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1.
Retina ; 40(2): 233-240, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31972792

RESUMO

PURPOSE: To compare the results of vitrectomy with internal limiting membrane (ILM) peeling and inverted ILM flap for treating myopic macular hole without retinal detachment. METHODS: Twenty-eight eyes of 28 patients undergoing vitrectomy with either ILM peeling (n = 16) or inverted ILM flap technique (n = 12) were included. Outcomes were myopic macular hole closure by optical coherence tomography and visual acuity at 6 months and at the end of follow-up. RESULTS: Closure of myopic macular hole was achieved in 13 eyes (81.2%) of the ILM peeling group and in 11 eyes (91.7%) of the inverted ILM flap group. The median length of follow-up was 18 months in the peeling group and 10.3 in the inverted group. There were not statistically significant differences between restoration of the external limiting membrane, external limiting membrane and ellipsoid zone, and none of both layers between the two groups. The median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.25 (20/35 Snellen) in the peeling group and 0.4 (20/50) in the inverted group (P = 0.027). CONCLUSION: Both techniques were associated with high closure rates of myopic macular hole but the small sample size and the retrospective design prevents any claims of superiority of one technique over the other.

2.
Eur J Anaesthesiol ; 36(2): 93-104, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30431500

RESUMO

BACKGROUND: Postoperative pneumonia is associated with increased morbidity, mortality and costs. Prediction models of pneumonia that are currently available are based on retrospectively collected data and administrative coding systems. OBJECTIVE: To identify independent variables associated with the occurrence of postoperative pneumonia. DESIGN: A prospective observational study of a multicentre cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe database). SETTING: Sixty-three hospitals in Europe. PATIENTS: Patients undergoing surgery under general and/or regional anaesthesia during a 7-day recruitment period. MAIN OUTCOME MEASURE: The primary outcome was postoperative pneumonia. DEFINITION: the need for treatment with antibiotics for a respiratory infection and at least one of the following criteria: new or changed sputum; new or changed lung opacities on a clinically indicated chest radiograph; temperature more than 38.3 °C; leucocyte count more than 12 000 µl. RESULTS: Postoperative pneumonia occurred in 120 out of 5094 patients (2.4%). Eighty-two of the 120 (68.3%) patients with pneumonia required ICU admission, compared with 399 of the 4974 (8.0%) without pneumonia (P < 0.001). We identified five variables independently associated with postoperative pneumonia: functional status [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.58 to 3.12], pre-operative SpO2 values while breathing room air (OR 0.83, 95% CI 0.78 to 0.84), intra-operative colloid administration (OR 2.97, 95% CI 1.94 to 3.99), intra-operative blood transfusion (OR 2.19, 95% CI 1.41 to 4.71) and surgical site (open upper abdominal surgery OR 3.98, 95% CI 2.19 to 7.59). The model had good discrimination (c-statistic 0.89) and calibration (Hosmer-Lemeshow P = 0.572). CONCLUSION: We identified five variables independently associated with postoperative pneumonia. The model performed well and after external validation may be used for risk stratification and management of patients at risk of postoperative pneumonia. TRIAL REGISTRATION: NCT 01346709 (ClinicalTrials.gov).


Assuntos
Modelos Biológicos , Pneumonia/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Pneumonia/etiologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Prospectivos , Medição de Risco/métodos
3.
Retina ; 2018 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-30383715

RESUMO

PURPOSE: To compare the results of vitrectomy with internal limiting membrane (ILM) peeling and inverted ILM flap for treating myopic macular hole without retinal detachment. METHODS: Twenty-eight eyes of 28 patients undergoing vitrectomy with either ILM peeling (n = 16) or inverted ILM flap technique (n = 12) were included. Outcomes were myopic macular hole closure by optical coherence tomography and visual acuity at 6 months and at the end of follow-up. RESULTS: Closure of myopic macular hole was achieved in 13 eyes (81.2%) of the ILM peeling group and in 11 eyes (91.7%) of the inverted ILM flap group. The median length of follow-up was 18 months in the peeling group and 10.3 in the inverted group. There were not statistically significant differences between restoration of the external limiting membrane, external limiting membrane and ellipsoid zone, and none of both layers between the two groups. The median best-corrected visual acuity (logarithm of minimal angle of resolution) at the end of follow-up was 0.25 (20/35 Snellen) in the peeling group and 0.4 (20/50) in the inverted group (P = 0.027). CONCLUSION: Both techniques were associated with high closure rates of myopic macular hole but the small sample size and the retrospective design prevents any claims of superiority of one technique over the other.

4.
Minerva Anestesiol ; 84(11): 1261-1269, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-29405670

RESUMO

BACKGROUND: Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia. METHODS: Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mL on radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block. RESULTS: Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV). CONCLUSIONS: dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.


Assuntos
Analgesia/métodos , Anestésicos Locais/administração & dosagem , Levobupivacaína/administração & dosagem , Bloqueio Nervoso/métodos , Manejo da Dor/métodos , Dor Pós-Operatória/prevenção & controle , Trapézio/cirurgia , Idoso , Procedimentos Cirúrgicos Ambulatórios , Axila , Feminino , Humanos , Masculino , Nervo Mediano , Pessoa de Meia-Idade , Estudos Prospectivos , Nervo Radial
6.
Age Ageing ; 46(6): 925-931, 2017 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-28655169

RESUMO

Objective: to analyse the clinical impact of a home-based Intermediate Care model in the Catalan health system, comparing it with usual bed-based care. Design: quasi-experimental longitudinal study. Setting: hospital Municipal de Badalona and El Carme Intermediate Care Hospital, Badalona, Catalonia, Spain. Participants: we included older patients with medical and orthopaedic disabling health crises in need of Comprehensive Geriatric Assessment (CGA) and rehabilitation. Methods: a CGA-based hospital-at-home Integrated Care Programme (acute care and rehabilitation) was compared with a propensity score matched cohort of contemporary patients attended by usual inpatient hospital care (acute care plus intermediate care hospitalisation), for the management of medical and orthopaedics processes. Main outcomes measures were: (a) Health crisis resolution (referral to primary care at the end of the intervention); (b) functional resolution: relative functional gain (functional gain/functional loss) ≥ 0.35; and (c) favourable crisis resolution (health + functional) = a + b. We compared between-groups outcomes using uni/multivariable logistic regression models. Results: clinical characteristics were similar between home-based and bed-based groups. Acute stay was shorter in home group: 6.1 (5.3-6.9) versus 11.2 (10.5-11.9) days, P < 0.001. The home-based scheme showed better results on functional resolution 79.1% (versus 75.2%), OR 1.62 (1.09-2.41) and on favourable crisis resolution 73.8% (versus 69.6%), OR 1.54 (1.06-2.22), with shorter length of intervention, with a reduction of -5.72 (-9.75 and -1.69) days. Conclusions: in our study, the extended CGA-based hospital-at-home programme was associated with shorter stay and favourable clinical outcomes. Future studies might test this intervention to the whole Catalan integrated care system.


Assuntos
Estado Terminal/terapia , Prestação Integrada de Cuidados de Saúde , Serviços Hospitalares de Assistência Domiciliar , Procedimentos Ortopédicos , Admissão do Paciente , Fatores Etários , Idoso de 80 Anos ou mais , Envelhecimento , Avaliação da Deficiência , Feminino , Avaliação Geriátrica , Humanos , Tempo de Internação , Modelos Lineares , Modelos Logísticos , Estudos Longitudinais , Masculino , Análise Multivariada , Razão de Chances , Alta do Paciente , Avaliação de Programas e Projetos de Saúde , Pontuação de Propensão , Recuperação de Função Fisiológica , Espanha , Fatores de Tempo , Resultado do Tratamento
7.
Int J Cardiovasc Imaging ; 33(9): 1385-1394, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28409259

RESUMO

OBJECTIVE: The aim of our study was to evaluate the level of agreement between tricuspid annular plane systolic excursion (TAPSE) measured by transthoracic echocardiography (TTE) and TAPSE measured using transesophageal echocardiography (TEE) in anesthetized patients. MATERIALS AND METHODS: Thirty patients scheduled for elective cardiac surgery were prospectively studied. Shortly after induction of anesthesia before the operation, TAPSE was measured by TTE using M-mode in apical 4chamber view (4CH) and by TEE in six different views: using 2D echocardiography in midesophageal (ME) 4CH view, using M-mode in deep transgastric right ventricle (dTG RV) view at 0° and dTG RV longaxis view (LAX) as well as using anatomical M-mode (AM-mode) in ME 4CH, dTG RV at 0° and dTG RV LAX views. RESULTS: Bland-Altman analysis showed a good agreement for TAPSE measured using M-mode in TTE and using AM-mode in TEE in the ME 4CH and dTG RV at 0° views (-2.5 ± 18 and -2.2 ± 14% respectively). The agreement between TAPSE measured in TTE and TEE using 2D in ME 4CH, using M-mode in dT GRV 0° and using M-mode and AM-mode in dTG RV LAX view showed a significant systematic underestimation of the measurements (-8.8 ± 21, -8.8 ± 24, -17.8 ± 28 and -6.4 ± 20%). CONCLUSION: Our study showed that the right ventricular function can be accurately and precisely estimated using TAPSE measurement by TEE in the midesophageal four chamber and deep transgastric right ventricle view at 0° using anatomical M-mode.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Transesofagiana , Valva Tricúspide/diagnóstico por imagem , Função Ventricular Direita , Idoso , Anestesia Geral , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Interpretação de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Assistência Perioperatória , Valor Preditivo dos Testes , Estudos Prospectivos , Reprodutibilidade dos Testes , Valva Tricúspide/fisiopatologia
8.
Minerva Anestesiol ; 82(3): 332-42, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25990430

RESUMO

Pulmonary complications are a source of greater postoperative morbidity and mortality and longer hospital stays. Although many factors have been implicated as predictors, few models have been developed with the rigorous methodology required for clinically useful tools. In this article we attempt to describe what to look for when developing or assessing a newly proposed predictive tool and to discuss what must be taken into consideration on incorporating a model into clinical practice. Above all, we stress that we still lack evidence for the clinical and cost effectiveness of many measures proposed for reducing risk or for managing complications perioperatively. For a good predictive model to truly prove its utility in clinical decision-making, such evidence is required.


Assuntos
Pneumopatias/diagnóstico , Pneumopatias/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Humanos , Pneumopatias/etiologia , Modelos Biológicos , Período Pós-Operatório , Fatores de Risco
9.
Anesthesiology ; 122(5): 1123-41, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25985024

RESUMO

BACKGROUND: Chronic postsurgical pain (CPSP) has been linked to many surgical settings. The authors aimed to analyze functional genetic polymorphisms and clinical factors that might identify CPSP risk after inguinal hernia repair, hysterectomy, and thoracotomy. METHODS: This prospective multicenter cohort study enrolled 2,929 patients scheduled for inguinal hernia repair, hysterectomy (vaginal or abdominal), or thoracotomy. The main outcome was the incidence of CPSP confirmed by physical examination 4 months after surgery. The secondary outcome was CPSP incidences at 12 and 24 months. The authors also tested the associations between CPSP and 90 genetic markers plus a series of clinical factors and built a CPSP risk model. RESULTS: Within a median of 4.4 months, CPSP had developed in 527 patients (18.0%), in 13.6% after hernia repair, 11.8% after vaginal hysterectomy, 25.1% after abdominal hysterectomy, and 37.6% after thoracotomy. CPSP persisted after a median of 14.6 months and 26.3 months in 6.2% and 4.1%, respectively, after hernia repair, 4.1% and 2.2% after vaginal hysterectomy, 9.9% and 6.7% after abdominal hysterectomy, and 19.1% and 13.2% after thoracotomy. No significant genetic differences between cases and controls were identified. The risk model included six clinical predictors: (1) surgical procedure, (2) age, (3) physical health (Short Form Health Survey-12), (4) mental health (Short Form Health Survey-12), (5) preoperative pain in the surgical field, and (6) preoperative pain in another area. Discrimination was moderate (c-statistic, 0.731; 95% CI, 0.705 to 0.755). CONCLUSIONS: Until unequivocal genetic predictors of CPSP are understood, the authors encourage systematic use of clinical factors for predicting and managing CPSP risk.


Assuntos
Herniorrafia/efeitos adversos , Histerectomia/efeitos adversos , Dor Pós-Operatória/genética , Dor Pós-Operatória/terapia , Toracotomia/efeitos adversos , Adulto , Fatores Etários , Idoso , Doença Crônica , Estudos de Coortes , Feminino , Seguimentos , Nível de Saúde , Humanos , Masculino , Saúde Mental , Pessoa de Meia-Idade , Dor Pós-Operatória/epidemiologia , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento
10.
Eur J Anaesthesiol ; 32(7): 458-70, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26020123

RESUMO

BACKGROUND: Postoperative respiratory failure (PRF) is the most frequent respiratory complication following surgery. OBJECTIVE: The objective of this study was to build a clinically useful predictive model for the development of PRF. DESIGN: A prospective observational study of a multicentre cohort. SETTING: Sixty-three hospitals across Europe. PATIENTS: Patients undergoing any surgical procedure under general or regional anaesthesia during 7-day recruitment periods. MAIN OUTCOME MEASURES: Development of PRF within 5 days of surgery. PRF was defined by a partial pressure of oxygen in arterial blood (PaO2) less than 8 kPa or new onset oxyhaemoglobin saturation measured by pulse oximetry (SpO2) less than 90% whilst breathing room air that required conventional oxygen therapy, noninvasive or invasive mechanical ventilation. RESULTS: PRF developed in 224 patients (4.2% of the 5384 patients studied). In-hospital mortality [95% confidence interval (95% CI)] was higher in patients who developed PRF [10.3% (6.3 to 14.3) vs. 0.4% (0.2 to 0.6)]. Regression modelling identified a predictive PRF score that includes seven independent risk factors: low preoperative SpO2; at least one preoperative respiratory symptom; preoperative chronic liver disease; history of congestive heart failure; open intrathoracic or upper abdominal surgery; surgical procedure lasting at least 2 h; and emergency surgery. The area under the receiver operating characteristic curve (c-statistic) was 0.82 (95% CI 0.79 to 0.85) and the Hosmer-Lemeshow goodness-of-fit statistic was 7.08 (P = 0.253). CONCLUSION: A risk score based on seven objective, easily assessed factors was able to predict which patients would develop PRF. The score could potentially facilitate preoperative risk assessment and management and provide a basis for testing interventions to improve outcomes.The study was registered at ClinicalTrials.gov (identifier NCT01346709).


Assuntos
Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/prevenção & controle , Adulto , Idoso , Anestesia por Condução , Anestesia Geral , Estudos de Coortes , Cuidados Críticos/estatística & dados numéricos , Europa (Continente) , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Oximetria , Oxigênio/sangue , Oxiemoglobinas/análise , Oxiemoglobinas/metabolismo , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Insuficiência Respiratória/mortalidade , Fatores de Risco , Resultado do Tratamento
12.
Surgery ; 157(2): 249-59, 2015 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-25616941

RESUMO

BACKGROUND: Ischemic preconditioning (IPC) and anesthetic preconditioning (APC) have been reported to attenuate ischemia-reperfusion (IR) injury after liver resection under continuous inflow occlusion. This study evaluates whether these strategies enhance hepatic protection of remnant liver against IR after liver resection with intermittent clamping (INT). METHODS: A total of 106 patients without underlying liver disease and submitted to liver resection using INT were randomized into 3 groups: IPC (10 minutes of inflow occlusion followed by 10 minutes of reperfusion before liver transection), APC (sevoflurane administration for 20 minutes before liver transection), and INT (no preconditioning). Patients were also stratified according to the extent of the hepatectomy. Cytoprotection was evaluated by comparing hepatocyte and endothelial dysfunction markers, apoptosis, histologic lesions, and postoperative outcome. RESULTS: No differences were observed in preoperative chemotherapy and steatosis, total warm ischemia time, operative time, or blood loss. Kinetics of transaminases (aspartate aminotransferase, P = .137; alanine aminotransferase, P = .616), bilirubin (P = .980), and hyaluronic acid increase (P = .514) revealed no differences. Significant apoptosis was present in 40% of patients, mild-to-moderate leukocyte infiltration and steatosis in 45% and 55%, respectively, and mild sinusoidal congestion in 65%, with a similar distribution in the 3 groups. When patients were stratified by major versus minor resections, no differences were observed in any of the variables studied. Postoperative clinical outcomes were also similar. CONCLUSION: These results suggest that these protocols of IPC and APC used in this study do not provide better cytoprotection from IR when INT is used.


Assuntos
Hepatectomia/métodos , Precondicionamento Isquêmico/métodos , Neoplasias Hepáticas/cirurgia , Traumatismo por Reperfusão/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Inalatórios/administração & dosagem , Caspase 3/metabolismo , Feminino , Hepatectomia/efeitos adversos , Humanos , Fígado/irrigação sanguínea , Fígado/lesões , Fígado/fisiopatologia , Testes de Função Hepática , Masculino , Éteres Metílicos/administração & dosagem , Pessoa de Meia-Idade , Óxido Nítrico Sintase Tipo II/genética , RNA Mensageiro/genética , RNA Mensageiro/metabolismo , Sevoflurano
13.
Anesthesiology ; 121(2): 219-31, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24901240

RESUMO

BACKGROUND: No externally validated risk score for postoperative pulmonary complications (PPCs) is currently available. The authors tested the generalizability of the Assess Respiratory Risk in Surgical Patients in Catalonia risk score for PPCs in a large European cohort (Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe). METHODS: Sixty-three centers recruited 5,859 surgical patients receiving general, neuraxial, or plexus block anesthesia. The Assess Respiratory Risk in Surgical Patients in Catalonia factors (age, preoperative arterial oxygen saturation in air, acute respiratory infection during the previous month, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration, and emergency surgery) were recorded, along with PPC occurrence (respiratory infection or failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis). Discrimination, calibration, and diagnostic accuracy measures of the Assess Respiratory Risk in Surgical Patients in Catalonia score's performance were calculated for the Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe cohort and three subsamples: Spain, Western Europe, and Eastern Europe. RESULTS: The full Prospective Evaluation of a RIsk Score for postoperative pulmonary COmPlications in Europe data set included 5,099 patients; 725 PPCs were recorded for 404 patients (7.9%). The score's discrimination was good: c-statistic (95% CI), 0.80 (0.78 to 0.82). Predicted versus observed PPC rates for low, intermediate, and high risk were 0.87 and 3.39% (score <26), 7.82 and 12.98% (≥ 26 and <45), and 38.13 and 38.01% (≥ 45), respectively; the positive likelihood ratio for a score of 45 or greater was 7.12 (5.93 to 8.56). The score performed best in the Western Europe subsample-c-statistic, 0.87 (0.83 to 0.90) and positive likelihood ratio, 11.56 (8.63 to 15.47)-and worst in the Eastern Europe subsample. The predicted (5.5%) and observed (5.7%) PPC rates were most similar in the Spain subsample. CONCLUSIONS: The Assess Respiratory Risk in Surgical Patients in Catalonia score predicts three levels of PPC risk in hospitals outside the development setting. Performance differs between geographic areas.


Assuntos
Pneumopatias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/complicações , Calibragem , Estudos de Coortes , Coleta de Dados , Emergências , Feminino , Humanos , Tempo de Internação , Pneumopatias/etiologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Controle de Qualidade , Infecções Respiratórias/complicações , Medição de Risco , Fatores de Risco , Tamanho da Amostra
14.
Curr Opin Anaesthesiol ; 27(2): 201-9, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24419159

RESUMO

PURPOSE OF REVIEW: This review of progress toward reliable prediction of postoperative pulmonary complications (PPCs) discusses risk assessment against the background of patient management strategies, clinical outcomes, and cost of healthcare. RECENT FINDINGS: Among the variety of conditions grouped as PPCs are pneumonia, aspiration pneumonitis, respiratory failure, reintubation within 48 h, weaning failure, pleural effusion, atelectasis, bronchospasm, and pneumothorax. PPC incidence rates range from 2 to 40% depending on context. These events increase mortality, postoperative length of stay, ICU admissions, hospital readmissions, and costs. PPC-associated mortality varies, but can reach as high as 48% in some contexts. ICU admission rates are between 9.5 and 91% higher in patients with PPCs. The mean increase in PPC-related postoperative length of stay is approximately 8 days. The cost of surgery can be two-fold to 12-fold higher when PPCs develop. Strategies proposed to reduce the impact of modifiable risk factors include alcohol and smoking abstinence before surgery, shortening the duration of surgery, and physiotherapy and incentive spirometry techniques; however, little scientific evidence supports them at this time. SUMMARY: PPCs are associated with a higher incidence of life-threatening events and higher costs. Reliable PPC risk-stratification tools are essential for guiding clinical decision-making in the perioperative period. The care team can act on modifiable factors and optimize vigilance over nonmodifiable ones. It would be useful to focus resources on determining whether low-cost preemptive interventions improve outcomes satisfactorily or new strategies need to be developed.


Assuntos
Pneumopatias/etiologia , Complicações Pós-Operatórias/etiologia , Custos de Cuidados de Saúde , Humanos , Pneumopatias/mortalidade , Programas de Assistência Gerenciada , Respiração com Pressão Positiva , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/mortalidade , Fatores de Risco , Resultado do Tratamento
15.
Eur J Anaesthesiol ; 31(3): 143-52, 2014 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-24247414

RESUMO

BACKGROUND: Airway assessment and management are cornerstones of anaesthesia, yet airway complications remain an important source of morbidity. OBJECTIVE: We performed a before-and-after evaluation of a collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia. DESIGN: A prospective, multicentre before-and-after evaluation of a collaborative intervention. SETTING: Collaborative intervention to improve adherence to airway assessment and management guidelines in patients scheduled for surgery under general anaesthesia. Data were collected on 21 consecutive days before and after the intervention. PARTICIPANTS: Anaesthetists with staff or residency positions at 22 hospitals. Patients aged 18 years or older undergoing nonemergency surgery were recruited. INTERVENTION: Establishing a learning network that included local leaders, meetings to share experiences and knowledge, interactive sessions and provision of printed materials on airway assessment and management. Clinical airway management for general anaesthesia was provided by the anaesthetists participating in the study. MAIN OUTCOME MEASURES: Outcomes were the completion of airway assessment at the preanaesthetic visit, rates of unanticipated difficult airway, algorithm adherence and related airway complications. RESULTS: The study included 3753 patients (1947 preintervention and 1806 postintervention). The percentage of patients with a complete airway assessment increased from 25.1% preintervention to 48.4% postintervention (P <0.001). The incidences of unanticipated difficult airway were 4.1% before the intervention and 3% after it (P = 0.433). Rates of adherence to the algorithms for anticipated and unanticipated difficult airway management were similar in the two periods. The incidences of related adverse events were also similar. CONCLUSION: The collaborative intervention was effective in improving airway assessment but not in changing difficult airway management practices.


Assuntos
Manuseio das Vias Aéreas/métodos , Anestesia Geral/métodos , Anestesiologia/métodos , Guias de Prática Clínica como Assunto , Adulto , Idoso , Algoritmos , Anestesia Geral/efeitos adversos , Comportamento Cooperativo , Feminino , Fidelidade a Diretrizes , Humanos , Internato e Residência , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
17.
Rev. esp. anestesiol. reanim ; 58(10): 571-577, dic. 2011. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-138753

RESUMO

Introducción: tradicionalmente se ha relacionado el uso de bloqueantes neuromusculares con la posibilidad de aparición de complicaciones respiratorias, aunque establecer este tipo de conclusiones requiere de la elaboración de estudios complejos, con una muestra importante. En este estudio se pretende analizar los datos obtenidos del estudio ARISCAT para ofrecer una visión global del uso de bloqueantes neuromusculares (BNM) y de su reversión en Cataluña. Material y Métodos: de los datos obtenidos en el estudio ARISCAT se han analizado los relacionados con el uso de BNM. Se agruparon a los pacientes en cuatro grupos: NO-BNM si no se había administrado ningún BNM, SC si los pacientes habían recibido únicamente succinilcolina como BNM, BNM-DU si habían recibido una única dosis de BNM no despolarizante y BNM-DR más de una dosis de BNM no despolarizante o administración en perfusión continua. Se analizaron las características demográficas, clínicas y quirúrgicas y las complicaciones intra y postoperatorias en cada uno de los grupos. También se analizaron estas variables en función de si hubo o no reversión. Resultados: de los 2991 pacientes incluidos en el estudio ARISCAT, 1545 fueron sometidos a anestesia general o combinada. De éstos, 1267 (89%) recibieron BNM y en el 54.4% de ellos se realizó reversión con anticolinesterásicos. La distribución de los pacientes fue: NO-BNM (n=103), SC (n=31), BNM-DU (n=527) y BNM DR (n=709). Este último grupo presentó más patología asociada, una duración más prolongada de la cirugía, un mayor número de complicaciones intra y postoperables, y una mayor estancia hospitalaria. La reversión fue significativamente más frecuente en cirugía cardiotorácica y abdominal superior. No se encontraron diferencias en las complicaiones entre ambos grupos. Conclusiones: el uso de bloqueantes neuromusculares no despolarizantes es muy frecuente en Cataluña durante la anestesia general y está asociado a la duración y el tipo de cirugía. El uso de reversión farmacológica de los BNM es relativamente alto en Cataluña respecto a otras zonas geográficas (AU)


BACKGROUND AND OBJECTIVE: Neuromuscular blockers (NMBs) have traditionally been thought to increase the risk of respiratory complications, although drawing conclusions in this respect would require complex studies in large patient samples. The aim of this study was to analyze data from the ARISCAT study to obtain an overall picture of how NMBs are being used and blocks are reversed in Catalonia, Spain. MATERIAL AND METHODS: NMB use as reflected in data from the ARISCAT study was analyzed. Case information from the database was organized into 4 groups: for patients not receiving a NMB (No-NMB), patients whose NMB block was performed with succinylcholine alone (SC), patients who received a single dose of a nondepolarizing NMB (SD-NMB), and patients who received additional doses of a nondepolarizing NMB or a continuous perfusion (AD-NMB). We analyzed patient characteristics, clinical and surgical characteristics, and complications during and after surgery in each of the groups. Variables were also analyzed according to whether the NMB effect had to be reversed. RESULTS: Of the 2991 patients included in the ARISCAT study, 1545 received general or combined anesthesia. Of the 1545 patients, 1267 (89%) received a NMB and the block was reversed with an anticholinesterase agent in 54%. The group distribution was as follows: No-NMB, 103 patients; SC, 31; SD-NMB, 527; and AD-NMB, 709. The highest rate of comorbidity, longest duration of surgery, highest rate of complications during and after surgery, and the longest hospital stays were observed in the last of the 4 groups (AD-NMB). Reversion was required significantly more often after cardiothoracic and upper abdominal surgical procedures; the complication rates after those 2 types of surgery were statistically similar. CONCLUSIONS: Nondepolarizing NMBs are used in combination with general anesthesia often in Catalonia; their use is associated with duration and type of surgery. A reversal drug is administered relatively more often in Catalonia than in other geographic areas (AU)


Assuntos
Feminino , Humanos , Masculino , Fármacos Neuromusculares/administração & dosagem , Fármacos Neuromusculares/efeitos adversos , Fármacos Neuromusculares/uso terapêutico , Bloqueadores Neuromusculares/efeitos adversos , Bloqueadores Neuromusculares/uso terapêutico , Succinilcolina/uso terapêutico , Fármacos Neuromusculares Despolarizantes/uso terapêutico , Doenças Respiratórias/complicações , Doenças Respiratórias/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Complicações Intraoperatórias/tratamento farmacológico , Inibidores da Colinesterase/uso terapêutico
19.
Anesthesiology ; 113(6): 1338-50, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21045639

RESUMO

BACKGROUND: Current knowledge of the risk for postoperative pulmonary complications (PPCs) rests on studies that narrowly selected patients and procedures. Hypothesizing that PPC occurrence could be predicted from a reduced set of perioperative variables, we aimed to develop a predictive index for a broad surgical population. METHODS: Patients undergoing surgical procedures given general, neuraxial, or regional anesthesia in 59 hospitals were randomly selected for this prospective, multicenter study. The main outcome was the development of at least one of the following: respiratory infection, respiratory failure, bronchospasm, atelectasis, pleural effusion, pneumothorax, or aspiration pneumonitis. The cohort was randomly divided into a development subsample to construct a logistic regression model and a validation subsample. A PPC predictive index was constructed. RESULTS: Of 2,464 patients studied, 252 events were observed in 123 (5%). Thirty-day mortality was higher in patients with a PPC (19.5%; 95% [CI], 12.5-26.5%) than in those without a PPC (0.5%; 95% CI, 0.2-0.8%). Regression modeling identified seven independent risk factors: low preoperative arterial oxygen saturation, acute respiratory infection during the previous month, age, preoperative anemia, upper abdominal or intrathoracic surgery, surgical duration of at least 2 h, and emergency surgery. The area under the receiver operating characteristic curve was 90% (95% CI, 85-94%) for the development subsample and 88% (95% CI, 84-93%) for the validation subsample. CONCLUSION: The risk index based on seven objective, easily assessed factors has excellent discriminative ability. The index can be used to assess individual risk of PPC and focus further research on measures to improve patient care.


Assuntos
Pneumopatias/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia , Estudos de Coortes , Coleta de Dados/normas , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Pneumopatias/epidemiologia , Pneumopatias/mortalidade , Masculino , Pessoa de Meia-Idade , População , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Respiração Artificial , Fatores de Risco , Tamanho da Amostra , Estações do Ano , Espanha/epidemiologia , Resultado do Tratamento
20.
Reg Anesth Pain Med ; 34(4): 357-60, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-19574869

RESUMO

BACKGROUND AND OBJECTIVES: In different peripheral nerve blocks, it has been speculated that needle guidance by ultrasound improves onset time and success rate compared with the more frequently used nerve stimulation-guided technique. In the present study, we tested the hypothesis that ultrasound guidance improves onset time of coracoid infraclavicular brachial plexus block (IBPB) when compared with a nerve stimulation-guided technique. METHODS: Seventy patients scheduled for hand or forearm surgery were randomly assigned to receive coracoid IBPB using either ultrasound guidance (group U, n = 35), or nerve stimulation (group S, n = 35). Patients were assessed for sensory and motor block every 5 mins after injection of local anesthetic. Onset time, the primary end point, was defined as the time required for complete sensory and motor block. Time required to perform the block, success rate, and time to resolution of motor blockade were also recorded (secondary end points). RESULTS: Onset of complete sensory and motor blockade was similar in the 2 groups (17 mins [8 mins] in group U and 19 mins [8 mins] in group S; P = 0.321). Time required to perform the block was shorter in group U (3 mins [1 min]) as compared with group S (6 mins [2 mins]; P < 0.0001). No differences were observed in success rate (89% in group U and 91% in group S; P = 0.881) and time to resolution of motor blockade (237 mins [45 mins] in group U and 247 mins [57 mins] in group S; P = 0.418). CONCLUSIONS: The present investigation demonstrates that ultrasound guidance and nerve stimulation provide similar onset time, success rate, and duration of motor blockade for coracoid IBPB; however, ultrasound guidance reduces the time required to perform the block.


Assuntos
Bloqueio Nervoso/métodos , Estimulação Elétrica Nervosa Transcutânea/instrumentação , Ultrassonografia de Intervenção/métodos , Plexo Braquial , Clavícula , Feminino , Antebraço/cirurgia , Mãos/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Punções/métodos , Método Simples-Cego , Fatores de Tempo , Estimulação Elétrica Nervosa Transcutânea/métodos , Punho/cirurgia
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