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1.
Anesthesiology ; 2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33667304

RESUMO

BACKGROUND: Whether supplemental oxygen worsens long-term mortality remains unclear, with contradictory trial results. The authors therefore tested the hypothesis that supplemental oxygen (80% vs. 30%) increases the hazard for long-term mortality. METHODS: The authors conducted a post hoc analysis of a large multiple crossover cluster trial in which more than 5,000 colorectal surgeries on 4,088 adults were allocated to receive either 30% or 80% inspired oxygen during general anesthesia. The authors assessed the effect of 80% versus 30% target-inspired oxygen on long-term mortality and calculated Kaplan-Meier survival estimates. Analysis was restricted to patients with a home address in Ohio because the authors could obtain reliable vital status information from the Ohio Department of Health (Columbus, Ohio) for them. RESULTS: A total of 3,471 qualifying colorectal surgeries performed in 2,801 patients were analyzed, including 1,753 (51%) surgeries in 1,577 patients given 80% oxygen and 1,718 surgeries in 1,551 patients given 30% oxygen. The observed incidence of death after a median of 3 yr was 13% (234 of 1,753) in the 80% oxygen group and 14% (245 of 1,718) in the 30% oxygen group. The estimated hazard ratio for mortality was 0.94 (95% CI, 0.78 to 1.13; P = 0.493). CONCLUSIONS: In this post hoc analysis of a large, controlled trial, supplemental oxygen did not increase postoperative mortality.

2.
J Phys Chem A ; 2021 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-33651628

RESUMO

Mass-analyzed threshold ionization (MATI) spectroscopy was used to measure the vibronic spectra of LnO (Ln = La and Ce). Single-reference coupled cluster and relativistic multireference configuration calculations were carried out to compare with the measured vibronic energies. The spectrum of LaO displays a single vibronic band system, while that of CeO shows multiple ones. The ionization energies of LaO and CeO are measured as 5.2446(6) and 5.3332(6) eV, respectively, which are a 100-fold improvement over the literature values. The vibrational energies of the neutral molecule and corresponding ion reveal the charge effect on the metal-oxygen bond of both species. The single band system in the spectrum of LaO arises from the transition of the ground state of the neutral molecule with the La(6s1)O(2p6) valence configuration to the ground state of the singly charged ion with the La(6s0)O(2p6) configuration. The multiple band systems in the spectrum of CeO are attributed to the spin-orbit coupling for the Ce(4f16s1)O(2p6) configuration of the neutral molecule and an excited state for the Ce(4f1)O(2p6) configuration of the ion.

3.
J Clin Monit Comput ; 2021 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-33523352

RESUMO

It remains unclear whether reduced myocardial contractility, venous dilation with decreased venous return, or arterial dilation with reduced systemic vascular resistance contribute most to hypotension after induction of general anesthesia. We sought to assess the relative contribution of various hemodynamic mechanisms to hypotension after induction of general anesthesia with sufentanil, propofol, and rocuronium. In this prospective observational study, we continuously recorded hemodynamic variables during anesthetic induction using a finger-cuff method in 92 non-cardiac surgery patients. After sufentanil administration, there was no clinically important change in arterial pressure, but heart rate increased from baseline by 11 (99.89% confidence interval: 7 to 16) bpm (P < 0.001). After administration of propofol, mean arterial pressure decreased by 23 (17 to 28) mmHg and systemic vascular resistance index decreased by 565 (419 to 712) dyn*s*cm-5*m2 (P values < 0.001). Mean arterial pressure was < 65 mmHg in 27 patients (29%). After propofol administration, heart rate returned to baseline, and stroke volume index and cardiac index remained stable. After tracheal intubation, there were no clinically important differences compared to baseline in heart rate, stroke volume index, and cardiac index, but arterial pressure and systemic vascular resistance index remained markedly decreased. Anesthetic induction with sufentanil, propofol, and rocuronium reduced arterial pressure and systemic vascular resistance index. Heart rate, stroke volume index, and cardiac index remained stable. Post-induction hypotension therefore appears to result from arterial dilation with reduced systemic vascular resistance rather than venous dilation or reduced myocardial contractility.

4.
IEEE Trans Cybern ; PP2021 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-33531312

RESUMO

The heuristic dynamic programming (HDP) (λ)-based optimal control strategy, which takes a long-term prediction parameter λ into account using an iterative manner, accelerates the learning rate obviously. The computation complexity caused by the state-associated extra variable in λ-return value computing of the traditional value-gradient learning method can be reduced. However, as the iteration number increases, calculation costs have grown dramatically that bring huge challenge for the optimal control process with limited bandwidth and computational units. In this article, we propose an event-triggered HDP (ETHDP) (λ) optimal control strategy for nonlinear discrete-time (NDT) systems with unknown dynamics. The iterative relation for λ-return of the final target value is derived first. The event-triggered condition ensuring system stability is designed to reduce the computation and communication requirements. Next, we build a model-actor-critic neural network (NN) structure, in which the model NN evaluates the system state for getting λ-return of the current time target value, which is used to obtain the critic NN real-time update errors. The event-triggered optimal control signal and one-step-return value are approximated by actor and critic NN, respectively. Then, the event trigger-based uniformly ultimately bounded (UUB) stability of the system state and NN weight errors are demonstrated by applying the Lyapunov technology. Finally, we illustrate the effectiveness of our proposed ETHDP (λ) strategy by two cases.

5.
Crit Rev Food Sci Nutr ; : 1-16, 2020 Dec 16.
Artigo em Inglês | MEDLINE | ID: mdl-33325770

RESUMO

Beer is the most widely consumed alcoholic drink in the world, but it is not suitable for patients who suffer from celiac disease (CD) because its main ingresdients, barley or wheat, contain gluten. Approximately 1% of the world's population is affected by CD, and the development of gluten-free beer is imperative. Gluten-free beers produced using alternative materials, such as rice, sorghum, maize, millet, oats, and pseudocereals (e.g., buckwheat, quinoa and Amaranth), are studied in this review that examines the effects of specific substitutions on the different characteristics of the final beer to ensure the appropriateness of their use. The use of alternatives to malt may affect the quality of gluten-free beer and result in some negative consequences. Accordingly, the influential factors are discussed in terms of the total substitution of malt with other grains in the production of beer. Research results have provided some new alternative solutions for the production of gluten-free beer, such as the use of malted grains to improve hydrolytic enzyme activity, the application of nonconventional mashing procedures involving the decoction method and extrusion cooking techniques to increase the extract yield, the use of exogenous enzymes and nitrogen supplements to improve the sugar and amino acid spectra necessary for yeast fermentation, and the application of combinations of alternative grains to improve the flavor, body and foam stability of gluten-free beers.

6.
Asian J Anesthesiol ; 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-33176407

RESUMO

BACKGROUND: Extended-release local anesthetics allow for prolonged analgesia after a single administration. Although Asians demonstrate different pain thresholds than Caucasians, whether they have different postoperative local anesthetic analgesic effects has not been elucidated. OBJECTIVE: We aimed to compare the postoperative analgesic efficacy of liposomal bupivacaine on Asian and Caucasian adults, and the incidence of local anesthetic systemic toxicity (LAST) syndrome. METHODS: We conducted a retrospective, assessor-blinded cohort study of adult patients who received liposomal bupivacaine for surgery between 2012 and 2018. Asians and Caucasians were matched in a 1:1 ratio by clinical characteristics and surgery type. The primary outcome was pain management, defined as average pain score and opioid consumption during the initial 72 postoperative hours. The secondary outcome was the incidence of LAST syndrome. Reviewers were blinded to the ethnicity of the patient. RESULTS: After 1:1 propensity score matching, 130 Asians and 129 Caucasians were analyzed. All confounding variables were balanced, except for higher body mass index in the Asian group. Pain scores were lower (adjusted mean difference of -0.50 [97.5% CI, -0.98, -0.01]; superiority p = 0.011) and opioid consumption was not greater (geometric means ratio, 0.61 [97.5% CI, 0.36, 1.04]; non-inferiority p < 0.001) in Asian patients compared to Caucasian patients. Only one Caucasian patient was judged as having a potential case of LAST syndrome. The length of hospital stay and the incidence of additional complications were not different between the groups. CONCLUSION: Asian adults receiving liposomal bupivacaine as part of multimodal perioperative analgesia demonstrated lower pain scores compared to matching Caucasians, despite not having greater opioid consumption.

7.
Anesth Analg ; 131(5): 1540-1550, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079877

RESUMO

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.


Assuntos
Pressão Arterial , Cateteres , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Área Sob a Curva , Diagnóstico Precoce , Feminino , Humanos , Hipotensão/terapia , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Oscilometria , Sensibilidade e Especificidade , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento
8.
Anesthesiology ; 133(6): 1214-1222, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-32960954

RESUMO

BACKGROUND: The Hypotension Prediction Index is a commercially available algorithm, based on arterial waveform features, that predicts hypotension defined as mean arterial pressure less than 65 mmHg for at least 1 min. We therefore tested the primary hypothesis that index guidance reduces the duration and severity of hypotension during noncardiac surgery. METHODS: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized to hemodynamic management with or without index guidance. Clinicians caring for patients assigned to guidance were alerted when the index exceeded 85 (range, 0 to 100) and a treatment algorithm based on advanced hemodynamic parameters suggested vasopressor administration, fluid administration, inotrope administration, or observation. Primary outcome was the amount of hypotension, defined as time-weighted average mean arterial pressure less than 65 mmHg. Secondary outcomes were time-weighted mean pressures less than 60 and 55 mmHg. RESULTS: Among 214 enrolled patients, guidance was provided for 105 (49%) patients randomly assigned to the index guidance group. The median (first quartile, third quartile) time-weighted average mean arterial pressure less than 65 mmHg was 0.14 (0.03, 0.37) in guided patients versus 0.14 (0.03, 0.39) mmHg in unguided patients: median difference (95% CI) of 0 (-0.03 to 0.04), P = 0.757. Index guidance therefore did not reduce amount of hypotension less than 65 mmHg, nor did it reduce hypotension less than 60 or 55 mmHg. Post hoc, guidance was associated with less hypotension when analysis was restricted to episodes during which clinicians intervened. CONCLUSIONS: In this pilot trial, index guidance did not reduce the amount of intraoperative hypotension. Half of the alerts were not followed by treatment, presumably due to short warning time, complex treatment algorithm, or clinicians ignoring the alert. In the future we plan to use a lower index alert threshold and a simpler treatment algorithm that emphasizes prompt treatment.

9.
Indian J Ophthalmol ; 68(10): 2190-2195, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32971638

RESUMO

Purpose: To determine the ocular and systemic safety of using topical Lambda-Cyhalothrin (LCL) in a canine model of infantile nystagmus syndrome (INS). The rationale for this proposal is based on a case study of a patient whose INS improved after inadvertent ocular exposure to a pyrethroid pesticide containing LCL. Methods: After in-vitro safety testing and IUCAC approval, we studied increasing concentrations of topical LCL drops (0.002% to 0.07%) in canines with a purposely bred defect in the RPE65 gene resulting in both retinal degeneration and INS. We collected data on ocular and systemic effects and performed eye-movement recordings (EMR). Results: At the 0.07% concentration dose of LCL, there was minimal, reversible, conjunctival hyperemia. There was no other ocular or systemic toxicity. At the 0.06% dose, there was a visible decrease in the INS and EMR showed a 153%-240% increase in the nystagmus acuity function and a 30%-70% decrease in amplitude across gaze. There was also a 40%-60% decrease in intraocular pressure while on the drop in both eyes. Conclusion: This animal study suggests this new pharmacological agent has potential for topical treatment of both INS and diseases with raised intraocular pressure. Further, this new treatment approach confirms the importance of extraocular muscle proprioception in ocular motor diseases and their treatment.

10.
Int J Antimicrob Agents ; 56(4): 106131, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32763373

RESUMO

BACKGROUND: High antimicrobial use (AMU) and antimicrobial resistance (AMR) in veal calves remain a source of concern. As part of the EFFORT project, the association between AMU and the abundance of faecal antimicrobial resistance genes (ARGs) in veal calves in three European countries was determined. METHODS: In 2015, faecal samples of veal calves close to slaughter were collected from farms located in France, Germany and the Netherlands (20 farms in France, 20 farms in the Netherlands and 21 farms in Germany; 25 calves per farm). Standardized questionnaires were used to record AMU and farm characteristics. In total, 405 faecal samples were selected for DNA extraction and quantitative polymerase chain reaction to quantify the abundance (16S normalized concentration) of four ARGs [aph(3')-III, ermB, sul2 and tetW] encoding for resistance to frequently used antimicrobials in veal calves. Multiple linear mixed models with random effects for country and farm were used to relate ARGs to AMU and farm characteristics. RESULTS: A significant positive association was found between the use of trimethoprim/sulfonamides and the concentration of sul2 in faeces from veal calves. A higher weight of calves on arrival at the farm was negatively associated with aph(3')-III and ermB. Lower concentrations of aph(3')-III were found at farms with non-commercial animals present. Furthermore, farms using only water for the cleaning of stables had a significantly lower abundance of faecal ermB and tetW compared with other farms. CONCLUSION: A positive association was found between the use of trimethoprim/sulfonamides and the abundance of sul2 in faeces in veal calves. Additionally, other relevant risk factors associated with ARGs in veal calves were identified, such as weight on arrival at the farm and cleaning practices.

11.
JAMA ; 324(4): 350-358, 2020 07 28.
Artigo em Inglês | MEDLINE | ID: mdl-32721009

RESUMO

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.


Assuntos
Acetaminofen/administração & dosagem , Analgésicos não Entorpecentes/administração & dosagem , Hipóxia/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/uso terapêutico , Método Duplo-Cego , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Falha de Tratamento
13.
Retrovirology ; 17(1): 10, 2020 05 06.
Artigo em Inglês | MEDLINE | ID: mdl-32375827

RESUMO

BACKGROUND: Human endogenous retroviruses (HERVs), suspected to be transposition-defective, may reshape the transcriptional network of the human genome by regulatory elements distributed in their long terminal repeats (LTRs). HERV-K (HML-2), the most preserved group with the least number of accumulated of mutations, has been associated with aberrant gene expression in tumorigenesis and autoimmune diseases. Because of the high sequence similarity between different HERV-Ks, current methods have limitations in providing genome-wide mapping specific for individual HERV-K (HML-2) members, a major barrier in delineating HERV-K (HML-2) function. RESULTS: In an attempt to obtain detailed distribution information of HERV-K (HML-2), we utilized a PCR-based target enrichment sequencing protocol for HERV-K (HML-2) (PTESHK) loci, which not only maps the presence of reference loci, but also identifies non-reference loci, enabling determination of the genome-wide distribution of HERV-K (HML-2) loci. Here we report on the genomic data obtained from three individuals. We identified a total of 978 loci using this method, including 30 new reference loci and 5 non-reference loci. Among the 3 individuals in our study, 14 polymorphic HERV-K (HML-2) loci were identified, and solo-LTR330 and N6p21.32 were identified as polymorphic for the first time. CONCLUSIONS: Interestingly, PTESHK provides an approach for the identification of the genome-wide distribution of HERV-K (HML-2) and can be used for the identification of polymorphic loci. Since polymorphic HERV-K (HML-2) integrations are suspected to be related to various diseases, PTESHK can supplement other emerging techniques in accessing polymorphic HERV-K (HML-2) elements in cancer and autoimmune diseases.

15.
Beilstein J Nanotechnol ; 11: 606-619, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32318321

RESUMO

Biomass-derived carbon dots (CDs) are biocompatible and have potential for a variety of applications, including bioimaging and biosensing. In this work, we use ground soybean residuals to synthesize carbon nanoparticles by hydrothermal carbonization (HTC), annealing at high temperature, and laser ablation (LA) in a NH4OH solution. The carbon nanoparticles synthesized with the HTC process (HTC-CDs) exhibit photoluminescent characteristics with strong blue emission. The annealing of the HTC-processed carbon particles in the range of 250 to 850 °C causes a loss of the photoluminescent characteristics of the CDs without any significant change in the microstructure (amorphous structure) of the carbon particles. The LA processing of the annealed HTC-processed carbon particles introduces nitrogen-containing surface-functional groups and leads to the recovery of the photoluminescent features that are different from those of the HTC-CDs and dependent on the fraction of nitrogen in the surface-functional groups. The photoluminescence of both the HTC-CDs and LA-CDs is largely due to the presence of N-containing surface-functional groups. The quantum yield of the LA-CDs is more constant than that of the HTC-CDs under continuous UV excitation and does not exhibit a significant reduction after 150 min of excitation. The methods used in this work provide a simple and green strategy to introduce N-surface-functional groups to carbon nanoparticles made from biomass and biowaste and to produce stable photoluminescent CDs with excellent water-wettability.

16.
J Chem Phys ; 152(14): 144304, 2020 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-32295351

RESUMO

A Ce atom reaction with propene is carried out in a pulsed laser vaporization molecule beam source. Several Ce-hydrocarbon species formed by the C-H and C-C bond activation of propene are observed by time-of-flight mass spectrometry, and Ce(C3Hn) (n = 4 and 6) are characterized by mass-analyzed threshold ionization (MATI) spectroscopy and density functional theory, multiconfiguration, and relativistic quantum chemical calculations. The MATI spectrum of each species consists of two vibronic band systems, each with several vibronic bands. Ce(C3H6) is identified as an inserted species with Ce inserting into an allylic C-H bond of propene and Ce(C3H4) as a metallocycle through 1,2-vinylic dehydrogenation. Both species have a Cs structure with the Ce 4f16s1 ground valence electron configuration in the neutral molecule and the Ce 4f1 configuration in the singly charged ion. The two vibronic band systems observed for each species are attributed to the ionization of two pairs of the lowest spin-orbit coupled states with each pair being nearly degenerate.

17.
Acta Pharmacol Sin ; 2020 Mar 02.
Artigo em Inglês | MEDLINE | ID: mdl-32123300

RESUMO

Herbal and dietary supplements (HDS)-induced liver injury has been a great concern all over the world. Polygonum multiflorum Thunb., a well-known Chinese herbal medicine, is recently drawn increasing attention because of its hepatotoxicity. According to the clinical and experimental studies, P. multiflorum-induced liver injury (PM-DILI) is considered to be immune-mediated idiosyncratic liver injury, but the role of immune response and the underlying mechanisms are not completely elucidated. Previous studies focused on the direct toxicity of PM-DILI by using animal models with intrinsic drug-induced liver injury (DILI). However, most epidemiological and clinical evidence demonstrate that PM-DILI is immune-mediated idiosyncratic liver injury. The aim of this review is to assess current epidemiological, clinical and experimental evidence about the possible role of innate and adaptive immunity in the idiosyncratic hepatotoxicity of P. multiflorum. The potential effects of factors associated with immune tolerance, including immune checkpoint molecules and regulatory immune cells on the individual's susceptibility to PM-DILI are also discussed. We conclude by giving our hypothesis of possible immune mechanisms of PM-DILI and providing suggestions for future studies on valuable biomarkers identification and proper immune models establishment.

18.
Eur J Anaesthesiol ; 2020 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-32205572

RESUMO

BACKGROUND: Serratus anterior and paravertebral blocks can both be used for video-assisted thoracic surgery. However, serratus anterior blocks are easier to perform, and possibly safer. We therefore tested the primary hypothesis that serratus anterior plane blocks and thoracic paravertebral blocks provide comparable analgesia for video-assisted thoracic surgery. Secondarily, we tested the hypothesis that both blocks lengthen the time to onset of surgical pain and reduce the need for rescue tramadol. METHODS: Patients having video-assisted thoracic lobectomy or segmentectomy were randomly allocated to ultrasound-guided thoracic paravertebral blocks, n = 30; ultrasound-guided serratus anterior plane blocks, n = 30; or, general anaesthesia alone, n = 30. Visual analogue pain scores analogue pain scores at rest, during coughing and Prince-Henry pain scores were used to assess postoperative analgesia. Our primary analysis was noninferiority of serratus anterior blocks compared with paravertebral blocks. RESULTS: Baseline characteristics were comparable among the three groups. Two hours after surgery, the mean difference in visual analogue pain scores between the serratus anterior and paravertebral blocks was 0.0 (96.8% CI -0.4 to 0.3) cm at rest, -0.2 (-0.8 to 0.4) cm during coughing and -0.1(-0.5 to 0.3) for Prince-Henry pain scores. After 24 h, the mean difference was 0.0 (-0.7 to 0.8) cm at rest, 0.1 (-0.8 to 0.9) cm during coughing and 0.1(-0.4 to 0.6) for Prince-Henry pain scores. All differences were significantly noninferior. Time to onset of pain after surgery was 19 ±â€Š5 (SD) hours with serratus anterior blocks, 16 ±â€Š5 h with paravertebral blocks and 12 ±â€Š5 h with general anaesthesia. Anaesthesia with either block was associated with significantly less intra-operative propofol and sufentanil, reduced postoperative rescue analgesia (tramadol) and less postoperative nausea and vomiting compared with general anaesthesia alone. Patients with serratus anterior block had a significantly lower incidence of intra-operative hypotension and requirement for intra-operative vasopressor (3.4%), compared with general anaesthesia alone. Serratus anterior block took less time to perform than paravertebral block (5.1 ±â€Š1.1 min versus 10.1 ±â€Š2.9 min). CONCLUSION: Serratus anterior plane blocks, which are easier and quicker than paravertebral blocks, provide comparable analgesia in patients having video-assisted thoracic surgery. CLINICAL TRIAL NUMBER AND REGISTRY URL: ChiCTR1800017671; http://www.chictr.org.cn/hvshowproject.aspx?id=13510.

19.
Anesthesiology ; 132(4): 854-866, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31996555

RESUMO

BACKGROUND: The basic perineural catheter design has changed minimally since inception, with the catheter introduced through or over a straight needle. The U.S. Food and Drug Administration recently cleared a novel perineural catheter design comprising a catheter attached to the back of a suture-shaped needle that is inserted, advanced along the arc of its curvature pulling the catheter past the target nerve, and then exited through the skin in a second location. The authors hypothesized that analgesia would be noninferior using the new versus traditional catheter design in the first two days after painful foot/ankle surgery with a primary outcome of average pain measured with the Numeric Rating Scale. METHODS: Subjects undergoing painful foot or ankle surgery with a continuous supraparaneural popliteal-sciatic nerve block 5 cm proximal to the bifurcation were randomized to either a suture-type or through-the-needle catheter and subsequent 3-day 0.2% ropivacaine infusion (basal 6 ml/h, bolus 4 ml, lockout 30 min). Subjects received daily follow-up for the first four days after surgery, including assessment for evidence of malfunction or dislodgement of the catheters. RESULTS: During the first two postoperative days the mean ± SD average pain scores were lower in subjects with the suture-catheter (n = 35) compared with the through-the-needle (n = 35) group (2.7 ± 2.4 vs. 3.4 ± 2.4) and found to be statistically noninferior (95% CI, -1.9 to 0.6; P < 0.001). No suture-style catheter was completely dislodged (0%), whereas the tips of three (9%) traditional catheters were found outside of the skin before purposeful removal on postoperative day 3 (P = 0.239). CONCLUSIONS: Suture-type perineural catheters provided noninferior analgesia compared with traditional catheters for continuous popliteal-sciatic blocks after painful foot and ankle surgery. The new catheter design appears to be a viable alternative to traditional designs used for the past seven decades.


Assuntos
Anestesia por Condução/métodos , Bloqueio Nervoso Autônomo/métodos , Cateteres de Demora , Dor Pós-Operatória/prevenção & controle , Nervo Isquiático/diagnóstico por imagem , Técnicas de Sutura , Adulto , Idoso , Anestésicos Locais/administração & dosagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/efeitos dos fármacos , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico por imagem , Nervo Isquiático/cirurgia , Ultrassonografia de Intervenção/métodos
20.
Anesthesiology ; 132(2): 291-306, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31939844

RESUMO

BACKGROUND: Arterial pressure is a complex signal that can be characterized by systolic, mean, and diastolic components, along with pulse pressure (difference between systolic and diastolic pressures). The authors separately evaluated the strength of associations among intraoperative pressure components with myocardial and kidney injury after noncardiac surgery. METHODS: The authors included 23,140 noncardiac surgery patients at Cleveland Clinic who had blood pressure recorded at 1-min intervals from radial arterial catheters. The authors used univariable smoothing and multivariable logistic regression to estimate probabilities of each outcome as function of patients' lowest pressure for a cumulative 5 min for each component, comparing discriminative ability using C-statistics. The authors further assessed the association between outcomes and both area and minutes under derived thresholds corresponding to the beginning of increased risk for the average patient. RESULTS: Out of 23,140 patients analyzed, myocardial injury occurred in 6.1% and acute kidney injury in 8.2%. Based on the lowest patient blood pressure experienced for greater than or equal to 5 min, estimated thresholds below which the odds of myocardial or kidney injury progressively increased (slope P < 0.001) were 90 mmHg for systolic, 65 mmHg for mean, 50 mmHg for diastolic, and 35 mmHg for pulse pressure. Weak discriminative ability was noted between the pressure components, with univariable C-statistics ranging from 0.55 to 0.59. Area under the curve in the highest (deepest) quartile of exposure below the respective thresholds had significantly higher odds of myocardial injury after noncardiac surgery and acute kidney injury compared to no exposure for systolic, mean, and pulse pressure (all P < 0.001), but not diastolic, after adjusting for confounding. CONCLUSIONS: Systolic, mean, and pulse pressure hypotension were comparable in their strength of association with myocardial and renal injury. In contrast, the relationship with diastolic pressure was poor. Baseline factors were much more strongly associated with myocardial and renal injury than intraoperative blood pressure, but pressure differs in being modifiable.


Assuntos
Lesão Renal Aguda/fisiopatologia , Pressão Sanguínea/fisiologia , Monitorização Intraoperatória/métodos , Isquemia Miocárdica/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/etiologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
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