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1.
Medicine (Baltimore) ; 99(11): e19279, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32176051

RESUMO

The present study aims to analyze the effects of breast-conserving surgery and modified radical mastectomy on operation indexes, Symptom checklist-90 scores and prognosis in patients with early breast cancer.The clinical data of 128 patients with breast cancer who were treated in our hospital from May 2015 to May 2016 were included into the analysis. These patients were divided into 2 groups, according to the different modes of operation (n = 64): control group, patients underwent modified radical mastectomy; observation group, patients underwent early breast conserving surgery. Then, the surgical indexes and prognosis were compared between these 2 groups.Intraoperative bleeding volume, incision length and hospitalization duration were better in the observation group than in the control group (P < .05). Furthermore, postoperative symptom checklist-90 scores in the observation group were better than scores before the operation, and were better than the scores in the control group (P < .05). Moreover, the incidence of postoperative complications was lower in the observation group (3.13%) than in the control group (21.88%, P < .05).Early breast-conserving surgery is more advantageous for breast cancers and results to lesser bleeding, rapid recovery, and fewer complications.


Assuntos
Neoplasias da Mama/cirurgia , Lista de Checagem/métodos , Detecção Precoce de Câncer , Mastectomia Radical Modificada/métodos , Mastectomia Segmentar/métodos , Adulto , Idoso , Perda Sanguínea Cirúrgica , Neoplasias da Mama/mortalidade , Estudos de Casos e Controles , China , Intervalo Livre de Doença , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/fisiopatologia , Tempo de Internação , Mastectomia Radical Modificada/mortalidade , Mastectomia Segmentar/mortalidade , Pessoa de Meia-Idade , Duração da Cirurgia , Prognóstico , Valores de Referência , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento
3.
Invest Ophthalmol Vis Sci ; 60(10): 3507-3513, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31408113

RESUMO

Purpose: We evaluate the efficacy of capsular tension rings (CTRs), iris retractors (IRs), and capsule expanders (CEs) in stabilizing the lens capsule under different degrees of zonular dehiscence using a porcine model. Methods: We developed an experimental model that can be used to observe the dynamics of lens capsules with different degrees of zonular dehiscence during phacoemulsification and aspiration (PEA). PEA was performed without any aid (control) and with devices. A CTR was used for a dehiscence of 30°, 45°, 60°, 90°, 120°, 150°, and 180° and one to four IRs or one to three CEs were used for a dehiscence of 90°, 120°, and 180°. The retention rate, calculated as the area of the capsular bag during PEA divided by the area before zonular dissection, and the number of lens fragments dropped into the vitreous cavity during PEA were examined and compared among the control and experimental groups. Results: The retention rate increased significantly with the use of devices compared to the control (P < 0.05). The number of dropped lens fragments decreased by one or less with the use of CTR, one IR, or one CE for 90°, two IRs, or one or two CEs for 120°, and three or four IRs, or two or three CEs for 180° of zonular dehiscence. Conclusions: The experimental porcine eye model with zonular dehiscence makes it possible to observe the entire configuration of the lens capsule, and demonstrates differences in the efficacy of capsular bag retention with CTR, IR, and CE.


Assuntos
Complicações Intraoperatórias/fisiopatologia , Cápsula do Cristalino/fisiologia , Ligamentos/lesões , Facoemulsificação , Próteses e Implantes , Implantação de Prótese , Dispositivos para Expansão de Tecidos , Animais , Iris/cirurgia , Modelos Animais , Ruptura , Sucção , Suínos
4.
Bone Joint J ; 101-B(6_Supple_B): 116-122, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31146555

RESUMO

AIMS: The aims of this study were to assess the exposure and preservation of the abductor mechanism during primary total hip arthroplasty (THA) using the posterior approach, and to evaluate gluteus maximus transfer to restore abductor function of chronically avulsed gluteus medius and minimus. PATIENTS AND METHODS: A total of 519 patients (525 hips) underwent primary THA using the posterior approach, between 2009 and 2013. The patients were reviewed preoperatively and at two and five years postoperatively. Three patients had mild acute laceration of the gluteus medius caused by retraction. A total of 54 patients had mild chronic damage to the tendon (not caused by exposure), which was repaired with sutures through drill holes in the greater trochanter. A total of 41 patients had severe damage with major avulsion of the gluteus medius and minimus muscles, which was repaired with sutures through bone and a gluteus maximus flap transfer to the greater trochanter. RESULTS: Abductor strength was maintained in the normal hips, but lateral hip pain progressed significantly, five years postoperatively (p < 0.0001). In the 54 patients with mild abductor tendon damage treated with simple repair, lateral hip pain also increased significantly during follow-up (p = 0.002). In the 35 patients with severe avulsion but good muscle repaired using a gluteus maximus flap transfer, abductor function was restored. The six patients with complete avulsion and poor muscle did not regain strong abductor power, but lateral hip pain decreased. CONCLUSION: The posterior approach offered excellent exposure and preservation of the abductor mechanism during primary THA. Augmentation of the repair with a gluteus maximus flap provided stable reconstruction of the abductor muscles and seemed to restore function in the hips with functioning muscles. Cite this article: Bone Joint J 2019;101-B(6 Supple B):116-122.


Assuntos
Artroplastia de Quadril/efeitos adversos , Tendinopatia/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/métodos , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Força Muscular/fisiologia , Músculo Esquelético/lesões , Músculo Esquelético/fisiopatologia , Complicações Pós-Operatórias/etiologia , Técnicas de Sutura , Tendinopatia/fisiopatologia , Traumatismos dos Tendões/etiologia , Traumatismos dos Tendões/fisiopatologia
5.
Semin Cardiothorac Vasc Anesth ; 23(3): 300-308, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31068104

RESUMO

Background and Objective. End-stage liver disease is characterized by a precarious imbalance of hemostasis. Detrimental consequences of hypofibrinolysis, also known as fibrinolytic shutdown, have been recently demonstrated, and its significance in visceral (ie, an allograft that contains the intestine) transplant remains unknown. Design and Setting. To fill this gap, following institutional review board approval, this retrospective study included 49 adult recipients of visceral allografts (14 "visceral allograft without the liver" and 35 "multivisceral" with the liver) transplanted between 2010 and 2018 in a single university hospital, and for whom pre-incisional thromboelastography was available. Based on percent clot lysis 30 minutes after maximal amplitude, patients were stratified into 3 fibrinolysis phenotypes: fibrinolytic shutdown, physiologic fibrinolysis, and hyperfibrinolysis. Results. Fibrinolytic shutdown occurred in 57% of patients, with higher incidence in recipients of multivisceral transplant (69%) compared with visceral allograft without liver (29%) allografts (P = .04). Fibrinolytic shutdown was associated with an increase in both intraoperative thrombosis and hemorrhage. Intraoperative thrombosis (18%) occurred only with multivisceral transplant, and accounted for 36% of in-hospital mortality. A clinically meaningful reduction in incidence of intraoperative thrombosis was noted in recipients who received intravenous heparin thromboprophylaxis. Logistic regression identified pretransplant platelet count as a risk factor for fibrinolytic shutdown (odds ratio = 0.992, 95% confidence interval = [0.984-0.998]; χ2 = 7.8, P = .005). Conclusions. This study highlights fibrinolytic shutdown as a dominant and clinically important feature of the hemostatic imbalance in recipients undergoing visceral transplantation.


Assuntos
Doença Hepática Terminal/cirurgia , Fibrinólise/fisiologia , Hemorragia/epidemiologia , Transplante de Fígado/métodos , Trombose/epidemiologia , Adulto , Anticoagulantes/administração & dosagem , Doença Hepática Terminal/fisiopatologia , Feminino , Hemorragia/etiologia , Hemostasia/fisiologia , Heparina/administração & dosagem , Humanos , Incidência , Intestinos/transplante , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombose/etiologia , Trombose/prevenção & controle , Adulto Jovem
6.
J Invasive Cardiol ; 31(5): E97, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31034445

RESUMO

Percutaneous approaches have become routine in transcatheter aortic valve replacement (TAVR). Despite numerous advantages, vascular complications associated with percutaneous access can occur during and after TAVR, and increase morbidity and mortality significantly. Effective management of potentially catastrophic vascular complications often requires prompt recognition, diagnosis, and management by multidisciplinary teams.


Assuntos
Aorta Torácica , Estenose da Valva Aórtica/cirurgia , Angiografia por Tomografia Computadorizada/métodos , Procedimentos Endovasculares/métodos , Complicações Intraoperatórias , Substituição da Valva Aórtica Transcateter , Lesões do Sistema Vascular , Idoso de 80 Anos ou mais , Aorta Torácica/diagnóstico por imagem , Aorta Torácica/lesões , Aorta Torácica/cirurgia , Estenose da Valva Aórtica/diagnóstico , Técnicas Hemostáticas , Humanos , Artéria Ilíaca/diagnóstico por imagem , Artéria Ilíaca/lesões , Complicações Intraoperatórias/diagnóstico por imagem , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/cirurgia , Masculino , Índice de Gravidade de Doença , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento , Lesões do Sistema Vascular/diagnóstico por imagem , Lesões do Sistema Vascular/etiologia , Lesões do Sistema Vascular/fisiopatologia , Lesões do Sistema Vascular/cirurgia
7.
Br J Anaesth ; 122(5): 563-574, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30916004

RESUMO

BACKGROUND: Intraoperative mortality is now rare, but death within 30 days of surgery remains surprisingly common. Perioperative myocardial infarction is associated with a remarkably high mortality. There are strong associations between hypotension and myocardial injury, myocardial infarction, renal injury, and death. Perioperative arterial blood pressure management was thus the basis of a Perioperative Quality Initiative consensus-building conference held in London in July 2017. METHODS: The meeting featured a modified Delphi process in which groups addressed various aspects of perioperative arterial pressure. RESULTS: Three consensus statements on intraoperative blood pressure were established. 1) Intraoperative mean arterial pressures below 60-70 mm Hg are associated with myocardial injury, acute kidney injury, and death. Injury is a function of hypotension severity and duration. 2) For adult non-cardiac surgical patients, there is insufficient evidence to recommend a general upper limit of arterial pressure at which therapy should be initiated, although pressures above 160 mm Hg have been associated with myocardial injury and infarction. 3) During cardiac surgery, intraoperative systolic arterial pressure above 140 mm Hg is associated with increased 30 day mortality. Injury is a function of arterial pressure severity and duration. CONCLUSIONS: There is increasing evidence that even brief durations of systolic arterial pressure <100 mm Hg and mean arterial pressure <60-70 mm Hg are harmful during non-cardiac surgery.


Assuntos
Pressão Sanguínea/fisiologia , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hipotensão/complicações , Complicações Intraoperatórias/fisiopatologia , Lesão Renal Aguda/etiologia , Humanos , Hipotensão/fisiopatologia , Monitorização Intraoperatória/métodos , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia
8.
Br J Anaesth ; 123(1): e38-e49, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30916022

RESUMO

Perioperative hypersensitivity reactions (POH) constitute a clinical and diagnostic challenge, a consequence of heterogeneous clinical presentations, and multiple underlying pathomechanisms. POH do not necessarily involve an allergen-specific immune response with cross-linking of specific immunoglobulin E (sIgE) antibodies on mast cells and basophils. POH can also result from alternative specific and non-specific effector cell activation/degranulation such as complement-derived anaphylatoxins and off-target occupancy of mast cell, basophil, or both surface receptors. Moreover, POH and anaphylaxis can occur independent from mast cell and basophil degranulation. The manifestations of POH primarily affect the cardiovascular, respiratory, and integumentary systems. POH present within the context of surgical or procedural pathology and the effects of surgical and anaesthetic techniques on pre-existing physiological reserve. The majority of cases of appropriately-treated intraoperative anaphylaxis can be considered a compensated cardiovascular anaphylaxis. With increasing severity of anaphylaxis, maldistribution and hypovolaemia lead to reduced venous return and circulatory failure. Treatment with a combination of epinephrine and i.v. fluid is critical for successful resuscitation, although the excessive use of epinephrine without adequate volume expansion may be deleterious. Neural control of the airways is important in the pathophysiology of bronchospasm. Anticholinergic drug premedication is beneficial in patients with hyperreactive airways. Pulmonary oedema can result from a combination of pulmonary capillary hypertension, incompetence of the alveolocapillary membrane, or both. Angioedema can be distinguished mechanistically into histaminergic and non-histaminergic (e.g. bradykinin-mediated). An understanding of the molecular mechanisms and pathophysiology of POH are essential for the immediate management and subsequent investigation of these cases.


Assuntos
Hipersensibilidade a Drogas/imunologia , Hipersensibilidade a Drogas/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Anafilaxia/imunologia , Anafilaxia/fisiopatologia , Basófilos/imunologia , Humanos , Complicações Intraoperatórias/imunologia , Mastócitos/imunologia , Complicações Pós-Operatórias/imunologia
9.
Br J Anaesth ; 122(5): 605-612, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30916032

RESUMO

BACKGROUND: During general anaesthesia, intraoperative hypotension (IOH), defined as a mean arterial pressure (MAP) reduction of > 20%, is frequent and may lead to complications. Pulse oximetry is mandatory in the operating room, making the photoplethysmographic signal and parameters, such as relative dicrotic notch height (Dicpleth) or perfusion index (PI), readily available. The purpose of this study was to investigate whether relative variations of Dicpleth and PI could detect IOH during anaesthesia induction, and to follow their variations during vasopressor boluses. METHODS: MAP, Dicpleth, and PI were monitored at 1-min intervals during target control induction of anaesthesia with propofol and remifentanil in 61 subjects. Vasopressor infusion (norepinephrine or phenylephrine) was performed when hypotension occurred according to the decision of the physician. RESULTS: The delta in Dicpleth and PI accurately detected IOH, with areas under the receiver operating characteristic curves (AUC) of 0.86 and 0.83, respectively. The optimal thresholds were -19% (sensitivity 79%; specificity 84%) and 51% (sensitivity 82%; specificity 74%) for ΔDicpleth and ΔPI, respectively. There was no difference between the ROC of ΔDicpleth and ΔPI (P=0.22). Combining both ΔDicpleth and ΔPI further improved the hypotension detection power (AUC=0.91) with a sensitivity and specificity of 84%. MAP variations were correlated with ΔDicpleth and ΔPI during vasopressor infusion (r=0.73 and -0.62, respectively; P<0.001). CONCLUSIONS: The relative variation in Dicpleth and PI derived from the photoplethysmographic signal can be used as a non invasive, continuous, and simple tool to detect intraoperative hypotension, and to track the vascular response to vasoconstrictor drugs during induction of general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT03756935.


Assuntos
Anestesia Geral/efeitos adversos , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Adulto , Pressão Sanguínea/efeitos dos fármacos , Determinação da Pressão Arterial/métodos , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/tratamento farmacológico , Hipotensão/fisiopatologia , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/induzido quimicamente , Complicações Intraoperatórias/tratamento farmacológico , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Fotopletismografia/métodos , Estudo de Prova de Conceito , Estudos Prospectivos , Sensibilidade e Especificidade , Vasoconstritores/farmacologia , Vasoconstritores/uso terapêutico
10.
J Clin Neurophysiol ; 36(2): 161-165, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30694942

RESUMO

PURPOSE: Monitoring of somatosensory evoked potentials (SSEPs) serves as an early warning system to detect spinal cord injury and is correlated with postoperative sensory findings. It is an indirect indicator of motor function. This study aimed to evaluate the usefulness of intraoperative SSEPs monitoring as a stand-alone tool during spinal surgeries when motor evoked potentials are not available, to prevent and predict new postoperative neurologic deficits. Motor evoked potentials were not used as the equipment needed to record them was not available at the time of this study. METHODS: This study included 50 patients, aged 14 to 67 years, undergoing extramedullary manipulations, decompression of an epidural abscess or neoplasm, removal of intramedullary tumor, or arteriovenous malformation or spine correction procedures. Somatosensory evoked potentials were analyzed for latency and peak-to-peak amplitude. Critical SSEP changes were defined as a 50% decrease in amplitude or a 10% increase in latency. RESULTS: Somatosensory evoked potentials had an overall sensitivity of 81.8%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 91.3%. CONCLUSIONS: Intraoperative SSEPs have proved to be highly sensitive and specific for iatrogenic injury, mechanical stress caused by cord traction/compression, dural traction, lowered systemic blood pressure, and cord hypothermia. The reversibility of intraoperative SSEP changes showed a highly significant relation to the number of cases with new postoperative deficits as well as type and site of pathologic study (P = 0.00, P = 0.01, and P = 0.00, respectively) but not with the level of pathologic study (P = 0.49).


Assuntos
Potenciais Somatossensoriais Evocados , Monitorização Neurofisiológica Intraoperatória , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Egito , Feminino , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/prevenção & controle , Dados Preliminares , Sensibilidade e Especificidade , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/etiologia , Traumatismos da Medula Espinal/fisiopatologia , Adulto Jovem
11.
J Clin Neurophysiol ; 36(2): 155-160, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30694945

RESUMO

PURPOSE: Intraoperative neurophysiological monitoring using somatosensory evoked potentials has been linked to a reduction in the incidence of neurological deficits during corrective surgery. Nonetheless, quantitative assessments of somatosensory evoked potential waveforms are often difficult to evaluate, because they are affected by anesthesia, injury, and noise. Here, we discuss a novel method that integrates somatosensory evoked potential signals into a single metric by calculating the area under the curve (AUC). METHODOLOGY: Thirty-two Sprague-Dawley rats underwent a laminectomy procedure and were then randomly assigned to a control group or to receive a contusive spinal cord injury ranging from 100 to 200 kilodynes. Neurophysiological testing was completed at various points perioperatively and postoperatively. Somatosensory evoked potential traces obtained were processed and the AUC metric was calculated. RESULTS: The AUC significantly decreased to 11% of its baseline value after impact and remained at 25% baseline after 1 hour for the 200-kdyn cohort. Postimpact, AUC for the control versus the 150-kdyn and 200-kdyn groups, and the 150-kdyn versus 200-kdyn groups were significantly higher (P < 0.01, P < 0.001, and P < 0.05, respectively). Across days, the only significant parameter accounting for AUC variability was impact force, P < 0.0001 (subject parameters and number of days were not significant). CONCLUSIONS: The AUC metric can detect an iatrogenic contusive spinal cord injury immediately after its occurrence. Moreover, this metric can detect different iatrogenic injury impact force levels and identify injury in the postoperative period. The AUC integrates multiple Intraoperative neurophysiological monitoring measures into a single metric and thus has the potential to help clinicians and investigators evaluate spinal cord impact injury status.


Assuntos
Eletrodiagnóstico , Potenciais Somatossensoriais Evocados , Traumatismos da Medula Espinal/diagnóstico , Animais , Área Sob a Curva , Modelos Animais de Doenças , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/fisiopatologia , Monitorização Neurofisiológica Intraoperatória , Laminectomia , Distribuição Aleatória , Ratos Sprague-Dawley , Processamento de Sinais Assistido por Computador , Medula Espinal/fisiopatologia , Traumatismos da Medula Espinal/fisiopatologia
12.
Am J Vet Res ; 80(1): 24-32, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30605039

RESUMO

OBJECTIVE To evaluate the use of a modified passive leg-raising maneuver (PLRM) to predict fluid responsiveness during experimental induction and correction of hypovolemia in isoflurane-anesthetized pigs. ANIMALS 6 healthy male Landrace pigs. PROCEDURES Pigs were anesthetized with isoflurane, positioned in dorsal recumbency, and instrumented. Following induction of a neuromuscular blockade, pigs were mechanically ventilated throughout 5 sequential experimental stages during which the blood volume was manipulated so that subjects transitioned from normovolemia (baseline) to hypovolemia (blood volume depletion, 20% and 40%), back to normovolemia, and then to hypervolemia. During each stage, hemodynamic variables were measured before and 3 minutes after a PLRM and 1 minute after the pelvic limbs were returned to their original position. The PLRM consisted of raising the pelvic limbs and caudal portion of the abdomen to a 15° angle relative to the horizontal plane. RESULTS Hemodynamic variables did not vary in response to the PLRM when pigs were normovolemic or hypervolemic. When pigs were hypovolemic, the PLRM resulted in a significant increase in cardiac output and decrease in plethysomographic variability index and pulse pressure variation. When the pelvic limbs were returned to their original position, cardiac output and pulse pressure variation rapidly returned to their pre-PLRM values, but the plethysomographic variability index did not. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested a modified PLRM might be useful for identification of hemodynamically unstable animals that are likely to respond to fluid therapy. Further research is necessary to validate the described PLRM for prediction of fluid responsiveness in clinically ill animals.


Assuntos
Anestesia/veterinária , Anestésicos Inalatórios/farmacologia , Débito Cardíaco/efeitos dos fármacos , Isoflurano/farmacologia , Postura , Suínos/fisiologia , Animais , Hemodinâmica/efeitos dos fármacos , Hipovolemia/fisiopatologia , Hipovolemia/veterinária , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/veterinária , Masculino
13.
Anesth Analg ; 129(2): e37-e40, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-29916865

RESUMO

Intraoperative transesophageal echocardiography (TEE) is a helpful diagnostic tool when hemodynamic compromise is encountered during noncardiac surgery. At our institution, a Rescue Echo Protocol was created to provide a structured means for requesting and performing a rescue TEE. We analyzed our institutional utilization of this service and found that it was used throughout the spectrum of patients' American Society of Anesthesiologists classifications and surgical services. We demonstrated that 72.9% of rescue examinations resulted in a change in management, supporting the use of TEE as a diagnostic tool during hemodynamic compromise.


Assuntos
Ecocardiografia Transesofagiana , Hemodinâmica , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/diagnóstico por imagem , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Protocolos Clínicos , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos
14.
A A Pract ; 12(5): 145-146, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30130281

RESUMO

A 52-year-old patient was scheduled for a cystoscopy. Anesthesia was induced by intravenous injection of fentanyl and propofol. After administration of atracurium, he became bradycardic and suffered a cardiac arrest. Despite prolonged cardiopulmonary resuscitation, the patient could not be revived. Electrolytes and hemoglobin levels were normal, and a transthoracic echocardiogram showed no signs of pericardial effusions or of any left ventricular contraction. The postmortem found no pathology. However, mast cell tryptase was raised significantly, indicating fatal anaphylaxis. Having presented no classic clinical signs, this case is a reminder that rapid cardiovascular collapse can be the sole clinical feature of anaphylaxis.


Assuntos
Anafilaxia/induzido quimicamente , Anafilaxia/diagnóstico , Atracúrio/efeitos adversos , Complicações Intraoperatórias/induzido quimicamente , Complicações Intraoperatórias/diagnóstico , Fármacos Neuromusculares não Despolarizantes/efeitos adversos , Anafilaxia/fisiopatologia , Evolução Fatal , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade
16.
J Interv Card Electrophysiol ; 54(2): 101-108, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30232688

RESUMO

PURPOSE: Transmural thermal injury (TTI), such as esophageal erosion/ulcer and periesophageal nerve injury leading to gastric hypomotility, is not rare complications associated with pulmonary vein isolation (PVI). However, the mechanism and predicting factors of TTI have not yet been fully elucidated with second-generation cryoballoon (CB) PVI. METHODS: One hundred ten consecutive patients, who underwent CB PVI for atrial fibrillation and received esophagogastroduodenoscopy 2 days later, were investigated. The relationships between TTI and both clinical and anatomical parameters were examined. We measured the following parameters based on the computed tomography data: the angle of the left atrial (LA) posterior wall to the descending aorta (Ao) (LA-Ao angle); the branching angle of the left inferior pulmonary vein (LIPV) to the coronal plane (LIPV angle); and the minimum distance between the LA posterior wall and descending Ao enclosing the esophagus (LA-Ao distance). RESULTS: TTIs occurred in 19 patients (esophageal erosion in 2 and gastric hypomotility in 17). The patients with TTI were significantly older than those without TTI. In the anatomical parameters, the LIPV angle was larger and the LA-Ao distance was shorter in the TTI (+) group compared to the TTI (-) group. With the multivariate logistic regression analysis, the age (odds ratio [OR] 2.148, P = 0.022) and LA-Ao distance (OR 0.430, P = 0.013) were independent predictors of TTI. CONCLUSIONS: The occurrence of TTI in CB PVI was associated with aging, suggesting compromised periesophageal circulation, and the anatomical proximities between the LA and the descending Ao, which enclose the esophagus.


Assuntos
Fibrilação Atrial/cirurgia , Queimaduras/etiologia , Ablação por Cateter/efeitos adversos , Criocirurgia/efeitos adversos , Imagem Tridimensional , Veias Pulmonares/cirurgia , Idoso , Fibrilação Atrial/diagnóstico por imagem , Queimaduras/epidemiologia , Queimaduras/patologia , Ablação por Cateter/métodos , Estudos de Coortes , Criocirurgia/métodos , Eletrocardiografia/métodos , Feminino , Hospitais Universitários , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/fisiopatologia , Japão , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Veias Pulmonares/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodos
17.
Anesthesiology ; 130(1): 72-82, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30312182

RESUMO

BACKGROUND: Triple-low events (mean arterial pressure less than 75 mmHg, Bispectral Index less than 45, and minimum alveolar fraction less than 0.8) are associated with mortality but may not be causal. This study tested the hypothesis that providing triple-low alerts to clinicians reduces 90-day mortality. METHODS: Adults having noncardiac surgery with volatile anesthesia and Bispectral Index monitoring were electronically screened for triple-low events. Patients having triple-low events were randomized in real time, with clinicians either receiving an alert, "consider hemodynamic support," or not. Patients were blinded to treatment. Helpful responses to triple-low events were defined by administration of a vasopressor within 5 min or a 20% reduction in end-tidal volatile anesthetic concentration within 15 min. RESULTS: Of the qualifying patients, 7,569 of 36,670 (20%) had triple-low events and were randomized. All 7,569 were included in the primary analysis. Ninety-day mortality was 8.3% in the alert group and 7.3% in the nonalert group. The hazard ratio (95% CI) for alert versus nonalert was 1.14 (0.96, 1.35); P = 0.12, crossing a prespecified futility boundary. Clinical responses were helpful in about half the patients in each group, with 51% of alert patients and 47% of nonalert patients receiving vasopressors or having anesthetics lowered after start of triple low (P < 0.001). There was no relationship between the response to triple-low events and adjusted 90-day mortality. CONCLUSIONS: Real-time alerts to triple-low events did not lead to a reduction in 90-day mortality, and there were fewer responses to alerts than expected. However, similar mortality with and without responses suggests that there is no strong relationship between responses to triple-low events and mortality.


Assuntos
Pressão Arterial/fisiologia , Monitores de Consciência/estatística & dados numéricos , Hipotensão/diagnóstico , Hipotensão/mortalidade , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/mortalidade , Monitorização Intraoperatória/métodos , Feminino , Humanos , Hipotensão/fisiopatologia , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade
18.
J Intensive Care Med ; 34(1): 67-76, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28110613

RESUMO

BACKGROUND:: Patients undergoing vascular surgery are prone to perioperative organ injury because of both higher prevalence of cardiovascular risk factors and the extent of surgery. Early detection of organ failure is essential to facilitate appropriate medical care. Midregional pro-adrenomedullin (MR-proADM) has been investigated in acute medical care settings to guide clinical decision-making regarding patient pathways and to identify patients prone to imminent cardiovascular or inflammatory complications. In this study, we evaluated the impact of perioperative MR-proADM levels as an early marker of perioperative cardiovascular and inflammatory stress reactions and kidney injury. METHODS:: The study was conducted as a monocentric, prospective, noninterventional trial at Hannover Medical School, Germany. A total of 454 consecutive patients who underwent open vascular surgery were followed from the day prior to until 30 days after surgery. The composite primary end point was defined as the occurrence of major adverse cardiac events (MACEs), acute kidney injury (AKI), or systemic inflammatory response syndrome (SIRS). Measurements were correlated with both medical history and postoperative MACE, AKI, or SIRS using univariate and multivariate regression analysis. RESULTS:: One hundred thirty-nine (31%) of the patients reached the primary end point within the study interval. Midregional pro-adrenomedullin change was associated with the combined primary end point and with the intensity of surgical trauma. Midregional pro-adrenomedullin change was increased in patients reaching the secondary end points, SIRS (optimal cutoff: 0.2 nmol/L) and AKI (optimal cutoff: 0.7 nmol/L), but not in patients with MACEs. CONCLUSION:: Increased levels of MR-proADM within the perioperative setting (1) were linked to the invasiveness of surgery and (2) identified patients with ongoing loss of renal function. Increased MR-proADM levels may therefore identify a subgroup of patients prone to excessive cardiovascular stress but did not directly correlate with adverse cardiac events. Consistently low levels of MR-proADM may identify a subgroup of patients with acceptable low risk to guide discharge from high-density care units.


Assuntos
Adrenomedulina/sangue , Complicações Intraoperatórias/sangue , Fragmentos de Peptídeos/sangue , Precursores de Proteínas/sangue , Insuficiência Renal/sangue , Síndrome de Resposta Inflamatória Sistêmica/sangue , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Procedimentos Clínicos , Feminino , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos
19.
Clin Neurophysiol ; 130(1): 55-60, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30476711

RESUMO

OBJECTIVE: Electroencephalogram burst-suppression during general anesthesia is associated with post-operative delirium (POD). Whether burst-suppression causes POD or merely reflects susceptibility to POD is unclear. We hypothesized decreased intraoperative alpha (8-12 Hz) and beta (13-33 Hz) power prior to the occurrence of burst-suppression in susceptible patients. METHODS: We analyzed intraoperative electroencephalogram data of cardiac surgical patients undergoing cardiopulmonary bypass (CPB). We detected the incidence and duration of CPB burst-suppression with an automated burst-suppression detection algorithm. We analyzed EEG data with multitaper spectral estimation methods. We assessed associations between patient characteristics and burst-suppression using Binomial and Zero-inflated Poisson Regression Models. RESULTS: We found significantly decreased alpha and beta power (7.8-22.95 Hz) in the CPB burst-suppression cohort. The odds ratio for the association between point estimates for alpha and beta power (7.8-22.95 Hz) and the incidence of burst-suppression was 0.88 (95% CI: 0.79-0.98). The incidence rate ratio for the association between point estimates for power between the alpha and beta range and the duration of burst-suppression was 0.89 (95% CI: 0.84-0.93). CONCLUSION: Decreased intra-operative power within the alpha and beta range was associated with susceptibility to burst-suppression during CPB. SIGNIFICANCE: This dynamic may be used to develop principled neurophysiological-based approaches to aid the preemptive identification and targeted care of POD vulnerable patients.


Assuntos
Anestesia Geral/tendências , Ponte Cardiopulmonar/tendências , Eletroencefalografia/tendências , Monitorização Intraoperatória/tendências , Idoso , Anestesia Geral/efeitos adversos , Ondas Encefálicas/fisiologia , Ponte Cardiopulmonar/efeitos adversos , Eletroencefalografia/efeitos adversos , Feminino , Humanos , Incidência , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes
20.
Pacing Clin Electrophysiol ; 42(2): 230-237, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30549044

RESUMO

BACKGROUND: The cryoballoon (CB) can be utilized for extra pulmonary vein (PV) ablation such as for a left atrial (LA) posterior wall (LAPW) isolation. However, scrutiny of the esophageal injuries during the LAPW isolation has never been performed. We sought to thoroughly investigate the esophageal lesions (ELs) and gastric hypomotility (GH) caused by an LAPW isolation using a CB. METHODS: A total of 101 persistent atrial fibrillation patients who underwent an LAPW isolation using a CB were enrolled. The CB was applied on the roof and bottom area of the LAPW after a PV isolation. The luminal esophageal temperature (LET) was monitored by a thermistor probe during the CB applications. When the LET reached 15°C, the freezing application was prematurely interrupted. Esophagogastroscopy was performed on the next day following the ablation. RESULTS: All PVs were successfully isolated in all patients. A successful LAPW isolation solely with CB ablation was performed in 72 (71.3%) patients. Cryofreezing applications were prematurely interrupted due to low LETs in 49 (48.5%) patients predominantly during the LA bottom line ablation. ELs and GH were observed in 11 (10.9%) and 16 patients (15.8%), respectively. The nadir LET tended to be lower in patients with ELs and GH than in those without (ELs: 14.8 ± 4.5°C vs 17.4 ± 6.0°C, P = 0.17; GH: 15.5 ± 4.5°C vs 17.5 ± 6.1°C, P = 0.23, respectively). CONCLUSIONS: Esophageal complications such as ELs and GH occur during the LAPW isolation with a CB. There was no reliable predictor of those adverse events.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/métodos , Criocirurgia/efeitos adversos , Esôfago/lesões , Complicações Intraoperatórias/etiologia , Veias Pulmonares/cirurgia , Idoso , Feminino , Motilidade Gastrointestinal , Humanos , Complicações Intraoperatórias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estômago/fisiopatologia
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