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1.
Biomed Res Int ; 2018: 1978968, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30175118

RESUMO

Objective: To test if splenic Doppler resistive index (SDRI) allows noninvasive monitoring of changes in stroke volume and regional splanchnic perfusion in response to fluid challenge. Design and Setting. Prospective observational study in cardiac intensive care unit. Patients: Fifty-three patients requiring mechanical ventilation and fluid challenge for hemodynamic optimization after cardiac surgery. Interventions: SDRI values were obtained before and after volume loading with 500 mL of normal saline over 20 min and compared with changes in systemic hemodynamics, determined invasively by pulmonary artery catheter, and arterial lactate concentration as expression of splanchnic perfusion. Changes in stroke volume >10% were considered representative of fluid responsiveness. Results: A <4% SDRI reduction excluded fluid responsiveness, with 100% sensitivity and 100% negative predictive value. A >9% SDRI reduction was a marker of fluid responsiveness with 100% specificity and 100% positive predictive value. A >4% SDRI reduction was always associated with an improvement of splanchnic perfusion mirrored by an increase in lactate clearance and a reduction in systemic vascular resistance, regardless of fluid responsiveness. Conclusions: This study shows that SDRI variations after fluid administration is an effective noninvasive tool to monitor systemic hemodynamics and splanchnic perfusion upon volume administration, irrespective of fluid responsiveness in mechanically ventilated patients after cardiac surgery.


Assuntos
Hidratação , Hemodinâmica , Respiração Artificial , Volume Sistólico , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Estudos Prospectivos
3.
Eur J Prev Cardiol ; 25(1_suppl): 32-41, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29708035

RESUMO

Background Gender-related biases in outcomes after thoracic aortic surgery are an important factor to consider in the prevention of potential complications related to aortic diseases and in the analysis of surgical results. Methods The aim of this study is to provide an up-to-date review of gender-related differences in the epidemiology, specific risk factors, outcome, and screening and prevention programmes in aortic aneurysms. Results Female patients affected by aortic disease still have worse outcomes and higher early and late mortality than men. It is difficult to plan new specific strategies to improve outcomes in women undergoing major aortic surgery, given that the true explanations for their poorer outcomes are as yet not clearly identified. Some authors recommend further investigation of hormonal or molecular explanations for the sex differences in aortic disease. Others stress the need for quality improvement projects to quantify the preoperative risk in high-risk populations using non-invasive tests such as cardiopulmonary exercise testing. Conclusions The treatment of patients classified as high risk could thus be optimised before surgery becomes necessary by means of numerous strategies, such as the administration of high-dose statin therapy, antiplatelet treatment, optimal control of hypertension, lifestyle improvement with smoking cessation, weight loss and careful control of diabetes. Future efforts are needed to understand better the gender differences in the diagnosis, management and outcome of aortic aneurysm disease, and for appropriate and modern management of female patients.

4.
Intensive Care Med ; 43(11): 1572-1584, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29149418

RESUMO

PURPOSE: The lateral Trendelenburg position (LTP) may hinder the primary pathophysiologic mechanism of ventilator-associated pneumonia (VAP). We investigated whether placing patients in the LTP would reduce the incidence of VAP in comparison with the semirecumbent position (SRP). METHODS: This was a randomized, multicenter, controlled study in invasively ventilated critically ill patients. Two preplanned interim analyses were performed. Patients were randomized to be placed in the LTP or the SRP. The primary outcome, assessed by intention-to-treat analysis, was incidence of microbiologically confirmed VAP. Major secondary outcomes included mortality, duration of mechanical ventilation, and intensive care unit length of stay. RESULTS: At the second interim analysis, the trial was stopped because of low incidence of VAP, lack of benefit in secondary outcomes, and occurrence of adverse events. A total of 194 patients in the LTP group and 201 in the SRP group were included in the final intention-to-treat analysis. The incidence of microbiologically confirmed VAP was 0.5% (1/194) and 4.0% (8/201) in LTP and SRP patients, respectively (relative risk 0.13, 95% CI 0.02-1.03, p = 0.04). The 28-day mortality was 30.9% (60/194) and 26.4% (53/201) in LTP and SRP patients, respectively (relative risk 1.17, 95% CI 0.86-1.60, p = 0.32). Likewise, no differences were found in other secondary outcomes. Six serious adverse events were described in LTP patients (p = 0.01 vs. SRP). CONCLUSIONS: The LTP slightly decreased the incidence of microbiologically confirmed VAP. Nevertheless, given the early termination of the trial, the low incidence of VAP, and the adverse events associated with the LTP, the study failed to prove any significant benefit. Further clinical investigation is strongly warranted; however, at this time, the LTP cannot be recommended as a VAP preventive measure. CLINICALTRIALS. GOV IDENTIFIER: NCT01138540.


Assuntos
Cuidados Críticos/métodos , Decúbito Inclinado com Rebaixamento da Cabeça/efeitos adversos , Posicionamento do Paciente/métodos , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Idoso , Feminino , Humanos , Incidência , Análise de Intenção de Tratamento , Masculino , Pessoa de Meia-Idade , Posicionamento do Paciente/efeitos adversos , Pneumonia Associada à Ventilação Mecânica/microbiologia , Pneumonia Associada à Ventilação Mecânica/mortalidade , Respiração Artificial/efeitos adversos
5.
Int Heart J ; 58(5): 647-653, 2017 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-28966319

RESUMO

Although improved long-term outcomes obtained with the use of arterial grafts for coronary revascularization in comparison with the traditional association of a single arterial and saphenous vein grafts have been demonstrated in the overall population, the efficacy of this newer technique in the elderly is difficult to prove because their shorter life expectancy due to advanced heart disease, associated with severe comorbidities. Moreover, more widespread use of this technique is limited by the concerns on the potential morbidity, particularly the longer time required to perform the operation and the possibility of deep sternal wound infection in case of bilateral internal thoracic artery harvesting due to the decreased blood supply to the sternum and surrounding tissues.The review of the recent literature indicates that the use of bilateral internal thoracic arteries in very elderly patients should not be considered routinely. It seems reasonable to avoid it in octogenarians in the presence of well-known predictors of sternal complications such as diabetes, morbid obesity, and severe chronic lung disease.There is also still controversy about the superiority of the radial artery over the saphenous vein graft as a second or third conduit for surgical myocardial revascularization, although the majority of recent studies seem to support more liberal use of the radial artery as second arterial conduit in the elderly. Although a clinical benefit of arterial graft revascularization cannot be formally excluded for elderly patients, the increased complexity of this technique suggests that careful clinical judgment is necessary to select grafts for individual patients.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Artéria Torácica Interna/transplante , Artéria Radial/transplante , Idoso , Humanos
7.
Int J Cardiol ; 241: 109-114, 2017 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-28389122

RESUMO

BACKGROUND: The evidence of the benefits of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is scarce. METHODS: We analyzed the outcomes of patients who received VA-ECMO therapy due to cardiac or respiratory failure after isolated CABG in 12 centers between 2005 and 2016. Patients treated preoperatively with ECMO were excluded from this study. RESULTS: VA-ECMO was employed in 148 patients after CABG for median of 5.0days (mean, 6.4, SD 5.6days). In-hospital mortality was 64.2%. Pooled in-hospital mortality was 65.9% without significant heterogeneity between the centers (I2 8.6%). The proportion of VA-ECMO in each center did not affect in-hospital mortality (p=0.861). No patients underwent heart transplantation and six patients received a left ventricular assist device. Logistic regression showed that creatinine clearance (p=0.004, OR 0.98, 95% CI 0.97-0.99), pulmonary disease (p=0.018, OR 4.42, 95% CI 1.29-15.15) and pre-VA-ECMO blood lactate (p=0.015, OR 1.10, 95% CI 1.02-1.18) were independent baseline predictors of in-hospital mortality. One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively. CONCLUSIONS: One third of patients with need for VA-ECMO after CABG survive to discharge. In view of the burden of resources associated with VA-ECMO treatment and the limited number of patients surviving to discharge, further studies are needed to identify patients who may benefit the most from this treatment.


Assuntos
Ponte de Artéria Coronária/tendências , Oxigenação por Membrana Extracorpórea/tendências , Insuficiência Cardíaca/cirurgia , Mortalidade Hospitalar/tendências , Alta do Paciente/tendências , Idoso , Ponte de Artéria Coronária/mortalidade , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Seguimentos , Insuficiência Cardíaca/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade
8.
Intensive Care Med ; 43(11): 1594-1601, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28289815

RESUMO

PURPOSE: The aim of this study was to compare the success rate and safety of short-axis versus long-axis approaches to ultrasound-guided subclavian vein cannulation. METHODS: A total of 190 patients requiring central venous cannulation following cardiac surgery were randomized to either short-axis or long-axis ultrasound-guided cannulation of the subclavian vein. Each cannulation was performed by anesthesiologists with at least 3 years' experience of ultrasound-guided central vein cannulation (>150 procedures/year, 50% short-axis and 50% long-axis). Success rate, insertion time, number of needle redirections, number of separate skin or vessel punctures, rate of mechanical complications, catheter misplacements, and incidence of central line-associated bloodstream infection were documented for each procedure. RESULTS: The subclavian vein was successfully cannulated in all 190 patients. The mean insertion time was significantly shorter (p = 0.040) in the short-axis group (69 ± 74 s) than in the long-axis group (98 ± 103 s). The short-axis group was also associated with a higher overall success rate (96 vs. 78%, p < 0.001), first-puncture success rate (86 vs. 67%, p = 0.003), and first-puncture single-pass success rate (72 vs. 48%, p = 0.002), and with fewer needle redirections (0.39 ± 0.88 vs. 0.88 ± 1.15, p = 0.001), skin punctures (1.12 ± 0.38 vs. 1.28 ± 0.54, p = 0.019), and complications (3 vs. 13%, p = 0.028). CONCLUSIONS: The short-axis procedure for ultrasound-guided subclavian cannulation offers advantages over the long-axis approach in cardiac surgery patients.


Assuntos
Cateterismo Venoso Central/métodos , Veia Subclávia/diagnóstico por imagem , Ultrassonografia de Intervenção/métodos , Idoso , Idoso de 80 Anos ou mais , Procedimentos Cirúrgicos Cardíacos , Cateterismo Venoso Central/efeitos adversos , Feminino , Humanos , Veias Jugulares/diagnóstico por imagem , Estimativa de Kaplan-Meier , Masculino , Período Pós-Operatório , Estudos Prospectivos , Fatores de Tempo
9.
J Cardiothorac Vasc Anesth ; 31(2): 719-730, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27693206

RESUMO

OBJECTIVE: Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. DESIGN AND SETTING: A web-based international consensus conference. PARTICIPANTS: The study comprised 500 clinicians from 61 countries. INTERVENTIONS: A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey. MEASUREMENTS AND MAIN RESULTS: The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective decontamination of the gastrointestinal tract, insulin for tight glycemic control, preoperative intra-aortic balloon pump, leuko-depleted red blood cells transfusion, levosimendan, volatile agents, and remote ischemic preconditioning) and 2 interventions showing increased mortality (beta-blocker therapy and aprotinin). Interventions then were voted on by participating clinicians. Percentages of agreement among clinicians in different countries differed significantly for 6 interventions, and a variable gap between evidence and clinical practice was noted. CONCLUSIONS: The authors identified 13 nonsurgical interventions that may decrease or increase perioperative mortality, with variable agreement by clinicians. Such interventions may be optimal candidates for investigation in high-quality trials and discussion in international guidelines to reduce perioperative mortality.


Assuntos
Consenso , Assistência Perioperatória/mortalidade , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Congressos como Assunto , Humanos , Complicações Pós-Operatórias/prevenção & controle
10.
Biomed Res Int ; 2017: 9829487, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29423414

RESUMO

The aim of this retrospective multicenter registry study was to investigate age-dependent trends in mortality, long-term survival, and comorbidity over time in patients who underwent isolated CABG from 2003 to 2015. The percentage of patients < 60 years of age was 18.9%. Female sex, chronic pulmonary disease, extracardiac arteriopathy, and neurologic dysfunction disease were significantly less frequent in this younger population. The prevalence of BMI ≥ 30, previous myocardial infarction, preoperative severe depressed left ventricular ejection fraction, and history of previous PCI were significantly higher in this population. After PS matching, at 5 years, patients < 60 years of age reported significantly lower overall mortality (p < 0.0001), cardiac-related mortality (p < 0.0001), incidence of acute myocardial infarction (p = 0.01), and stroke rates (p < 0.0001). Patients < 60 years required repeated revascularization more frequently than older patients (p = 0.05). Patients < 60 who underwent CABG had a lower risk of adverse outcomes than older patients. Patients < 60 have a different clinical pattern of presentation of CAD in comparison with more elderly patients. These issues require focused attention in order to design and improve preventive strategies aiming to reduce the impact of specific cardiovascular risk factors for younger patients, such as diet, lifestyle, and weight control.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença da Artéria Coronariana/mortalidade , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/mortalidade , Taxa de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda/fisiologia
11.
J Cardiothorac Vasc Anesth ; 31(2): 719-730, 2017.
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: ses-34731

RESUMO

Objective: Out of the 230 million patients undergoing major surgical procedure every year, morethan 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. We decided to update a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. Design and Setting: A web-based international consensus conference. Participants: 500 hundred clinicians from 61 countries. Interventions: A systematic literature search was performed to identify published literature aboutnonsurgical interventions, supported by randomized evidence showing a statistically significant impact on mortality. Eligible papers were discussed by a Consensus Conference of experts. The interventions identified by the conference were then submitted to colleagues worldwide through aweb-based survey...(AU)


Assuntos
Assistência Perioperatória , Mortalidade , Anestesia , Consenso , Cuidados Críticos
12.
J Cardiothorac Vasc Anesth ; 31(2): 719-730, 2017.
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: ses-37195

RESUMO

OBJECTIVE:Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. (AU)


Assuntos
Humanos , Anestesia , Mortalidade
13.
J Cardiothorac Surg ; 11(1): 144, 2016 Sep 30.
Artigo em Inglês | MEDLINE | ID: mdl-27716382

RESUMO

BACKGROUND: The main purpose of this study was to evaluate the impact of gender on outcomes after isolated coronary artery bypass grafting, in terms of 5-year rates of overall death, cardiac-related death, myocardial infarction, re-hospitalization, repeat percutaneous or surgical revascularization, stroke, new pacemaker implantation, postoperative renal failure, heart failure and need for long-term care. METHODS: Two propensity-score matched cohorts, each of 1331 patients, undergoing isolated surgical coronary revascularization at the regional public and private centers of Emilia-Romagna region (Italy) from January 1st 2003 to December 31th 2013, were used to compare long-term outcomes of male (5976 patients) versus female gender (1332 patients). RESULTS: In the matched cohort, males received significantly more bypass grafts (3.0 ± 1.0 vs 2.8 ± 1.0, p = 0.001). Left internal mammary artery use and total arterial revascularization were similarly performed in both matched subgroups. Both groups reported similar cumulative rate of all-cause, cardiac-related mortality and stroke at five years. Females experienced significantly higher rate of myocardial infarction, and not significantly higher occurrence of heart failure, and need for long-term care. Males experienced significantly higher rate of cumulative re-hospitalization and higher need for pacemaker implantation. Female gender was not an independent predictor of death at long-term follow-up. CONCLUSIONS: Women are more likely to be readmitted with myocardial infarction and congestive heart failure after CABG but experience survival similar to that observed in men. Female gender was not an independent risk factor for mortality. Prevention of new occurrence of postoperative myocardial infarction and enhancement of complete coronary revascularization should be future endpoints.


Assuntos
Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/mortalidade , Complicações Pós-Operatórias/epidemiologia , Fatores Sexuais , Idoso , Idoso de 80 Anos ou mais , Ponte de Artéria Coronária/estatística & dados numéricos , Doença das Coronárias/cirurgia , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Humanos , Itália/epidemiologia , Assistência de Longa Duração/estatística & dados numéricos , Masculino , Infarto do Miocárdio/epidemiologia , Marca-Passo Artificial/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Intervenção Coronária Percutânea/estatística & dados numéricos , Pontuação de Propensão , Insuficiência Renal/epidemiologia , Reoperação , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
14.
Chest ; 150(3): 640-51, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27130285

RESUMO

BACKGROUND: Lung ultrasonography (LUS) has been used for noninvasive detection of pulmonary edema. Semiquantitative LUS visual scores (visual LUS [V-LUS]) based on B lines are moderately correlated with pulmonary capillary wedge pressure (PCWP) and extravascular lung water (EVLW). A new computer-aided quantitative LUS (Q-LUS) analysis has been recently proposed. This study investigated whether Q-LUS better correlates with PCWP and EVLW than V-LUS and to what extent positive end-expiratory pressure (PEEP) affects the assessment of pulmonary edema by Q-LUS or V-LUS. METHODS: Forty-eight mechanically ventilated patients with PEEP of 5 or 10 cm H2O and monitored by PCWP (n = 28) or EVLW (n = 20) were studied. RESULTS: PCWP was significantly and strongly correlated with Q-LUS gray (Gy) unit value (r(2) = 0.70) but weakly correlated with V-LUS B-line score (r(2) = 0.20). EVLW was significantly and more strongly correlated with Q-LUS Gy unit mean value (r(2) = 0.68) than with V-LUS B-line score (r(2) = 0.34). Q-LUS showed a better diagnostic accuracy than V-LUS for the detection of PCWP >18 mm Hg or EVLW ≥ 10 mL/kg. With 5-cm H2O PEEP, the correlations with PCWP or EVLW were stronger for Q-LUS than V-LUS. With 10-cm H2O PEEP, the correlations with PCWP or EVLW were still significant for Q-LUS but insignificant for V-LUS. Interobserver reproducibility was better for Q-LUS than V-LUS. CONCLUSIONS: Both V-LUS and Q-LUS are acceptable indicators of pulmonary edema in mechanically ventilated patients. However, at high PEEP only Q-LUS provides data that are significantly correlated with PCWP and EVLW. Computer-aided Q-LUS has the advantages of being not only independent of operator perception but also of PEEP.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Água Extravascular Pulmonar/diagnóstico por imagem , Pulmão/diagnóstico por imagem , Complicações Pós-Operatórias/diagnóstico por imagem , Edema Pulmonar/diagnóstico por imagem , Pressão Propulsora Pulmonar , Respiração Artificial , Idoso , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Pessoa de Meia-Idade , Respiração com Pressão Positiva , Estudos Prospectivos , Reprodutibilidade dos Testes , Ultrassonografia
15.
Eur J Cardiothorac Surg ; 50(3): 528-35, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27118313

RESUMO

OBJECTIVES: The aim of this study was to compare 5-year rates of overall death, cardiac-related death, myocardial infarction, repeat revascularization, stroke and new occurrence of postoperative renal failure in a large cohort of patients with coronary disease, treated with on- or off-pump coronary artery bypass grafting (CABG). METHODS: Two propensity score-matched cohorts, each of 560 patients, undergoing isolated surgical coronary revascularization at the regional public and private centres of Emilia-Romagna region (Italy) over the period 1 January 2003 - 31 December 2013, were used to compare long-term outcomes of on-pump CABG (6711 patients) and off-pump CABG (597 patients). RESULTS: The matched on-pump group received significantly more bypass grafts than the matched off-pump group (2.4 ± 1.1 vs 1.6 ± 0.9, P < 0.0001). The on-pump group reported statistically significant lower cardiac-related mortality. There was a trend towards higher overall mortality and the need for repeat revascularization procedures in the off-pump group. No difference was found for myocardial infarction, stroke or new occurrence of postoperative renal failure between groups in the follow-up. The multivariate analysis of significant predictors of mortality in the overall population confirmed that the off-pump revascularization strategy was an independent predictor of death at long-term follow-up. On-pump CABG reported significantly better results in terms of mortality in the subgroups of patients with a depressed left ventricular ejection fraction and in patients with three-vessel disease. CONCLUSIONS: In patients undergoing elective isolated CABG, on-pump strategy conferred a long-term survival advantage compared with off-pump strategy, particularly for patients with more extensive coronary disease. No benefits were found in terms of reduction of postoperative morbidity with the off-pump strategy. On-pump surgery should be the preferred revascularization technique, and off-pump surgery reserved for patients for whom the perioperative risk of cardiopulmonary bypass is greater than the risk of a less complete coronary revascularization.


Assuntos
Ponte de Artéria Coronária/métodos , Doença da Artéria Coronariana/cirurgia , Previsões , Complicações Pós-Operatórias/epidemiologia , Sistema de Registros , Idoso , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Ponte de Artéria Coronária sem Circulação Extracorpórea/métodos , Feminino , Seguimentos , Humanos , Itália/epidemiologia , Masculino , Pontuação de Propensão , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências
16.
J Thorac Dis ; 8(12): 3633-3638, 2016 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28149558

RESUMO

BACKGROUND: The aim of our study is to compare the classical surgical tracheostomy (TT) technique with a modified surgical technique designed and created by the cardiothoracic surgery staff of our department to reduce surgical trauma and postoperative complications. This modified technique combines features of percutaneous TT and surgical TT avoiding the use of specialized tools, which are required in percutaneous TT. METHODS: From October 2008 to March 2014 we performed 67 tracheostomies using this New Modified Surgical Technique (NMST) and 56 TT with the Classical Surgical Technique (CST). We collected data about the early clinical complications, deaths TT-related, deaths due to other complications and the presence of late TT's complications were performed by a telephone follow-up. SPSS software (IMB version 21) was used for the statistical analysis. Categorical data were treated with chi-square test and continuous data were treated with t-test for independent samples. RESULTS: NMST group had a significant lower number of early complications (P=0.005) compared to CST group (5 vs. 15). In-hospital mortality was significantly higher in CST group (18 deaths vs. 4 in NMST group, P=0.001) but we registered only one case of TT-related mortality in CST group (P=0.280). We did not note other differences between the two groups regarding short or mid-long term complications. CONCLUSIONS: In our experience the NMST demonstrated to be easily safe and reproducible with an amount of early, mid- and long-term complications similar to the CST; furthermore the aesthetic results of the procedure appear similar to those of percutaneous TT.

17.
Biomed Res Int ; 2015: 763940, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26605339

RESUMO

BACKGROUND AND OBJECTIVE: Renal Doppler resistive index (RDRI) is a noninvasive index considered to reflect renal vascular perfusion. The aim of this study was to identify the independent hemodynamic determinants of RDRI in mechanically ventilated patients after cardiac surgery. METHODS: RDRI was determined in 61 patients by color and pulse Doppler ultrasonography of the interlobar renal arteries. Intermittent thermodilution cardiac output measurements were obtained and blood samples taken from the tip of pulmonary artery catheter to measure hemodynamics and mixed venous oxygen saturation (SvO2). RESULTS: By univariate analysis, RDRI was significantly correlated with SvO2, oxygen extraction ratio, left ventricular stroke work index, and cardiac index, but not heart rate, central venous pressure, mean artery pressure, pulmonary capillary wedge pressure, systemic vascular resistance index, oxygen delivery index, oxygen consumption index, arterial lactate concentration, and age. However, by multivariate analysis RDRI was significantly correlated with SvO2 only. CONCLUSIONS: The present data suggests that, in mechanically ventilated patients after cardiac surgery, RDRI increases proportionally to the decrease in SvO2, thus reflecting an early vascular response to tissue hypoxia.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Oxigênio/sangue , Ultrassonografia Doppler em Cores , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Feminino , Humanos , Rim/irrigação sanguínea , Rim/diagnóstico por imagem , Rim/fisiopatologia , Masculino
18.
Acta Biomed ; 86(1): 17-26, 2015 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-25948023

RESUMO

There is an increasing number of patients with mitral regurgitation secondary to dilated cardiomyopathy. Ischemic mitral regurgitation is a common complication of left ventricular dysfunction related to chronic coronary artery disease: it is present in 10-20% of these patients and is associated with a worse prognosis also after coronary revascularization. Currently, coronary artery bypass grafting combined with restrictive annuloplasty is the most commonly performed surgical procedure, although novel approaches have been used with varying degrees of success. The suboptimal results obtained with the commonly used surgical approaches require the development of alternative surgical techniques with the aim to correct  the causal mechanisms of the disease. In fact the pathophysiology of ischemic mitral regurgitation is  multifactorial involving global and regional left ventricular remodeling, as well as the dysfunction and distortion of the components of the entire mitral valve apparatus. The purpose of this review is to present the current surgical techniques available for the treatment of ischemic mitral regurgitation and to discuss novel approaches to the repair of this complex disease. (www.actabiomedica.it).


Assuntos
Insuficiência da Valva Mitral/cirurgia , Isquemia Miocárdica/complicações , Ponte de Artéria Coronária , Humanos , Anuloplastia da Valva Mitral , Insuficiência da Valva Mitral/etiologia , Insuficiência da Valva Mitral/fisiopatologia , Isquemia Miocárdica/fisiopatologia , Isquemia Miocárdica/cirurgia
19.
Acta Biomed ; 86(1): 32-7, 2015 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-25948025

RESUMO

Background and Aim Laboratory blood tests for hospitalized patients are often overused. Excessive costs and no proof of benefit suggest re-evaluating the current approach to laboratory test ordering. The aim of the study is to improve the decision-making process of test ordering and to investigate what effect a rational, evidence-based use of laboratory test ordering in surgical wards would have on costs and healthcare resources. Methods Three-phase experimental prospective study carried out at the tertiary referral teaching hospital of Parma. Phase 1 (baseline status). The baseline status of laboratory test ordering was evaluated by recording the number of biochemical tests requested for patients undergoing elective surgery. Laboratory tests were grouped in "recommended" (RT) and "non recommended" (nRT) tests on the basis of pertinent literature. Phase 2 (improvement action): new guidelines were introduced into clinical practice. Phase 3 (feedback): Prospective data collection for first and second feedback was performed with no advance notice. Results A highly significant reduction in test ordering was found on occasion of the phases 2 and 3 of the study. The overall number of tests decreased, largely due to a decrease in the use of nRT. Conclusions Analysis was justified by the fact that most test requests proved not to be supported by clinical evidence. Inappropriate ordering of laboratory tests results in an unnecessarily high number of requests, which do not in turn improve patient management. Moreover, more appropriate, evidence-based laboratory test ordering for patients undergoing elective surgery may produce a significant reduction in costs, particularly in high-cost settings. (www.actabiomedica.it).


Assuntos
Técnicas de Laboratório Clínico/economia , Técnicas de Laboratório Clínico/estatística & dados numéricos , Custos de Cuidados de Saúde , Centro Cirúrgico Hospitalar , Procedimentos Cirúrgicos Eletivos , Hospitalização , Humanos , Itália , Seleção de Pacientes , Estudos Prospectivos
20.
Acta Biomed ; 86 Suppl 1: 40-5, 2015 Mar 13.
Artigo em Inglês | MEDLINE | ID: mdl-25835764

RESUMO

BACKGROUND: The concept of self-assess it's a central mechanism in human agency for behavior change and should translate to desirable practice patterns. There are no many studies that have investigated the relationship between the perception of the ability to perform cardiopulmonary resuscitation (CPR) and the quality of the same. The aim of this work is to investigate the relation between physiological and psychosocial variables in cardiac resuscitation in order to improve the involvement and motivation of professionals in training courses. METHODS: During the year 2012, 322 medical staff of Ospedale-Universitario of Parma were trained to basic life support defibrillation (BLSD). Before started the course the partecipants were randomly selected among the staff working in the same department to create a team of two persons and involved in a simulation that reproduced the first five minutes that occurs for a cardiac arrest in a medical or surgical department in our hospital before the intervention of the hospital emergency team. Before and after simulation to each participant was asked to answer a self-efficacy questionnaire on a 10-point scale on the management of cardiac. During simulation were registered the activation time of the emergency response system, hands-on time, defibrillation time, number of compression and correct compression rate. RESULTS: Activation time of the emergency response system was 70.52 ± 78.77 seconds. In 55 teams was not made the allert. The defibrillation time was 148.63 ± 58.43 seconds. In 44 teams the defibrillator were used within 120 seconds, in 36 (22.1%) it was not used. Hands-on time average was of 166.20 ± 62.9 seconds. The mean number of compression was 216.22 ± 115.57. The percentage of satisfactory compression was 9.97 ± 21.23 %. The level of self-efficacy was under the average for the 35.6%, while the 26.8% of the participants had a medium level of 5 and the 38.5% of the sample declared to feel an efficacy level included in 6-10. The sense of self efficacy after the simulation was constant in the 38.3% of the sample, while increased in the 30.5% and decreased in the 31.2%. We found no significant correlations between self-efficacy levels and specific results in scenario acting before simulation, instead, after the simulation the skills performances are much more correlated with self-efficacy. CONCLUSIONS: The medical staff reported an individual's perception of good efficacy in the management of simulation of cardiac arrest, but it does not correspond to a high skills. An open question is if and how these psychosocial variables may play a role in improving the quality of CPR and if knowledge of the low capacity to manage a cardiac arrest can be translated into the need for the medical staff to be regularly engaged in BLSD retraining.


Assuntos
Atitude do Pessoal de Saúde , Reanimação Cardiopulmonar/educação , Competência Clínica , Parada Cardíaca/terapia , Autoeficácia , Treinamento por Simulação , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Motivação , Desempenho Psicomotor , Inquéritos e Questionários
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