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1.
Radiol Oncol ; 55(3): 333-340, 2021 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-33991470

RESUMO

BACKGROUND: Breast intraoperative electron radiation therapy (B-IOERT) can be used in clinical practice both as elective irradiation (partial breast irradiation - APBI) in low risk breast cancer patients, and as an anticipated boost. The procedure generally includes the use of a shielding disk between the residual breast and the pectoralis fascia for the protection of the tissues underneath the target volume. The aim of the study was to evaluate the role of intraoperative ultrasound (IOUS) in improving the quality of B-IOERT. PATIENTS AND METHODS: B-IOERT was introduced in Trieste in 2012 and its technique was improved in 2014 with IOUS. Both, needle and IOUS were used to measure target thickness and the latter was used even to check the correct position of the shielding disk. The primary endpoint of the study was the evaluation of the effectiveness of IOUS in reducing the risk of a disk misalignment related to B-IOERT and the secondary endpoint was the analysis of acute and late toxicity, by comparing two groups of patients treated with IOERT as a boost, either measured with IOUS and needle (Group 1) or with needle alone (Group 2). Acute and late toxicity were evaluated by validated scoring systems. RESULTS: From the institutional patients who were treated between June 2012 and October 2019, 109 were eligible for this study (corresponding to 110 cases, as one patients underwent bilateral conservative surgery and bilateral B-IOERT). Of these, 38 were allocated to group 1 and 72 to group 2. The target thickness measured with the IOUS probe and with the needle were similar (mean difference of 0.1 mm, p = 0.38). The percentage of patients in which the shield was perfectly aligned after IOUS introduction increased from 23% to more than 70%. Moreover, patients treated after IOUS guidance had less acute toxicity (36.8% vs. 48.6%, p = 0.33) from radiation therapy, which reached no statistical significance. Late toxicity turned out to be similar regardless of the use of IOUS guidance: 39.5% vs. 37.5% (p = 0.99). CONCLUSIONS: IOUS showed to be accurate in measuring the target depth and decrease the misalignment between collimator and disk. Furthermore there was an absolute decrease in acute toxicity, even though not statistically significant, in the group of women who underwent B-IOERT with IOUS guidance.


Assuntos
Neoplasias da Mama/radioterapia , Cuidados Intraoperatórios/métodos , Lesões por Radiação/prevenção & controle , Proteção Radiológica/instrumentação , Ultrassonografia de Intervenção/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/diagnóstico por imagem , Neoplasias da Mama/cirurgia , Elétrons/uso terapêutico , Feminino , Dosimetria Fotográfica/métodos , Humanos , Cuidados Intraoperatórios/instrumentação , Pessoa de Meia-Idade , Estudos Retrospectivos
2.
Anesth Analg ; 133(1): 233-242, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33939649

RESUMO

BACKGROUND: Surgical patients are vulnerable to opioid dependency and related risks. Clinical-translational data suggest that caffeine may enhance postoperative analgesia. This trial tested the hypothesis that intraoperative caffeine would reduce postoperative opioid consumption. The secondary objective was to assess whether caffeine improves neuropsychological recovery postoperatively. METHODS: This was a single-center, randomized, placebo-controlled trial. Participants, clinicians, research teams, and data analysts were all blinded to the intervention. Adult (≥18 years old) surgical patients (n = 65) presenting for laparoscopic colorectal and gastrointestinal surgery were randomized to an intravenous caffeine citrate infusion (200 mg) or dextrose 5% in water (40 mL) during surgical closure. The primary outcome was cumulative opioid consumption through postoperative day 3. Secondary outcomes included subjective pain reporting, observer-reported pain, delirium, Trail Making Test performance, depression and anxiety screens, and affect scores. Adverse events were reported, and hemodynamic profiles were also compared between the groups. RESULTS: Sixty patients were included in the final analysis, with 30 randomized to each group. The median (interquartile range) cumulative opioid consumption (oral morphine equivalents, milligrams) was 77 mg (33-182 mg) for caffeine and 51 mg (15-117 mg) for placebo (estimated difference, 55 mg; 95% confidence interval [CI], -9 to 118; P = .092). After post hoc adjustment for baseline imbalances, caffeine was associated with increased opioid consumption (87 mg; 95% CI, 26-148; P = .005). There were otherwise no differences in prespecified pain or neuropsychological outcomes between the groups. No major adverse events were reported in relation to caffeine, and no major hemodynamic perturbations were observed with caffeine administration. CONCLUSIONS: Caffeine appears unlikely to reduce early postoperative opioid consumption. Caffeine otherwise appears well tolerated during anesthetic emergence.


Assuntos
Analgésicos Opioides/administração & dosagem , Cafeína/administração & dosagem , Cuidados Intraoperatórios/métodos , Laparoscopia/efeitos adversos , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/prevenção & controle , Adulto , Idoso , Estimulantes do Sistema Nervoso Central/administração & dosagem , Método Duplo-Cego , Feminino , Humanos , Laparoscopia/tendências , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Dor Pós-Operatória/diagnóstico , Resultado do Tratamento
3.
Anesth Analg ; 132(6): 1563-1575, 2021 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-34032660

RESUMO

Intraoperative handoffs between anesthesia clinicians are critical for care continuity. However, such handoffs pose a significant threat to patient safety. This systematic review synthesizes the empirical evidence on the (a) effect of intraoperative handoffs on outcomes and (b) effect of intraoperative handoff tools on outcomes. All studies on intraoperative handoffs and handoff tools published until September 2019, in any study setting and population, and with no prespecified criteria on the type of comparison and outcome were included. Data extracted from the included studies were aggregated to identify common patterns related to the type of surgery, clinician(s) involved, patient population, handoff tool, the tool design approach (where relevant), tool implementation strategies, and finally, all reported clinical and process outcomes. Quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). Fourteen studies met the inclusion criteria. All included studies used adult patients. Eight studies were retrospective cohort studies that used administrative or electronic health record (EHR)-based databases to investigate the effects of intraoperative handoffs on morbidity and mortality. These studies included a total of 680,855 surgeries, with 139,426 of these surgeries having at least 1 handoff (20.47%). Seven of the studies found a positive association between intraoperative handoffs and considered outcomes. However, a pooled meta-analysis across these studies was not feasible across the retrospective studies due to differing surgical populations and varying definitions of the considered outcomes. Six studies used a nonrandomized prospective design to evaluate the effects of handoff tools on process-based outcomes such as clinician satisfaction, information transfer, handoff duration, and adherence. Five of the 6 handoff tools were checklist based. All prospective tool-based studies relied on small samples and reported a significant improvement on the considered process-based outcomes. The median quality score among retrospective (median [interquartile range {IQR}] = 9 [1]) was significantly higher than that of prospective (median [IQR] = 5 [1.5]) studies (U = 21, P = .0017). This systematic review provides a unique appraisal of the current state of intraoperative handoff research. To improve the quality and outcomes of handoffs, future efforts should focus on design and implementation of standardized handoff tools integrated within EHR systems, consider the use of similar metrics for evaluating handoff process and clinical outcomes, and improve the execution and reporting of studies using standard protocols and guidelines.


Assuntos
Anestesia/métodos , Anestesia/normas , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/normas , Transferência da Responsabilidade pelo Paciente/normas , Anestesia/efeitos adversos , Humanos , Cuidados Intraoperatórios/efeitos adversos , Estudos Retrospectivos
4.
Int J Surg Oncol ; 2021: 2476527, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33953982

RESUMO

Background: The standard treatment for breast cancer is breast-conserving surgery (BCS) with radiotherapy. If external beam radiation therapy (EBRT) can be safely replaced with intraoperative radiotherapy (IORT), it will help patients to save their breast and to have equivocal or better results in DFS and overall survival (OS). Methods: A total of 2022 patients with breast cancer treated during 6 years were enrolled in the current study. A total of 657, 376, and 989 patients received EBRT, radical, and boost dose by IORT, respectively, according to the IRIORT consensus protocol. The primary endpoint was recurrence and death. The secondary endpoint was the role of variables in recurrence and death. Results: With a mean follow-up of 34.5 and 40.18 months for the IORT and EBRT groups, respectively, there was a significant difference in DFS between electron boost and X-ray boost groups (P=0.037) and the electron radical group compared with EBRT (P=0.025), but there was no significant difference between other boost and radical groups in DFS and OS. Conclusions: IORT can be a preferred treatment modality because of its noninferior outcomes, and in some special conditions, it has superior outcomes compared to EBRT, particularly in delivering radical dose with IORT.


Assuntos
Neoplasias da Mama/radioterapia , Neoplasias da Mama/cirurgia , Carcinoma/radioterapia , Carcinoma/cirurgia , Cuidados Intraoperatórios/métodos , Mastectomia Segmentar/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/mortalidade , Carcinoma/mortalidade , Feminino , Seguimentos , Humanos , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/prevenção & controle , Doses de Radiação , Radioterapia Adjuvante , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento
5.
Best Pract Res Clin Anaesthesiol ; 35(2): 171-179, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34030802

RESUMO

Since 2015, endovascular thrombectomy has been established as the standard of care for re-establishing cerebral blood flow in patients with acute ischemic stroke. Several retrospective observational studies and prospective clinical trials have investigated two anesthetic techniques for endovascular stroke therapy: general anesthesia (GA) and conscious sedation (CS). The recent randomized studies suggest that GA is associated with higher rates of successful recanalization and better functional independence at 3 months compared with the CS technique. However, CS techniques are highly variable, and there is currently a lack of consensus on which anesthetic approach is best in all patients. Numerous patient and procedural factors should ultimately guide the decision of whether GA or CS should be used for a particular patient.


Assuntos
Anestesia Geral/métodos , Isquemia Encefálica/cirurgia , Sedação Consciente/métodos , Cuidados Intraoperatórios/métodos , AVC Isquêmico/cirurgia , Trombectomia/métodos , Anestesia Geral/efeitos adversos , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Sedação Consciente/efeitos adversos , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/fisiopatologia , Estudos Prospectivos , Estudos Retrospectivos
6.
Knee ; 30: 106-112, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33887621

RESUMO

BACKGROUND: Total knee arthroplasty (TKA) is particularly challenging in patients with marked deformities or existing hardware due to the inability to use traditional instrumentation. One potential technique to mitigate this obstacle is the use of patient-specific cutting guides. The purpose of this study was to evaluate the use of custom cutting guides in complex primary TKAs. METHODS: Twenty complex TKAs performed in 18 patients were identified. Of these, 11 were performed in patients with existing hardware, three in patients with dwarfism, three in patients with post-traumatic deformities, two in a patient with multiple epiphyseal dysplasia, and one in a patient with a large deformity from Blount's disease. All prior hardware was retained. One patient died from unrelated causes three months following surgery. The remaining patients were followed for a mean of 5.2 years (range: 1.2-9.7 years). RESULTS: One patient sustained a non-displaced, medial tibial plateau fracture intra-operatively that was successfully treated with plating. Mean operative time was 112.1 ± 44.4 min, and mean hospital stay was 2.7 ± 1.6 days. Average deviation from the mechanical axis improved from 10.5° pre-operatively to 3.1° postoperatively (P < 0.001). Average Knee Society Scores improved from 48.1 to 77.4 points (P < 0.001). Mean extension improved from 5.9° to 1.4° (P = 0.049). Two patients subsequently required a manipulation under anesthesia, and one patient had delayed wound healing that resolved without surgery. CONCLUSIONS: Custom cutting guides are a viable option in complex primary TKAs where the use of traditional instrumentation would be challenging.


Assuntos
Artroplastia do Joelho/instrumentação , Artroplastia do Joelho/métodos , Cuidados Intraoperatórios/instrumentação , Cuidados Intraoperatórios/métodos , Articulação do Joelho/cirurgia , Tíbia/cirurgia , Idoso , Artroplastia do Joelho/efeitos adversos , Mau Alinhamento Ósseo/diagnóstico por imagem , Mau Alinhamento Ósseo/prevenção & controle , Feminino , Seguimentos , Humanos , Articulação do Joelho/diagnóstico por imagem , Prótese do Joelho , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Tíbia/diagnóstico por imagem , Resultado do Tratamento
7.
J Surg Oncol ; 124(3): 271-281, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33866558

RESUMO

BACKGROUND AND OBJECTIVE: The Food and Drug Administration has cleared a probe-based near-infrared autofluorescence (NIRAF) detection system called PTeye™ as an adjunct tool for label-free intraoperative parathyroid gland (PG) identification. Since PTeye™ has been investigated only in a "blinded" manner to date, this study describes the preliminary impressions of PTeye™ when used by surgeons without being blinded to the device output. METHODS: Patients undergoing thyroid and parathyroid procedures were prospectively recruited. Target tissues were intraoperatively assessed with PTeye™. The surgeon's confidence in PG identification was recorded concomitantly with NIRAF parameters that were output in real-time from PTeye™. RESULTS: A retrospective review of prospectively collected data on 83 patients was performed. PTeye™ was used for interrogating 336 target tissues in 46 parathyroid and 37 thyroid procedures. PTeye™ yielded an overall accuracy of 94.3% with a positive predictive value of 93.0% and a negative predictive value of 100%. An increase in confidence for intraoperative PG identification with PTeye™ was observed by all three participating high-volume surgeons, irrespective of their level of accrued surgical experience. CONCLUSIONS: Probe-based NIRAF detection with PTeye™ can be a valuable adjunct device to intraoperatively identify PGs for surgeons of varied training and experience.


Assuntos
Glândulas Paratireoides/diagnóstico por imagem , Glândulas Paratireoides/cirurgia , Paratireoidectomia/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Tireoidectomia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Espectroscopia de Luz Próxima ao Infravermelho/instrumentação , Adulto Jovem
8.
Lancet Respir Med ; 9(5): 487-497, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33811829

RESUMO

BACKGROUND: Lung transplantation is a life-saving treatment for patients with end-stage lung disease; however, it is infrequently considered for patients with acute respiratory distress syndrome (ARDS) attributable to infectious causes. We aimed to describe the course of disease and early post-transplantation outcomes in critically ill patients with COVID-19 who failed to show lung recovery despite optimal medical management and were deemed to be at imminent risk of dying due to pulmonary complications. METHODS: We established a multi-institutional case series that included the first consecutive transplants for severe COVID-19-associated ARDS known to us in the USA, Italy, Austria, and India. De-identified data from participating centres-including information relating to patient demographics and pre-COVID-19 characteristics, pretransplantation disease course, perioperative challenges, pathology of explanted lungs, and post-transplantation outcomes-were collected by Northwestern University (Chicago, IL, USA) and analysed. FINDINGS: Between May 1 and Sept 30, 2020, 12 patients with COVID-19-associated ARDS underwent bilateral lung transplantation at six high-volume transplant centres in the USA (eight recipients at three centres), Italy (two recipients at one centre), Austria (one recipient), and India (one recipient). The median age of recipients was 48 years (IQR 41-51); three of the 12 patients were female. Chest imaging before transplantation showed severe lung damage that did not improve despite prolonged mechanical ventilation and extracorporeal membrane oxygenation. The lung transplant procedure was technically challenging, with severe pleural adhesions, hilar lymphadenopathy, and increased intraoperative transfusion requirements. Pathology of the explanted lungs showed extensive, ongoing acute lung injury with features of lung fibrosis. There was no recurrence of SARS-CoV-2 in the allografts. All patients with COVID-19 could be weaned off extracorporeal support and showed short-term survival similar to that of transplant recipients without COVID-19. INTERPRETATION: The findings from our report show that lung transplantation is the only option for survival in some patients with severe, unresolving COVID-19-associated ARDS, and that the procedure can be done successfully, with good early post-transplantation outcomes, in carefully selected patients. FUNDING: National Institutes of Health. VIDEO ABSTRACT.


Assuntos
COVID-19 , Estado Terminal/terapia , Transplante de Pulmão/métodos , Pulmão , Síndrome do Desconforto Respiratório , Transfusão de Sangue/métodos , COVID-19/complicações , COVID-19/diagnóstico , COVID-19/fisiopatologia , COVID-19/cirurgia , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/métodos , Feminino , Humanos , Cuidados Intraoperatórios/métodos , Pulmão/diagnóstico por imagem , Pulmão/patologia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Fibrose Pulmonar/etiologia , Fibrose Pulmonar/patologia , Respiração Artificial/métodos , Síndrome do Desconforto Respiratório/etiologia , Síndrome do Desconforto Respiratório/cirurgia , SARS-CoV-2/patogenicidade
9.
Ann Surg ; 274(1): e97-e99, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33856374

RESUMO

OBJECTIVE: Given the role of celiac plexus block (CPB) in the management of chronic pain, we sought to investigate the utility of CPB in the control of postoperative pain in major hepato-pancreato-biliary surgeries. SUMMARY BACKGROUND DATA: CPB has been in practice for decades for the management of upper abdominal visceral pain, especially in cancer patients. Typically, in this group of patients with chronic pain, a neurolytic agent is injected to cause irreversible neural damage to achieve pain control. We apply this concept to postoperative pain control by injecting bupivacaine to the celiac plexus instead of a neurolytic agent. We aim to investigate if this novel technique decreases postoperative opioid usage, offers better pain relief and leads to earlier ambulation. METHODS: A retrospective, single institution study comparing consecutive patients who received intraoperative CPB and preperitoneal infusion with patients who received only preperitoneal infusion in open hepato-pancreato-biliary surgery between the years 2016 and 2019 by a single surgeon. Patients with incomplete data on patient-controlled analgesia usage and postoperative ambulation information were excluded. RESULTS: Patients with CPB used 31% less morphine on postoperative day 1 compared to patient without CPB and 42% less morphine on postoperative day 2. Overall average morphine usage was significantly lower in patients with CPB. Duration of patient-controlled analgesia was shorter for patient with CPB compared with patient without CPB. The dynamic visual analogue score was marginally better in patients with CPB. Time to ambulation was similar in both groups. CONCLUSIONS: CPB can be considered as part of a multimodal approach for postoperative pain management in open hepato-pancreato-biliary surgeries.


Assuntos
Analgésicos Opioides/uso terapêutico , Plexo Celíaco , Hepatectomia , Cuidados Intraoperatórios/métodos , Bloqueio Nervoso/métodos , Dor Pós-Operatória/prevenção & controle , Pancreaticoduodenectomia , Adulto , Idoso , Deambulação Precoce , Feminino , Humanos , Infusões Parenterais , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Projetos Piloto , Estudos Retrospectivos , Resultado do Tratamento
10.
Anesthesiology ; 135(2): 273-283, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-33901281

RESUMO

BACKGROUND: Excessive or inadequate fluid administration causes complications, but despite this, fluid administration during noncardiac surgery is highly variable. Goal-directed management helps optimize the amount and timing of fluid administration; however, implementation is difficult because algorithms are complex. The authors therefore tested the performance of the Acumen Assisted Fluid Management software (Edwards Lifesciences, USA), which is designed to guide optimal intravenous fluid administration during surgery. METHODS: In this multicenter, prospective, single-arm cohort evaluation, the authors enrolled 330 adults scheduled for moderate- to high-risk noncardiac surgery that required arterial catheter insertion and mechanical ventilation. Clinicians chose a fluid strategy based on a desired 10%, 15%, or 20% increase in stroke volume (SV) in response to a fluid bolus. Dedicated fluid management software prompted "test" or "recommended" boluses, and clinicians were free to initiate a "user" bolus of 100 to 500 ml of crystalloid or colloid. Clinicians were free to accept or decline the software prompts. The authors primarily compared the fraction of software-recommended boluses that produced suitable increases in SV to a 30% reference rate. On an exploratory basis, we compared responses to software-recommended and clinician-initiated boluses. RESULTS: Four hundred twenty-four of 479 (89%) software-recommended fluid boluses and 508 of 592 (86%) clinician-initiated fluid boluses were analyzed per protocol. Of those, 66% (95% CI, 62 to 70%) of delivered fluid boluses recommended by the software resulted in desired increases in SV, compared with the 30% reference rate, whereas only 41% (95% CI, 38 to 44%) of clinician-initiated boluses did (P < 0.0001). The mean ± SD increase in SV after boluses recommended by the software was 14.2 ± 13.9% versus 8.3 ± 12.1% (P < 0.0001) for those initiated by clinicians. CONCLUSIONS: Fluid boluses recommended by the software resulted in desired SV increases more often, and with greater absolute SV increase, than clinician-initiated boluses. Automated assessment of fluid responsiveness may help clinicians optimize intraoperative fluid management during noncardiac surgery.


Assuntos
Hidratação/métodos , Cuidados Intraoperatórios/métodos , Terapia Assistida por Computador/métodos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
11.
BMC Pregnancy Childbirth ; 21(1): 267, 2021 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-33789610

RESUMO

BACKGROUND: The effect of maternal amino acid (AA) infusion before and during cesarean delivery on neonatal temperature remains unknown. We hypothesized that thermogenic effects of AA metabolism would help maintain body temperature of newborn babies and their mothers. METHODS: Seventy-six parturients scheduled for elective singleton term cesarean delivery were equally randomized to receive intravenous 200 ml of AA or placebo approximately 1 h before subarachnoid block (infusion rate:100 ml/h). The primary outcome was the newborn rectal temperature at 0, 5 and 10 min after birth. The secondary outcomes included the maternal rectal temperature at six time-points: T0 = before starting study solution infusion, T1 = 30 min after starting infusion, T2 = one hour after starting infusion, T3 = during spinal block, T4 = half an hour after spinal block, T5 = at the time of birth and T6 = at the end of infusion, as well as maternal thermal discomfort and shivering episodes. RESULTS: There were no differences in newborn temperature between the two groups at any of the time-points (intervention-time-interaction effect, P = 0.206). The newborn temperature (mean [95%CI] °C) at birth was 37.5 [37.43-37.66] in the AA and 37.4 [37.34-37.55] in the placebo group. It showed a significant (P < 0.001) downward trend at 5 and 10 min after birth (time effect) in both groups. One neonate in the AA and five in the placebo group were hypothermic (temperature < 36.5 °C) (P = 0.20). There was a significant difference in the maternal temperature at all time points between the two groups (Intervention-time interaction effect, P < 0.001). However, after adjustment for multiplicity, the difference was significant only at T6 (P = 0.001). The mean difference [95%CI] in temperature decline from baseline (T0) till the end of infusion (T6) between the two groups was - 0.39 [- 0.55;- 0.22] °C (P < 0.0001). Six mothers receiving placebo and none receiving AA developed hypothermia (temperature < 36 °C) (P = 0.025). Maternal thermal discomfort and shivering episodes were unaffected by AA therapy. CONCLUSIONS: Under the conditions of this study, maternal AA infusion before and during spinal anesthesia for cesarean delivery did not influence the neonatal temperature within 10 min after birth. In addition, the maternal temperature was only maintained at two hours of AA infusion. TRIAL REGISTRATION: ClinicalTrials.government, Identifier NCT02575170 . Registered on 10th April, 2015 - Retrospectively registered.


Assuntos
Aminoácidos/administração & dosagem , Temperatura Corporal/fisiologia , Cesárea/efeitos adversos , Hipotermia/prevenção & controle , Recém-Nascido/fisiologia , Complicações Intraoperatórias/prevenção & controle , Adulto , Temperatura Corporal/efeitos dos fármacos , Feminino , Humanos , Hipotermia/diagnóstico , Hipotermia/etiologia , Infusões Intravenosas , Cuidados Intraoperatórios/métodos , Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Troca Materno-Fetal/fisiologia , Gravidez , Estudos Prospectivos , Lactato de Ringer/administração & dosagem , Resultado do Tratamento , Adulto Jovem
12.
World Neurosurg ; 150: e108-e116, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33647485

RESUMO

BACKGROUND: Frozen section is a time- and labor-intensive method for intraoperative pathologic diagnosis. As a result, there exists a need to expedite and streamline the acquisition and interpretation of diagnostic histologic data to inform surgical decision making. Stimulated Raman histology (SRH) is an emerging technology that may serve to expedite the acquisition and interpretation of histologic data in the operating room. METHODS: A blinded, prospective cohort study of 82 patients undergoing resection for tumors of the central nervous system was performed. Twenty-six patients with diagnoses of meningioma on SRH, frozen, or permanent section were included in this subanalysis. Diagnostic time and accuracy of stimulated SRH histology images were compared with the gold standard (frozen section). Agreement of SRH and frozen section diagnosis with permanent section (true) diagnosis was also compared. RESULTS: Mean time-to-diagnosis was significantly shorter for SRH-mediated diagnosis compared with frozen section (9.2 vs. 35.8, P < 0.0001). Diagnostic accuracy was not significantly different between methods (P = 0.15). Diagnostic agreement was not significantly different between SRH versus frozen, SRH versus permanent, or frozen versus permanent section methods (P = 0.5, P = 0.5, P = 1.00). CONCLUSIONS: SRH is a promising adjuvant technology that may expedite intraoperative neuropathologic consult without sacrificing diagnostic accuracy.


Assuntos
Neoplasias Encefálicas/patologia , Glioma/patologia , Neoplasias Meníngeas/patologia , Meningioma/patologia , Procedimentos Neurocirúrgicos , Microscopia Óptica não Linear/métodos , Neoplasias Encefálicas/diagnóstico , Neoplasias Encefálicas/cirurgia , Feminino , Secções Congeladas/métodos , Glioma/diagnóstico , Glioma/cirurgia , Humanos , Cuidados Intraoperatórios/métodos , Masculino , Neoplasias Meníngeas/diagnóstico , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico , Meningioma/cirurgia , Fatores de Tempo
13.
Plast Reconstr Surg ; 147(4): 865-874, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33760575

RESUMO

BACKGROUND: Cell-based treatments have demonstrated the capacity to enhance reconstructive outcomes in recent decades but are hindered in clinical utility by regulatory hurdles surrounding cell culture. This investigation examines the ability of a noncultured stromal vascular fraction derived from lipoaspirate to enhance bone healing during fracture repair to further the development of translatable cell therapies that may improve outcomes in irradiated reconstruction. METHODS: Isogenic male Lewis rats were divided into three groups: fracture, irradiated fracture, and irradiated fracture with stromal vascular fraction treatment. Irradiated groups received a fractioned dose of 35 Gy before mandibular osteotomy. Stromal vascular fraction was harvested from the inguinal fat of isogenic donors, centrifuged, and placed intraoperatively into the osteotomy site. All mandibles were evaluated for bony union and vascularity using micro-computed tomography before histologic analysis. RESULTS: Union rates were significantly improved in the irradiated fracture with stromal vascular fraction treatment group (82 percent) compared to the irradiated fracture group (25 percent) and were not statistically different from the fracture group (100 percent). Stromal vascular fraction therapy significantly improved all metrics of bone vascularization compared to the irradiated fracture group and was not statistically different from fracture. Osteocyte proliferation and mature bone formation were significantly reduced in the irradiated fracture group. Bone cellularity and maturity were restored to nonirradiated levels in the irradiated fracture with stromal vascular fraction treatment group despite preoperative irradiation. CONCLUSIONS: Vascular and cellular depletion represent principal obstacles in the reconstruction of irradiated bone. This study demonstrates the efficacy of stromal vascular fraction therapy in remediating these damaging effects and provides a promising foundation for future studies aimed at developing noncultured, cell-based therapies for clinical implementation.


Assuntos
Tecido Adiposo/citologia , Extratos Celulares/uso terapêutico , Consolidação da Fratura , Cuidados Intraoperatórios/métodos , Mandíbula/efeitos da radiação , Fraturas Mandibulares/terapia , Animais , Terapia Combinada , Masculino , Fraturas Mandibulares/cirurgia , Ratos , Ratos Endogâmicos Lew , Resultado do Tratamento
14.
Plast Reconstr Surg ; 147(4): 627e-633e, 2021 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-33776038

RESUMO

BACKGROUND: Deliberate fluid administration has been used to maintain a hyperdynamic systemic circulation in free tissue transfer operations. The effects of intraoperative volume loading on postoperative complications have been controversial. The authors hypothesized that increasing intraoperative fluid administration was associated with increased postoperative surgical complications. METHODS: Free flap operations for head and neck reconstruction between 2004 and 2014 were reviewed. A generalized estimating equation model was used to estimate the effect of intraoperative fluid administration on surgical outcomes. The optimized thresholds of anesthetic time were tested by the Youden index for flap compromise and major complications. RESULTS: A total of 2983 consecutive cases were included in the study. The incidences of flap compromise and total loss were 1.5 and 3.3 percent, respectively. Intraoperative fluid administration was not associated with surgical complications (p = 0.195). However, a 1-hour increase in anesthesia time was associated with a 19 percent increased risk of flap compromise (adjusted OR, 1.19; 95 percent CI, 1.10 to 1.29; p < 0.001). CONCLUSION: Prolonged anesthetic time, but not fluid administration, was associated with adverse surgical outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Hidratação , Retalhos de Tecido Biológico/irrigação sanguínea , Neoplasias de Cabeça e Pescoço/cirurgia , Cuidados Intraoperatórios/métodos , Microcirurgia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Vasculares/métodos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
15.
Laryngoscope ; 131(9): 2154-2159, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-33720388

RESUMO

OBJECTIVES/HYPOTHESIS: To compare effect of 1 and 2 mg/kg of sugammadex on the incidence of intraoperative bucking and intraoperative neuromonitoring (IONM) quality in thyroid surgery. STUDY DESIGN: Randomized controlled trial. METHODS: Patients qualified for thyroid surgery with IONM were eligible for this double-blind, randomized, controlled trial. After tracheal intubation with 0.6 mg/kg rocuronium, 1 or 2 mg/kg of sugammadex was administered to patients in group I or II, respectively. The quality of the IONM for the external branch of the superior laryngeal nerve (EBSLN) was evaluated (strong/intermediate/weak). The initial amplitude of electromyography for the vagus nerve (V1) and the recurrent laryngeal nerve (R1) were recorded. Intraoperative bucking movements was recorded. RESULTS: A total of 102 patients (51 in each group) completed the study. Time from sugammadex administration to initial checking for the EBSLN was not different between group I and II (25.0 ± 7.9 vs. 25.5 ± 9.0 minutes, P = .788). There was no difference in the neuromonitoring quality for the EBSLN between group I and II (strong/intermediate/weak: 46/5/0 vs. 50/1/0, P = .205). The amplitudes of V1 (1,086.3 ± 673.3 µV vs. 1,161.8 ± 727.5 µV, P = .588) and R1 (1,328.2 ± 934.1 µV vs. 1,410.5 ± 919.6 µV, P = .655) were comparable between the groups. Patients who experienced bucking were significantly fewer in the group I than the group II (13.7% vs. 35.3%, P = .020). CONCLUSION: A dose of 1 mg/kg sugammadex induced less bucking than 2 m/kg while providing comparable IONM quality during thyroid surgery. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:2154-2159, 2021.


Assuntos
Cuidados Intraoperatórios/métodos , Monitorização Intraoperatória/instrumentação , Traumatismos do Nervo Laríngeo Recorrente/etiologia , Sugammadex/efeitos adversos , Glândula Tireoide/cirurgia , Adulto , Idoso , Sistema Nervoso Central/efeitos dos fármacos , Sistema Nervoso Central/fisiologia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Eletromiografia/métodos , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Nervo Laríngeo Recorrente/fisiologia , Traumatismos do Nervo Laríngeo Recorrente/prevenção & controle , Síndrome do Desconforto Respiratório/induzido quimicamente , Síndrome do Desconforto Respiratório/epidemiologia , Sugammadex/administração & dosagem , Nervo Vago/fisiologia
16.
Anesthesiology ; 134(5): 709-721, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33667304

RESUMO

BACKGROUND: Whether supplemental oxygen worsens long-term mortality remains unclear, with contradictory trial results. The authors therefore tested the hypothesis that supplemental oxygen (80% vs. 30%) increases the hazard for long-term mortality. METHODS: The authors conducted a post hoc analysis of a large multiple crossover cluster trial in which more than 5,000 colorectal surgeries on 4,088 adults were allocated to receive either 30% or 80% inspired oxygen during general anesthesia. The authors assessed the effect of 80% versus 30% target-inspired oxygen on long-term mortality and calculated Kaplan-Meier survival estimates. Analysis was restricted to patients with a home address in Ohio because the authors could obtain reliable vital status information from the Ohio Department of Health (Columbus, Ohio) for them. RESULTS: A total of 3,471 qualifying colorectal surgeries performed in 2,801 patients were analyzed, including 1,753 (51%) surgeries in 1,577 patients given 80% oxygen and 1,718 surgeries in 1,551 patients given 30% oxygen. The observed incidence of death after a median of 3 yr was 13% (234 of 1,753) in the 80% oxygen group and 14% (245 of 1,718) in the 30% oxygen group. The estimated hazard ratio for mortality was 0.94 (95% CI, 0.78 to 1.13; P = 0.493). CONCLUSIONS: In this post hoc analysis of a large, controlled trial, supplemental oxygen did not increase postoperative mortality.


Assuntos
Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/cirurgia , Cuidados Intraoperatórios/mortalidade , Cuidados Intraoperatórios/métodos , Oxigenoterapia/mortalidade , Oxigenoterapia/métodos , Análise por Conglomerados , Estudos Cross-Over , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
17.
Medicine (Baltimore) ; 100(10): e24430, 2021 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-33725821

RESUMO

OBJECTIVE: It remains unclear whether transfusion strategies during orthopedic surgery and infection are related. The purpose of this study is to evaluate whether liberal blood transfusion strategies contribute to infection risk in orthopedic patients by analyzing randomized controlled trials (RCTs). METHODS: RCTs with liberal versus restrictive red blood cell (RBC) transfusion strategies were identified by searching PubMed, Embase, the Cochrane Central Register of Controlled Trials from their inception to July 2019. Ten studies with infections as outcomes were included in the final analysis. According to the Jadad scale, all studies were considered to be of high quality. RESULTS: Ten trials involving 3938 participants were included in this study. The pooled risk ratio (RR) for the association between liberal transfusion strategy and infection was 1.34 (95% confidence intervals [CI], 0.94-1.90; P = .106). The sensitivity analysis indicated unstable results, and no significant publication bias was observed. CONCLUSION: This pooled analysis of RCTs demonstrates that liberal transfusion strategies in orthopedic patients result in a nonsignificant increase in infections compared with more restrictive strategies. The conclusions are mainly based on retrospective studies and should not be considered as recommendation before they are supported by larger scale and well-designed RCTs.


Assuntos
Transfusão de Sangue/estatística & dados numéricos , Infecções/epidemiologia , Cuidados Intraoperatórios/efeitos adversos , Procedimentos Ortopédicos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Perda Sanguínea Cirúrgica/prevenção & controle , Humanos , Infecções/etiologia , Cuidados Intraoperatórios/métodos , Cuidados Intraoperatórios/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco/estatística & dados numéricos , Fatores de Risco
18.
BMC Cancer ; 21(1): 293, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33740930

RESUMO

BACKGROUND: Breast cancer-related lymphedema (BCRL) is associated with extensive axillary dissection. Axillary lymph node dissection (ALND) based on breast lymphatics level (BLL) was proposed to minimize the surgical extent for node-positive breast cancer patients. METHODS: A total of 156 consecutive sentinel lymph node-positive (SLN+) or clinically node-positive (cN+) patients underwent sentinel lymph node biopsy (SLNB) with indocyanine green and methylene blue (MB). The SLNs were injected with 0.1 ml MB before removal, and a standard ALND was subsequently performed. The nodes adjacent to the blue-stained axillary lymph nodes from the breast (bALNs) were sent for pathological examination separately by resecting serial tissue every 0.5 cm away from the marginal blue-stained bALNs. Then, a pilot study comparing ALND based on BLL and standard ALND was performed. RESULTS: BLL were successfully identified in 20 SLN+ (100%) and 134 cN+ (98.5%) patients. The median number of BLL was four, ranging from three to six. A horizontal line 1.0 cm away from the superior blue-stained bALN and a vertical line 1.0 cm away from the medial blue-stained bALN formed BLL II, III, and IV. All of the additional positive nodes were within 1.0 cm of the blue-stained bALNs. The minimized axillary dissection should resect upwards from the lowest BLL that contains the first confirmed negative blue-stained bALNs. In the pilot study, no patient developed axillary recurrence. CONCLUSION: The ALND surgical procedure based on BLL could minimize the surgical extent for pathological node-positive breast cancer patients and potentially reduce the BCRL rate. TRIAL REGISTRATION: ChiCTR1800014247 .


Assuntos
Neoplasias da Mama/cirurgia , Excisão de Linfonodo/normas , Linfedema/cirurgia , Guias de Prática Clínica como Assunto , Linfonodo Sentinela/diagnóstico por imagem , Axila , Mama/patologia , Mama/cirurgia , Neoplasias da Mama/complicações , Neoplasias da Mama/patologia , Dissecação , Feminino , Humanos , Verde de Indocianina/administração & dosagem , Cuidados Intraoperatórios/métodos , Excisão de Linfonodo/efeitos adversos , Metástase Linfática/diagnóstico , Metástase Linfática/patologia , Metástase Linfática/terapia , Linfedema/diagnóstico , Linfedema/etiologia , Mastectomia/métodos , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Linfonodo Sentinela/patologia , Linfonodo Sentinela/cirurgia , Biópsia de Linfonodo Sentinela
19.
Br J Radiol ; 94(1121): 20201406, 2021 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-33684305

RESUMO

Intraoperative ultrasound (IOUS) is a valuable adjunctive tool that can provide real-time diagnostic information in surgery that has the potential to alter patient management and decrease complications. Lesion localization, characterization and staging can be performed, as well as surveying for additional lesions and metastatic disease. IOUS is commonly used in the liver for hepatic metastatic disease and hepatocellular carcinoma, in the pancreas for neuroendocrine tumors, and in the kidney for renal cell carcinoma. IOUS allows real-time evaluation of vascular patency and perfusion in organ transplantation and allows for early intervention for anastomotic complications. It can also be used to guide intraoperative procedures such as biopsy, fiducial placement, radiation, or ablation. A variety of adjuncts including microbubble contrast and elastography may provide additional information at IOUS. It is important for the radiologist to be familiar with the available equipment, common clinical indications, technique, relevant anatomy and intraoperative imaging appearance to optimize performance of this valuable imaging modality.


Assuntos
Cuidados Intraoperatórios/métodos , Ultrassonografia/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Hepatocelular/diagnóstico por imagem , Carcinoma Hepatocelular/patologia , Carcinoma de Células Renais/diagnóstico por imagem , Carcinoma de Células Renais/secundário , Meios de Contraste , Feminino , Procedimentos Cirúrgicos em Ginecologia , Hepatectomia/métodos , Humanos , Neoplasias Renais/diagnóstico por imagem , Neoplasias Renais/cirurgia , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/patologia , Masculino , Pessoa de Meia-Idade , Transplante de Órgãos , Pâncreas/diagnóstico por imagem , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/secundário , Cuidados Pré-Operatórios , Transdutores , Ultrassonografia/instrumentação , Ultrassonografia de Intervenção/instrumentação , Ultrassonografia de Intervenção/métodos , Adulto Jovem
20.
J Urol ; 205(6): 1671-1680, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-33605794

RESUMO

PURPOSE: Catheter-related bladder discomfort occurs in up to 63% of patients following robot-assisted radical prostatectomy. The optimal intraoperative anesthesia regime to prevent patients from catheter-related bladder discomfort is unknown. MATERIALS AND METHODS: A prospective cohort analysis was conducted. Patients with biopsy-proven prostate cancer selected for robot-assisted radical prostatectomy were included between January 2017 and April 2020 from a high volume prostate cancer center. Eight different treatment regimens were compared, ie a combination of general anesthesia and a transversus abdominis plane block with either an additional dose of clonidine or an additional dose of ketamine, or perivesical infiltrations (with 20 ml ropivacaine), or periurethral infiltrations (with ropivacaine); or a dorsal penile nerve block (with 20 ml ropivacaine). Multiple logistic regression and linear mixed models were used to analyze differences in catheter-related bladder discomfort and pain (0-10) at the postoperative recovery unit between the treatment protocols. RESULTS: Of the 391 patients included, those with a combination transversus abdominis plane block, perivesical and periurethral block with ropivacaine had the lowest incidence of catheter-related bladder discomfort, clinically relevant and statistically significantly lower compared to our baseline protocol (transversus abdominis plane block only), ie 36% vs 70%, p=0.001. Overall, patients who were treated with periurethral and/or perivesical infiltrations reported a statistically significantly lower incidence of catheter-related bladder discomfort compared to patients who did not receive this local infiltration (46.5% vs 60.7%, p=0.001). CONCLUSIONS: Perivesical and periurethral injections with ropivacaine have the potential to reduce the incidence of early postoperative catheter-related bladder discomfort by up to 49%. Further randomized studies are necessary to determine the optimal treatment regime to prevent early postoperative catheter-related bladder discomfort.


Assuntos
Cuidados Intraoperatórios/métodos , Dor Processual/etiologia , Dor Processual/prevenção & controle , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Prostatectomia , Procedimentos Cirúrgicos Robóticos , Bexiga Urinária , Cateteres Urinários/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral , Humanos , Masculino , Pessoa de Meia-Idade , Bloqueio Nervoso , Estudos Prospectivos , Prostatectomia/métodos , Fatores de Tempo
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