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2.
Br J Anaesth ; 123(6): 795-807, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31623842

RESUMO

BACKGROUND: Several systematic reviews have reported the benefits of perioperative α2-adrenoceptor agonist use for various conditions, but safety evidence is poorly documented. METHODS: We performed a systematic review focusing on adverse events. We searched the MEDLINE, Embase, LILACS, Cochrane, and Clinical Trials Register databases for RCTs comparing the effects of α2-adrenoceptor agonists and placebo during non-cardiovascular surgery under general anaesthesia, for any indication, in patients not at risk of cardiovascular events. The primary outcome was the incidence of severe adverse events during or after α2-adrenoceptor agonist administration. The secondary endpoints were other adverse events. A meta-analysis was carried out on the combined data. Evidence quality was rated by the Grading of Recommendations Assessment, Development and Evaluation method. RESULTS: We included 56 studies (4868 patients). Our review, based on moderate-quality evidence, revealed that hypotension occurred frequently during the preoperative and postoperative periods, for both clonidine and dexmedetomidine. Bradycardia was reported only with dexmedetomidine. In contrast, dexmedetomidine seemed to protect against intraoperative hypertension and tachycardia. Subgroup analysis suggested that the risk of hypotension and bradycardia persisted after cessation of treatment. Interestingly, intraoperative hypotension and postoperative bradycardia were not observed with a bolus dosage of dexmedetomidine less than 0.5 µg kg-1 or with continuous administration alone. CONCLUSIONS: Pooled data for the incidence of adverse events associated with use of α2-adrenoceptor agonists in various perioperative contexts provide high-confidence evidence for a risk of hypotension and bradycardia, and protective effects against hypertension and tachycardia. PROTOCOL REGISTRATION: CRD42017071583.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/efeitos adversos , Clonidina/efeitos adversos , Dexmedetomidina/efeitos adversos , Complicações Intraoperatórias/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Bradicardia/induzido quimicamente , Humanos , Hipotensão/induzido quimicamente , Período Pré-Operatório , Taquicardia/induzido quimicamente
3.
Bone Joint J ; 101-B(9): 1093-1099, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31474134

RESUMO

AIMS: Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA. PATIENTS AND METHODS: A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS). RESULTS: TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA. CONCLUSION: For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.


Assuntos
Ácido Aminocaproico/administração & dosagem , Antifibrinolíticos/administração & dosagem , Artroplastia de Substituição/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Hemorragia Pós-Operatória/prevenção & controle , Ácido Tranexâmico/administração & dosagem , Administração Intravenosa , Idoso , Ácido Aminocaproico/uso terapêutico , Antifibrinolíticos/uso terapêutico , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Transfusão de Sangue , Feminino , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/etiologia , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/terapia , Estudos Prospectivos , Ácido Tranexâmico/uso terapêutico
4.
Anticancer Res ; 39(8): 4549-4554, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31366558

RESUMO

BACKGROUND/AIM: The aim of this study was to investigate the effects of preoperative chemotherapy on the healthy, metastasis-free part of the liver in colorectal cancer patients with liver metastasis, and the relationship between chemotherapy and postoperative complications. PATIENTS AND METHODS: Our study included 90 cases of colorectal cancer liver metastasis resected after preoperative chemotherapy. The patients were divided into three groups according to the received chemotherapy regimen: 20 cases received mFOLFOX6, 54 cases a combination of mFOLFOX6 with bevacizumab, and 16 cases a combination of mFOLFOX6 and cetuximab or panitumumab. RESULTS: The mean numbers of sinusoidal injuries for each chemotherapy type were compared. The group treated with the combination of mFOLFOX6 and bevacizumab showed a lower extent of sinusoidal injury relative to other groups; this intergroup difference became increasingly remarkable as the number of chemotherapy cycles increased. Complications of various extents were found in all three groups, but no significant differences were observed between the three groups. CONCLUSION: In cases where preoperative chemotherapy was extended over a long period, combined use of bevacizumab was thought to be effective because of stabilization of disturbed liver hemodynamics resulting from sinusoidal injury suppression effects, allowing effective distribution of anti-cancer agents to tumors.


Assuntos
Neoplasias Colorretais/tratamento farmacológico , Hepatopatia Veno-Oclusiva/cirurgia , Neoplasias Hepáticas/tratamento farmacológico , Complicações Pós-Operatórias/cirurgia , Adulto , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/administração & dosagem , Bevacizumab/administração & dosagem , Neoplasias Colorretais/complicações , Neoplasias Colorretais/patologia , Neoplasias Colorretais/cirurgia , Intervalo Livre de Doença , Feminino , Fluoruracila/administração & dosagem , Hepatectomia , Hepatopatia Veno-Oclusiva/induzido quimicamente , Hepatopatia Veno-Oclusiva/patologia , Humanos , Leucovorina/administração & dosagem , Neoplasias Hepáticas/complicações , Neoplasias Hepáticas/patologia , Neoplasias Hepáticas/secundário , Masculino , Pessoa de Meia-Idade , Metástase Neoplásica , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/patologia , Período Pré-Operatório
5.
Transplant Proc ; 51(6): 1962-1971, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303410

RESUMO

BACKGROUND: The impact of immunosuppressive drugs in patients following liver transplantation (LT) is very individual. Despite the multiple beneficial effects of the mammalian target of rapamycin (mTOR) inhibitor everolimus (EVR) in LT recipients, some patients do not benefit from EVR administration. We investigated whether the presence of common single-nucleotide polymorphisms (SNPs) in the mTOR gene are predictive for adverse events following the introduction of EVR after LT. MATERIALS AND METHODS: The feasibility and efficacy of EVR in 127 liver transplant recipients who were converted to EVR-based immunosuppression was documented retrospectively. Blood samples of these patients were analyzed for the occurrence of 4 SNPs in the mTOR promoter region (mTOR3099/rs2295079 C>G, mTOR3162/rs2295080 A>C) and the mTOR 3' untranslated regio (mTOR8167/rs12139042 C>T, mTOR8600/rs2536 A>G); the specific allele variants were also associated with the incidence of adverse events (AEs). RESULTS: Of all patients, 21 (16.5%) did not tolerate the medication and had to discontinue. Of those patients who continued, 37% developed signs of reduced tolerance within the first 6 months, resolving after 12 months. When the cohort was divided according to genotype and allele frequency, patients with the mTOR3162/rs2295080 CC variant had a significantly higher risk (odds ratio = 5.89; 95% confidence interval = 1.48-23.40; P = .012) of developing new-onset diabetes mellitus following EVR treatment than AA or AC genotype carriers. CONCLUSION: Our results suggest that the SNP mTOR3162/rs2295080 CC genotype is associated with the development of new-onset diabetes mellitus following EVR treatment.


Assuntos
Diabetes Mellitus/induzido quimicamente , Everolimo/efeitos adversos , Imunossupressores/efeitos adversos , Transplante de Fígado/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Serina-Treonina Quinases TOR/genética , Diabetes Mellitus/genética , Feminino , Humanos , Imunossupressão/efeitos adversos , Imunossupressão/métodos , Masculino , Pessoa de Meia-Idade , Polimorfismo de Nucleotídeo Único , Complicações Pós-Operatórias/genética , Estudos Retrospectivos
6.
A A Pract ; 12(11): 385-387, 2019 Jun 03.
Artigo em Inglês | MEDLINE | ID: mdl-31162162

RESUMO

Acute angle-closure glaucoma is a rare complication of general anesthesia. If not treated in time, acute angle-closure glaucoma can potentially cause permanent loss of vision. Physicians should therefore be vigilant for the possibility of acute angle-closure glaucoma in patients who experience postoperative change or loss of vision. Recently, some reported a case of bilateral acute angle-closure glaucoma after general anesthesia, in which the use of ephedrine was a possible trigger. This report begins by examining a case of unilateral acute angle-closure glaucoma. The potential triggers of this complication are discussed. This article concludes with a flowchart to aid anesthesiologists to accurately diagnose postoperative ophthalmic pathology.


Assuntos
Efedrina/efeitos adversos , Glaucoma de Ângulo Fechado/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Adulto , Anestesia Geral/efeitos adversos , Feminino , Humanos , Histerectomia Vaginal , Prolapso Uterino/cirurgia
7.
Carbohydr Polym ; 216: 213-216, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31047059

RESUMO

Oxidized regenerated cellulose has become a major local surgical hemostatic biomaterial because of its ease of use, favorable biocompatibility, bactericidal activity and bioabsorption characteristics. Additional clinical indications of oxidized regenerated cellulose include wound repair and tissue reconstruction. Sometimes, some unusual adverse events are described. Studies report cases of minor postoperative complications as nidus of infection or allergic reaction mainly presenting as acute dermatitis, eczema and sieroma. Also, rare and serious cases of foreign body reaction or impingement on nerve, due to not optimal bioabsorption, are showed in various surgical sites. Thus, on the one hand, patients should be informed by their clinicians of the possibility of these low incidence postoperative complications when considering preparations made of cellulose derivatives; and the clinicians should clearly indicate use of this biomaterial in the surgical procedure report so that radiologists may appropriately interpret any unusual findings potentially associated with this biomaterial use and thus avoid misdiagnosis and undue alarm in the follow-up of patients. On the other hand, the biomedical carbohydrate scientist must consider effective experimental design that substantially addresses the clinical adverse events associated with carbohydrate polymer use. Optimal development of carbohydrates for clinical use depends on excellent clinician/biomedical scientist communication.


Assuntos
Plásticos Biodegradáveis/efeitos adversos , Celulose Oxidada/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Quitosana/efeitos adversos , Hemostáticos/efeitos adversos , Humanos , Hipersensibilidade , Tecidos Suporte/efeitos adversos
8.
Medicine (Baltimore) ; 98(18): e15383, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31045788

RESUMO

BACKGROUND: Neuroprotective effects of dexmedetomidine are reported in preclinical and clinical studies but evidence regarding the postoperative neurocognitive function is still unclear. This study performed a meta-analysis on outcomes of studies which examined neurocognitive performance and inflammatory factors to investigate the effects of dexmedetomidine on postoperative cognitive dysfunction (POCD) and inflammation in patients after general anaesthesia. METHODS: Literatures were searched in several electronic databases and studies were selected by following precise inclusion criteria. We searched PubMed, EMBASE, the Cochrane Library, China Academic Journals full-text database (CNKI), and Google Scholar to find randomized controlled trials (RCTs) of the influence of dexmedetomidine on POCD and inflammation in patients who had undergone general anaesthesia. Two researchers independently screened the literature, extracted data, and evaluated quality of methodology against inclusion and exclusion criteria. Meta-analyses of pooled ORs of POCD incidences and mean differences in neurocognitive assessment scores and inflammation levels were carried out and subgroup analyses were performed. Stata 12.0 was used to conduct our meta-analysis. RESULTS: Twenty-six RCTs were included. Compared with controls, perioperative dexmedetomidine treatment significantly reduced the incidence of POCD (pooled ORs = 0.59, 95% confidence interval (CI) 0.45-2.95) and improved Mini-Mental State Examination (MMSE) score (standardized mean difference (SMD) = 1.74, 95% CI 0.43-3.05) on the first postoperative day. Furthermore, perioperative dexmedetomidine treatment significantly decreased IL-6 (SMD = -1.31, 95% CI -1.87-0.75, P < .001) and TNF-α (SMD = -2.14, 95% CI -3.14-1.14, P < .001) compared to saline/comparators treatment. In the stratified analysis by surgical type, age, type of control, and study region, the differences were also significant between dexmedetomidine- and saline-treated patients. CONCLUSION: Perioperative dexmedetomidine treatment is associated with significantly reduced incidence of POCD and inflammation and better neurocognitive function postoperatively in comparison with both saline controls and comparator anaesthetics.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Anestesia Geral/efeitos adversos , Disfunção Cognitiva/induzido quimicamente , Disfunção Cognitiva/prevenção & controle , Dexmedetomidina/administração & dosagem , China , Humanos , Inflamação/tratamento farmacológico , Mediadores da Inflamação/metabolismo , Interleucina-6/biossíntese , Testes de Estado Mental e Demência , Razão de Chances , Período Perioperatório , Complicações Pós-Operatórias/induzido quimicamente , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Fator de Necrose Tumoral alfa/biossíntese
9.
Br J Anaesth ; 123(1): 27-36, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31060732

RESUMO

BACKGROUND: Perioperative diabetic ketoacidosis (DKA) with near-normal blood glucose concentrations, termed euglycaemic ketoacidosis (EDKA), is an adverse effect associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i). Guidelines are still evolving concerning the perioperative management of patients on SGLT2i. We performed a systematic review of published reports of DKA from SGLT2i in the surgical setting to understand better the clinical presentation and characteristics of SGLT2i-associated DKA. METHODS: We searched PubMed, Embase, and ProQuest for reports of perioperative DKA involving SGLT2i up to January 2019. RESULTS: Forty-two reports of EDKA and five cases of hyperglycaemic diabetic ketoacidosis (HDKA) were identified from 33 publications. Canagliflozin was implicated in 26 cases. Presentation time varied from a few hours up to 6 weeks after operation. Precipitating factors may include diabetes medication changes, diet modifications, and intercurrent illnesses. There were 13 cases (12 EDKA and one HDKA) of bariatric surgery, 10 of them noted very-low-calorie diet regimes as a precipitating factor. No precise association between interruption of SGLT2i and the occurrence of DKA could be identified. Seven patients required mechanical ventilation, and acute kidney injury was noted in five. Five cases needed imaging to rule out anastomotic leak and pulmonary embolism, all of them revealed negative findings. Outcome data were available in 32 cases, all of them recovered completely. CONCLUSIONS: EDKA is likely to be under-recognised because of its atypical presentation and may delay the diagnosis. Understanding this clinical entity, vigilance towards monitoring plasma/capillary ketones helps in early identification and assists in the management.


Assuntos
Cetoacidose Diabética/sangue , Cetoacidose Diabética/induzido quimicamente , Complicações Intraoperatórias/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversos , Cetoacidose Diabética/diagnóstico , Humanos , Complicações Intraoperatórias/sangue , Complicações Intraoperatórias/diagnóstico , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/diagnóstico
10.
Curr Med Sci ; 39(2): 325-329, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31016529

RESUMO

Despite growing attention to patients' safety worldwide, no data were available on the impact of adverse respiratory events (AREs) on post-anesthesia care and post-operation care in China. This study evaluated the occurrence of AREs, the impact of AREs on length of stay (LOS) in post-anesthesia care unit (PACU) and postoperative time in hospital, and PACU cost and inpatient healthcare costs. A retrospective, matched-cohort study was conducted by prospectively collecting the data of 159 AREs in PACU during 2016-2017 in an university hospital in China. Records were reviewed by pre-trained, qualified nurses and/or anesthesiologists. The incidence and the impact of AREs were analyzed. The LOS in PACU and postoperative time in hospital and the costs in PACU and inpatient healthcare costs were also obtained. Results showed that there were 253 AREs involving 156 patients. Hypoxia (n=141, 55.73%) and respiratory depression (n=70, 27.67%) were the most common AREs. Measurement data including body mass index (BMI) (22.85±4.36 vs. 22.32±3.83), duration of procedure (138.47±77.33 min vs. 137.44±72.33 min), duration of anesthesia (176.35±82.66 min vs. 174.61±78.08 min), LOS (16.53±10.65 days vs. 16.57±9.56 days), inpatient healthcare costs ($9465.57±9416.33 vs. $8166.51±5762.01), and postoperative LOS (11.26±8.77 days vs. 11.19±8.30 days) showed no significant differences between ARE and matched groups (P>0.05). Duration (81.65±54.79 min vs. 38.89±26.09 min) and costs ($31.99±17.80 vs. $18.72±8.39) in PACU were significantly different in ARE group from those in matched group (P<0.001). Proportion of patients with prolonged stay in PACU was significantly higher in ARE group than in matched group (18.59% vs. 1.28%), with an odds ratio (after matching) of 17.58 (95% CI=4.11 to 75.10; P<0.001). The AREs that occurred during the immediate postoperative period in PACU increased the incidence rate of prolonged stay, delayed the PACU stay, and increased the costs in PACU, resulting in the need of higher levels of postoperative care than anticipated, but the postoperative LOS and inpatient healthcare costs were unchanged.


Assuntos
Anestesia/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Transtornos Respiratórios/induzido quimicamente , Adolescente , Criança , Pré-Escolar , China , Feminino , Humanos , Hipóxia/induzido quimicamente , Lactente , Recém-Nascido , Pacientes Internados , Tempo de Internação , Masculino , Estudos Retrospectivos
11.
Br J Anaesth ; 123(1): e135-e143, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30954238

RESUMO

BACKGROUND: Neuromuscular blocking agents (NMBAs) remain the leading cause of perioperative anaphylaxis in Australia. Standard evaluation comprises history, skin tests, and in vitro specific immunoglobulin E tests. Drug provocation tests to suspected NMBA culprits are associated with a significant risk. Basophil activation testing (BAT) is a potentially useful in vitro test that is not commercially available in Australia or as part of standard evaluation. METHODS: All patients attending the Anaesthetic Allergy Clinic in Sydney, Australia between May 2017 and July 2018 exposed to an NMBA before the onset of anaphylaxis during their anaesthetic qualified for the study. We recruited 120 patients sequentially who received standard evaluation plus BAT using CD63, CD203c, and CD300a as surface activation markers. RESULTS: BAT results were expressed as % upregulation above the negative control and stimulation index (mean fluorescence index of stimulated sample divided by the negative control). We calculated cut-offs of 4.45% and 1.44 for CD63, and 8.80% and 1.49 for CD203c, respectively. Sensitivity was 77% with specificity of 76%. A subgroup of 10 patients with NMBA anaphylaxis had no sensitisation on skin tests. BAT using CD63 and CD203c showed sensitisation in six of these 10, and adding CD300a identified sensitisation in nine patients. BAT was positive in seven of nine patients with anaphylaxis of unknown aetiology. CONCLUSIONS: BAT may be a useful supplement to the standard evaluation in diagnosing NMBA anaphylaxis in patients with suggestive histories, but no sensitisation on skin tests. Ongoing study of this specific group of patients is required to clarify its utility in clinical practice.


Assuntos
Anafilaxia/diagnóstico , Basófilos/imunologia , Hipersensibilidade a Drogas/diagnóstico , Complicações Intraoperatórias/induzido quimicamente , Bloqueadores Neuromusculares/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Adolescente , Adulto , Idoso , Anafilaxia/imunologia , Austrália , Hipersensibilidade a Drogas/imunologia , Feminino , Humanos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/imunologia , Masculino , Pessoa de Meia-Idade , Bloqueadores Neuromusculares/imunologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/imunologia , Sensibilidade e Especificidade , Adulto Jovem
12.
Br J Anaesth ; 122(6): e180-e188, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30982564

RESUMO

BACKGROUND: Fentanyl is one of the most frequently administered intraoperative drugs and may increase the risk of postoperative respiratory complications (PRCs). METHODS: We performed a pre-specified analysis of 145 735 adult non-cardiac surgical cases under general anaesthesia. Using multivariable logistic regression, we evaluated the association of intraoperative fentanyl dose and PRCs within 3 days after surgery (defined as reintubation, respiratory failure, pneumonia, pulmonary oedema, or atelectasis). We examined effect modification by patient characteristics, surgical site, and anaesthetics used. RESULTS: PRCs within 3 days after surgery occurred in 18 839 (12.9%) patients. In comparison with high intraoperative fentanyl doses [median: 3.85; inter-quartile range (IQR): 3.42-4.50 µg kg-1, quartile 4 (Q4)], low intraoperative fentanyl dose [median: 0.80, IQR: 0.00-1.14 µg kg-1, quartile 1 (Q1)] was significantly associated with lower odds of PRCs [Q1 vs Q4: 10.9% vs 16.2%; adjusted odds ratio (aOR) 0.79; 95% confidence intervals (CI) 0.75-0.84; P<0.001; adjusted absolute risk difference (aARD) -1.7%]. This effect was augmented by thoracic surgery (P for interaction <0.001; aARD -6.2%), high doses of inhalation anaesthetics (P for interaction=0.016; aARD -2.2%) and neuromuscular blocking agents (NMBAs) (P for interaction=0.001; aARD -3.4%). Exploratory analysis demonstrated that compared with no fentanyl, low-dose fentanyl was associated with lower rates of PRCs (decile 2 vs decile 1: aOR 0.82, CI 0.75-0.89, P<0.001). CONCLUSIONS: Intraoperative low-dose fentanyl (about 60-120 µg for a 70 kg patient) was associated with lower risk of postoperative respiratory complications compared with both no fentanyl and high-dose fentanyl. Beneficial effects of low-dose fentanyl were magnified in specific patient subgroups. CLINICAL TRIAL REGISTRATION: NCT03198208.


Assuntos
Analgésicos Opioides/administração & dosagem , Fentanila/administração & dosagem , Complicações Pós-Operatórias/prevenção & controle , Transtornos Respiratórios/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos Opioides/efeitos adversos , Anestesia Geral/métodos , Relação Dose-Resposta a Droga , Feminino , Fentanila/efeitos adversos , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/induzido quimicamente , Sistema de Registros , Transtornos Respiratórios/induzido quimicamente , Estudos Retrospectivos , Adulto Jovem
14.
Ann Surg Oncol ; 26(6): 1712-1719, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30863940

RESUMO

BACKGROUND: Angiotensin receptor blocker (ARB), a commonly used antihypertensive drug, is reported to affect wound healing and flap survival in animal models. However, this has not been elucidated in a clinical series. This study aimed to investigate the impact that perioperative use of ARB has on outcomes after breast reconstruction. METHODS: Patients who underwent immediate breast reconstruction using a tissue expander or a deep inferior epigastric perforator (DIEP) flap were reviewed. The patients were categorized according to the types of antihypertensive medications as follows: the ARB group consisted of hypertensive patients treated with ARB alone or a combination of ARB and other drugs; the non-ARB group included those receiving drugs other than ARB; and the control group did not receive any medication. The effects of antihypertensive drugs on the development of complications were evaluated. RESULTS: The study analyzed 1390 cases including 999 cases of tissue-expander insertion and 391 cases of DIEP flap reconstruction. With regard to tissue-expander reconstruction, the rates of seroma, reoperation, reconstruction failure, and overall complications were significantly higher in the ARB group than in the other two groups. Compared with no medication, ARB use was an independent risk factor for these complications. With regard to DIEP flap reconstruction, the ARB group showed a significantly higher rate of fat necrosis and significantly greater odds for the development of overall perfusion-related complications and fat necrosis than the control group after adjustment for other variables. CONCLUSIONS: Perioperative administration of ARB might be associated with adverse outcomes after breast reconstruction.


Assuntos
Anti-Hipertensivos/efeitos adversos , Neoplasias da Mama/cirurgia , Mamoplastia/métodos , Mastectomia/métodos , Complicações Pós-Operatórias/induzido quimicamente , Seroma/induzido quimicamente , Adulto , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/patologia , Necrose Gordurosa , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Retalho Perfurante , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Dispositivos para Expansão de Tecidos
15.
J Bone Joint Surg Am ; 101(5): 384-391, 2019 Mar 06.
Artigo em Inglês | MEDLINE | ID: mdl-30845032

RESUMO

BACKGROUND: Preoperative opioid use results in adverse outcomes and higher costs after elective surgery. However, duration thresholds for higher risk are not entirely known. Therefore, the purpose of our study was to determine the number and duration of preoperative opioid prescriptions in order to estimate the risk of postoperative adverse events after major joint replacement and lumbar fusion. METHODS: National insurance claims data (2007 to September 30, 2015) were used to identify primary total knee arthroplasties (TKAs), total hip arthroplasties (THAs), and 1 or 2-level posterior lumbar fusions (PLFs) performed for degenerative disease. The effect of preoperative opioid burden (naive, ≤3 months, >3 to 6 months, >6 months but stopped 3 months before surgery, and >6 months of continuous use) on the risks of various adverse outcomes was studied using Cox proportional hazards analysis with adjustment for demographic and clinical covariates. RESULTS: A total of 58,082 patients stratified into 3 cohorts of 32,667 with TKA, 14,734 with THA, and 10,681 with 1 or 2-level PLF were included for this analysis. A duration of preoperative opioids of >3 months was associated with a higher risk of 90-day emergency department (ED) visits for all causes and readmission after TKA. Preoperative opioid prescription for >6 months was associated with a higher risk of all-cause and pain-related ED visits, wound dehiscence/infection, and hospital readmission within 90 days as well as revision surgery within 1 year after TKA, THA, and PLF. Stopping the opioid prescription 3 months preoperatively for chronic users resulted in a significant reduction in the risk of adverse outcomes, with the greatest impact seen after THA and PLF. CONCLUSIONS: Patients with a preoperative opioid prescription for up to 3 months before a major arthroplasty or a 1 or 2-level lumbar fusion had a similar risk of adverse outcomes as opioid-naive patients. While >6 months of opioid use was associated with a higher risk of adverse outcomes, a 3-month prescription-free period before the surgery appeared to mitigate this risk for chronic users. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.


Assuntos
Analgésicos Opioides/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Artroplastia do Joelho/efeitos adversos , Fusão Vertebral/efeitos adversos , Acidentes por Quedas/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/induzido quimicamente , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/induzido quimicamente , Cuidados Pré-Operatórios/estatística & dados numéricos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Sepse/induzido quimicamente , Deiscência da Ferida Operatória/induzido quimicamente , Infecção da Ferida Cirúrgica/induzido quimicamente , Fatores de Tempo , Trombose Venosa/induzido quimicamente
16.
Anaesthesia ; 74(7): 929-939, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30821852

RESUMO

In the peri-operative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting. The objective of this meta-analysis was to assess the adverse effects of an incidental steroid load of dexamethasone in adult surgical patients. We searched in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials and the Web of Science for randomised controlled trials comparing an incidental steroid load of dexamethasone with a control intervention in adult patients undergoing surgery. Two review authors independently screened studies for eligibility, extracted data and assessed all included studies for bias. Our primary outcomes were postoperative systemic or wound infection, delayed wound healing and glycaemic response within 24 h. We included 37 studies in this meta-analysis. The pooled results found no evidence that dexamethasone increased the risk of a postoperative wound infection, Peto OR (95%CI) 1.01 (0.80-1.27); 4603 participants, 26 studies; I² = 32%; moderate-quality evidence. Whether dexamethasone influenced wound healing was unclear due to the large confidence intervals, Peto OR (95%CI) 0.99 (0.28-3.43); 1072 participants, 8 studies; I² = 0%; low-quality evidence. Dexamethasone produced a mild increase in glucose levels among participants without diabetes during the first 12 h after surgery, mean difference (95%CI) 0.7 mmol.l-1 (0.3-1.2) 10 studies; 595 participants; I² = 50%; low-quality evidence. This article is an abridged version of a Cochrane Review.


Assuntos
Dexametasona/efeitos adversos , Glucocorticoides/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Humanos
17.
Dtsch Med Wochenschr ; 144(2): 109-113, 2019 01.
Artigo em Alemão | MEDLINE | ID: mdl-30674059

RESUMO

HISTORY AND CLINICAL FINDING: A 76-year-old patient suffered a non-ST-elevation myocardial infarction (NSTEMI) and was admitted to our Chest Pain Unit (CPU) for further diagnostics and therapy. EXAMINATIONS AND DIAGNOSIS: Coronary angiography revealed an occlusion of the right coronary artery and catheter intervention with stent implantation was performed. Due to a high thrombotic burden, application of tirofiban was initiated. In the following, the patient developed hemodynamic instability, hemoptysis and a substantial decrease of the platelet count. THERAPY AND COURSE: Tirofiban therapy was immediately stopped. Volume therapy led to hemodynamic stabilisationand hemoptysisdisappeared. Thrombocytes normalised after application of a platelet concentrate and prednisolone. One day later, the patient developed pulmonary hemorrhage with asphyxial cardiac arrest.Within the next few days, a renewed decrease of thrombocytes occurred. Despite normalization of thrombocytes after another transfusion, the patient died in consequence of a severe sepsis. CONCLUSIONS: Thrombocytopenia is a rare but potentially severe complication of tirofiban therapy. Therapeutic strategies include termination of the triggering medication, clarification of differential diagnoses and transfusion of platelet concentrates, if necessary.


Assuntos
Intervenção Coronária Percutânea/efeitos adversos , Complicações Pós-Operatórias/induzido quimicamente , Trombocitopenia/induzido quimicamente , Microangiopatias Trombóticas/induzido quimicamente , Tirofibana/efeitos adversos , Idoso , Evolução Fatal , Humanos , Masculino
18.
BMJ Case Rep ; 11(1)2018 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-30567238

RESUMO

Post-transplant lymphoproliferative disorder (PTLD) is a recognised complication of solid and haematopoietic stem cell transplant. It consists of a heterogeneous group of lymphoid neoplasms that arises secondary to post-transplant immunosuppression. Although there is no definite standard of care for the optimal treatment for PTLD, rituximab, a monoclonal antibody, with and/or without chemotherapy (usually CHOP=cytoxan, doxorubicin, vincristine, prednisone) has become a routine part of the treatment of any CD20 (+) PTLD, with response rates similar to chemotherapy with decreased toxicity. A rare and often lethal, complication of rituximab therapy for PTLD is bowel perforation secondary to tumour lysis of lymphoma involving the intestine. A small number of cases of bowel perforation have been reported, with very few documented survivors. The risk for recurrent perforation in the setting of ongoing rituximab treatment is unknown. There is sparse data supporting how to best treat the survivors.


Assuntos
Fatores Imunológicos/efeitos adversos , Perfuração Intestinal/induzido quimicamente , Transtornos Linfoproliferativos/tratamento farmacológico , Complicações Pós-Operatórias/induzido quimicamente , Rituximab/efeitos adversos , Feminino , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Humanos , Imunossupressão/efeitos adversos , Transtornos Linfoproliferativos/etiologia , Pessoa de Meia-Idade , Período Pós-Operatório
19.
Transplant Proc ; 50(7): 2176-2178, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30177132

RESUMO

INTRODUCTION: Patients subjected to long-term immunosuppressive therapy after organ and cells transplantation are more susceptible than healthy people to the development of the pathologic changes in the oral cavity, including precancerous lesions, oral cancers, lesions following viral infections (herpes simplex virus, Epstein-Barr virus, and cytomegalovirus), fungal infections mainly caused by Candida albicans, drug-induced gingival overgrowth, stomatitis, and tongue disorders. MATERIAL AND METHODS: Clinical case material included 38 patients after kidney, liver, or blood-forming cells transplantation subjected to various immunosuppressive therapy schemes. The study comprised standard case taking and physical examination of the patient, including detailed intraoral and extraoral stomatological examinations. RESULTS: Extraoral examination confirmed 1 case of multifocal basal cell carcinoma in the auricular region and one case of systemic lupus erythematosus. Intraoral examination revealed gingivitis (60.5%), gingival recession (58%), periodontitis (55.26%), macroglossia (15.8%), lingual papillary atrophy (13.16%), leukoplakia aphthae/ulcerations (10.5%), lichen planus, pallor of mucous membranes (7.9%), pathologic pigmentation of oral mucosa, geographic tongue (5.26%) and erythroplakia (2.6%). When their histories were taken, patients reported xerostomia (68.42%), halitosis (23.68%), gum bleeding while brushing teeth (18.42%), and dysgeusia (15.78%). DISCUSSION: Both the patients after organ and hematopoietic stem cells transplantations and those qualified for a transplant should undergo multispecialty treatment, particularly dental treatment, to enable the detection of pathologies at an early stage and commencement of effective therapy. Cooperation between the main doctor and the dentist is crucial in the process of treatment of this group of patients.


Assuntos
Imunossupressão/efeitos adversos , Imunossupressores/efeitos adversos , Doenças da Boca/induzido quimicamente , Boca/patologia , Complicações Pós-Operatórias/induzido quimicamente , Adulto , Candida albicans , Citomegalovirus , Feminino , Transplante de Células-Tronco Hematopoéticas , Humanos , Imunossupressão/métodos , Imunossupressores/administração & dosagem , Transplante de Rim , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Boca/efeitos dos fármacos , Boca/microbiologia , Doenças da Boca/microbiologia , Doenças da Boca/patologia , Complicações Pós-Operatórias/microbiologia , Complicações Pós-Operatórias/patologia , Período Pós-Operatório , Fatores de Tempo
20.
Medicine (Baltimore) ; 97(34): e12029, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30142853

RESUMO

RATIONALE: Drug-induced angioedema has been reported as an adverse effect of many different drugs. But small bowel angioedema associated with sirolimus (SRL) used was barely understood. It must be necessary to report a case suffering from small bowel angioedema with detailed discussion and literature review. PATIENT CONCERNS: A 38-year-old Chinese woman presented with generalized gastric pain in the following day after renal transplantation. The patient began to crampy abdominal pain accompanied by nausea, vomiting, and diarrhea on postoperative day 6 (POD). DIAGNOSES: We strongly suspected the angioedema was an adverse reaction to SRL. INTERVENTION: The immunosuppressive regimen was switched from tacrolimus (TAC), SRL, and prednisone to TAC, mycophenolate and prednisone. OUTCOMES: The symptoms were relieved within next 48 hours after withdrawing the SRL. One more CT scan showed complete resolution of bowel wall thickening and ascites. LESSONS: This was the first report of small bowel angioedema associated with SRL. Drug-induced-angioedema is a relatively common presentation and is potentially fatal. It must be aware of potential adverse effects.


Assuntos
Angioedema/induzido quimicamente , Imunossupressores/efeitos adversos , Enteropatias/induzido quimicamente , Complicações Pós-Operatórias/induzido quimicamente , Sirolimo/efeitos adversos , Adulto , Feminino , Humanos , Intestino Delgado/efeitos dos fármacos , Transplante de Rim/efeitos adversos
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