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1.
JAMA ; 327(24): 2403-2412, 2022 06 28.
Artigo em Inglês | MEDLINE | ID: mdl-35665794

RESUMO

Importance: Intraoperative handovers of anesthesia care are common. Handovers might improve care by reducing physician fatigue, but there is also an inherent risk of losing critical information. Large observational analyses report associations between handover of anesthesia care and adverse events, including higher mortality. Objective: To determine the effect of handovers of anesthesia care on postoperative morbidity and mortality. Design, Setting, and Participants: This was a parallel-group, randomized clinical trial conducted in 12 German centers with patients enrolled between June 2019 and June 2021 (final follow-up, July 31, 2021). Eligible participants had an American Society of Anesthesiologists physical status 3 or 4 and were scheduled for major inpatient surgery expected to last at least 2 hours. Interventions: A total of 1817 participants were randomized to receive either a complete handover to receive anesthesia care by another clinician (n = 908) or no handover of anesthesia care (n = 909). None of the participating institutions used a standardized handover protocol. Main Outcomes and Measures: The primary outcome was a 30-day composite of all-cause mortality, hospital readmission, or serious postoperative complications. There were 19 secondary outcomes, including the components of the primary composite, along with intensive care unit and hospital lengths of stay. Results: Among 1817 randomized patients, 1772 (98%; mean age, 66 [SD, 12] years; 997 men [56%]; and 1717 [97%] with an American Society of Anesthesiologists physical status of 3) completed the trial. The median total duration of anesthesia was 267 minutes (IQR, 206-351 minutes), and the median time from start of anesthesia to first handover was 144 minutes in the handover group (IQR, 105-213 minutes). The composite primary outcome occurred in 268 of 891 patients (30%) in the handover group and in 284 of 881 (33%) in the no handover group (absolute risk difference [RD], -2.5%; 95% CI, -6.8% to 1.9%; odds ratio [OR], 0.89; 95% CI, 0.72 to 1.10; P = .27). Nineteen of 889 patients (2.1%) in the handover group and 30 of 873 (3.4%) in the no handover group experienced all-cause 30-day mortality (absolute RD, -1.3%; 95% CI, -2.8% to 0.2%; OR, 0.61; 95% CI, 0.34 to 1.10; P = .11); 115 of 888 (13%) vs 136 of 872 (16%) were readmitted to the hospital (absolute RD, -2.7%; 95% CI, -5.9% to 0.6%; OR, 0.80; 95% CI, 0.61 to 1.05; P = .12); and 195 of 890 (22%) vs 189 of 874 (22%) experienced serious postoperative complications (absolute RD, 0.3%; 95% CI, -3.6% to 4.1%; odds ratio, 1.02; 95% CI, 0.81 to 1.28; P = .91). None of the 19 prespecified secondary end points differed significantly. Conclusions and Relevance: Among adults undergoing extended surgical procedures, there was no significant difference between the patients randomized to receive handover of anesthesia care from one clinician to another, compared with the no handover group, in the composite primary outcome of mortality, readmission, or serious postoperative complications within 30 days. Trial Registration: ClinicalTrials.gov Identifier: NCT04016454.


Assuntos
Anestesia , Anestesiologia , Transferência da Responsabilidade pelo Paciente , Idoso , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia/estatística & dados numéricos , Anestesiologia/estatística & dados numéricos , Feminino , Alemanha/epidemiologia , Humanos , Unidades de Terapia Intensiva , Cuidados Intraoperatórios , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/mortalidade , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Transferência da Responsabilidade pelo Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade
2.
Ann Intern Med ; 2022 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-35696684

RESUMO

BACKGROUND: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING: 46 U.S. and Canadian hospitals. PARTICIPANTS: Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION: Spinal or general anesthesia. MEASUREMENTS: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION: Missing outcome data and multiple outcomes assessed. CONCLUSION: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

3.
Anesth Analg ; 135(1): e5, 2022 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-35709458
4.
J Pediatr Surg ; 2022 Apr 12.
Artigo em Inglês | MEDLINE | ID: mdl-35568523

RESUMO

BACKGROUND: It is unknown whether racial/ethnic disparities exist in surgical utilization for children. The aim, therefore, was to evaluate the odds of surgery among children in the US by race/ethnicity to test the hypothesis that minority children have less surgery. METHODS: Cross-sectional data were analyzed on children 0-18 years old from the 1999 to 2018 National Health Interview Survey, a large, nationally representative survey. The primary outcome was odds of surgery in the prior 12 months for non Latino African-American, Asian, and Latino children, compared with non Latino White children, after adjustment for relevant covariates. The National Surgical Quality Improvement Program Pediatric Dataset was used to analyze the odds of emergent/urgent surgery by race/ethnicity. RESULTS: Data for 219,098 children were analyzed, of whom 10,644 (4.9%) received surgery. After adjustment for relevant covariates, African-American (AOR, 0.54; 95% CI, 0.50-0.59), Asian (AOR, 0.39; 95% CI, 0.33-0.46), and Latino (AOR, 0.62; 95% CI, 0.57-0.67) children had lower odds of surgery than White children. Latino children were more likely to require emergent or urgent surgery (AOR, 1.71; 95% CI, 1.68-1.74). CONCLUSIONS: Latino, African-American, and Asian children have significantly lower adjusted odds of having surgery than White children in America, and Latino children were more likely to have emergent or urgent surgery. These racial/ethnic differences in surgery may reflect disparities in healthcare access which should be addressed through further research, ongoing monitoring, targeted interventions, and quality-improvement efforts. LEVEL OF EVIDENCE: II. TYPE OF STUDY: Prognosis study.

7.
Anesth Analg ; 2022 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-35417425

RESUMO

BACKGROUND: Two trials reported that a high inspiratory oxygen fraction (Fio2) does not promote myocardial infarction or death. Observational studies can provide larger statistical strength, but associations can be due to unobserved confounding. Therefore, we evaluated the association between intraoperative Fio2 and cardiovascular complications in a large international cohort study to see if spurious associations were observed. METHODS: We included patients from the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were ≥45 years of age, scheduled for overnight hospital admission, and had intraoperative Fio2 recorded. The primary outcome was myocardial injury after noncardiac surgery (MINS), and secondary outcomes included mortality and pneumonia, all within 30 postoperative days. Data were analyzed with logistic regression, adjusted for many baseline cardiovascular risk factors, and illustrated in relation to findings from 2 recent controlled trials. RESULTS: We included 6588 patients with mean age of 62 years of whom 49% had hypertension. The median intraoperative Fio2 was 0.46 (5%-95% range, 0.32-0.94). There were 808 patients (12%) with MINS. Each 0.10 increase in median Fio2 was associated with a confounder-adjusted increase in odds for MINS: odds ratio (OR), 1.17 (95% confidence interval [CI], 1.12-1.23; P < .0001). MINS occurred in contrast with similar frequencies and no significant difference in controlled trials (2240 patients, 194 events), in which patients were given 80% vs 30% oxygen. Mortality was 2.4% and was not significantly associated with a median Fio2 (OR, 1.07; 95% CI, 0.97-1.19 per 0.10 increase; P = .18), and 2.9% of patients had pneumonia (OR, 1.05; 95% CI, 0.95-1.15 per 0.10 increase; P = .34). CONCLUSIONS: We observed an association between intraoperative Fio2 and risk of myocardial injury within 30 days after noncardiac surgery, which contrasts with recent controlled clinical trials. Fio2 was not significantly associated with mortality or pneumonia. Unobserved confounding presumably contributed to the observed association between Fio2 and myocardial injury that is not supported by trials.

8.
N Engl J Med ; 386(21): 1986-1997, 2022 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-35363452

RESUMO

BACKGROUND: Perioperative bleeding is common in patients undergoing noncardiac surgery. Tranexamic acid is an antifibrinolytic drug that may safely decrease such bleeding. METHODS: We conducted a trial involving patients undergoing noncardiac surgery. Patients were randomly assigned to receive tranexamic acid (1-g intravenous bolus) or placebo at the start and end of surgery (reported here) and, with the use of a partial factorial design, a hypotension-avoidance or hypertension-avoidance strategy (not reported here). The primary efficacy outcome was life-threatening bleeding, major bleeding, or bleeding into a critical organ (composite bleeding outcome) at 30 days. The primary safety outcome was myocardial injury after noncardiac surgery, nonhemorrhagic stroke, peripheral arterial thrombosis, or symptomatic proximal venous thromboembolism (composite cardiovascular outcome) at 30 days. To establish the noninferiority of tranexamic acid to placebo for the composite cardiovascular outcome, the upper boundary of the one-sided 97.5% confidence interval for the hazard ratio had to be below 1.125, and the one-sided P value had to be less than 0.025. RESULTS: A total of 9535 patients underwent randomization. A composite bleeding outcome event occurred in 433 of 4757 patients (9.1%) in the tranexamic acid group and in 561 of 4778 patients (11.7%) in the placebo group (hazard ratio, 0.76; 95% confidence interval [CI], 0.67 to 0.87; absolute difference, -2.6 percentage points; 95% CI, -3.8 to -1.4; two-sided P<0.001 for superiority). A composite cardiovascular outcome event occurred in 649 of 4581 patients (14.2%) in the tranexamic acid group and in 639 of 4601 patients (13.9%) in the placebo group (hazard ratio, 1.02; 95% CI, 0.92 to 1.14; upper boundary of the one-sided 97.5% CI, 1.14; absolute difference, 0.3 percentage points; 95% CI, -1.1 to 1.7; one-sided P = 0.04 for noninferiority). CONCLUSIONS: Among patients undergoing noncardiac surgery, the incidence of the composite bleeding outcome was significantly lower with tranexamic acid than with placebo. Although the between-group difference in the composite cardiovascular outcome was small, the noninferiority of tranexamic acid was not established. (Funded by the Canadian Institutes of Health Research and others; POISE-3 ClinicalTrials.gov number, NCT03505723.).


Assuntos
Antifibrinolíticos , Ácido Tranexâmico , Antifibrinolíticos/efeitos adversos , Antifibrinolíticos/uso terapêutico , Canadá , Hemorragia/etiologia , Hemorragia/prevenção & controle , Humanos , Procedimentos Cirúrgicos Operatórios , Trombose/induzido quimicamente , Trombose/tratamento farmacológico , Ácido Tranexâmico/efeitos adversos , Ácido Tranexâmico/uso terapêutico
9.
Lancet ; 399(10337): 1799-1808, 2022 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-35390321

RESUMO

BACKGROUND: Moderate intraoperative hypothermia promotes myocardial injury, surgical site infections, and blood loss. Whether aggressive warming to a truly normothermic temperature near 37°C improves outcomes remains unknown. We aimed to test the hypothesis that aggressive intraoperative warming reduces major perioperative complications. METHODS: In this multicentre, parallel group, superiority trial, patients at 12 sites in China and at the Cleveland Clinic in the USA were randomly assigned (1:1) to receive either aggressive warming to a target core temperature of 37°C (aggressively warmed group) or routine thermal management to a target of 35·5°C (routine thermal management group) during non-cardiac surgery. Randomisation was stratified by site, with computer-generated, randomly sized blocks. Eligible patients (aged ≥45 years) had at least one cardiovascular risk factor, were scheduled for inpatient non-cardiac surgery expected to last 2-6 h with general anaesthesia, and were expected to have at least half of the anterior skin surface available for warming. Patients requiring dialysis and those with a body-mass index exceeding 30 kg/m2 were excluded. The primary outcome was a composite of myocardial injury (troponin elevation, apparently of ischaemic origin), non-fatal cardiac arrest, and all-cause mortality within 30 days of surgery, as assessed in the modified intention-to-treat population. This study is registered with ClinicalTrials.gov, NCT03111875. FINDINGS: Between March 27, 2017, and March 16, 2021, 5056 participants were enrolled, of whom 5013 were included in the intention-to-treat population (2507 in the aggressively warmed group and 2506 in the routine thermal management group). Patients assigned to aggressive warming had a mean final intraoperative core temperature of 37·1°C (SD 0·3) whereas the routine thermal management group averaged 35·6°C (SD 0·3). At least one of the primary outcome components (myocardial injury after non-cardiac surgery, cardiac arrest, or mortality) occurred in 246 (9·9%) of 2497 patients in the aggressively warmed group and in 239 (9·6%) of 2490 patients in the routine thermal management group. The common effect relative risk of aggressive versus routine thermal management was an estimated 1·04 (95% CI 0·87-1·24, p=0·69). There were 39 adverse events in patients assigned to aggressive warming (17 of which were serious) and 54 in those assigned to routine thermal management (30 of which were serious). One serious adverse event, in an aggressively warmed patient, was deemed to be possibly related to thermal management. INTERPRETATION: The incidence of a 30-day composite of major cardiovascular outcomes did not differ significantly in patients randomised to 35·5°C and to 37°C. At least over a 1·5°C range from very mild hypothermia to full normothermia, there was no evidence that any substantive outcome varied. Keeping core temperature at least 35·5°C in surgical patients appears sufficient. FUNDING: 3M and the Health and Medical Research Fund, Food and Health Bureau, Hong Kong. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.


Assuntos
Hipotermia , Anestesia Geral/efeitos adversos , China/epidemiologia , Hemorragia/etiologia , Humanos , Hipotermia/etiologia , Hipotermia/prevenção & controle , Infecção da Ferida Cirúrgica
10.
J Clin Anesth ; 79: 110715, 2022 08.
Artigo em Inglês | MEDLINE | ID: mdl-35306353

RESUMO

STUDY OBJECTIVE: Postinduction and intraoperative hypotension are associated with organ injury in non-cardiac surgery patients. Automated ambulatory blood pressure monitoring can identify chronic arterial hypertension and nocturnal blood pressure non-dipping. We tested the hypotheses that: a) chronic arterial hypertension and nocturnal non-dipping are independent risk factors for postinduction and intraoperative hypotension; and b) adding information on chronic arterial hypertension and nocturnal non-dipping improves hypotension prediction models based on readily available preoperative clinical information. DESIGN: Prediction model development based on a secondary analysis of a prospective observational study. SETTING: German university medical center. PATIENTS: 366 non-cardiac surgery patients who had preoperative automated ambulatory blood pressure monitoring. MEASUREMENTS: Multivariable analyses to identify risk factors for postinduction and intraoperative hypotension. Area under receiver operating characteristics curves (AUROC) and likelihood-ratio tests to test whether adding information on chronic arterial hypertension and nocturnal non-dipping improves hypotension prediction models based on readily available preoperative clinical information. MAIN RESULTS: Risk factors for postinduction hypotension were age in years (odds ratio: 1.06 (95% confidence interval: 1.03 to 1.10), P = 0.001), American Society of Anesthesiologists physical status class (1.85 (1.02 to 3.35), P = 0.043), preoperative use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (15.19 (1.76 to 131.46), P = 0.013), chronic arterial hypertension (2.54 (1.49 to 4.34), P = 0.001), and nocturnal non-dipping (3.61 (2.09 to 6.23), P < 0.001). The model's AUROC was 0.76 (95% confidence interval: 0.71 to 0.81) with and 0.67 (0.62 to 0.73) without information on chronic arterial hypertension and nocturnal non-dipping (P < 0.001). Risk factors for intraoperative hypotension were male sex (1.73 (1.07 to 2.80), P = 0.025), chronic arterial hypertension (4.35 (2.33 to 8.14), P < 0.001), and nocturnal non-dipping (3.56 (2.07 to 6.11), P < 0.001). The model's AUROC was 0.76 (0.70 to 0.81) with and 0.63 (0.57 to 0.69) without information on chronic arterial hypertension and nocturnal non-dipping (P < 0.001). CONCLUSIONS: Chronic arterial hypertension and nocturnal non-dipping are independent risk factors for postinduction and intraoperative hypotension in non-cardiac surgery patients. Adding information on chronic arterial hypertension and nocturnal non-dipping moderately improved hypotension prediction models based on preoperative clinical information.


Assuntos
Hipertensão , Hipotensão , Pressão Sanguínea/fisiologia , Monitorização Ambulatorial da Pressão Arterial , Feminino , Humanos , Hipertensão/epidemiologia , Hipertensão/etiologia , Hipotensão/diagnóstico , Hipotensão/epidemiologia , Hipotensão/etiologia , Masculino , Estudos Prospectivos
11.
Anesth Analg ; 2022 Feb 07.
Artigo em Inglês | MEDLINE | ID: mdl-35130198

RESUMO

BACKGROUND: The risk of myocardial injury progressively increases at intraoperative mean arterial pressures (MAPs) ≤65 mm Hg. Higher pressures might be required in chronically hypertensive patients. We aimed to test the hypothesis that the harm threshold is higher in patients with chronic hypertension than in normotensive patients. METHODS: We conducted a single-center retrospective cohort analysis of adults >45 years old who had noncardiac surgery between 2010 and 2018 and scheduled, rather than symptom-driven, postoperative troponin measurements. The MAP thresholds under which risk started to increase were compared between patients with chronic hypertension (baseline MAP ≥110 mm Hg) and normotensive patients (baseline MAP <110 mm Hg). The primary outcome was a composite of in-hospital mortality and myocardial injury within 30 days, defined by any postoperative 4th-generation troponin T measurement ≥0.03 ng/mL apparently due to cardiac ischemia. Multivariable logistic regression and moving average smoothing methods were used to evaluate confounder-adjusted associations between the composite outcome and the lowest intraoperative MAP sustained for either 5 or 10 cumulative minutes, and whether the relationship depended on baseline pressure (normotensive versus hypertensive). RESULTS: Among 4576 eligible surgeries, 2066 were assigned to the normotensive group with mean (standard deviation [SD]) baseline MAP of 100 (7) mm Hg, and 2510 were assigned to the hypertensive group with mean baseline MAP of 122 (10) mm Hg. The overall incidence of the composite outcome was 5.6% in normotensive and 6.0% in hypertensive patients (P = .55). The relationship between intraoperative hypotension and the composite outcome was not found to depend on baseline MAP in a multivariable mixed effects logistic regression model. Furthermore, no statistical change points were found for either baseline MAP group. CONCLUSIONS: Baseline blood pressure of the hypertensive patients was only moderately increased on average, and the event rate was low. Nonetheless, we were not able to demonstrate a difference in the harm threshold between normotensive and chronically hypertensive patients. Our results do not support the theory that hypertensive patients should be kept at higher intraoperative pressures than normotensive patients.

12.
PLoS One ; 17(2): e0262264, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35108291

RESUMO

We estimated excess mortality in Medicare recipients in the United States with probable and confirmed Covid-19 infections in the general community and amongst residents of long-term care (LTC) facilities. We considered 28,389,098 Medicare and dual-eligible recipients from one year before February 29, 2020 through September 30, 2020, with mortality followed through November 30th, 2020. Probable and confirmed Covid-19 diagnoses, presumably mostly symptomatic, were determined from ICD-10 codes. We developed a Risk Stratification Index (RSI) mortality model which was applied prospectively to establish baseline mortality risk. Excess deaths attributable to Covid-19 were estimated by comparing actual-to-expected deaths based on historical (2017-2019) comparisons and in closely matched concurrent (2020) cohorts with and without Covid-19. Overall, 677,100 (2.4%) beneficiaries had confirmed Covid-19 and 2,917,604 (10.3%) had probable Covid-19. A total of 472,329 confirmed cases were community living and 204,771 were in LTC. Mortality following a probable or confirmed diagnosis in the community increased from an expected incidence of about 4.0% to actual incidence of 7.5%. In long-term care facilities, the corresponding increase was from 20.3% to 24.6%. The absolute increase was therefore similar at 3-4% in the community and in LTC residents. The percentage increase was far greater in the community (89.5%) than among patients in chronic care facilities (21.1%) who had higher baseline risk of mortality. The LTC population without probable or confirmed Covid-19 diagnoses experienced 38,932 excess deaths (34.8%) compared to historical estimates. Limitations in access to Covid-19 testing and disease under-reporting in LTC patients probably were important factors, although social isolation and disruption in usual care presumably also contributed. Remarkably, there were 31,360 (5.4%) fewer deaths than expected in community dwellers without probable or confirmed Covid-19 diagnoses. Disruptions to the healthcare system and avoided medical care were thus apparently offset by other factors, representing overall benefit. The Covid-19 pandemic had marked effects on mortality, but the effects were highly context-dependent.


Assuntos
COVID-19/mortalidade , Medicare/tendências , Idoso , Idoso de 80 Anos ou mais , COVID-19/economia , Feminino , Humanos , Incidência , Benefícios do Seguro/tendências , Assistência de Longa Duração/tendências , Masculino , Mortalidade , Fatores de Risco , SARS-CoV-2/patogenicidade , Instituições de Cuidados Especializados de Enfermagem/tendências , Estados Unidos
13.
Anesthesiology ; 136(4): 551-566, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35226725

RESUMO

BACKGROUND: Postoperative pulmonary complications are common. Aging and respiratory disease provoke airway hyperresponsiveness, high-risk surgery induces diaphragmatic dysfunction, and general anesthesia contributes to atelectasis and peripheral airway injury. This study therefore tested the hypothesis that inhalation of penehyclidine, a long-acting muscarinic antagonist, reduces the incidence of pulmonary complications in high-risk patients over the initial 30 postoperative days. METHODS: This single-center double-blind trial enrolled 864 patients age over 50 yr who were scheduled for major upper-abdominal or noncardiac thoracic surgery lasting 2 h or more and who had an Assess Respiratory Risk in Surgical Patients in Catalonia score of 45 or higher. The patients were randomly assigned to placebo or prophylactic penehyclidine inhalation from the night before surgery through postoperative day 2 at 12-h intervals. The primary outcome was the incidence of a composite of pulmonary complications within 30 postoperative days, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis. RESULTS: A total of 826 patients (mean age, 64 yr; 63% male) were included in the intention-to-treat analysis. A composite of pulmonary complications was less common in patients assigned to penehyclidine (18.9% [79 of 417]) than those receiving the placebo (26.4% [108 of 409]; relative risk, 0.72; 95% CI, 0.56 to 0.93; P = 0.010; number needed to treat, 13). Bronchospasm was less common in penehyclidine than placebo patients: 1.4% (6 of 417) versus 4.4% (18 of 409; relative risk, 0.327; 95% CI, 0.131 to 0.82; P = 0.011). None of the other individual pulmonary complications differed significantly. Peak airway pressures greater than 40 cm H2O were also less common in patients given penehyclidine: 1.9% (8 of 432) versus 4.9% (21 of 432; relative risk, 0.381; 95% CI, 0.171 to 0.85; P = 0.014). The incidence of other adverse events, including dry mouth and delirium, that were potentially related to penehyclidine inhalation did not differ between the groups. CONCLUSIONS: In high-risk patients having major upper-abdominal or noncardiac thoracic surgery, prophylactic penehyclidine inhalation reduced the incidence of pulmonary complications without provoking complications.


Assuntos
Espasmo Brônquico , Atelectasia Pulmonar , Espasmo Brônquico/induzido quimicamente , Espasmo Brônquico/complicações , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Atelectasia Pulmonar/complicações , Quinuclidinas/efeitos adversos , Quinuclidinas/uso terapêutico
14.
Anesth Analg ; 134(6): 1260-1269, 2022 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-35110515

RESUMO

BACKGROUND: Myocardial injury after coronary artery bypass grafting (CABG) is defined as troponin concentrations >10 times 99th percentile upper reference limit (URL) according to the Fourth Universal Definition. However, troponin concentrations after non-CABG cardiac surgery which indicate greater-than-expected myocardial injury and increased risk for complications remain unclear. Our goal was to assess procedure-specific relationships between troponin T and a composite outcome of low cardiac output syndrome and in-hospital mortality in cardiac surgical patients. METHODS: Patients having cardiac surgery between January 2010 and December 2017 were categorized into 4 groups by procedure: (1) CABG; (2) mitral valve repair; (3) aortic valve repair/replacement (AVR); (4) mitral valve replacement (MVR) or CABG + valve surgeries. Exclusion criteria were elevated preoperative troponin T, preoperative kidney failure, circulatory arrest, or preoperative/planned mechanical circulatory support. Logistic regression was used to assess the association between troponin T and composite outcome, both overall and by procedure, including assessment of the interaction between procedure and troponin T on outcome. RESULTS: Among 10,253 patients, 37 (0.4%) died and 393 (3.8%) developed the primary outcome. Troponin T concentrations differed by procedure (P < .001). Compared to CABG, AVR had 0.53 (99.2% confidence interval [CI], 0.50-0.56; unadjusted P < .001) times lower troponin T concentrations, while MVR/CABG + valve were 1.54 (99.2% CI, 1.45-1.62, unadjusted P < .001) times higher. There were linear relationships between log2 troponin T concentration and log odds mortality/low cardiac output syndrome. The (unadjusted) relationships were parallel for various types of surgery (interaction P = .59), but at different levels of the outcome. CONCLUSIONS: The relative increase in odds for mortality/low cardiac output syndrome per a similar increase in troponin T concentrations did not differ among cardiac surgical procedures, but the absolute troponin T concentrations did. Troponin concentrations should thus be interpreted in context of surgical procedure.


Assuntos
Traumatismos Cardíacos , Implante de Prótese de Valva Cardíaca , Baixo Débito Cardíaco/diagnóstico , Baixo Débito Cardíaco/etiologia , Ponte de Artéria Coronária/métodos , Traumatismos Cardíacos/etiologia , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Troponina , Troponina T
15.
J Clin Med ; 11(2)2022 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-35054148

RESUMO

BACKGROUND: Naloxegol antagonizes peripheral opioid-related side effects without preventing opioid-related analgesia. However, the effect of naloxegol on opioid-induced bladder dysfunction remains unknown. HYPOTHESIS: patients given naloxegol have lower residual bladder urine volume than those given placebo. METHODS: 136 patients scheduled for elective hip and knee surgery were randomized to oral naloxegol or placebo given the morning of surgery, and on the first two postoperative mornings. Residual urine volume was measured ultrasonographically within 30 min after voiding once in the morning and once in the afternoon for two postoperative days. Opioid-related Symptom Distress Scale (ORSDS), the need for indwelling urinary catheterization, and quality of recovery (QoR) score were secondary outcomes. RESULTS: 67 were randomized to naloxegol and 64 to placebo. We did not identify a significant effect on urine residual volume, with an estimated ratio of geometric means of 0.9 (0.3, 2.6), p = 0.84. There were no significant differences in ORSDS or QoR. There were 19 (29%) patients assigned to naloxegol who needed indwelling urination catheterization versus 7 (11%) patients in the placebo group, p = 0.012. CONCLUSIONS: Our results do not support use of naloxegol for postoperative urinary retention after hip and knee surgery.

16.
Eur J Anaesthesiol ; 39(4): 315-323, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35066561

RESUMO

BACKGROUND: Whether intra-operative hypertension causes postoperative complications remains unclear. OBJECTIVE: We sought to assess whether there is an absolute systolic hypertensive threshold associated with increased odds of a composite of postoperative myocardial injury and mortality, and acute kidney injury. DESIGN: A retrospective cohort analysis using an electronic medical record registry. SETTING: The Cleveland Clinic Main Campus, Cleveland, Ohio, USA, between January 2005 and December 2018. PATIENTS: A total of 76 042 adults who had inpatient noncardiac surgery lasting at least an hour, creatinine recorded preoperatively and postoperatively, and had an available clinic blood pressure within 6 months before surgery. MAIN OUTCOME MEASURES: Univariable smoothing and multivariable logistic regression were used to estimate the probability of each outcome as a function of the highest intra-operative pressure for a cumulative 5, 10, or 30 min. We further assessed whether the relationships between intra-operative hypertension and each outcome depended on baseline systolic blood pressure. RESULTS: The composite of myocardial injury and mortality was observed in 1.9%, and acute kidney injury in 4.5% of patients. After adjustment for confounders, there was little or no relationship between systolic pressure and either outcome over the range from 120 to 200 mmHg. There were also no obvious change points or thresholds above which odds of each outcome increased. And finally, there was no interaction with preoperative clinic blood pressure. CONCLUSIONS: There was no clinically meaningful relationship between intra-operative systolic pressure and the composite of myocardial injury and mortality, or acute kidney injury, over the range from 120 and 200 mmHg.


Assuntos
Injúria Renal Aguda , Hipertensão , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Adulto , Estudos de Coortes , Humanos , Hipertensão/complicações , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
17.
Anesth Analg ; 134(5): 1043-1053, 2022 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-35020636

RESUMO

BACKGROUND: Sugammadex and neostigmine given to reverse residual neuromuscular blockade can cause side effects including bradycardia, anaphylaxis, bronchospasm, and even cardiac arrest. We tested the hypothesis that sugammadex is noninferior to neostigmine on a composite of clinically meaningful side effects, or vice versa. METHODS: We analyzed medical records of patients who had general, cardiothoracic, or pediatric surgery and were given neostigmine or sugammadex from June 2016 to December 2019. Our primary outcome was a collapsed composite of bradycardia, anaphylaxis, bronchospasm, and cardiac arrest occurring between administration of the reversal agent and departure from the operation room. We a priori restricted our analysis to side effects requiring pharmacologic treatment that were therefore presumably clinically meaningful. Sugammadex would be considered noninferior to neostigmine (or vice versa) if the odds ratio for composite of side effects did not exceed 1.2. RESULTS: Among 89,753 surgeries in 70,690 patients, 16,480 (18%) were given sugammadex and 73,273 (82%) were given neostigmine. The incidence of composite outcome was 3.4% in patients given sugammadex and 3.0% in patients given neostigmine. The most common individual side effect was bradycardia (2.4% in the sugammadex group versus 2.2% neostigmine). Noninferiority was not found, with an estimated odds ratio of 1.21 (sugammadex versus neostigmine; 95% confidence interval [CI], 1.09-1.34; noninferiority P = .57), and neostigmine was superior to sugammadex with an estimated odds ratio of 0.83 (0.74-0.92), 1-side superiority P < .001. CONCLUSIONS: The composite incidence was less with neostigmine than with sugammadex, but only by 0.4% (a negligible clinical effect). Since 250 patients would need to be given neostigmine rather than sugammadex to avoid 1 episode of a minor complication such as bradycardia or bronchospasm, we conclude that sugammadex and neostigmine are comparably safe.


Assuntos
Neostigmina , Bloqueio Neuromuscular , Sugammadex , Anafilaxia/induzido quimicamente , Bradicardia/induzido quimicamente , Bradicardia/diagnóstico , Bradicardia/epidemiologia , Espasmo Brônquico/induzido quimicamente , Criança , Estudos de Coortes , Recuperação Demorada da Anestesia/induzido quimicamente , Parada Cardíaca/etiologia , Humanos , Neostigmina/efeitos adversos , Bloqueio Neuromuscular/efeitos adversos , Estudos Retrospectivos , Sugammadex/efeitos adversos
18.
Anesthesiology ; 136(1): 93-103, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34843618

RESUMO

BACKGROUND: Age- and sex-specific reference nomograms for intraoperative blood pressure have been published, but they do not identify harm thresholds. The authors therefore assessed the relationship between various absolute and relative characterizations of hypotension and acute kidney injury in children having noncardiac surgery. METHODS: The authors conducted a retrospective cohort study using electronic data from two tertiary care centers. They included inpatients 18 yr or younger who had noncardiac surgery with general anesthesia. Postoperative renal injury was defined using the Kidney Disease Improving Global Outcomes definitions, based on serum creatinine concentrations. The authors evaluated potential renal harm thresholds for absolute lowest intraoperative mean arterial pressure (MAP) or largest MAP reduction from baseline maintained for a cumulative period of 5 min. Separate analyses were performed in children aged 2 yr or younger, 2 to 6 yr, 6 to 12 yr, and 12 to 18 yr. RESULTS: Among 64,412 children who had noncardiac surgery, 4,506 had creatinine assessed preoperatively and postoperatively. The incidence of acute kidney injury in this population was 11% (499 of 4,506): 17% in children under 6 yr old, 11% in children 6 to 12 yr old, and 6% in adolescents, which is similar to the incidence reported in adults. There was no association between lowest cumulative MAP sustained for 5 min and postoperative kidney injury. Similarly, there was no association between largest cumulative percentage MAP reduction and postoperative kidney injury. The adjusted estimated odds for kidney injury was 0.99 (95% CI, 0.94 to 1.05) for each 5-mmHg decrease in lowest MAP and 1.00 (95% CI, 0.97 to 1.03) for each 5% decrease in largest MAP reduction from baseline. CONCLUSIONS: In distinct contrast to adults, the authors did not find any association between intraoperative hypotension and postoperative renal injury. Avoiding short periods of hypotension should not be the clinician's primary concern when trying to prevent intraoperative renal injury in pediatric patients.


Assuntos
Injúria Renal Aguda/fisiopatologia , Pressão Sanguínea/fisiologia , Hipotensão/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Monitorização Intraoperatória/métodos , Injúria Renal Aguda/diagnóstico , Adolescente , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Hipotensão/diagnóstico , Lactente , Complicações Intraoperatórias/diagnóstico , Masculino , Estudos Retrospectivos
19.
Anesthesiology ; 136(1): 127-137, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34724045

RESUMO

BACKGROUND: Colloids are thought to sustain blood pressure and cardiac index better than crystalloids. However, the relative effects of intraoperative hydroxyethyl starch and crystalloid administration on the cardiac index and blood pressure remain unclear. This study therefore tested in this subanalysis of a previously published large randomized trial the hypothesis that intraoperative goal-directed colloid administration increases the cardiac index more than goal-directed crystalloid administration. Further, the effects of crystalloid and colloid boluses on blood pressure were evaluated. METHODS: This planned subanalysis of a previous trial analyzed data from 973 patients, of whom 480 were randomized to colloids and 493 were randomized to crystalloids. Fluid administration was guided by esophageal Doppler. The primary outcome was the time-weighted average cardiac index during surgery between the colloid and crystalloid group. The secondary outcomes were the cardiac index just after bolus administration, time elapsed between boluses, and the average real variability during surgery. The study recorded cardiac index, corrected flow time, and blood pressure at 10-min intervals, as well as before and after each bolus. RESULTS: Time-weighted average of cardiac index over the duration of anesthesia was only slightly greater in patients given colloid than crystalloid, with the difference being just 0.20 l · min-1 · m-2 (95% CI, 0.11 to 0.29; P < 0.001). However, the hazard for needing additional boluses was lower after colloid administration (hazard ratio [95% CI], 0.60 [0.55 to 0.66]; P < 0.001) in a frailty time-to-event model accounting for within-subject correlation. The median [quartiles] number of boluses per patient was 4 [2, 6] for colloids and 6 [3, 8] for crystalloids, with a median difference (95% CI) of -1.5 (-2 to -1; P < 0.001). The average real mean arterial pressure variability did not differ significantly between the groups (difference in means [95% CI] of -0.03 (-0.07 to 0.02) mmHg, P = 0.229). CONCLUSIONS: There were not clinically meaningful differences in the cardiac index or mean pressure variability in patients given goal-directed colloid and crystalloids. As might be expected from longer intravascular dwell time, the interval between boluses was longer with colloids. However, on a case basis, the number of boluses differed only slightly. Colloids do not appear to provide substantial hemodynamic benefit.


Assuntos
Coloides/administração & dosagem , Soluções Cristaloides/administração & dosagem , Hemodinâmica/efeitos dos fármacos , Derivados de Hidroxietil Amido/administração & dosagem , Cuidados Intraoperatórios/métodos , Substitutos do Plasma/administração & dosagem , Adulto , Idoso , Pressão Sanguínea/efeitos dos fármacos , Pressão Sanguínea/fisiologia , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade
20.
Anesthesiology ; 136(1): 115-126, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34780602

RESUMO

BACKGROUND: Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications. METHODS: The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing. RESULTS: A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009). CONCLUSIONS: Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly.


Assuntos
Analgésicos Opioides/administração & dosagem , Limitação da Mobilidade , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Recuperação de Função Fisiológica/efeitos dos fármacos , Adulto , Idoso , Analgésicos Opioides/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/epidemiologia , Recuperação de Função Fisiológica/fisiologia , Estudos Retrospectivos
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