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2.
Transplant Proc ; 52(6): 1788-1790, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32571703

RESUMO

BACKGROUND: The use of a minimally invasive laparoscopic approach in living donor hepatectomy is increasing with the need for enhanced management of living donors. Hypotensive bradycardia often occurs during abdominal surgery and can be fatal without proper management. We conducted a retrospective study to investigate the incidence and risk factors of symptomatic (hypotensive) bradycardia in laparoscopic living donor hepatectomy. METHODS: Hypotensive bradycardia is defined as the heart rate below 60 beats per minute with simultaneous mean arterial blood pressure (MAP) below 65 mm Hg. Clinical characteristics of liver donors were collected and analyzed from May 2018 to July 2019. RESULTS: This study included 129 cases of living donor hepatectomy; 11 donors of open hepatectomy were excluded, and 118 donors undergoing laparoscopic hepatectomy were analyzed. Hypotensive bradycardia was shown in 27 donors. Hypertension or angiotensin receptor blocker medication were significantly related to hypotensive bradycardia. Hypotensive bradycardia occurred after incision in 22 donors, and the onset time from the incision was 7.5 minutes [first quartile (Q1) 5.75, third quartile (Q3) 11.5, range 0-25], the minimum heart rate was 48.5 beats per minute (Q1 41.5, Q3 53.25, range 25-57), and the minimum MAP was 55 mm Hg (Q1 45, Q3 57.5, range 35-63). It took 132 seconds (Q1 42, Q3 189, range 12-408) to recover MAP over 65 mm Hg. CONCLUSIONS: Hypotensive bradycardia occurred in 22.9% of the laparoscopic living donor hepatectomy cases, and 80.6% of cases occurred after incision. Thorough preoperative evaluation and close monitoring is important even in a healthy donor.


Assuntos
Bradicardia/epidemiologia , Hepatectomia/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Laparoscopia/efeitos adversos , Coleta de Tecidos e Órgãos/efeitos adversos , Adulto , Bradicardia/etiologia , Feminino , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Incidência , Complicações Intraoperatórias/etiologia , Fígado/cirurgia , Transplante de Fígado , Doadores Vivos , Masculino , Estudos Retrospectivos , Fatores de Risco , Ferida Cirúrgica
3.
Am J Otolaryngol ; 41(4): 102553, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32485298

RESUMO

PURPOSE: The purpose of this study is to determine whether bradycardia associated with the oculocardiac reflex is a significant source of morbidity in the post injury period following orbital floor fractures in children. MATERIALS/METHODS: A retrospective review of all pediatric patients who presented to our emergency department with an orbital floor fracture from May 1, 2016 to June 1, 2018 were included. Basic demographic data was collected as well as mechanism of injury, presence of bradycardia, and time to operating room. Morbidity was based on the need for medications to treat bradycardia. RESULTS: Thirty-five pediatric patients with orbital floor fractures were reviewed. 6 (17.1%) patients had post injury bradycardia, with one patient requiring medication to stabilize their heart rate. There was no statistically significant difference in sex, race/ethnicity, or age in patients with or without bradycardia (p > 0.05) however there was a significant relationship between bradycardia and need for operative repair (X2 = 7.88, df = 1, p = 0.005). The most common mechanism of injury was motor vehicle collision (45.7%). The average time to the operating room was 145 h (6.04 days). CONCLUSIONS: While activation of the oculocardiac reflex is a legitimate concern in the post injury period, there is unlikely to be significant morbidity due to bradycardia, and the greater concern should be for the ischemic muscle injury incurred from the fracture.


Assuntos
Bradicardia/etiologia , Fraturas Orbitárias/complicações , Fraturas Orbitárias/cirurgia , Reflexo Oculocardíaco , Acidentes de Trânsito , Adolescente , Bradicardia/epidemiologia , Bradicardia/fisiopatologia , Criança , Feminino , Humanos , Masculino , Morbidade , Estudos Retrospectivos , Fatores de Tempo
4.
Arch Gynecol Obstet ; 302(4): 829-836, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32588134

RESUMO

OBJECTIVE: To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS: Patients (n = 97) were randomized to receive a bolus of NE (6 µg) immediately following spinal anesthesia with maintenance NE (0.05 µg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS: The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION: Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Infusões Parenterais/efeitos adversos , Norepinefrina/administração & dosagem , Profilaxia Pré-Exposição/métodos , Vasoconstritores/administração & dosagem , Adulto , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Pressão Sanguínea , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Cesárea/métodos , China/epidemiologia , Feminino , Humanos , Hipertensão/induzido quimicamente , Hipertensão/complicações , Hipotensão/epidemiologia , Recém-Nascido , Infusões Parenterais/métodos , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/epidemiologia , Norepinefrina/efeitos adversos , Gravidez , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vômito/induzido quimicamente , Vômito/epidemiologia , Adulto Jovem
6.
J Pediatr ; 221: 32-38.e2, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32446489

RESUMO

OBJECTIVE: To investigate the features of cardiorespiratory events in infants born preterm during the transitional period, and to evaluate whether different neonatal characteristics may correlate with event type, duration, and severity. STUDY DESIGN: Infants with gestational age (GA) <32 weeks and/or birth weight <1500 g were enrolled in this observational prospective study. Heart rate (HR) and peripheral oxygen saturation (SpO2) were recorded continuously over the first 72 hours. Cardiorespiratory events of ≥10 seconds were clustered into isolated desaturation (SpO2 <85%), isolated bradycardia (HR <100 bpm or <70% of baseline), or combined desaturation/bradycardia and classified as mild, moderate, or severe. The daily incidences of isolated desaturation, isolated bradycardia, and combined desaturation and bradycardia were analyzed. The effects of relevant clinical variables on cardiorespiratory event type and severity were assessed using generalized estimating equations. RESULTS: Among the 1050 events analyzed, isolated desaturations were the most frequent (n = 625) and isolated bradycardias the least common (n = 171). The number of cardiorespiratory events increased significantly from day 1 to day 2 (P = .028). One in 5 events had severe characteristics; event severity was highest for combined desaturation and bradycardia (P < .001). Compared with other event types, the incidence of combined desaturation and bradycardia was inversely correlated with GA (P = .029) and was higher with the use of continuous positive airway pressure (P = .002). The presence of a hemodynamically significant patent ductus arteriosus was associated with the occurrence of isolated desaturations (P = .001) and with a longer duration of cardiorespiratory events (P = .003). CONCLUSIONS: Cardiorespiratory events during transition exhibit distinct types, duration, and severity. Neonatal characteristics are associated with the clinical features of these events, indicating that a tailored clinical approach may reduce the hypoxic burden in preterm infants aged 0-72 hours.


Assuntos
Bradicardia/epidemiologia , Hipóxia/epidemiologia , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Masculino , Estudos Prospectivos , Fatores de Tempo
7.
Pediatr. aten. prim ; 22(85): e13-e19, ene.-mar. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-193435

RESUMO

INTRODUCCIÓN: el objetivo del estudio es describir los hallazgos electrocardiográficos y ecocardiográficos en mujeres adolescentes con anorexia nerviosa y correlacionarlos con parámetros clínicos. PACIENTES Y MÉTODOS: estudio observacional, retrospectivo, de casos y controles. Se estudiaron 98 mujeres adolescentes ingresadas en un hospital terciario por anorexia nerviosa restrictiva (ANR) durante los últimos 15 años, en las que se realizó valoración electrocardiográfica y ecocardiográfica al ingreso. RESULTADOS: la edad media fue similar en ambos grupos (14,6 ± 2,0 frente a 14,7 ± 2,0 años). Las pacientes con ANR presentaban menor frecuencia cardiaca (57 ± 12 frente a 72 ± 13 lpm), voltajes más bajos (rV5 = 1,1 ± 0,5 frente a 1,6 ± 0,4 mV) y menor masa ventricular izquierda (65,7 ± 14,8 frente a 90 ± 15,3 g/m2) que las pacientes controles. No se encontraron diferencias en la medición del QTc. En las pacientes con ANR, la bradicardia no se correlacionó con el peso (r = -0,20; p = 0,05), ni con el índice de masa corporal (IMC) (r = 0,02; p = 0,22) al ingreso. El grosor del septo interventricular y la masa del ventrículo izquierdo fueron significativamente menores en los pacientes con ANR (5,7 mm frente a 6,8 mm, p <0,001; 65,7 frente a 90 g/m2; p <0,001). La masa ventricular izquierda se correlacionó de forma significativa con el IMC (r = 0,21; p <0,001) y con la frecuencia cardiaca (FC) (r = -0,225; p <0,001). CONCLUSIONES: las alteraciones cardiacas fueron más prevalentes en pacientes con ANR. La bradicardia, los trastornos de la repolarización ventricular y la disminución de la masa cardiaca fueron los más frecuentemente identificados


INTRODUCTION: the aim of the study was to describe the electrocardiographic and echocardiographic findings in female adolescents with anorexia nervosa and to assess their correlation with clinical variables. PATIENTS AND METHODS: we conducted a retrospective observational case-control study. The analysis included 98 female adolescents admitted to a tertiary hospital due to anorexia nervosa over the last 15 years, all of who underwent an electrocardiographic and echocardiographic evaluation. RESULTS: the mean age was similar in both groups: 14.6 ± 2.0 years in cases vs. 14.7 ± 2.0 years in controls. Patients with anorexia had significantly lower heart rates (57 ± 12 vs. 72 ± 13 bpm), a smaller R-wave in V5 (1.1 ± 0.5 vs 1.6 ± 0.4 mV) and a lesser left ventricular mass (65.7 ± 14.8 vs 90 ± 15.3 g/m2) compared to controls. We found no differences in the QTc interval. In patients with anorexia, the presence of bradycardia was not correlated to weight (r = -0.20, p = 0.05) or body mass index (r = 0.02, p = 0.22) at admission. We found that the left ventricular mass was significantly correlated to the body mass index (r = 0.21, p <0.001,) and the heart rate (r = -0.225, p <0.001). CONCLUSIONS: cardiac abnormalities were more prevalent in patients with anorexia nervosa. Bradycardia, changes in ventricular repolarization, and a lesser left ventricular mass were the most frequent abnormalities in our sample


Assuntos
Humanos , Feminino , Adolescente , Anorexia Nervosa/complicações , Eletrocardiografia/estatística & dados numéricos , Ecocardiografia/estatística & dados numéricos , Bradicardia/epidemiologia , Disfunção Ventricular Esquerda/epidemiologia , Anorexia Nervosa/epidemiologia , Estudos Retrospectivos , Estudos de Casos e Controles , Pesos e Medidas Corporais/estatística & dados numéricos
8.
J Anesth ; 34(3): 342-347, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32100117

RESUMO

PURPOSE: Batten disease or neuronal ceroid lipofuscinosis is the most prevalent neurodegenerative disorder of childhood. Previously reported perioperative complications in children with Batten disease have come mainly from single case reports. The primary aim of the current study was to investigate perioperative complications of patients with Batten disease in the largest cohort known to date. The secondary objective was to characterize the anesthetic management including the use of propofol and to assess its association with adverse events. METHOD: We conducted a single center, retrospective descriptive study by querying the hospital's electronic medical record to identify patients with a diagnosis of Batten disease or ICD10 E75.4 who received anesthetic care from December 2014 to May 2019. RESULTS: Thirty-five patients who underwent a total of 93 anesthetic encounters (range 1-11) were included in the analysis. A total of 29 adverse events were identified. Hypotension (N = 6, 6.5%) and bradycardia (N = 7, 7.5%) requiring treatment with medications were the most common adverse events. Other adverse events include oxygen desaturation (N = 4, 4.3%), seizures (N = 4, 4.3%), unanticipated hospital or ICU admission (N = 1, 1.1%), PACU phase 1 stay > 120 min (N = 2, 2.2%), hypothermia (N = 4, 4.3%), agitation (N = 1, 1.1%), and laryngospasm requiring treatment (N = 1, 1.1%). The number of preoperative anti-epileptic drugs (AEDs) had a positive correlation with the rate of perioperative adverse events. There was no statistical relationship of adverse events with intraoperative use of propofol (odds ratio 1.03, 95% CI 0.42-2.51). CONCLUSIONS: The majority of these patients were managed without clinically significant perioperative complications. As previously reported, bradycardia, hypotension, and hypothermia were the most common adverse events. Routine avoidance of propofol in patients with Batten disease does not appear warranted.


Assuntos
Anestésicos , Hipotermia , Lipofuscinoses Ceroides Neuronais , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Criança , Humanos , Estudos Retrospectivos
9.
Am J Obstet Gynecol ; 223(2): 242.e1-242.e22, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32109464

RESUMO

BACKGROUND: Pregnancy loss prediction based on routinely measured ultrasound characteristics is generally aimed toward distinguishing nonviability. Physicians also use ultrasound indicators for patient counseling, and in some cases to decide upon the frequency of follow-up sonograms. To improve clinical utility, allocation of cut-points should be based on clinical data for multiple sonographic characteristics, be specific to gestational week, and be determined by methods that optimize prediction. OBJECTIVES: To identify routinely measured features of the early first trimester ultrasound and the gestational age-specific cut-points that are most predictive of pregnancy loss. MATERIALS AND METHODS: This was a secondary analysis of 617 pregnant women enrolled in the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial; all women had 1-2 previous pregnancy losses and no documented infertility. Each participant had a single ultrasound with a detectable fetal heartbeat between 6 weeks 0 days and 8 weeks 6 days. Cut-points for low fetal heart rate and small crown-rump length were separately defined for gestational weeks 6, 7, and 8 to optimize prediction. Identity and log-binomial regression models were used to estimate absolute and relative risks, respectively, and 95% confidence intervals between jointly categorized low fetal heart rate, small crown-rump length, and clinical pregnancy loss. Adjusted models accounted for gestational age at ultrasound in weeks. Missing data were addressed using multiple imputation. RESULTS: A total of 64 women experienced a clinical pregnancy loss following the first ultrasound (10.4%), 7 were lost to follow-up (1.1%), and 546 women (88.5%) had a live birth. Low fetal heart rate and small crown-rump length (≤122, 123, and 158 bpm; ≤6.0, 8.5, and 10.9 mm for gestational weeks 6, 7, and 8, respectively) were independent predictors of clinical pregnancy loss, with greatest risks observed for pregnancies having both characteristics (relative risk, 2.08; 95% confidence interval, 1.24-2.91). The combination of low fetal heart rate and small crown-rump length was linked to a 16% (95% confidence interval, 9.1-23%) adjusted absolute increase in risk of subsequent loss, from 5.0% (95% confidence interval, 1.5-8.5%) to 21% (95% confidence interval, 15-27%). Abnormal yolk sac diameter or the presence of a subchorionic hemmhorage did not improve prediction of clinical pregnancy loss. CONCLUSION: Identified cut-points can be used by physicians for patient counseling, and in some cases to decide upon the frequency of follow-up sonograms. The specified criteria should not be used to diagnose nonviability.


Assuntos
Aborto Espontâneo/epidemiologia , Bradicardia/epidemiologia , Estatura Cabeça-Cóccix , Retardo do Crescimento Fetal/epidemiologia , Frequência Cardíaca Fetal , Primeiro Trimestre da Gravidez , Ultrassonografia Pré-Natal , Adulto , Bradicardia/diagnóstico por imagem , Córion/diagnóstico por imagem , Regras de Decisão Clínica , Feminino , Retardo do Crescimento Fetal/diagnóstico por imagem , Idade Gestacional , Humanos , Gravidez , Medição de Risco , Saco Vitelino/diagnóstico por imagem , Adulto Jovem
10.
Anesth Analg ; 130(3): 685-695, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-30896593

RESUMO

BACKGROUND: The anticholinesterase neostigmine and the muscarinic inhibitor glycopyrrolate are frequently coadministered for the reversal of neuromuscular blockade. This practice can precipitate severe bradycardia or tachycardia, but whether it affects the incidence of cardiovascular complications remains unclear. We hypothesized that anticholinesterase reversal with neostigmine and glycopyrrolate versus no anticholinesterase reversal increases the risk of postoperative cardiovascular complications among adult patients undergoing noncardiac surgery with general anesthesia. METHODS: We conducted a prespecified retrospective analysis of hospital registry data from a major health care network for patients undergoing surgery with general anesthesia from January 2007 to December 2015. The primary outcome was a composite of cardiac dysrhythmia, acute heart failure, transient ischemic attack, ischemic stroke, and acute myocardial infarction within 30 days after surgery. We performed sensitivity analyses in subgroups and propensity score adjustment and explored the association between exposure and outcome in subgroups of patients with high risk of cardiovascular complications. RESULTS: Of the 98,147 cases receiving neuromuscular blockade, 73,181 (74.6%) received neostigmine and glycopyrrolate, while 24,966 (25.4%) did not. A total of 5612 patients (7.7%) in the anticholinesterase reversal group and 1651 (6.6%) in the control group (P < .001) experienced the primary outcome. After adjustment for clinical covariates, neostigmine and glycopyrrolate exposure was significantly associated in a dose-dependent fashion (P for trend <.001, respectively) with tachycardia (adjusted odds ratio = 2.1 [95% CI, 1.97-2.23]; P < .001) and bradycardia (adjusted odds ratio = 2.84 [95% CI, 2.49-3.24]; P < .001) but not with postoperative cardiovascular complications (adjusted odds ratio = 1.03 [95% CI, 0.97-1.1]; P = .33). We identified a significant effect modification of anticholinesterase reversal by high age, high-risk surgery, and history of atrial fibrillation (P for interaction = .002, .001, and .02, respectively). By using linear combinations of main effect and exposure-risk interaction terms, we detected significant associations between anticholinesterase reversal and cardiovascular complications toward a higher vulnerability in these patient subgroups. CONCLUSIONS: Neuromuscular blockade reversal with neostigmine and glycopyrrolate was associated with an increased incidence of intraoperative tachycardia and bradycardia but not with 30-day postoperative cardiovascular complications. Exploratory analyses suggest that a high postoperative cardiovascular complication risk profile may modify the effects of anticholinesterase reversal toward clinical relevance.


Assuntos
Anestesia Geral/efeitos adversos , Bradicardia/induzido quimicamente , Inibidores da Colinesterase/efeitos adversos , Glicopirrolato/efeitos adversos , Frequência Cardíaca/efeitos dos fármacos , Antagonistas Muscarínicos/efeitos adversos , Neostigmina/efeitos adversos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Taquicardia/induzido quimicamente , Adulto , Idoso , Boston/epidemiologia , Bradicardia/diagnóstico , Bradicardia/epidemiologia , Bradicardia/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taquicardia/diagnóstico , Taquicardia/epidemiologia , Taquicardia/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
11.
Ned Tijdschr Geneeskd ; 1632019 11 21.
Artigo em Holandês | MEDLINE | ID: mdl-31769635

RESUMO

OBJECTIVE: To investigate the incidence of hypoxaemia, bradycardia and post-operative bleeding in non-intubated Sluder method adenotonsillectomy patients in sitting versus supine position. DESIGN: Explorative study. METHOD: A retrospective database was drawn up with data from all patients on whom a Sluder method non-intubated adenotonsillectomy was performed in a Dutch district general hospital between 01 January 2012 and 01 May 2018. Depending on the preference of the surgeon and following discussion with the anaesthesiologist, the operation was performed with the patient in either a sitting or supine position. The primary outcome measure was hypoxaemia, defined as SpO2 < 85% for ≥ 60 seconds. Secondary outcome measures included bradycardia and post-operative bleeding. RESULTS: We analysed the data of 723 adenotonsillectomy patients (46% female, average age 4.5 years), of whom 193 (27%) in sitting and 530 (73%) in supine position. Hypoxaemia occurred in 13 (7%) 'sitting' cohort patients and in 13 (2%) of the supine cohort patients (p = 0.011). No perioperative complications developed as a result of the hypoxaemia. The frequency of bradycardia did not differ between the two cohorts (4 vs 2%; p = 0.442). None of the patients developed both hypoxaemia and bradycardia. In 8 (1%) patients, a secondary intervention was required due to the occurrence of post-operative haemorrhage. CONCLUSION: Patients who undergo non-intubated Sluder guillotine method adenotonsillectomy when in a sitting position are more likely to develop hypoxaemia than those who are operated on in a supine position. In order to make an informed recommendation, a randomized trial is indicated.


Assuntos
Adenoidectomia/efeitos adversos , Hipóxia/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Postura Sentada , Decúbito Dorsal , Tonsilectomia/efeitos adversos , Bradicardia/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Estudos Retrospectivos
12.
J Clin Hypertens (Greenwich) ; 21(12): 1813-1820, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31670874

RESUMO

This was a post hoc analysis of Systolic Blood Pressure Intervention Trial (SPRINT), aimed to investigate whether intensive blood pressure treatment has differential therapeutic outcomes on patients with different baseline Framingham risk score (FRS). The 9298 SPRINT participants were categorized into low-risk (baseline FRS < 10%), intermediate-risk (FRS = 10%-20%), or high-risk (FRS > 20%) arms. The primary outcome was a composite of myocardial infarction, acute coronary syndrome not resulting in myocardial infarction, stroke, acute decompensated heart failure, or death from cardiovascular causes. Serious adverse events were defined as hypotension, syncope, and bradycardia. Multiple Cox regression was used to calculate hazard ratios for study outcomes with intensive compared with standard SBP treatment between these three groups. After a median follow-up time of 3.26 years, the primary outcome hazard ratio (HR) for intensive versus standard treatment was 0.73 (95% CI: 0.61-0.88, P = .0044) in the high-risk arm. And, for all-cause mortality, the hazard ratio with intensive SBP treatment was 1.58 (95% CI: 0.55-1.06), 0.9 (95% CI: 0.26-9.50), and 0.53 (95% CI: 0.34-0.82) in three arms (all P values for interaction > 0.05). Effects of intensive versus standard SBP control on serious adverse events were similar among patients with different FRS. Our results suggested that regardless of the FRS level, the intensive blood pressure control was beneficial.


Assuntos
Anti-Hipertensivos/efeitos adversos , Pressão Sanguínea/fisiologia , Hipertensão/tratamento farmacológico , Sístole/efeitos dos fármacos , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/epidemiologia , Lesão Renal Aguda/induzido quimicamente , Lesão Renal Aguda/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Estudos de Casos e Controles , Morte , Feminino , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Humanos , Hipertensão/complicações , Hipertensão/fisiopatologia , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/etiologia , Modelos de Riscos Proporcionais , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Síncope/induzido quimicamente , Síncope/epidemiologia , Resultado do Tratamento
13.
Hosp Pediatr ; 9(10): 813-817, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31527051

RESUMO

OBJECTIVES: To describe temporal trends in car seat tolerance screening (CSTS) failure within a large hospital system (2014-2018). METHODS: We conducted a retrospective cohort study using electronic medical record data for infants who underwent a CSTS. Our primary outcome measure was the CSTS failure rate. Covariates included year, CSTS location (well nursery or NICU), gestational age (GA), race, sex, birth weight, CSTS date, and age at CSTS. Associations of covariates with CSTS failure were examined by using χ2 tests, t tests, analysis of variance, and Wilcoxon rank tests. Multivariable logistic regression was used to determine the adjusted odds of CSTS failure. RESULTS: Of 4849 infants tested, the failure rate was 8.1% (n = 394). Most CSTS occurred in the well nursery (79.5%) and involved late preterm (55.2%) or term infants (23.7%). In bivariate analyses, year, unit location, higher birth weight, younger chronological age at testing, and higher GA were positively associated with CSTS failure (P < .05). After stratification by CSTS location, the CSTS failure rate rose in the well nursery but remained stable in the NICU, and use of screening rose among term infants. In the adjusted model, year, GA, and corrected gestational age at CSTS were associated with failure. Each subsequent year was associated with a 19% increase in odds of CSTS failure (P < .001). CONCLUSIONS: We found a higher rate of CSTS failure in the well nursery compared with the NICU, and the difference in failure rates increased over time. Improved understanding of infants at the highest risk of CSTS failure could impact routine screening guidelines.


Assuntos
Apneia/epidemiologia , Bradicardia/epidemiologia , Sistemas de Proteção para Crianças , Hipóxia/epidemiologia , Posicionamento do Paciente/efeitos adversos , Apneia/etiologia , Bradicardia/etiologia , Feminino , Humanos , Hipóxia/etiologia , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal , Masculino , Programas de Rastreamento , Berçários Hospitalares , Estudos Retrospectivos
14.
J Perinat Med ; 47(8): 885-893, 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31421044

RESUMO

Background Preterm newborns may be discharged when clinical conditions are stable. Several criteria for early discharge have been proposed in the literature. This study carried out the first quantitative comparison of their impact in terms of hospitalization savings, safety and costs. Methods This study was based on the clinical histories of 213 premature infants born in the Neonatal Intensive Care Unit of Padova University Hospital between 2013 and 2014. Seventeen early discharge criteria were drawn from the literature and retrospectively applied to these data, and computation of hospitalization savings, safety and costs implied by each criterion was carried out. Results Among the criteria considered, average gains ranged from 1.1 to 10.3 hospital days and between 0.3 and 1.1 fewer infections per discharged infant. Criteria that led to saving more hospital days had higher cost-effectiveness in terms of crisis and infection, and they spared infants from more infections. However, episodes of apnea and bradycardia were detected after the potential early discharge date for all criteria, with a mean number of episodes numbering between 0.3 and 1.4. Conclusion The results highlight a clear trade-off between days saved and health risks for infants, with potential consequences for health care costs.


Assuntos
Protocolos Clínicos , Lactente Extremamente Prematuro , Unidades de Terapia Intensiva Neonatal/economia , Alta do Paciente/economia , Apneia/epidemiologia , Bradicardia/epidemiologia , Feminino , Humanos , Recém-Nascido , Infecções/epidemiologia , Itália/epidemiologia , Masculino , Estudos Retrospectivos
15.
Anesthesiology ; 131(4): 830-839, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31335549

RESUMO

BACKGROUND: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia. METHODS: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location. RESULTS: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255). CONCLUSIONS: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.


Assuntos
Anestesia/métodos , Bradicardia/epidemiologia , Hipóxia/epidemiologia , Laringoscopia/estatística & dados numéricos , Estudos de Coortes , Estudos Transversais , Humanos , Lactente , Recém-Nascido , Estudos Retrospectivos
16.
Emerg Med J ; 36(9): 520-528, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31320332

RESUMO

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.


Assuntos
Protocolos Clínicos/normas , Estado Terminal/terapia , Intubação Intratraqueal/normas , Guias de Prática Clínica como Assunto , Ressuscitação/normas , Adolescente , Bradicardia/epidemiologia , Bradicardia/etiologia , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Hipóxia/epidemiologia , Hipóxia/etiologia , Lactente , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Laringoscópios/efeitos adversos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Estudos Retrospectivos , Gravação em Vídeo , Adulto Jovem
17.
World Neurosurg ; 131: e211-e217, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31349074

RESUMO

BACKGROUND: Reports have emerged describing the successful endovascular recanalization of the chronically occluded internal carotid artery (COICA). The impact this restoration of flow has on the sensitive carotid sinus baroreceptors has not been previously described. In this manuscript, we present the largest COICA surgical series to date, with a specific focus on perioperative heart rate abnormalities. METHODS: Patient demographics were obtained, and the COICAs were radiographically classified based on the anatomic distribution of the stenosis and collateral flow. Thirty-six patients had a total of 37 COICA revascularization procedures. RESULTS: A total of 23 patients had intraprocedural bradycardia during balloon angioplasty. Three patients went into transient asystole during the procedure, and 2 of these patients had symptomatic bradycardia with ischemic cerebral changes, 1 of which required permanent pacemaking. All other patients had immediate resolution of their bradycardia, asystole, and neurologic symptoms immediately following balloon deflation and pharmaceutical management. There was a statistically significant difference in the observed proportion of bradycardic patients among COICA classifications (P = 0.014). There was no statistically significant difference in mean age between patients with bradycardia and those without (aged 63.36 vs. 67.71 years, P = 0.2265). CONCLUSIONS: Bradycardia associated with angioplasty of the carotid bulb was observed in the majority of patients receiving COICA revascularization. A small percentage of these patients were symptomatic. Our results suggest that carotid sinus baroreceptors remain active while residing in a complete arterial occlusion, and close monitoring is necessary during balloon angioplasty of the proximal COICA.


Assuntos
Angioplastia com Balão , Bradicardia/epidemiologia , Estenose das Carótidas/terapia , Parada Cardíaca/epidemiologia , Complicações Intraoperatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Seio Carotídeo , Estenose das Carótidas/classificação , Estenose das Carótidas/diagnóstico por imagem , Doença Crônica , Circulação Colateral , Procedimentos Endovasculares , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pressorreceptores
18.
Heart Rhythm ; 16(9): 1348-1356, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31125673

RESUMO

BACKGROUND: Management of atrial fibrillation (AF) with rate and rhythm therapy can cause bradyarrhythmia. OBJECTIVES: To assess overall risk, temporal risk, and subgroup at risk of bradyarrhythmia-related events by rate and/or rhythm therapy drugs. METHODS: Using Danish nationwide registries, patients with AF between 2000 and 2014 were included if prescribed with rate-lowering drugs (RLDs) or antiarrhythmic drugs (AADs). An adjusted time-dependent Poisson regression model estimated the association between RLDs and AADs with a composite endpoint of pacemaker, temporary pacing, and bradyarrhythmia hospitalization. Secondary outcomes were each individual event. RESULTS: Among 135,017 AF patients, 9196 (6.8%) patients experienced the composite endpoint with a median follow-up of 3.7 (interquartile range [IQR]: 1.6-7.0) years. Median age was 74 (IQR: 65-82) years and 47.6% were women. With rate-lowering monotherapy as the reference, the incidence rate ratios (IRR) (95% confidence interval) for the composite endpoint were 1.36 (1.29-1.43) for rate-lowering dual therapy, 1.62 (1.43-1.84) for antiarrhythmic monotherapy, and 2.49 (2.29-2.71) for AAD combined with RLDs. Similar trend was found for each secondary outcome. Particularly amiodarone increased the risk. This association was strongest within the first 2 weeks of treatment. In those treated with AAD combined with RLDs, high-risk populations were patients ≥70 years (IRR: 3.35 [2.51-4.45] compared to patients <60 years), and women (IRR: 1.35 [1.15-1.57], compared to men). CONCLUSIONS: In real-world AF patients, rate-lowering dual therapy, antiarrhythmic monotherapy, and AADs combined with RLDs were positively associated with bradyarrhythmia-related events. The risk was highest in those treated with amiodarone, in the initial 2 weeks of treatment, in women, and in the elderly.


Assuntos
Amiodarona , Antiarrítmicos , Fibrilação Atrial/tratamento farmacológico , Bradicardia , Frequência Cardíaca/efeitos dos fármacos , Efeitos Adversos de Longa Duração , Fatores Etários , Idoso , Amiodarona/administração & dosagem , Amiodarona/efeitos adversos , Antiarrítmicos/administração & dosagem , Antiarrítmicos/efeitos adversos , Antiarrítmicos/classificação , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/fisiopatologia , Bradicardia/induzido quimicamente , Bradicardia/diagnóstico , Bradicardia/epidemiologia , Dinamarca/epidemiologia , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Efeitos Adversos de Longa Duração/induzido quimicamente , Efeitos Adversos de Longa Duração/diagnóstico , Efeitos Adversos de Longa Duração/epidemiologia , Masculino , Administração dos Cuidados ao Paciente/métodos , Administração dos Cuidados ao Paciente/estatística & dados numéricos , Sistema de Registros , Medição de Risco , Fatores de Risco , Fatores Sexuais
19.
Early Hum Dev ; 134: 14-18, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31112857

RESUMO

BACKGROUND: The association between cardiorespiratory events (CRE) and gastro-esophageal reflux (GER) among neonates is still controversial. AIMS: To test such an association in preterm and term infants. STUDY DESIGN: Prospective observational study. SUBJECTS: Forty-seven infants with suspected GER and recurrent CRE admitted at a neonatal intensive care unit, who underwent simultaneous and synchronized 24-hour recording of heart rate (HR), peripheral oxygen saturation (SpO2) and pH-impedance monitoring (MII-pH). HR/SpO2 data were filtered to avoid artefactual episodes of hypoxia and hypoperfusion. OUTCOME MEASURES: The main outcome measure was the symptom association probability (SAP), with a 2-minute time window. Infants with positive (>95%) and negative (≤95%) SAP index tests were compared by univariate and multivariate statistics. RESULTS: Median gestational age at birth was 294/7 weeks, median age at study 36 days. We recorded 3341 GER events and 4936 CRE (4710 desaturations, 226 bradycardias); 609/4936 (12%) CRE were temporally associated with GER episodes: 338 preceded and 271 followed GER events. The SAP index was significant in 5/47 (11%) patients. The SAP index including only CRE following GER events was significant in 3/47 (6%). There was no significant difference in the number of acid, weakly acid, non-acid, pH-only events preceding or following CRE between infants with SAP-positive and SAP-negative tests. Infants with positive SAP-index tests compared to those with SAP-negative tests had lower weight gain in the three days preceding the test and tended to have lower birth weight. CONCLUSIONS: GER and CRE were associated in <11% of patients. The evaluation of ponderal growth might be helpful in predicting such an association.


Assuntos
Apneia/epidemiologia , Bradicardia/epidemiologia , Refluxo Gastroesofágico/epidemiologia , Recém-Nascido Prematuro/fisiologia , Feminino , Frequência Cardíaca , Humanos , Recém-Nascido , Masculino , Consumo de Oxigênio
20.
J Pediatr Hematol Oncol ; 41(7): 537-541, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30994505

RESUMO

Systemic corticosteroids are widely used for the treatment of acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma. Anecdotal case reports demonstrate bradycardia in patients receiving corticosteroids; however, a more in-depth analysis is lacking. This study aimed to describe the incidence, timing, and outcomes of bradycardia in children with ALL receiving corticosteroids during induction chemotherapy at our center from 2010 to 2016. A total of 153 children were included, with 150 (98%) demonstrating decreased heart rate following steroid administration with a median HR decrease of 23 beats per minute. Bradycardia ≤first percentile for age developed in 90 (59%) patients, with nadir occurring, on average, 7 doses into treatment, corresponding to 79 hours after initiation of therapy. No patient experienced adverse events related to bradycardia. Resolution of bradycardia at outpatient follow-up occurred in 62 of 71 (87%). Examination of nadir heart rate during subsequent hospitalizations in which steroids were not being administered did not demonstrate a significant incidence of bradycardia. Corticosteroid-induced bradycardia is common in children with ALL receiving induction chemotherapy. It was not associated with clinical adverse events and self-resolved without intervention. Therefore, further cardiac assessment may not be warranted in the presence of asymptomatic bradycardia suspected to be secondary to steroid administration.


Assuntos
Corticosteroides/efeitos adversos , Bradicardia/induzido quimicamente , Leucemia-Linfoma Linfoblástico de Células Precursoras/tratamento farmacológico , Adolescente , Adulto , Bradicardia/epidemiologia , Criança , Pré-Escolar , Feminino , Humanos , Incidência , Quimioterapia de Indução/efeitos adversos , Quimioterapia de Indução/métodos , Lactente , Masculino , Adulto Jovem
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