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1.
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
2.
Br J Anaesth ; 123(5): 618-626, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31540668

RESUMO

BACKGROUND: Preoperative hyponatraemia is an independent risk factor for postoperative mortality in adults. To our knowledge, this has not been investigated in children. METHODS: Using data from the 2014 and 2015 data sets of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P), we conducted a retrospective study of children undergoing surgery. The primary outcome was 30-day all-cause mortality. The secondary outcomes of interest were postoperative seizure within 30 days and prolonged length of stay. To identify any independent association between preoperative hyponatraemia, defined as mild (serum sodium of 131-135 mEq L-1) or severe (≤130 mEq L-1), and death, postoperative seizures, or prolonged length of stay, multivariable logistic regression models were generated. RESULTS: A total of 152 894 patients were identified, and of these 35 291 were included in the final analysis. Preoperative hyponatraemia was present in 5422 patients or 15.4% of the final cohort. There were 432 (0.80%) deaths at 30 days. Compared with patients with a normal preoperative sodium concentration, those with mild (P=0.003; odds ratio [OR]: 1.59; 95% confidence interval [CI]: 1.17-2.18) and severe (P=0.002; OR: 2.16; 95% CI: 1.32-3.54) hyponatraemia had increased rates of death, after adjusting for co-morbidity and procedural complexity. Both mild (P<0.001; OR: 1.53; 95% CI: 1.42-1.65) and severe (P<0.001; OR: 1.51; 95% CI: 1.19-1.93) hyponatraemia were independently associated with prolonged length of stay, after adjusting for relevant co-variates. CONCLUSIONS: This retrospective analysis identified an association between preoperative hyponatraemia and perioperative mortality and length of stay in paediatric patients.


Assuntos
Hiponatremia/mortalidade , Complicações Intraoperatórias/mortalidade , Complicações Pós-Operatórias/mortalidade , Período Pré-Operatório , Chicago/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Retrospectivos , Fatores de Risco
3.
Bone Joint J ; 101-B(9): 1129-1137, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31474142

RESUMO

AIMS: The aim of this study was to investigate mortality and risk of intraoperative medical complications depending on delay to hip fracture surgery by using data from the Norwegian Hip Fracture Register (NHFR) and the Norwegian Patient Registry (NPR). PATIENTS AND METHODS: A total of 83 727 hip fractures were reported to the NHFR between 2008 and 2017. Pathological fractures, unspecified type of fractures or treatment, patients less than 50 years of age, unknown delay to surgery, and delays to surgery of greater than four days were excluded. We studied total delay (fracture to surgery, n = 38 754) and hospital delay (admission to surgery, n = 73 557). Cox regression analyses were performed to calculate relative risks (RRs) adjusted for sex, age, American Society of Anesthesiologists (ASA) classification, type of surgery, and type of fracture. Odds ratio (OR) was calculated for intraoperative medical complications. We compared delays of 12 hours or less, 13 to 24 hours, 25 to 36 hours, 37 to 48 hours, and more than 48 hours. RESULTS: Mortality remained unchanged when total delay was less than 48 hours. Total delay exceeding 48 hours was associated with increased three-day mortality (RR 1.69, 95% confidence interval (CI) 1.23 to 2.34; p = 0.001) and one-year mortality (RR 1.06, 95% CI 1.04 to 1.22; p = 0.003). More intraoperative medical complications were reported when hospital delay exceeded 24 hours. CONCLUSION: Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. Cite this article: Bone Joint J 2019;101-B:1129-1137.


Assuntos
Artroplastia de Quadril/mortalidade , Fixação Interna de Fraturas/mortalidade , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Complicações Intraoperatórias/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Artroplastia de Quadril/estatística & dados numéricos , Feminino , Fixação Interna de Fraturas/estatística & dados numéricos , Hemiartroplastia/estatística & dados numéricos , Fraturas do Quadril/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Masculino , Noruega/epidemiologia , Sistema de Registros/estatística & dados numéricos , Fatores de Risco
4.
Biomed Res Int ; 2019: 4572130, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31467891

RESUMO

Purpose: Acute kidney injury (AKI) is a major and severe complication following donation-after-circulatory-death (DCD) liver transplantation (LT) and is associated with increased postoperative morbidity and mortality. However, the risk factors and the prognosis factors of AKI still need to be further explored, and the relativity of intraoperative hepatic blood inflow (HBI) and AKI following LT has not been discussed yet. The purpose of this study was to investigate the correlation between HBI and AKI and to construct a prediction model of early acute kidney injury (EAKI) following DCD LT with the combination of HBI and other clinical parameters. Methods: Clinical data of 132 patients who underwent DCD liver transplantation at the first hospital of China Medical University from April 2005 to March 2017 were analyzed. Data of 105 patients (the first ten years of patients) were used to develop the prediction model. Then we assessed the clinical usefulness of the prediction models in the validation cohort (27 patients). EAKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria based on serum creatinine increase during 7-day of postoperative follow-up. Results: After Least Absolute Shrinkage and Selection Operator (LASSO) regression and simplification, a simplified prediction model consisting of the Child-Turcotte-Pugh (CTP) score (p=0.033), anhepatic phase (p=0.014), packed red blood cell (pRBC) transfusion (p=0.027), and the HBI indexed by height (HBI/h) (p=0.002) was established. The C-indexes of the model in the development and validation cohort were 0.823 [95% CI, 0.738-0.908] and 0.921 [95% CI, 0.816-1.000], respectively. Conclusions: In this study, we demonstrated the utility of HBI/h as a predictor for EAKI following DCD LT, as well as the clinical usefulness of the prediction model through the combination of the CTP score, anhepatic phase, pRBC transfusion and HBI/h.


Assuntos
Lesão Renal Aguda/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/efeitos adversos , Fígado/irrigação sanguínea , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/mortalidade , Adulto , Creatinina/metabolismo , Feminino , Sobrevivência de Enxerto , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Fígado/patologia , Masculino , Pessoa de Meia-Idade , Medição de Risco , Fatores de Risco , Obtenção de Tecidos e Órgãos
5.
J Surg Oncol ; 120(4): 603-610, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31292970

RESUMO

BACKGROUND: Gallbladder adenocarcinoma is often incidentally identified following cholecystectomy. We hypothesized that intraoperative bile spillage would be a negative prognostic factor. METHODS: A retrospective review of patients treated at a cancer center with histologically confirmed gallbladder adenocarcinoma, 2009-2017, was performed. Patient, disease, and treatment factors were analyzed in terms of progression-free survival (PFS) and overall survival (OS). RESULTS: Sixty-six patients were identified. Tumor stage was T1 (n = 8, 12%), T2 (n = 23, 35%), T3 (n = 35, 53%). Node stage was N0 (n = 22, 33%), N1+ (n = 26, 39%), Nx (n = 18, 27%). Operations included cholecystectomy alone (n = 27, 36%), cholecystectomy and partial hepatectomy (n = 30, 45%), or hepaticojejunostomy (n = 9, 14%). Median PFS was 7 months (interquartile range [IQR], 2-19); median OS was 16 months (IQR, 10-31). Subset multivariate proportional hazards regression of 41 patients who underwent initial cholecystectomy showed decreased PFS was associated with intraoperative spillage (n = 12, 29%; hazard ratio [HR], 5.5; P = .0014); decreased OS was associated with drain placement (n = 21, 51%; HR, 8.1; P = .006). CONCLUSIONS: Intraoperative bile spillage and surgical drain placement at initial cholecystectomy are negatively associated with PFS and OS in gallbladder adenocarcinoma. Explicit documentation of spillage and drain placement rationale is critical, possibly indicating locally advanced disease and prompting stronger consideration of systemic therapy before definitive resection.


Assuntos
Adenocarcinoma/mortalidade , Bile , Colecistectomia/mortalidade , Neoplasias da Vesícula Biliar/mortalidade , Vesícula Biliar/lesões , Complicações Intraoperatórias/mortalidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Idoso , Feminino , Seguimentos , Neoplasias da Vesícula Biliar/patologia , Neoplasias da Vesícula Biliar/cirurgia , Humanos , Achados Incidentais , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
6.
World Neurosurg ; 129: e776-e781, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31289000

RESUMO

OBJECTIVE: To identify predictors of short-term mortality and complications after anterior odontoid screw fixation. METHODS: This was a retrospective analysis of a national database. The American College of Surgeons National Quality Improvement Database was queried using Current Procedural Terminology codes to identify patients aged ≥60 years who underwent surgery for anterior fixation of odontoid fracture admitted from 2007 to 2016. Univariate analysis and subsequent multivariate analysis were used to analyze risk factors for postoperative complications and 30-day postoperative mortality. Complications were defined as surgical-site infection, wound breakdown, pneumonia, venous thromboembolism, stroke, myocardial infarction, sepsis, renal progressive renal insufficiency/acute kidney injury, or cardiac arrest. RESULTS: A total of 198 patients were identified. Mean age was 77.7 (±8.7) years and 60.6% were female. Overall mortality rate was 7.6%, and the complication rate was 9.1%. In multivariate analysis, dependent functional status (0.012; odds ratio [OR] 5.2; 95% confidence interval [CI] 1.42-18.72) and preoperative systemic inflammatory response syndrome (P = 0.011; OR 6.2; 95% CI 1.52-25.79) predicted mortality. Emergency case status (P = 0.033; OR 3.4; 95% CI 1.10-10.70) predicted perioperative complications. Age was not significantly associated with either complications or mortality in multivariate analysis. CONCLUSIONS: Functional dependence and preoperative systemic inflammatory response syndrome predict mortality following odontoid screw placement. Although age often is considered a limiting factor in pursuing surgical intervention in patients with odontoid fracture, age did not independently increase odds of either complications or perioperative mortality in this analysis. Further studies are needed to explore these findings.


Assuntos
Fixação Interna de Fraturas/efeitos adversos , Complicações Intraoperatórias/mortalidade , Processo Odontoide/cirurgia , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Parafusos Ósseos/efeitos adversos , Bases de Dados Factuais , Feminino , Fixação Interna de Fraturas/mortalidade , Humanos , Complicações Intraoperatórias/etiologia , Masculino , Processo Odontoide/lesões , Complicações Pós-Operatórias/etiologia , Fraturas da Coluna Vertebral/cirurgia
7.
Anesth Analg ; 128(6): 1286-1291, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31094801

RESUMO

BACKGROUND: Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality. METHODS: This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality. RESULTS: There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001). CONCLUSIONS: Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.


Assuntos
Anestesia/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Tratamento de Emergência/efeitos adversos , Mortalidade Hospitalar , Complicações Intraoperatórias/mortalidade , Assistência Perioperatória , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Benchmarking , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Lactente , Modelos Logísticos , Malaui , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Adulto Jovem
8.
World J Surg ; 43(8): 1880-1889, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30953195

RESUMO

BACKGROUND: Approximately 5 billion people do not have access to safe, timely, and affordable surgical and anesthesia care, with this number disproportionately affecting those from low-middle-income countries (LMICs). Perioperative mortality rates (POMRs) have been identified by the World Health Organization as a potential health metric to monitor quality of surgical care provided. The purpose of this systematic review was to evaluate published reports of POMR and suggest recommendations for its appropriate use as a health metric. METHODS: The protocol was registered a priori with PROSPERO. A peer-reviewed search strategy was developed adhering with the PRISMA guidelines. Relevant articles were identified through Medline, Embase, CENTRAL, CDSR, LILACS, PubMed, BIOSIS, Global Health, Africa-Wide Information, Scopus, and Web of Science databases. Two independent reviewers performed a primary screening analysis based on titles and abstracts, followed by a full-text screen. Studies describing POMRs of adult emergency abdominal surgeries in LMICs were included. RESULTS: A total of 7787 articles were screened of which 7466 were excluded based on title and abstract. Three hundred and twenty-one articles entered full-text screen of which 70 articles met the inclusion criteria. Variables including timing of POMR reporting, intraoperative mortality, length of hospital stay, complication rates, and disease severity score were collected. Complication rates were reported in 83% of studies and postoperative stay in 46% of studies. 40% of papers did not report the specific timing of POMR collection. 7% of papers reported on intraoperative death. Additionally, 46% of papers used a POMR timing specific to the duration of their study. Vital signs were discussed in 24% of articles, with disease severity score only mentioned in 20% of studies. CONCLUSION: POMR is an important health metric for quantifications of quality of care of surgical systems. Further validation and standardization are necessary to effectively use this health metric.


Assuntos
Abdome Agudo/cirurgia , Período Perioperatório/mortalidade , Indicadores de Qualidade em Assistência à Saúde , Abdome Agudo/mortalidade , Anestesia/normas , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Renda , Complicações Intraoperatórias/mortalidade , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias/mortalidade , Procedimentos Cirúrgicos Operatórios/mortalidade , Procedimentos Cirúrgicos Operatórios/normas
9.
J Am Acad Orthop Surg ; 27(7): 256-263, 2019 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-30897607

RESUMO

INTRODUCTION: Large cohort studies evaluating cardiac complications in patients undergoing spine surgery are lacking. The purpose of this study was to determine the incidence, timing, risk factors, and effect of cardiac complications in spine surgery by using a national database, the American College of Surgeons National Surgical Quality Improvement Program. METHODS: Patients who underwent spine surgery in the 2005 to 2012 National Surgical Quality Improvement Program database were identified. The primary outcome was an occurrence of cardiac arrest or myocardial infarction during the operation or the 30-day postoperative period. Risk factors for development of cardiac complications were identified using multivariate regression. The postoperative length of stay, 30-day readmission, and mortality were compared between patients who did and did not experience a cardiac complication. RESULTS: A total of 30,339 patients who underwent spine surgery were identified. The incidence of cardiac complications was 0.34% (95% confidence interval [CI], 0.27% to 0.40%). Of the cases in which a cardiac complication developed, 30% were diagnosed after discharge. Risk factors for the development of cardiac complications were greater age (most notably ≥80 years, relative risk [RR] = 5.53; 95% CI = 2.28 to 13.43; P < 0.001), insulin-dependent diabetes (RR = 2.58; 95% CI = 1.51 to 4.41; P = 0.002), preoperative anemia (RR = 2.46; 95% CI = 1.62 to 3.76; P < 0.001), and history of cardiac disorders and treatments (RR = 1.88; 95% CI = 1.16 to 3.07; P = 0.011). Development of a cardiac complication before discharge was associated with a greater length of stay (7.9 versus 2.6 days; P < 0.001), and a cardiac complication after discharge was associated with increased 30-day readmission (RR = 12.32; 95% CI = 8.17 to 18.59; P < 0.001). Development of a cardiac complication any time during the operation or 30-day postoperative period was associated with increased mortality (RR = 113.83; 95% CI = 58.72 to 220.68; P < 0.001). DISCUSSION: Perioperative cardiac complications were diagnosed in approximately 1 in 300 patients undergoing spine surgery. High-risk patients should be medically optimized and closely monitored through the perioperative period. LEVEL OF EVIDENCE: Level III.


Assuntos
Parada Cardíaca/epidemiologia , Complicações Intraoperatórias/epidemiologia , Infarto do Miocárdio/epidemiologia , Procedimentos Ortopédicos , Complicações Pós-Operatórias/epidemiologia , Coluna Vertebral/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Parada Cardíaca/mortalidade , Parada Cardíaca/prevenção & controle , Humanos , Incidência , Complicações Intraoperatórias/mortalidade , Complicações Intraoperatórias/prevenção & controle , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica , Análise Multivariada , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Procedimentos Ortopédicos/mortalidade , Procedimentos Ortopédicos/estatística & dados numéricos , Readmissão do Paciente , Período Perioperatório , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Fatores de Tempo , Adulto Jovem
10.
Clin Transl Oncol ; 21(9): 1197-1206, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30689183

RESUMO

BACKGROUND: Whether intraoperative blood loss (IBL) was independently associated with poor prognosis of gastric cancer (GC) patients remains controversial. In the present study, we evaluated the impact of IBL on the disease-free survival (DFS) of GC patients. METHODS: A total of 1669 patients who underwent curative gastrectomy for GC were reviewed retrospectively. All patients were classified as IBL < 400 mL and IBL ≥ 400 mL group according to the amount of IBL. The prognostic difference between two patient groups was compared and clinicopathologic factors associated with the prognosis of GC patients were analyzed. RESULTS: The 5-year DFS rate of the patients with IBL < 400 mL and those with IBL ≥ 400 mL was 52.1% and 41.5%, respectively (P < 0.001). The 5-year DFS rate of the patients who did and did not receive intraoperative blood transfusion was 36.9% and 53.2%, respectively (P < 0.001). However, the similar survival outcomes were not observed in the subgroup analysis based on the TNM stage. The multivariate analysis indicated that IBL (HR 1.021, 95% CI 0.875-1.191, P > 0.05) and intraoperative blood transfusion (HR 1.111, 95% CI 0.943-1.309, P > 0.05) were not independent prognostic factors for GC patients. In addition, the patients with IBL ≥ 400 mL had a higher risk of postoperative complications than those with IBL < 400 mL, especially for intraabdominal infection and wound infection. The tumor located in upper 1/3 stomach, total gastrectomy, combined organ resection and advanced tumor stage (stage III) were independent risk factors for intraoperative massive hemorrhage. CONCLUSION: Intraoperative blood loss was significantly associated with tumor-related and surgery-related factors. Intraoperative blood loss itself could not independently affect survival outcome of GC patients after curative gastrectomy.


Assuntos
Perda Sanguínea Cirúrgica/mortalidade , Transfusão de Sangue/métodos , Gastrectomia/mortalidade , Complicações Intraoperatórias/mortalidade , Neoplasias Gástricas/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Neoplasias Gástricas/patologia , Neoplasias Gástricas/cirurgia , Taxa de Sobrevida , Adulto Jovem
12.
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
13.
J Am Acad Orthop Surg ; 27(10): 375-380, 2019 May 15.
Artigo em Inglês | MEDLINE | ID: mdl-30461519

RESUMO

INTRODUCTION: We determined mortality rates after intraoperative and postoperative periprosthetic femur fractures in primary and revision total hip arthroplasty (THA). METHODS: The study population comprised 522 intraoperative and 480 postoperative femur fractures in 26,250 primary THA patients and 590 intraoperative and 224 postoperative femur fractures in 4,532 revision THA patients. The risk of death was examined using Cox regression models. RESULTS: In primary THA, intraoperative periprosthetic femur fractures were not associated with excess risk of death (hazard ratio, 1.03; 95% confidence interval, 0.86 to 1.22). The risk of death was slightly elevated among primary THA patients with postoperative femur fractures (hazard ratio, 1.19; 95% confidence interval, 1.08 to 1.43), but the excess risk was only confined to patients with comorbid orthopaedic conditions. In revision THA, neither intraoperative nor postoperative periprosthetic femur fractures were associated with excess risk of death. CONCLUSION: Periprosthetic femur fractures are not associated with excess mortality among primary osteoarthritis patients. LEVEL OF EVIDENCE: Level III.


Assuntos
Artroplastia de Quadril/efeitos adversos , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/mortalidade , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Reoperação/efeitos adversos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Risco
14.
J Cardiothorac Vasc Anesth ; 33(4): 961-966, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30097315

RESUMO

OBJECTIVES: The primary objective of this study was to determine whether liver transplantation recipients with preoperative prolonged corrected (QTc) intervals have a higher incidence of intraoperative cardiac events and/or postoperative mortality compared with their peers with normal QTc intervals. DESIGN: This was a retrospective cohort study. SETTING: Single academic hospital in New York, NY. PARTICIPANTS: Patients undergoing liver transplantation between 2007 and 2016. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Data relating to all liver transplantation recipients with preoperative electrocardiograms were queried from an institutional anesthesia data warehouse and electronic medical records. Primary outcomes were a composite outcome of intraoperative cardiac events and postoperative mortality. Patients with a prolonged QTc interval (>450 ms for men, >470 ms for women) did not demonstrate an association with intraoperative cardiac events, 30- or 90-day mortality, in-hospital mortality, or overall mortality compared with recipients in the normal QTc interval group. A prolonged QTc was found to be associated with increased anesthesia time, surgical time, length of hospital stay, and incidence of fresh frozen plasma and platelets transfusion. CONCLUSIONS: Prolonged QTc interval is not associated with an increased incidence of intraoperative cardiac events or mortality in liver transplantation recipients. The demonstrated correlation among QTc length and Model for End-stage Liver Disease score, blood component requirements, surgical and anesthetic times, and hospital length of stay likely represents the association between QTc length and severity of liver disease.


Assuntos
Mortalidade Hospitalar/tendências , Complicações Intraoperatórias/fisiopatologia , Transplante de Fígado/tendências , Síndrome do QT Longo/fisiopatologia , Cuidados Pré-Operatórios/tendências , Adulto , Idoso , Estudos de Coortes , Eletrocardiografia/mortalidade , Eletrocardiografia/tendências , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Transplante de Fígado/efeitos adversos , Transplante de Fígado/mortalidade , Síndrome do QT Longo/mortalidade , Síndrome do QT Longo/cirurgia , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/mortalidade , Estudos Retrospectivos
15.
Sci Rep ; 8(1): 18023, 2018 12 21.
Artigo em Inglês | MEDLINE | ID: mdl-30575797

RESUMO

Preoperative hyponatremia is associated with an increased risk of mortality on the liver transplantation (LT) waiting list. We sought to investigate the impact of pre- and intraoperative serum sodium levels on the one-year mortality after LT. We identified 1,164 patients for whom preoperative and intraoperative serum sodium levels were available. Cox regression analysis with multivariable adjustment was performed for one-year mortality. A propensity score matching analysis was performed for preoperative and intraoperative serum sodium groups to compare one-year survival. The cutoff of sodium level with minimal p-value was 130 mEq/L for both preoperative and intraoperative sodium. Intraoperative hyponatremia was an independent predictor of one-year mortality in the multivariable Cox regression analysis, while preoperative hyponatremia was not. Kaplan-Meier curve showed that there was a significant difference in the one-year mortality between preoperative and intraoperative serum sodium groups. However, after propensity score matching, there was no difference in the one-year mortality among the preoperative sodium groups, while there was a significant difference among the intraoperative sodium groups. Intraoperative hyponatremia defined by mean sodium <130 mEq/L was independently associated with a significantly high one-year mortality. Mean intraoperative serum sodium levels may be a better prognostic predictor than preoperative serum sodium levels.


Assuntos
Doença Hepática Terminal/mortalidade , Doença Hepática Terminal/cirurgia , Hiponatremia/diagnóstico , Complicações Intraoperatórias/diagnóstico , Transplante de Fígado/mortalidade , Doença Hepática Terminal/sangue , Doença Hepática Terminal/diagnóstico , Feminino , Seguimentos , Humanos , Hiponatremia/complicações , Hiponatremia/mortalidade , Complicações Intraoperatórias/mortalidade , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
17.
Acta Orthop ; 89(6): 615-621, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30328746

RESUMO

Background and purpose - Controversies exist regarding thromboprophylaxis in orthopedic surgery. We studied whether the thromboprophylaxis in hip fracture patients treated with osteosynthesis should start preoperatively or postoperatively. Data were extracted from the nationwide Norwegian Hip Fracture Register (NHFR). The risks of postoperative deaths, reoperations, and intraoperative bleeding were studied within 6 months after surgery. Patients and methods - After each operation for hip fracture in Norway the surgeon reports information on the patient, the fracture, and the operation to the NHFR. Cox regression analyses were performed with adjustments for age group, ASA score, sex, duration of surgery, and year of surgery. During the period 2005-2016, 96,599 hip fractures were reported to the register. Only osteosyntheses where low-molecular-weight heparin (LMWH) were given and with known information on preoperative start of the prophylaxis were included in the analyses. Dalteparin and enoxaparin were used in 58% and 42% of the operations respectively (n = 45,913). Results - Mortality (RR =1.01, 95% CI 0.97-1.06) and risk of reoperation (RR =0.99, CI 0.90-1.08) were similar comparing preoperative and postoperative start of LMWH. Postoperative start reduced the risk of intraoperative bleeding complications compared with preoperative start (RR =0.67, CI 0.51-0.90). Interpretation - The initiation of LMWH did not influence the mortality or the risk of reoperation in hip fracture patients treated with osteosynthesis. Postoperative start of LMWH could possibly decrease the risk of intraoperative bleeding.


Assuntos
Anticoagulantes/uso terapêutico , Fixação Interna de Fraturas/métodos , Heparina de Baixo Peso Molecular/uso terapêutico , Fraturas do Quadril/cirurgia , Tromboembolia Venosa/prevenção & controle , Idoso de 80 Anos ou mais , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Parafusos Ósseos , Feminino , Fixação Interna de Fraturas/estatística & dados numéricos , Fraturas do Quadril/mortalidade , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Estimativa de Kaplan-Meier , Masculino , Noruega/epidemiologia , Duração da Cirurgia , Cuidados Pós-Operatórios/mortalidade , Cuidados Pós-Operatórios/estatística & dados numéricos , Cuidados Pré-Operatórios/mortalidade , Cuidados Pré-Operatórios/estatística & dados numéricos , Sistema de Registros , Reoperação/mortalidade , Reoperação/estatística & dados numéricos , Tromboembolia Venosa/mortalidade
18.
Cardiovasc Revasc Med ; 19(6S): 41-46, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30327095

RESUMO

BACKGROUND: Transfemoral TAVR (tf-TAVR) under conscious sedation (CS) has become popular. The need of anesthesiologic support during tf-TAVR has been questioned. Critical events during the procedure might require immediate action. We analyzed the frequency of periprocedural critical adverse events (CAE) during tf-TAVR with CS in our institution. METHODS: Tf-TAVR has been performed at our institution since 2007. We excluded patients from the first four years to minimize the influence of any learning curve. CAE were defined as occurrence of 1.) "CPR", 2.) "defibrillation", 3.) "emergency extracorporeal circulation (ECC)" and 4.) "conversion to general anesthesia (GA) not related to 1.)-3.)". Data was prospectively collected in our AVIATOR TAVR registry. RESULTS: 601 patients were analyzed retrospectively. Overall, CAE were recorded in 54 patients (9%). CPR was necessary in 12 patients (2%) and defibrillation in 10 patients (1.6%). ECC was rarely needed (n = 2, 0.3%). Conversion to GA was necessary in 34 patients (5.65%). Procedure-related conversion was necessary in 10 patients. With 24 patients, sedation-related conversion occurred more frequently. Unrest and pain were the most common reasons for conversion (n = 13, 2%) and respiratory distress in 11 patients (2%). Catecholaminergic support was needed in 269 (45%) patients. Vasopressors were more often applied (n = 249, 41%) than inotropes (n = 59, 10%). CONCLUSION: Even in a high-volume center, CAE may occur in nearly every tenth patient. Conversion to GA was the most common CAE. Catecholaminergic support (primary vasopressor support) was needed in nearly every second patient. These points underline the necessity of a cardiac anaesthesiologist to be in the room during the procedure. SUMMARY: Despite experience, critical adverse events (CAE) still occur in TAVR patients. We analyzed the occurrence of CAE and the need for catecholaminergic support in sedated TAVR patients.


Assuntos
Estenose da Valva Aórtica/cirurgia , Sedação Consciente/efeitos adversos , Complicações Intraoperatórias/terapia , Complicações Pós-Operatórias/terapia , Substituição da Valva Aórtica Transcateter/efeitos adversos , Anestesia Geral/efeitos adversos , Estenose da Valva Aórtica/mortalidade , Valvuloplastia com Balão/efeitos adversos , Reanimação Cardiopulmonar , Cardiotônicos/uso terapêutico , Catecolaminas/uso terapêutico , Sedação Consciente/mortalidade , Circulação Extracorpórea , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/mortalidade , Masculino , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Sistema de Registros , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do Tratamento , Vasoconstritores/uso terapêutico
19.
J Am Geriatr Soc ; 66(11): 2072-2078, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30247747

RESUMO

OBJECTIVES: To quantify preoperative illness burden in older adults undergoing emergency major abdominal surgery (EMAS), to examine the association between illness burden and postoperative outcomes, and to describe end-of-life care in the year after discharge. DESIGN: Retrospective study using data from Health and Retirement Study interviews linked to Medicare claims (2000-2012). SETTING: National population-based dataset. PARTICIPANTS: Medicare beneficiaries who underwent EMAS. MEASUREMENTS: High illness burden, defined as ≥2 of the following vulnerabilities: functional dependence, dementia, use of helpers, multimorbidity, poor prognosis, high healthcare utilization. In-hospital outcomes were complications and mortality. Postdischarge outcomes included emergency department (ED) visits, hospitalization, intensive care unit (ICU) stay, and 365-day mortality. For individuals discharged alive who died within 365 days of surgery, outcomes included hospice use, hospitalization, ICU use, and ED use in the last 30 days of life. Multivariable regression was used to determine the association between illness burden and outcomes. RESULTS: Of 411 participants, 57% had high illness burden. More individuals with high illness burden had complications (45% vs 28% p=0.00) and in-hospital death (20% vs 9%, p=0.00) than those without. After discharge (n=349), individuals with high illness burden experienced more ED visits (57% vs 46%, P=.04) and were more likely to die (35% vs 13%, p=0.00). Of those who died after discharge (n=86), 75% had high illness burden, median survival was 67 days (range 21-141 days), 48% enrolled in hospice, 32% died in the hospital, 23% were in the ICU in the last 30 days of life and 37% had an ED visit in the last 30 days of life. CONCLUSION: Most older adults undergoing EMAS have preexisting high illness burden and experience high mortality and healthcare use in the year after surgery, particularly near the end of life. Concurrent surgical and palliative care may improve quality of life and end-of-life care in these people. J Am Geriatr Soc 66:2072-2078, 2018.


Assuntos
Abdome/cirurgia , Complicações Intraoperatórias/mortalidade , Mortalidade/tendências , Cuidados Paliativos/métodos , Aceitação pelo Paciente de Cuidados de Saúde , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Revisão da Utilização de Seguros/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Medicare , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos
20.
Medicine (Baltimore) ; 97(36): e12257, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30200161

RESUMO

Whether critically ill neonates needing a surgical intervention should be transferred to an operating room (OR) or receive the intervention in a neonatal intensive care unit (NICU) is controversial. In this study, we report our experience in performing surgical procedures in a NICU including air cleanliness.This was a retrospective study performed at a metropolitan hospital. The charts of all neonates undergoing surgical procedures in the NICU and OR were retrospectively reviewed from January 2007 to June 2017. Data on baseline characteristics, procedure and duration of surgery, ventilator use, hypothermia, instrument dislocations, surgery-related infections and complications, and outcomes were analyzed.Ninety-two neonates were enrolled in this study, including 44 in the NICU group and 48 in the OR group. The air cleanliness was International Organization for Standardization (ISO) 14644-1 class 7 in the NICU and class 5-6 in the OR. The NICU group had a younger gestational age and lower birth body weight than the OR group. The OR group had a higher incidence of hypothermia than in the NICU group (56.3% vs 9.1%, P < .001). However, there were no significant differences in surgical site related infections or mortality between the 2 groups.This study suggests that performing surgical procedures in a NICU with air cleanliness class 7 is as safe as in an OR, as least in part, when performing patent ductus arteriosus ligation and exploratory laparotomy.


Assuntos
Poluição do Ar em Ambientes Fechados , Unidades de Terapia Intensiva Neonatal , Procedimentos Cirúrgicos Operatórios , Poluição do Ar em Ambientes Fechados/efeitos adversos , Estado Terminal , Feminino , Humanos , Hipotermia/etiologia , Hipotermia/mortalidade , Recém-Nascido , Complicações Intraoperatórias/mortalidade , Masculino , Salas Cirúrgicas , Duração da Cirurgia , Complicações Pós-Operatórias/mortalidade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/métodos , Transporte de Pacientes , Resultado do Tratamento
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