humanos , Derivados de Hidroxietil Amido/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Insuficiência Renal/induzido quimicamente , Resultado do Tratamento
20.
Br J Anaesth ; 111(3): 406-16, 2013 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-23578862

RESUMO

BACKGROUND: To date, only limited data exist about the use of xenon as an anaesthetic agent in patients undergoing cardiac surgery. The favourable cardio- and neuroprotective properties of xenon might attenuate postoperative complications, improve outcome, and reduce the incidence of delirium. Thus, the aims of this study were to investigate the feasibility and safety of balanced xenon anaesthesia in patients undergoing cardiac surgery and to gather pilot data for a future randomized multicentre study. METHODS: Thirty patients undergoing elective coronary artery bypass grafting were enrolled in this randomized, single-blind controlled trial. They were randomized to receive balanced general anaesthesia with either xenon (45-50 vol%) or sevoflurane (1-1.4 vol%). The primary outcome was the occurrence of adverse events (AEs). Secondary outcome parameters were feasibility criteria (bispectral index, perioperative haemodynamic, and respiratory profile) and safety parameters (dosage of study treatments, renal function, intraoperative blood loss, need for inotropic support, regional cerebral tissue oxygenation). Furthermore, at predefined time points, systemic and pulmonary haemodynamics were assessed by the use of a pulmonary artery catheter. RESULTS: There were no patient characteristic differences between the groups. Patients undergoing xenon anaesthesia did not differ with respect to the incidence of AE (6 vs 8, P=0.464) compared with the sevoflurane group. No differences were detected regarding secondary feasibility and safety criteria. The haemodynamic and respiratory profile was comparable between the treatment groups. CONCLUSIONS: Balanced xenon anaesthesia is feasible and safe compared with sevoflurane anaesthesia in patients undergoing coronary artery bypass surgery. Acronym CARDIAX: A pre- and post-coronary artery bypass graft implantation disposed application of xenon. Clinical trial registration ClinicalTrials.gov: NCT01285271; EudraCT-number: 2010-023942-63. Approved by the ethics committee 'Ethik-Kommission an der Medizinischen Fakultät der Rheinisch-Westfälischen Technischen Hochschule Aachen (RWTH Aachen)': EK-218/10.


Assuntos
Anestésicos Inalatórios/efeitos adversos , Ponte de Artéria Coronária/métodos , Éteres Metílicos/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Xenônio/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Sevoflurano , Método Simples-Cego
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...