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1.
Medicine (Baltimore) ; 99(1): e18541, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31895792

RESUMO

Perioperative hypertension is a common occurrence in the neurosurgical population, where 60% to 90% of the patients require treatment for blood pressure (BP) control. Nicardipine and clevidipine have been commonly used in neurocritical settings. This retrospective, observational study assessed the effectivity of the administration of clevidipine after nicardipine treatment failure in neurosurgical patients.We retrospectively reviewed the medical charts of adult patients who were admitted to our neurosurgical department and received clevidipine after nicardipine treatment failure for the control of BP. The primary effectivity outcome was the comparison of the percentage of time spent at targeted SBP goals during nicardipine and clevidipine administration, respectively.A total of 12 adult patients treated with clevidipine after nicardipine treatment failure and were included for data analysis. The median number of events that required dose-titration was 20.5 vs 17 during the administration of nicardipine and clevidipine, respectively (P = .534). The median percentage of time spent at targeted SBP goal was 76.2% during the administration of nicardipine and 93.4% during the administration of clevidipine (P = .123).Our study suggests that clevidipine could be an alternative effective drug with an acceptable benefit/risk ratio in the neurosurgical population that fails to achieve BP control with nicardipine treatment.


Assuntos
Bloqueadores dos Canais de Cálcio/administração & dosagem , Hipertensão/tratamento farmacológico , Complicações Intraoperatórias/tratamento farmacológico , Procedimentos Neurocirúrgicos/efeitos adversos , Piridinas/administração & dosagem , Pressão Sanguínea/efeitos dos fármacos , Feminino , Humanos , Hipertensão/etiologia , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Nicardipino/uso terapêutico , Estudos Retrospectivos , Falha de Tratamento , Resultado do Tratamento
3.
BJOG ; 127(3): 397-403, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31749273

RESUMO

OBJECTIVE: To determine whether restrictive or routine episiotomy in term pregnant Southeast Asian women results in fewer complications. DESIGN: A multicentre randomised controlled trial. SETTING: Two tertiary and two general hospitals in Thailand. POPULATION: 3006 singleton pregnant women 18 years or older, ≥37 weeks of gestation, cephalic presentation and planned vaginal delivery. METHODS: This randomised controlled trial compared routine versus restrictive episiotomies in Thai women giving birth vaginally. Participants were singleton, term pregnant women with cephalic presentation. Block randomisation was stratified by study site and parity. Risk ratios (RR) and 95% confidence intervals (CI) were calculated to indicate between-group differences. MAIN OUTCOME MEASURES: Primary outcome was severe perineal laceration. Secondary outcomes included vaginal laceration, cervical laceration, and pregnancy outcomes. RESULTS: 3006 women were randomly assigned to restrictive (1502) and routine (1504) episiotomy. There was no difference in severe perineal laceration between the groups (RR 0.72, 95% CI 0.46-1.12). Restrictive episiotomy resulted in more intact perineums in multiparous women (RR 3.09, 95% CI 2.10-4.56). Restrictive episiotomy increased the risk of vaginal laceration in primiparous (RR 1.96, 95% CI 1.62-2.37) and multiparous women (RR 2.21, 95% CI 1.77-2.75) but did not lead to more suturing. There were comparable risks of cervical laceration, postpartum haemorrhage, wound complication, birth asphyxia, and admission to neonatal intensive care unit. CONCLUSIONS: Restrictive episiotomy results in more intact perineum in multiparous women. Risks of maternal and neonatal outcomes were comparable between the two practices. These results strengthen the certainty of the existing Cochrane review findings in supporting restrictive episiotomy. TWEETABLE ABSTRACT: Restrictive episiotomy results in more intact perineums after vaginal birth in multiparous Southeast Asian women.


Assuntos
Parto Obstétrico , Episiotomia , Complicações Intraoperatórias , Lacerações , Períneo/lesões , Adulto , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Episiotomia/efeitos adversos , Episiotomia/métodos , Feminino , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/prevenção & controle , Apresentação no Trabalho de Parto , Lacerações/diagnóstico , Lacerações/etiologia , Lacerações/prevenção & controle , Paridade , Gravidez , Resultado da Gravidez/epidemiologia , Risco Ajustado/métodos , Nascimento a Termo , Tailândia
4.
Br J Anaesth ; 124(1): 44-62, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31653394

RESUMO

Most cases of serotonin toxicity are provoked by therapeutic doses of a combination of two or more serotonergic drugs, defined as drugs affecting the serotonin neurotransmitter system. Common serotonergic drugs include many antidepressants, antipsychotics, and opioid analgesics, particularly fentanyl, tramadol, meperidine (pethidine), and methadone, but rarely morphine and other related phenanthrenes. Symptoms of serotonin toxicity are attributable to an effect on monoaminergic transmission caused by an increased synaptic concentration of serotonin. The serotonin transporter (SERT) maintains low serotonin concentrations and is important for the reuptake of the neurotransmitter into the presynaptic nerve terminals. Some opioids inhibit the reuptake of serotonin by inhibiting SERT, thus increasing the plasma and synaptic cleft serotonin concentrations that activate the serotonin receptors. Opioids that are good inhibitors of SERT (tramadol, dextromethorphan, methadone, and meperidine) are most frequently associated with serotonin toxicity. Tramadol also has a direct serotonin-releasing action. Fentanyl produces an efflux of serotonin, and binds to 5-hydroxytryptamine (5-HT)1A and 5-HT2A receptors, whilst methadone, meperidine, and more weakly tapentadol, bind to 5-HT2A but not 5-HT1A receptors. The perioperative period is a time where opioids and other serotonergic drugs are frequently administered in rapid succession, sometimes to patients with other serotonergic drugs in their system. This makes the perioperative period a relatively risky time for serotonin toxicity to occur. The intraoperative recognition of serotonin toxicity is challenging as it can mimic other serious syndromes, such as malignant hyperthermia, sepsis, thyroid storm, and neuroleptic malignant syndrome. Anaesthetists must maintain a heightened awareness of its possible occurrence and a readiness to engage in early treatment to avoid poor outcomes.


Assuntos
Analgésicos Opioides/efeitos adversos , Anestesiologistas , Serotoninérgicos/efeitos adversos , Síndrome da Serotonina/terapia , Febre/induzido quimicamente , Humanos , Complicações Intraoperatórias/induzido quimicamente , Síndrome da Serotonina/diagnóstico
5.
Br J Anaesth ; 124(1): 101-109, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31733807

RESUMO

BACKGROUND: During general anaesthesia, most patients develop atelectasis, which promotes postoperative pulmonary complications. RCTs that investigated perioperative lung protection have failed to reduce postoperative pulmonary complications consistently. Ultrasound imaging could help confirm the effects of different protective ventilatory strategies, but this has not been tested in trials. The objective of this study was to use ultrasonography to evaluate whether lung-protective ventilation measures reduce perioperative atelectasis. METHODS: We conducted a prospective, randomised patient- and assessor-blinded controlled trial in women undergoing open gynaecological surgery. Subjects were randomised to either lung protection or zero end-expiratory pressure (ZEEP; with no recruitment manoeuvres [RMs]). Lung protection entailed PEEP (7 cm H2O) and RMs every 30 min. Lung ultrasonography was undertaken at five predefined time points. The primary outcome was the difference in lung ultrasonography score (LUS) between groups before emergence; a lower LUS indicates better lung aeration. RESULTS: We recruited 45 women (34-85 yr old). Women randomised to lung protection had lower mean (standard deviation) LUS before emergence (6.1 [3.7]), compared with women randomised to ZEEP (11.7 [3.9]; 95% confidence interval for the difference between group means [-7.9 to -3.2]; P<0.0001). This difference did not persist after extubation, with similar mean LUSs in women who had received intraoperative lung protection (7.0 [4.1]), compared with women randomised to receive ZEEP (7.7 [3.1]). CONCLUSIONS: As assessed by lung ultrasonography, intraoperative PEEP/RMs decreased aeration loss during general anaesthesia. However, similar degrees of aeration loss were observed after tracheal extubation regardless of intraoperative ventilatory strategy. CLINICAL TRIAL REGISTRATION: NCT02055807.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Complicações Intraoperatórias/diagnóstico por imagem , Complicações Intraoperatórias/epidemiologia , Respiração com Pressão Positiva/métodos , Atelectasia Pulmonar/diagnóstico por imagem , Atelectasia Pulmonar/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Feminino , Humanos , Pulmão/diagnóstico por imagem , Pessoa de Meia-Idade , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Atelectasia Pulmonar/etiologia , Respiração Artificial , Resultado do Tratamento , Ultrassonografia
6.
Urology ; 135: 171-172, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31589882

RESUMO

OBJECTIVE: To demonstrate how bladder ultrasound can be useful in completing morcellation during difficult Holmium Laser Enucleation of the Prostate (HoLEP). As HoLEP has emerged as a standard of care for the treatment of benign prostatic hyperplasia, multiple studies have reported the potentially catastrophic complication of bladder injury during morcellation. This video aims to assist any urologist performing HoLEP by providing step-by-step instruction for using ultrasound to complete morcellation safely. METHODS: Enucleation is performed using a 26-French continuous flow scope, off-set laser bridge with a laser stabilization catheter, and a 550 µm holmium laser fiber. Once the median and lateral lobes have been enucleated, the outer sheath is removed and the nephroscope is inserted to facilitate morcellation. Under dual inflow irrigation, the Piranha morcellator (Richard Wolf, Knittlingen, Germany) is introduced and set to the manufacturer's recommended settings of 1500 rpm. A 3.5-MHz convex abdominal ultrasound transducer (Hitachi Prosound Alpha 7; Hitachi Aloka Medical America, Wallingford, CT) under B-mode is used to visualize the bladder, predominantly in the sagittal orientation. Morcellation proceeds under simultaneous ultrasound and direct cystoscopic guidance. RESULTS: The distended bladder is visualized concurrently with the ultrasound and via the nephroscope as the Piranha engages the adenoma and begins morcellation. Once the adenoma is engaged, the operator then drops their hands to place the morcellator in the center of the bladder. Ultrasound provides real-time feedback as to the location of the morcellator in relation to the adenoma and bladder. CONCLUSION: This video highlights the use of intraoperative bladder ultrasound as a visual aid to assist during the morcellation portion of HoLEP. This proof of concept demonstrates that ultrasound can be an additional tool to utilize during difficult cases when cystoscopic visualization during morcellation is limited.


Assuntos
Complicações Intraoperatórias/prevenção & controle , Terapia a Laser/métodos , Morcelação/métodos , Prostatectomia/métodos , Bexiga Urinária/diagnóstico por imagem , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser/efeitos adversos , Terapia a Laser/instrumentação , Lasers de Estado Sólido/efeitos adversos , Lasers de Estado Sólido/uso terapêutico , Masculino , Morcelação/efeitos adversos , Morcelação/instrumentação , Estudo de Prova de Conceito , Próstata/diagnóstico por imagem , Próstata/cirurgia , Prostatectomia/efeitos adversos , Prostatectomia/instrumentação , Hiperplasia Prostática/cirurgia , Ultrassonografia , Bexiga Urinária/lesões
7.
World Neurosurg ; 133: e68-e75, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31465851

RESUMO

BACKGROUND: Horner syndrome is an infrequently seen complication of anterior cervical discectomy and fusion (ACDF). Multicenter studies have reported a very low incidence, less than 0.1%. OBJECTIVE: To identify the incidence in, characteristics of, and postoperative course in patients in whom postoperative Horner syndrome developed after ACDF. METHODS: We performed a retrospective review of all patients who experienced Horner syndrome after ACDF for cervical degenerative disease at a single tertiary care institution between 2017 and 2018. A systematic review was then performed to identify studies investigating prevalence, diagnosis, and treatment of postoperative Horner syndrome after ACDF. RESULTS: Of 1116 patients at our institution who underwent ACDF, the incidence of Horner syndrome was 0.45%. C4/5 and C5/6 were the 2 most common surgical levels. The complication was noted to occur immediately after surgery, and at least partial improvement was identified in all patients an average 3.5 months after surgery (range, 10 days to 6 months). These findings were consistent with our systematic review of 21 studies that showed an incidence of 0.6% (range, 0.02% to 4.0%), the most common surgical level C5/6 (64%), and 82% of patients experiencing at least partial resolution of symptoms within 1 year (60.7% complete, 21.4% partial resolution). CONCLUSION: Horner syndrome occurs in 0.6% of patients undergoing ACDF. Careful postoperative examination should reveal this complication, which may be underdiagnosed or underreported in larger multicenter case series. The majority of patients experience complete resolution of symptoms within 6 months to 1 year and can be treated conservatively and expectantly.


Assuntos
Vértebras Cervicais/cirurgia , Discotomia/efeitos adversos , Síndrome de Horner/etiologia , Degeneração do Disco Intervertebral/cirurgia , Complicações Intraoperatórias/etiologia , Fusão Vertebral/efeitos adversos , Idoso , Feminino , Síndrome de Horner/epidemiologia , Humanos , Incidência , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sistema Nervoso Simpático/lesões , Centros de Atenção Terciária/estatística & dados numéricos , Resultado do Tratamento
8.
BJOG ; 127(1): 28-35, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31541614

RESUMO

BACKGROUND: Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. OBJECTIVE: To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. SEARCH STRATEGY: Search strategies were developed for each indication for referral. SELECTION CRITERIA: Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. DATA COLLECTION AND ANALYSIS: Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. MAIN RESULTS: Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. CONCLUSIONS: The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. TWEETABLE ABSTRACT: Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.


Assuntos
Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/efeitos adversos , Incontinência Urinária por Estresse/cirurgia , Adolescente , Adulto , Idoso , Perda Sanguínea Cirúrgica , Dispareunia/etiologia , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Qualidade de Vida , Recidiva , Disfunções Sexuais Fisiológicas/etiologia , Resultado do Tratamento , Adulto Jovem
9.
BJOG ; 127(1): 88-97, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31544327

RESUMO

OBJECTIVE: To assess the short-term incidence of serious complications of surgery for urinary incontinence or pelvic organ prolapse. DESIGN: Prospective longitudinal cohort study using a surgical registry. SETTING: Thirteen public hospitals in France. POPULATION: A cohort of 1873 women undergoing surgery between February 2017 and August 2018. METHODS: Preliminary analysis of serious complications after a mean follow-up of 7 months (0-18 months), according to type of surgery. Surgeons reported procedures and complications, which were verified by the hospitals' information systems. MAIN OUTCOME MEASURES: Serious complication requiring discontinuation of the procedure or subsequent surgical intervention, life-threatening complication requiring resuscitation, or death. RESULTS: Fifty-two women (2.8%, 95% CI 2.1-3.6%) experienced a serious complication either during surgery, requiring the discontinuation of the procedure, or during the first months of follow-up, necessitating a subsequent reoperation. One woman also required resuscitation; no women died. Of 811 midurethral slings (MUSs), 11 were removed in part or totally (1.4%, 0.7-2.3%), as were two of 391 transvaginal meshes (0.5%, 0.1-1.6%), and four of 611 laparoscopically placed mesh implants (0.7%, 0.2-1.5%). The incidence of serious complications 6 months after the surgical procedure was estimated to be around 3.5% (2.0-5.0%) after MUS alone, 7.0% (2.8-11.3%) after MUS with prolapse surgery, 1.7% (0.0-3.8%) after vaginal native tissue repair, 2.8% (0.9-4.6%) after transvaginal mesh, and 1.0% (0.1-1.9%) after laparoscopy with mesh. CONCLUSIONS: Early serious complications are relatively rare. Monitoring must be continued and expanded to assess the long-term risk associated with mesh use and to identify its risk factors. TWEETABLE ABSTRACT: Short-term serious complications are rare after surgery for urinary incontinence or pelvic organ prolapse, even with mesh.


Assuntos
Diafragma da Pelve/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Colposcopia/efeitos adversos , Colposcopia/mortalidade , Colposcopia/estatística & dados numéricos , Feminino , França/epidemiologia , Humanos , Incidência , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Pessoa de Meia-Idade , Prolapso de Órgão Pélvico/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Estudos Prospectivos , Sistema de Registros , Slings Suburetrais/efeitos adversos , Slings Suburetrais/estatística & dados numéricos , Telas Cirúrgicas/estatística & dados numéricos , Centros Cirúrgicos/estatística & dados numéricos , Adulto Jovem
10.
Bone Joint J ; 101-B(12): 1489-1497, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31786989

RESUMO

AIMS: The aim of this meta-analysis was to compare the outcome of total elbow arthroplasty (TEA) undertaken for rheumatoid arthritis (RA) with TEA performed for post-traumatic conditions with regard to implant failure, functional outcome, and perioperative complications. MATERIALS AND METHODS: We completed a comprehensive literature search on PubMed, Web of Science, Embase, and the Cochrane Library and conducted a systematic review and meta-analysis. Nine cohort studies investigated the outcome of TEA between RA and post-traumatic conditions. The preferred reporting items for systematic reviews and meta-analysis (Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)) guidelines and Newcastle-Ottawa scale were applied to assess the quality of the included studies. We assessed three major outcome domains: implant failures (including aseptic loosening, septic loosening, bushing wear, axle failure, component disassembly, or component fracture); functional outcomes (including arc of range of movement, Mayo Elbow Performance Score (MEPS), and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire), and perioperative complications (including deep infection, intraoperative fracture, postoperative fracture, and ulnar neuropathy). RESULTS: This study included a total of 679 TEAs for RA (n = 482) or post-traumatic conditions (n = 197). After exclusion, all of the TEAs included in this meta-analysis were cemented with linked components. Our analysis demonstrated that the RA group was associated with a higher risk of septic loosening after TEA (odds ratio (OR) 3.96, 95% confidence interval (CI) 1.11 to 14.12), while there was an increased risk of bushing wear, axle failure, component disassembly, or component fracture in the post-traumatic group (OR 4.72, 95% CI 2.37 to 9.35). A higher MEPS (standardized mean difference 0.634, 95% CI 0.379 to 0.890) was found in the RA group. There were no significant differences in arc of range of movement, DASH questionnaire, and risk of aseptic loosening, deep infection, perioperative fracture, or ulnar neuropathy. CONCLUSION: The aetiology of TEA surgery appears to have an impact on the outcome in terms of specific modes of implant failures. RA patients might have a better functional outcome after TEA surgery. Cite this article: Bone Joint J 2019;101-B:1489-1497.


Assuntos
Artrite Reumatoide/cirurgia , Artroplastia de Substituição do Cotovelo , Articulação do Cotovelo/lesões , Artroplastia de Substituição do Cotovelo/reabilitação , Articulação do Cotovelo/cirurgia , Humanos , Complicações Intraoperatórias/etiologia , Complicações Pós-Operatórias/etiologia , Falha de Prótese/etiologia , Recuperação de Função Fisiológica , Resultado do Tratamento
11.
Actas urol. esp ; 43(10): 521-525, dic. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-185257

RESUMO

Objetivos: El objetivo de este estudio fue evaluar el rol de la aplicación de fluoroscopia en pacientes intervenidos mediante cirugía retrógrada intrarrenal y su efecto sobre los resultados quirúrgicos. Material y métodos: Los pacientes que ingresaron en nuestro centro con diagnóstico de cálculos renales se dividieron en 2 grupos. En el grupo 1 se utilizó fluoroscopia de rutina en todos los casos (n: 58). En el grupo 2 se ejecutó el mismo procedimiento sin fluoroscopia (n: 67). Posteriormente se compararon los resultados de los 2 grupos. Resultados: No hubo diferencias estadísticamente significativas entre los 2 grupos en términos de tiempo quirúrgico, tasa libre de cálculos, complicaciones, necesidad de analgésicos, requerimiento de nuevo tratamiento y escala visual analógica. Conclusión: El uso de fluoroscopia no altera la frecuencia de complicaciones ni la tasa libre de cálculos. Creemos que el uso de fluoroscopia no es indispensable en los casos en los que se consigue acceso a la pelvis renal (especialmente en procedimientos de ureteroscopia semirrígida) y que su uso debe ser limitado para evitar un aumento innecesario de exposición a la radiación


Objectives: The aim of this study was to evaluate the role of the use of fluoroscopy in patients undergoing retrograde intrarenal surgery and the effect on surgical outcomes. Material and methods: The patients who were admitted to our center with the diagnosis of kidney stones were divided into 2 groups. In group 1, routine fluoroscopy was used in all cases (n: 58). In group 2, the same procedure was performed without fluoroscopy (n: 67) and the results of the 2 groups were compared. Results: There were no statistically significant differences between the 2 groups in terms of operation time, stone-free rate, complication rate, need for analgesic and re-treatment requirement and Visual Analogic Scale score. Conclusion: The use of fluoroscopy does not alter the complication frequency and stone-free rate. We think that the use of fluoroscopy is not mandatory in cases in which renal pelvis access is achieved especially with semirigid ureteroscopy and that unnecessary fluoroscopy increases radiation exposure


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Fluoroscopia , Cálculos Renais/cirurgia , Avaliação de Resultado de Intervenções Terapêuticas , Nefrostomia Percutânea/métodos , Escala Visual Analógica , Ureteroscopia , Complicações Intraoperatórias , Procedimentos Cirúrgicos Urológicos/métodos
12.
Medicine (Baltimore) ; 98(47): e18004, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31764814

RESUMO

INTRODUCTION: Intraoperative seizures under general anesthesia are rare and our observation is the first to demonstrate a distinct electroencephalogram (EEG) pattern on the Narcotrend monitor. PATIENT CONCERNS: We present the case of a 30-year-old man undergoing craniotomy for glioblastoma resection under general anesthesia who suffered tonic-clonic seizures captured in a specific pattern by the intraoperative EEG. DIAGNOSES: Our depth of anesthesia monitor recorded, before the seizure, a widening of the beta-wave performance in a distinct "triangular-shaped" pattern. This pattern was repeated before the second seizure. The patient had no previous history of seizures and following surgery no further seizures were recorded. INTERVENTIONS: A spectrogram analysis showed a distinct increase in mean absolute beta power immediately prior to the first seizure. The EEG immediately prior to the second seizure was characterized by broadband noise. Both seizures were characterized by increased mean absolute delta, theta, and beta power. OUTCOMES: The increase in EEG beta activity seen before the tonic-clonic movements may represent cortical irritability secondary to surgical manipulation, induced by electrical stimulation, reflecting progressive brain over-arousal. The attentive analysis of the relative beta power may have helped forecast the occurrence of the second seizure. LESSONS: We report the use of a simple, inexpensive, and portable EEG-based monitoring device to assist seizure detection and decision making.


Assuntos
Anestesia Geral , Eletroencefalografia , Epilepsia Tônico-Clônica/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Neurofisiológica Intraoperatória , Adulto , Humanos , Monitorização Neurofisiológica Intraoperatória/instrumentação , Masculino
13.
Br J Anaesth ; 123(6): 777-794, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31668347

RESUMO

BACKGROUND: Dexmedetomidine (DEX) is a highly selective alpha2 adrenoceptor agonist with broad pharmacological effects, including sedation, analgesia, anxiolysis, and sympathetic tone inhibition. Here we report a systematic review and meta-analysis of its effects on stress, inflammation, and immunity in surgical patients during the perioperative period. METHODS: We searched MEDLINE, METSTR, Embase, and Web of Science for clinical studies or trials to analyse the effects of DEX on perioperative stress, inflammation, and immune function. RESULTS: Sixty-seven studies (including randomised controlled trials and eight cohort studies) with 4842 patients were assessed, of which 2454 patients were in DEX groups and 2388 patients were in control (without DEX) groups. DEX infusion during the perioperative period inhibited release of epinephrine, norepinephrine, and cortisol; decreased blood glucose, interleukin (IL)-6, tumour necrosis factor-α, and C-reactive protein; and increased interleukin-10 in surgical patients. In addition, the numbers of natural killer cells, B cells, and CD4+ T cells, and the ratios of CD4+:CD8+ and Th1:Th2 were significantly increased; CD8+ T-cells were decreased in the DEX group when compared with the control group. CONCLUSIONS: DEX, an anaesthesia adjuvant, can attenuate perioperative stress and inflammation, and protect the immune function of surgical patients, all of which may contribute to decreased postoperative complications and improved clinical outcomes.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/farmacologia , Dexmedetomidina/farmacologia , Inflamação/tratamento farmacológico , Complicações Intraoperatórias/tratamento farmacológico , Complicações Pós-Operatórias/tratamento farmacológico , Estresse Fisiológico/efeitos dos fármacos , Humanos , Imunidade , Período Pré-Operatório
14.
Tex Heart Inst J ; 46(3): 222-224, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31708709

RESUMO

Low origin of the coronary arteries, defined as an origin less than 10 mm above the functional aortic annulus, is not usually considered to be a notable anomaly because functional impairment is not intrinsic. We describe a case of severe complications after surgical aortic valve replacement in a 59-year-old woman who had symptomatic aortic valve stenosis, low origin of both main coronary arteries, and a hypoplastic aortic annulus less than 19 mm in diameter. The aortic prosthesis had to be implanted above the hypoplastic anatomic annulus. An inferior-wall myocardial infarction, hypotension, right-sided heart failure, and atrial fibrillation developed during the early perioperative period. Coronary angiograms showed occlusion of the right coronary artery ostium and critical stenosis of the left coronary ostium. During reoperation, posterior aortic patch annuloplasty enabled lower reimplantation of the prosthetic aortic valve, jointly with right coronary artery-venous grafting. To prevent potentially severe complications, we recommend that low origin of the coronary arteries be reported before patients undergo surgical aortic valve replacement. If the ostia are not seen when routine coronary angiography is used, computed tomography should be prospectively performed to characterize this anomaly.


Assuntos
Anormalidades Múltiplas , Estenose da Valva Aórtica/cirurgia , Valva Aórtica/anormalidades , Anuloplastia da Valva Cardíaca/métodos , Anomalias dos Vasos Coronários/diagnóstico , Implante de Prótese de Valva Cardíaca/métodos , Complicações Intraoperatórias , Valva Aórtica/diagnóstico por imagem , Estenose da Valva Aórtica/diagnóstico , Angiografia Coronária , Ponte de Artéria Coronária/métodos , Anomalias dos Vasos Coronários/cirurgia , Ecocardiografia , Eletrocardiografia , Feminino , Humanos , Pessoa de Meia-Idade
15.
Niger J Clin Pract ; 22(11): 1483-1488, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31719268

RESUMO

Background: Perioperative pulmonary aspiration of gastric contents is a serious complication and causes mortality and morbidity. The study aimed to assess the gastric content of patients undergoing cataract surgery by performing bedside ultrasonography. The secondary aim was to conduct a survey of hospital staff about fasting for cataract surgery. Subjects and Methods: This single-center, cross-sectional study included 65 patients who underwent cataract surgery. The quantitative and qualitative measurements of the gastric content and antral area were performed by gastric ultrasonography in the right lateral decubitus position. The incidence of risk to the stomach was defined according to different threshold levels: content >0.8 ml/kg and 1.5 ml/kg and cross-sectional antral area >340 mm2. A questionnaire was provided to anesthesiologists and ophthalmologists about fasting for cataract surgery. Results: The mean age was 69.48 ± 11.10 years. The mean gastric antrum cross-sectional area (CSA) was 11.08 ± 6.42 cm2. The predicted gastric volume was 103.39 ± 94.79 ml and 1.37 ± 1.20 ml/kg. The antral area CSA and gastric volume/kg decreased as the fasting time increased. About 98.5% of the patients exceeded the high-risk stomach antral cut-off CSA defined as 340 mm2. Gastric content exceeded 0.8 ml/kg in 58.33% of patients and exceeded 1.5 ml/kg in 41.67% of patients. Gastric content in patients was found to be 65.0% solid, 20.0% liquid, and 15.0% empty. All seven ophthalmologists did not apply fasting protocols for cataract surgery. Conclusion: Point of care ultrasonography is a useful, noninvasive tool in determining gastric content and volume. As majority of the patients presented with a full stomach for cataract surgery, we recommend that ophthalmologists and anesthesiologists follow preoperative fasting guidelines for cataract surgery.


Assuntos
Extração de Catarata , Catarata/diagnóstico , Conteúdo Gastrointestinal/diagnóstico por imagem , Complicações Intraoperatórias/prevenção & controle , Antro Pilórico/diagnóstico por imagem , Ultrassonografia/métodos , Idoso , Idoso de 80 Anos ou mais , Jejum/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistemas Automatizados de Assistência Junto ao Leito , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Estômago/diagnóstico por imagem
16.
Pan Afr Med J ; 33: 233, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31692841

RESUMO

Introduction: As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors. Methods: It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications. Results: Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation. Conclusion: This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.


Assuntos
Anestesia Geral/efeitos adversos , Artroplastia do Joelho/métodos , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/métodos , Artroplastia do Joelho/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Doenças Respiratórias/complicações , Estudos Retrospectivos , Fatores de Risco
17.
Medicine (Baltimore) ; 98(48): e18168, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31770265

RESUMO

RATIONALE: Recent years have witnessed a marked improvement in the safety and accuracy of nerve blocks with the help of ultrasound and other visualization technologies. This study reports a challenging case of a severe complication during the ultrasound-guided stellate ganglion block. PATIENT CONCERNS: A 28-year-old male patient with refractory migraine complained episodic pulsatile pain with photophobia, haphalgesia of the scalp for 3 years. INTERVENTIONS: Ultrasound-guided stellate ganglion block with 4 ml of 1% lidocaine was administrated. OUTCOMES: A sudden loss of consciousness and tonic-clonic seizure was occurred after negative aspiration and test dose. Further sonographic examination revealed a variation in the left vertebral artery, which remained unrecognized during the needle insertion because of its sliding ability under the differential pressure applied by the probe. LESSONS: Inadvertent intra-arterial injection of a local anesthetic agent could be minimized under the ultrasound guidance with various protective strategies, including the determination of any prior variation, optimizing the block route, maintaining a constant probe pressure, and using saline for the test dosage. This case resulted in the implementation of new protocols of the ultrasound-guided stellate ganglion block in our department.


Assuntos
Bloqueio Nervoso Autônomo , Complicações Intraoperatórias , Lidocaína , Convulsões , Gânglio Estrelado , Inconsciência , Artéria Vertebral , Adulto , Anestésicos Locais/administração & dosagem , Anestésicos Locais/efeitos adversos , Bloqueio Nervoso Autônomo/efeitos adversos , Bloqueio Nervoso Autônomo/métodos , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/terapia , Lidocaína/administração & dosagem , Lidocaína/efeitos adversos , Masculino , Erros Médicos/prevenção & controle , Transtornos de Enxaqueca/cirurgia , Assistência ao Paciente/métodos , Convulsões/etiologia , Convulsões/terapia , Gânglio Estrelado/diagnóstico por imagem , Gânglio Estrelado/cirurgia , Resultado do Tratamento , Ultrassonografia de Intervenção/métodos , Inconsciência/etiologia , Inconsciência/terapia , Artéria Vertebral/anatomia & histologia , Artéria Vertebral/lesões
18.
Actas urol. esp ; 43(9): 509-514, nov. 2019. tab
Artigo em Espanhol | IBECS | ID: ibc-185253

RESUMO

Objetivos: El objetivo del presente estudio es analizar el resultado de la implementación de una vía clínica para la corrección del prolapso de órganos pélvicos mediante colposacropexia mínimamente invasiva (CSMI) con 24 horas de ingreso en términos de seguridad y ahorro de costes de hospitalización. Material y métodos: Estudio observacional prospectivo de los primeros 78 procedimientos de CSMI realizados de forma consecutiva. Cuarenta y seis procedimientos (59%) se realizaron con estancia hospitalaria de 24 horas, mientras que 32 (41%) precisaron más de 24 horas. Para cada grupo se determinaron las complicaciones postoperatorias, visitas al servicio de urgencias, reintervenciones y el coste medio por procedimiento en términos de estancia hospitalaria y atención en el Servicio de Urgencias. El modelo de costes se estableció según los datos del Sistema de Contabilidad Analítica del Hospital Fundación Jiménez Díaz y del Boletín oficial de la Comunidad de Madrid. Resultados: No se encontraron diferencias entre ambos grupos respecto a las complicaciones intraoperatorias o postoperatorias. Las consultas en el servicio de urgencias, reintervenciones o reingresos hospitalarios fue menor en el grupo de 24 horas de ingreso, sin alcanzar la significación estadística. Mediante la implementación de la vía clínica de CSMI con 24 horas de ingreso se objetivó un ahorro de 607,91 € por procedimiento en estancia hospitalaria. Conclusiones: La corrección del prolapso de órganos pélvicos mediante CSMI con política de alta hospitalaria de 24 horas es factible y segura en al menos el 59% de las pacientes, sin objetivarse un mayor número de complicaciones, visitas al servicio de urgencias o reingresos hospitalarios


Objectives: The objective of this study is to analyze the impact (in terms of safety and saving of hospital costs) of the implementation of a new protocol for the correction of pelvic organ prolapse (POP) by minimally invasive sacrocolpopexy (MISC) with 24-hour hospital stay. Material and methods: Prospective observational study of the first 78 MISC procedures performed consecutively. 46 procedures (59%) were performed with 24-hour hospital stay, and 32 (41%) required more than 24 hours. The postoperative complications were determined for each group: visits to the Emergency Department, reoperations, and the average cost per procedure regarding hospital stay and ER visits. The cost model was established according to the data of the Analytical Accounting System of the Jiménez Díaz Foundation Hospital and of the Official State Gazette of Madrid. Results: There were no differences regarding intraoperative or postoperative complications between both groups. The number of visits to the Emergency Department, reinterventions or hospital re-admissions was lower in the 24-hour hospital stay group, without reaching statistical significance. The implementation of the MISC protocol with 24-hour hospital stay represented a saving of 607.91€ per procedure in hospital costs. Conclusions: Correction of the POP with MISC with a 24-hour hospital discharge policy was feasible and safe in at least 59% of the patients, with similar complications, visits to the Emergency Department or hospital readmission rates


Assuntos
Humanos , Prolapso de Órgão Pélvico/diagnóstico , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Hospitalização/economia , Estudos Prospectivos , Complicações Pós-Operatórias , Complicações Intraoperatórias
19.
Arq Gastroenterol ; 56(3): 246-251, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31633719

RESUMO

BACKGROUND: Pancreaticoduodenectomy (PD) with the resection of venous structures adjacent to the pancreatic head, even in cases of extensive invasion, has been practiced in recent years, but its perioperative morbidity and mortality are not completely determined. OBJECTIVE: To describe the perioperative outcomes of PD with venous resections performed at a tertiary university hospital. METHODS: A retrospective study was conducted, classified as a historical cohort, enrolling 39 individuals which underwent PD with venous resection from 2000 through 2016. Preoperative demographic, clinical and anthropometric variables were assessed and the main outcomes studied were 30-day morbidity and mortality. RESULTS: The median age was 62.5 years (IQ 54-68); 55% were male. The main etiology identified was ductal adenocarcinoma of the pancreas (82.1%). In 51.3% of cases, the portal vein was resected; in 35.9%, the superior mesenteric vein was resected and in the other 12.8%, the splenomesenteric junction. Regarding the complications, 48.7% of the patients presented some type of morbidity in 30 days. None of the variables analyzed was associated with higher morbidity. Perioperative mortality was 15.4% (six patients). The group of individuals who died within 30 days presented significantly higher values for both ASA (P=0.003) and ECOG (P=0.001) scores. CONCLUSION: PD with venous resection for advanced pancreatic neoplasms is a feasible procedure, but associated with high rates of morbidity and mortality; higher ASA e ECOG scores were significantly associated with a higher 30-day mortality.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Adenocarcinoma/mortalidade , Adulto , Idoso , Brasil/epidemiologia , Feminino , Humanos , Complicações Intraoperatórias , Masculino , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Morbidade , Neoplasias Pancreáticas/mortalidade , Pancreaticoduodenectomia/mortalidade , Veia Porta/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos
20.
Arq Bras Cir Dig ; 32(3): e1454, 2019.
Artigo em Inglês, Português | MEDLINE | ID: mdl-31644674

RESUMO

BACKGROUND: Percutaneous biliary drainage is a safe procedure. The risk of bleeding complications is acceptable. Frequently, patients with biliary obstructions usually have coagulation disorders thus increasing risk of bleeding. For this reason, patients should always fit the parameters of hemostasis. AIM: To determine whether the percentage of bleeding complications in percutaneous biliary drainage is greater in adults with corrected hemostasis prior to the procedure regarding those who did not require any. METHODS: : Prospective, observational, transversal, comparative by independent samples (unpaired comparison). Eighty-two patients with percutaneous biliary drainage were included. The average age was 64±16 years (20-92) being 38 male and 44 female. Patients who presented altered hemostasis were corrected and the presence of bleeding complications was evaluated with laboratory and ultrasound. RESULTS: Of 82 patients, 23 needed correction of hemostasis. The approaches performed were: 41 right, 30 left and 11 bilateral. The amount of punctures on average was 3±2. There were 13 (15.8%) bleeding complications, 12 (20%) in uncorrected and only one (4.34%) in the corrected group with no statistical difference. There were no differences in side, number of punctures and type of drainage, but number of passes and the size of drainage on the right side were different. There was no related mortality. CONCLUSION: Bleeding complications in patients requiring hemostasis correction for a percutaneous biliary drainage was not greater than in those who did not require any.


Assuntos
Perda Sanguínea Cirúrgica , Colestase/cirurgia , Drenagem/efeitos adversos , Hemostasia , Complicações Intraoperatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cateteres , Colestase/sangue , Estudos Transversais , Drenagem/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Punções , Fatores de Risco , Adulto Jovem
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