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1.
Medicine (Baltimore) ; 99(44): e22467, 2020 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-33126301

RESUMO

RATIONALE: Trigeminocardiac reflex (TCR) sometimes occurs during the percutaneous balloon compression (PBC) procedure to treat trigeminal neuralgia (TN), and it manifests as transient bradycardia or sinus arrest. However, recurrent intraoperative TCR cases are rarely reported. Meanwhile, the treatment for recurrent TCR is still unclear. PATIENT CONCERNS: A 74-year-old male with a 2-year TN history could no longer tolerate the side effects of carbamazepine and came to seek PBC treatment. DIAGNOSES: Bradycardia or sinus arrest occurred repeatedly during the operation, and the heart rate (HR) rapidly returned to normal when the operation was suspended. The C-arm image showed the puncture needle entering the foramen ovale. INTERVENTIONS: First, 0.5 mg atropine was administered twice, and then 1 mL of 2% lidocaine was injected locally at the puncture site. Finally, isoproterenol was continuously pumped and dynamically adjusted to maintain the HR above 90 bpm. OUTCOMES: The use of atropine and lidocaine did not prevent the recurrence of TCR. The use of isoproterenol to maintain the HR enabled the successful completion of the operation. The patient recovered quickly after the operation and was discharged 2 days later. No complaints of discomfort were reported during the sixth-month follow-up. LESSONS: The elimination of intraoperative TCR may be difficult. Maintaining a high HR intraoperatively by continuous isoproterenol infusion is effective for preventing or mitigating the onset of TCR.


Assuntos
Oclusão com Balão/efeitos adversos , Bradicardia/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Reflexo Trigêmino-Cardíaco/fisiologia , Neuralgia do Trigêmeo/cirurgia , Idoso , Bradicardia/etiologia , Frequência Cardíaca , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Recidiva
2.
Anesth Analg ; 131(4): 1060-1065, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925324

RESUMO

BACKGROUND: Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs. METHODS: This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine. RESULTS: A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%-0.081%, indicating an estimated risk of 1-8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%-0.021% and indicating a risk of approximately 0-2 events per 10,000 patients. CONCLUSIONS: In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.


Assuntos
Complicações Intraoperatórias/epidemiologia , Norepinefrina/efeitos adversos , Período Perioperatório , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Bases de Dados Factuais , Feminino , Humanos , Infusões Intravenosas , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Necrose , Resultados Negativos , Norepinefrina/administração & dosagem , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco , Pele/patologia
3.
J Am Acad Orthop Surg ; 28(21): 874-883, 2020 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-32796365

RESUMO

With an increasing number of total hip and knee arthroplasties being done at surgical centers and vascular surgeons often not immediately available in this setting, it is critical for orthopaedic surgeons to be comfortable with the acute surgical management of vascular injuries. Although they are fortunately uncommon in primary total hip and knee arthroplasties, damage to a major artery or vein can have potentially devastating consequences. Surgeons operating both in a hospital and an ambulatory surgical setting should be familiar with techniques to gain proximal control of massive bleeding because the principles can be helpful in primary and revision arthroplasties. In this study, we review the vascular anatomy around the hip and knee and the surgical management of these potentially catastrophic complications.


Assuntos
Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Complicações Intraoperatórias/etiologia , Lacerações/etiologia , Procedimentos Cirúrgicos Vasculares , Lesões do Sistema Vascular/etiologia , Amputação , Fasciotomia , Hemorragia/etiologia , Quadril/irrigação sanguínea , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/patologia , Complicações Intraoperatórias/cirurgia , Joelho/irrigação sanguínea , Lacerações/diagnóstico , Lacerações/patologia , Lacerações/cirurgia , Neuropatias Fibulares/etiologia , Lesões do Sistema Vascular/diagnóstico , Lesões do Sistema Vascular/patologia , Lesões do Sistema Vascular/cirurgia
5.
Medicine (Baltimore) ; 99(30): e21517, 2020 Jul 24.
Artigo em Inglês | MEDLINE | ID: mdl-32791767

RESUMO

INTRODUCTION: Pulmonary veno-occlusive disease (PVOD) is a rare form of pulmonary hypertension. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension (PAH). Inappropriate treatment may cause worsening of symptoms which may lead to fatal outcomes. Anesthetic considerations and management for pulmonary hypertension are well described, but few anesthesiologists are aware of the entity of PVOD and its management. PATIENT CONCERNS: We report a case of PVOD in a 73-year-old female who was on concurrent aspirin and anagrelide, requiring emergent open femoral hernia repair. DIAGNOSIS: PVOD and incarcerated femoral hernia INTERVENTION:: Combined spinal-epidural (CSE) was performed to enable the surgery. OUTCOME: Surgery was completed successfully under central neuraxial anesthesia and the patient remained stable and comfortable throughout, avoiding the need for general anesthesia. Due to the concurrent aspirin and anagrelide therapy, significant bleeding from the CSE puncture site was observed immediately post-operatively. This was resolved with external manual compression and withholding the aspirin and anagrelide. Patient remained well without neurological deficit and was discharged postoperative day seven. LESSONS: It is important to differentiate PVOD from PAH due to the controversial use of pulmonary vasodilators in PVOD. Pulmonary vasodilator is commonly used to treat acute pulmonary hypertension in PAH but its usage may lead to pulmonary edema in patients with PVOD. Hence, with no ideal treatment available, the avoidance of general anesthesia is crucial to prevent acute pulmonary hypertensive crisis in patient with PVOD. However, this needs to be weighed against the elevated risk of central neuraxial bleeding when performing a CSE in a patient on concurrent aspirin and anagrelide therapy. Calculated decision-making considering the risks and benefits of all alternatives should be carried out in such a scenario, and measures should be taken in anticipation of the potential consequences of the eventual decision. CONCLUSION: It is important to differentiate PVOD from PAH. PVOD has unique anesthetic considerations due to the controversial use of pulmonary vasodilators. This case also emphasizes the importance of active anticipation of potential issues and adequate follow up.


Assuntos
Anestesia Epidural , Raquianestesia , Complicações Intraoperatórias/prevenção & controle , Pneumopatia Veno-Oclusiva/complicações , Idoso , Feminino , Hérnia Femoral/cirurgia , Herniorrafia , Humanos , Complicações Intraoperatórias/etiologia
6.
Am J Cardiol ; 130: 37-45, 2020 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-32665131

RESUMO

Coronary artery perforation (CP) is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI). Given the marked increase in high-risk and complex PCIs, careful review and understanding of PCI complications may help to improve procedural and clinical outcomes. Our aim was to study the trends, predictors and outcomes of CP in the contemporary era. This cross-sectional multicenter analysis included data collected from institutions participating in the National Cardiovascular Data Registry CathPCI Registry between July 2009 and June 2015. Multivariable logistic regression models were created to identify predictors of CP and compare the in-hospital outcomes of CP and non-CP patients. Of 3,759,268 PCIs performed during the study period, there were 13,779 CP (0.37%). During the study period, the proportion of PCI that developed CP remained unchanged (0.33% to 0.4%) (p for trend 0.16). Chronic total occlusion (CTO) PCI as percentage of total PCI volume increased over the study period (3% to 4%) (p for trend <0.001) with a concomitant significant increase in CTOs with perforation (1.2% to 1.5%, p for trend = 0.02). CTO PCI (Odds Ratio [OR] 2.59) female gender (OR 1.38), saphenous vein graft PCI (OR 1.2), ACC Type C lesion (1.48), cardiogenic shock on presentation (1.15), and use of atherectomy (laser/ rotational) (OR 2.38) were significant predictors of CP. CP patients had significantly higher rates of cardiogenic shock (7.73% vs 1.02%), tamponade (9.6% vs 0.05%) and death (4.87% vs 1.14%) compared with those without CP. Strongest predictors of any adverse events amongst CP were cardiogenic shock (OR 3.93), cardiac arrest (OR 2.02) and use of atherectomy device (OR 2.5). Use of covered stents was also strongly associated with adverse events (OR 3.67) reflecting severity of these CPs. CP in CTO PCI had higher rates of any adverse event than non-CTO CP (26.8% vs 22%, p < 0.001). However non-CTO CP had higher rates of coronary artery bypass grafting (CABG) (urgent, emergent, or salvage) (5.8% vs 4.5%, p = 0.03) and death (6.9% vs 5.6%, p = 0.04). CP in CABG PCI had fewer adverse events compared with those without previous CABG (16.1% vs 24.7%). In a large real world experience, we identified several clinical and procedural factors associated with increased risk of CP and adverse outcomes. The trends in CP remained constant over the study period.


Assuntos
Vasos Coronários/lesões , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Intervenção Coronária Percutânea/efeitos adversos , Idoso , Oclusão Coronária/cirurgia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Medição de Risco
8.
Medicine (Baltimore) ; 99(28): e20946, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664094

RESUMO

BACKGROUND: The beach chair position (BCP), used during shoulder surgery, is associated with hypotension, bradycardia, and risk of cerebral hypoperfusion. Phenylephrine is commonly used as a first treatment of choice of intraoperative hypotension during surgery. We evaluated the hemodynamic effects of 2 doses of intravenous phenylephrine infusion administered before being placed in BCP for arthroscopic shoulder surgery. The primary endpoint was the incidence of hypotension after positional change. METHODS: Sixty-six patients were randomized to receive either intravenous normal saline (group NS) or intravenous phenylephrine infusion (0.5 µg/kg/min, group LP or 1.0 µg/kg/min, group HP) for 5 minutes before being placed in the BCP. Mean arterial pressure(MAP), heart rate, stroke volume variation, and cardiac index were measured before and after positional change. RESULTS: The total incidence of hypotension after the BCP was 93.65%, but was not significantly different among the 3 groups. However, there was a significant difference in trends between the groups for MAP for 5 minutes after BCP (P = .028). Comparison of changes in MAP at 1 minute compared to post-induction MAP was significantly different between group HP and group NS (P = .014). CONCLUSION: Infusion of 0.5 and 1.0 µg/kg/min of phenylephrine for 5 minutes before the BCP has no preventive effect for incidence of hypotension. However, this study showed that 1.0 µg/kg/min of phenylephrine infusion for 5 minutes can attenuate the severity of hypotension.


Assuntos
Hipotensão/etiologia , Hipotensão/prevenção & controle , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Posicionamento do Paciente/efeitos adversos , Fenilefrina/administração & dosagem , Idoso , Feminino , Humanos , Hipotensão/epidemiologia , Incidência , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego
9.
Ann R Coll Surg Engl ; 102(9): e1-e3, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32513016

RESUMO

The trigeminovagal reflex is a phenomenon that occurs rarely during maxillofacial surgery. Previously described as the oculocardiac reflex, this reflex can occur during ocular and periocular surgery. To be more anatomically precise, it was renamed the trigeminocardiac or trigeminovagal reflex, since stimulation of any part of the trigeminal nerve can elicit this reflex arc. We describe a case of asystole during mobilization of a maxilla following a Le Fort 1 osteotomy.


Assuntos
Parada Cardíaca/etiologia , Complicações Intraoperatórias/etiologia , Maxila/cirurgia , Osteotomia de Le Fort/efeitos adversos , Reflexo Trigêmino-Cardíaco , Nervo Trigêmeo/fisiopatologia , Parada Cardíaca/fisiopatologia , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Reflexo Trigêmino-Cardíaco/fisiologia , Fatores de Risco
10.
Khirurgiia (Mosk) ; (6): 82-89, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32573537

RESUMO

OBJECTIVE: To evaluate the effect of preoperative oral carbohydrate loading on the course of perioperative period. MATERIAL AND METHODS: We examined 93 patients who underwent elective abdominal and retroperitoneal surgery. In the main group (n=47), carbohydrate drink was prescribed prior to surgery (33.5 g of carbohydrates and 4 g of hydrolyzed protein per 100 ml): 400 ml in the evening before surgery and 200 ml 2 hours before surgery. The control group included 46 patients who followed conventional fasting protocol recommended by the ASA (solid food no later than 6 hours before surgery, intake of clear fluids no later than 2 hours before surgery). Surgical interventions and anesthetic management were similar in both groups. RESULTS: There were no differences in perioperative glycemia between both groups. The main group was characterized by less intraoperative infusion volume and more stable hemodynamic parameters, the number of patients with organ dysfunction and complications was significantly lower. Postoperative nausea and vomiting and general weakness were less significant in the main group while subjective assessment of patient's satisfaction with postoperative period was higher. CONCLUSION: Preoperative carbohydrate loading does not affect perioperative glycemia, reduces intraoperative infusion volume, the number of patients with organ dysfunction and complications, postoperative nausea and vomiting, ensures more stable intraoperative hemodynamics and more comfortable subjective perception of early postoperative period.


Assuntos
Dieta da Carga de Carboidratos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Jejum , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Eletivos/métodos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Complicações Pós-Operatórias/etiologia
11.
Int J Pediatr Otorhinolaryngol ; 134: 110057, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32388322

RESUMO

OBJECTIVES: Children admitted with stridor and respiratory distress comprise a complex patient group that requires the otolaryngologist to decide when to assess and intervene with direct laryngoscopy and bronchoscopy (DLB). Historically, the diagnosis of viral upper respiratory tract infection (URTI) can lead to postponement of surgery due to concerns of perioperative complications related to acute illness. Respiratory viral panels (RVP) are often used to confirm the presence of recent or active viral infection and can affect the differential diagnosis of upper airway obstruction. This study examined whether positive RVP testing is associated with perioperative complications and operative findings in pediatric patients undergoing inpatient DLB. METHODS: A retrospective chart review of 132 pediatric patient encounters was performed. Viral testing results, DLB indication, DLB findings, and perioperative complications were compared. RESULTS: Sixty encounters (45.5%) involved a positive RVP, and 72 (54.5%) involved a negative RVP. Those with positive RVP were less likely to have a preoperative structural airway diagnosis (P =.0250) and more likely to have a history of recurrent upper respiratory infections (P =.0464). The most common reason for DLB was the need to assess the airway due to concern for structural pathology. Anatomic abnormalities were seen in a majority of encounters (77.3%) Laryngospasm occurred in 1 (1.7%) RVP positive and 1 (1.4%) RVP negative encounter, and 2 (2.8%) RVP negative encounters required reintubation. No other major complications were observed. No association was noted between RVP results and incidence of major or minor complication. CONCLUSIONS: Major perioperative complications after surgical intervention with DLB for the management of complex, inpatient children with stridor and respiratory distress are rare. RVP positivity, specific pathogens identified on RVP, and presence of URI symptoms were not associated with perioperative complications.


Assuntos
Insuficiência Respiratória/etiologia , Sons Respiratórios/etiologia , Anormalidades do Sistema Respiratório/diagnóstico por imagem , Infecções Respiratórias/diagnóstico , Viroses/diagnóstico , Broncoscopia/efeitos adversos , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Lactente , Complicações Intraoperatórias/etiologia , Laringismo/diagnóstico por imagem , Laringismo/etiologia , Laringoscopia/efeitos adversos , Masculino , Complicações Pós-Operatórias/etiologia , Insuficiência Respiratória/cirurgia , Anormalidades do Sistema Respiratório/complicações , Infecções Respiratórias/complicações , Infecções Respiratórias/virologia , Estudos Retrospectivos , Medição de Risco , Viroses/complicações
12.
Spine Deform ; 8(4): 591-596, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32451978

RESUMO

The Scoliosis Research Society has developed an updated information statement on intraoperative neurophysiological monitoring of spinal cord function during spinal deformity surgery. The statement reviews the risks of spinal cord compromise associated with spinal deformity surgery; the statement then discusses the various modalities that are available to monitor the spinal cord, including somatosensory-evoked potentials, motor-evoked potentials, and electromyographic (EMG) options. Anesthesia considerations, the importance of a thoughtful team approach to successful monitoring, and the utility of checklists are also discussed. Finally, the statement expresses the opinion that utilization of intraoperative neurophysiological spinal cord monitoring in spinal deformity surgery is the standard of care when the spinal cord is at risk.


Assuntos
Monitorização Neurofisiológica Intraoperatória/métodos , Monitorização Neurofisiológica Intraoperatória/normas , Medula Espinal/fisiologia , Curvaturas da Coluna Vertebral/cirurgia , Anestesia , Eletromiografia , Potencial Evocado Motor , Potenciais Somatossensoriais Evocados , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Equipe de Assistência ao Paciente , Risco , Doenças da Medula Espinal/diagnóstico , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/prevenção & controle
13.
Am J Otolaryngol ; 41(4): 102511, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32402691

RESUMO

IMPORTANCE: While numerous techniques for costal cartilage harvesting have been described, one consistency in the published literature is that the procedure is performed under general anesthesia. This is the first report to offer IV sedation as a safe alternative to general inhalational anesthesia in cases involving costal cartilage harvesting. OBJECTIVE: To determine the feasibility and safety of costal cartilage harvest with IV sedation. DESIGN: A retrospective chart review was performed of 116 rhinoplasty patients who underwent harvest of costal cartilage grafts under IV sedation from 2005 to 2019. SETTING: Private practice of senior author (AF) at Lasky Clinical Surgical Center. PARTICIPANTS: Consecutive patients who underwent cosmetic and/or functional rhinoplasty. MAIN OUTCOME & MEASURES: The number of cases involving a pneumothorax, size of the pleural injury, radiographic findings, repair technique and treatment for pneumothorax were all recorded. RESULTS: There were 7 cases involving a pleural tear (size range 3-8 mm) during costal cartilage harvest and each of these was repaired intra-operatively. All 7 patients remained clinically stable in recovery room on 2 L of oxygen. Although clinically stable, one patient had radiologic evidence of a pneumothorax of 50%, and thus she was transferred to a hospital for placement of a Heimlich tube with overnight observation. CONCLUSIONS AND RELEVANCE: Although plenural tears can be attributed to surgical technique rather than the type of anesthesia, these cases do provide valuable insight to the fact that successful management of such complications can be accomplished without the need for general anesthesia.


Assuntos
Sedação Consciente/métodos , Cartilagem Costal/transplante , Rinoplastia/métodos , Coleta de Tecidos e Órgãos/métodos , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Pleura/lesões , Pneumotórax/etiologia , Estudos Retrospectivos , Segurança , Coleta de Tecidos e Órgãos/efeitos adversos
15.
Cochrane Database Syst Rev ; 5: CD013352, 2020 May 06.
Artigo em Inglês | MEDLINE | ID: mdl-32374421

RESUMO

BACKGROUND: Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments. OBJECTIVES: To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation. SEARCH METHODS: On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. SELECTION CRITERIA: We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. MAIN RESULTS: We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. AUTHORS' CONCLUSIONS: There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.


Assuntos
Laparoscopia/métodos , Leiomioma/cirurgia , Morcelação/métodos , Miomectomia Uterina/métodos , Neoplasias Uterinas/cirurgia , Adulto , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Tempo de Internação , Pessoa de Meia-Idade , Morcelação/efeitos adversos , Morcelação/instrumentação , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Manejo de Espécimes/instrumentação , Manejo de Espécimes/métodos , Miomectomia Uterina/efeitos adversos , Adulto Jovem
16.
BMC Neurol ; 20(1): 203, 2020 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-32438899

RESUMO

BACKGROUND: To our knowledge, the exposed nerve roots in thoracic spine are usually sacrificed to facilitate osteotomy during posterior vertebral column resection (PVCR) for severe spinal deformity. Currently we report a case with severe spine deformity in which intraoperative neurological monitoring (IOM) loss after interrupting T8 nerve root finally led to spinal cord injury during PVCR surgery. CASE PRESENTATION: The patient was a 14-year-old female with severe congenital kyphoscoliosis (CKS) without preoperative neurologic deficits. The IOM events (MEP loss and SSEP latency prolong) were showed when T8 nerve root at concave side was interrupted. And then we reduce the scope of osteotomy to control bleeding, raised blood pressure (MAP, 65-80) to increase blood supply for spinal cord, placed the bilateral rod to stabilized the spinal cord, used the methylprednisolone, explored the presence or absence of spinal cord compression, and prepared to change the surgical plan from PVCR to PSO. After that the IOM signals partial recovered from the lowest point. Postoperatively the patients showed transient motor function deficits of left lower limbs weak without somatosensory deficits, and come back to preoperative status 6 months later. CONCLUSIONS: Interrupting the thoracic spine nerve root is danger to trigger the spinal cord injury during PVCR procedure of severe CKS. That probably because the increasing tension of contralateral anterior horn area of spinal cord via the nerve root pulling.


Assuntos
Procedimentos Neurocirúrgicos/efeitos adversos , Traumatismos da Medula Espinal/etiologia , Raízes Nervosas Espinhais/cirurgia , Coluna Vertebral/cirurgia , Adolescente , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Cifose/complicações , Cifose/cirurgia , Monitorização Intraoperatória , Osteotomia/métodos , Estudos Retrospectivos , Escoliose/complicações , Escoliose/cirurgia , Resultado do Tratamento
19.
Anesth Analg ; 131(2): 527-536, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32371741

RESUMO

BACKGROUND: Catecholamine inotropes are frequently used after cardiopulmonary bypass (CPB) but may have undesirable effects. The aim was to identify whether the routine use of inhaled pulmonary vasodilators might reduce the requirement for inotrope drugs after cardiac surgery. METHODS: Retrospective cohort study of sequential patients undergoing cardiac surgery at the Royal Melbourne Hospital performed by a single surgeon and anesthesia care team, within 14 months before and after routine implementation of inhaled pulmonary vasodilators, August 2017. Milrinone 4 mg and iloprost 20 µg were inhaled using a vibrating mesh nebulizer (Aerogen) before initiation of CPB and at chest closure. Other aspects of clinical management were unaltered over the time period. Two investigators blinded to each other extracted data from electronic and written medical records. The primary outcome was any use of inotropes in the perioperative period; a Fisher exact test was used to analyze any differences between the 2 groups. Demographic data, hemodynamic data, and use of inotropes and vasopressors were collected from induction of anesthesia to 36 hours postoperative in the intensive care unit (ICU). Hospital and ICU length of stay, cost, and complications were collected. RESULTS: Any use of inotropes was significantly lower with inhaled pulmonary dilators (62.5% vs 86.8%, odds ratio [95% confidence interval {CI}], 0.253 (0.083-0.764); P = .011), including intraoperative inotrope use (37.5% vs 86.8%, odds ratio [95% CI], 0.091 (0.03-0.275); P < .001). ICU length of stay was significantly lower with inhaled pulmonary dilators (45 hours, interquartile range [IQR], 27-65 vs 50 hours, IQR, 45-74; P = .026). There were no significant differences among major postoperative complications or costs between groups. CONCLUSIONS: Routine use of inhaled milrinone 4 mg and iloprost 20 µg before and after CPB is associated with reduced postoperative inotrope use.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Iloprosta/administração & dosagem , Complicações Intraoperatórias/prevenção & controle , Milrinona/administração & dosagem , Contração Miocárdica/efeitos dos fármacos , Vasodilatadores/administração & dosagem , Administração por Inalação , Idoso , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Cardiotônicos/administração & dosagem , Estudos de Coortes , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/fisiologia , Projetos Piloto , Estudos Retrospectivos
20.
J Vis Exp ; (159)2020 05 05.
Artigo em Inglês | MEDLINE | ID: mdl-32449714

RESUMO

In the aging male population, the occurrence of lower urinary tract symptoms (LUTS) caused by benign prostatic hyperplasia (BPH) is a common problem. Here, we introduce a new technique called 980 nm diode laser enucleation (DiLEP) to treat BPH1. Diode lasers can absorb both water and hemoglobin at the same time, so they are good for cutting and hemostasis2. The diode laser was approved by the FDA in 2007, and has been used in the treatment of BPH because of its effective cutting and hemostasis effect3. DiLEP presents several advantages over other techniques, such as TURP, HoLEP, and PVP. During the procedure, we define the boundary of a high-volume prostate and separate it into three lobes with a diode laser by burning two rings and one groove (like a Cupid's arrow). Compared to other procedures, mDiLEP has fewer intraoperative complications, a shorter learning curve, and achieves more tissue resection.


Assuntos
Terapia a Laser/instrumentação , Lasers Semicondutores , Hiperplasia Prostática/cirurgia , Humanos , Complicações Intraoperatórias/etiologia , Terapia a Laser/efeitos adversos , Tempo de Internação , Masculino , Qualidade de Vida , Resultado do Tratamento
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