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1.
Medicine (Baltimore) ; 98(44): e17663, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31689778

RESUMO

RATIONALE: Postoperative delirium is extremely rare in young women and in minimally invasive endoscopic surgeries in gynecology and obstetrics. It greatly affects both physicians and patients. This report presents a special case of postoperative delirium after hysteroscopy in a young woman and a literature review of the associated etiology, diagnosis, and treatment. PATIENT CONCERNS: A 39-year-old woman was admitted to the gynecology ward following irregular vaginal bleeding for 3 months and an intrauterine space-occupying lesion for 1 week. Hysteroscopy, endometrial polypectomy, and fractional curettage procedures were successfully performed; however, the patient became unresponsive after surgery. DIAGNOSIS: Postoperative delirium. INTERVENTIONS: Sedatives and vasoactive medicines, such as dexmedetomidine, midazolam, and dopamine were administered for maintenance treatment. OUTCOMES: The patients gradually regained consciousness. LESSONS: Physicians should attach importance and improvise effective clinical management strategies for postoperative delirium based on clinical specialty characteristics and related guidelines.


Assuntos
Delírio do Despertar/etiologia , Histeroscopia/efeitos adversos , Adulto , Feminino , Humanos
2.
Curr Opin Anaesthesiol ; 32(3): 327-333, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31045639

RESUMO

PURPOSE OF REVIEW: Clonidine, an α2-receptor agonist is a widely used drug in pediatrics with a large scope of indications ranging from prevention of postoperative emergence agitation, analgesia, anxiolysis, sedation, weaning to shivering. In the era of 'opioid-free' medicine with much attention be directed toward increasing problems with opioid use, clonidine due to its global availability, low cost and safety profile has become an even more interesting option. RECENT FINDINGS: Increasing evidence from randomised clinical trials support the use of clonidine in healthy children in the perioperative setting. Clonidine appears to significantly reduce postoperative emergence agitation, opioid consumption, shivering, nausea and vomiting. In addition, emerging evidence support the use of clonidine for sedation of critically ill children in ICUs. In this review, the current evidence for clonidine in pediatrics is described and analyzed including a meta-analysis for prevention of emergence agitation. SUMMARY: Clonidine appears a safe and beneficial drug with moderate to high-quality evidence supporting its use in pediatric anesthesia. However, for some indications and populations such as children younger than 12 months old and those with hemodynamic instability, there is an urgent need for high-quality trials.


Assuntos
Agonistas de Receptores Adrenérgicos alfa 2/administração & dosagem , Anestesia/métodos , Clonidina/administração & dosagem , Delírio do Despertar/prevenção & controle , Náusea e Vômito Pós-Operatórios/prevenção & controle , Agonistas de Receptores Adrenérgicos alfa 2/efeitos adversos , Fatores Etários , Anestesia/efeitos adversos , Criança , Clonidina/efeitos adversos , Delírio do Despertar/etiologia , Humanos , Seleção de Pacientes , Náusea e Vômito Pós-Operatórios/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Tremor por Sensação de Frio/efeitos dos fármacos
3.
J Korean Med Sci ; 34(15): e124, 2019 Apr 22.
Artigo em Inglês | MEDLINE | ID: mdl-31001938

RESUMO

BACKGROUND: Despite well-known advantages, propofol remains off-label in many countries for general anesthesia in children under 3 years of age due to insufficient evidence regarding its use in this population. This study aimed to evaluate the efficacy and safety of propofol compared with other general anesthetics in children under 3 years of age undergoing surgery through a systematic review and meta-analysis of existing randomized clinical trials. METHODS: A comprehensive literature search was conducted of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials to find all randomized clinical trials comparing propofol with another general anesthetic that included children under 3 years of age. The relative risk or arcsine-transformed risk difference for dichotomous outcomes and the weighted or standardized mean difference for continuous outcomes were estimated using a random-effects model. RESULTS: A total of 249 young children from 6 publications were included. The children who received propofol had statistically significantly lower systolic and diastolic blood pressures, but hypotension was not observed in the propofol groups. The heart rate, stroke volume index, and cardiac index were not significantly different between the propofol and control groups. The propofol groups showed slightly shorter recovery times and a lower incidence of emergence agitation than the control groups, while no difference was observed for the incidence of hypotension, desaturation, and apnea. CONCLUSION: This systematic review and meta-analysis indicates that propofol use for general anesthesia in young healthy children undergoing surgery does not increase complications and that propofol could be at least comparable to other anesthetic agents.


Assuntos
Anestésicos Intravenosos/administração & dosagem , Propofol/administração & dosagem , Anestesia Geral , Anestésicos Intravenosos/efeitos adversos , Pré-Escolar , Bases de Dados Factuais , Delírio do Despertar/etiologia , Hemodinâmica , Humanos , Tiopental/administração & dosagem , Tiopental/efeitos adversos
4.
J Med Case Rep ; 13(1): 112, 2019 Apr 29.
Artigo em Inglês | MEDLINE | ID: mdl-31030668

RESUMO

BACKGROUND: Postoperative delirium is a relatively uncommon condition in middle aged patients, but very widespread in patients with psychiatric and neurological diseases undergoing general anesthesia. Few studies are currently available in the literature on the perioperative anesthesiological management of patients suffering from spinocerebellar ataxia. CASE PRESENTATION: A 58-year-old Caucasian woman affected by spinocerebellar ataxia type 2 underwent total hip arthroplasty for advanced osteoarthritis. One month later, debridement, antibiotics, and implant retention was performed for periprosthetic hip infection. Both times she underwent general anesthesia and developed an early postoperative delirium treated successfully with chlorpromazine. CONCLUSIONS: This case report highlights the need to correctly manage patients at high risk of developing postoperative delirium, especially if suffering from degenerative neurological diseases. On the other hand, further studies will be needed in order to evaluate if spinocerebellar ataxia is an independent risk factor for the development of this acute and transient pathological condition.


Assuntos
Anestesia Geral/efeitos adversos , Artroplastia de Quadril/efeitos adversos , Delírio do Despertar/etiologia , Ataxias Espinocerebelares/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Reoperação/efeitos adversos , Ataxias Espinocerebelares/diagnóstico
5.
Ann Thorac Surg ; 108(1): 190-195, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30817919

RESUMO

BACKGROUND: Postoperative delirium affects up to 50% of patients undergoing esophagectomy and is associated with negative outcomes. The perioperative risk factors for delirium in this population are not well understood. We conducted this study to assess perioperative risk factors for postoperative delirium among esophagectomy patients. METHODS: We performed a secondary data analysis of patients enrolled in a randomized controlled trial evaluating the efficacy of haloperidol prophylaxis postoperatively in reducing delirium among esophagectomy patients. Postoperative delirium was assessed twice daily using the Confusion Assessment Method for the ICU. Univariate and logistic regression analyses were performed to examine the association between perioperative variables and development of postoperative delirium. RESULTS: Of 84 consecutive esophagectomy patients, postoperative delirium developed in 27 (32%). These patients had higher Acute Physiology and Chronic Health Evaluation II scores (22.1 [SD, 6.5] vs 17.4 [SD, 6.8]; p = 0.003), longer mechanical ventilation days (1.7 [SD, 1.4] days vs 1.0 [SD, 1.1] days; p = 0.001), and longer intensive care unit (ICU) days (5.1 [SD, 2.6] days vs 2.6 [SD, 1.6] days; p < 0.001). In a logistic regression model, only ICU length of stay had a significant association with postoperative delirium (odds ratio, 1.65; 95% confidence interval, 1.21 to 2.25). CONCLUSIONS: ICU length of stay was significantly associated with postoperative delirium. Other perioperative factors, including duration of procedure, blood loss, and hemoglobin levels, were not significantly associated with postoperative delirium.


Assuntos
Delírio do Despertar/etiologia , Esofagectomia/efeitos adversos , Tempo de Internação , Idoso , Feminino , Hemoglobinas/análise , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Período Perioperatório , Fatores de Risco
6.
Br J Anaesth ; 122(4): 480-489, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30857604

RESUMO

BACKGROUND: The Strategy to Reduce the Incidence of Postoperative Delirium in the Elderly trial tested the hypothesis that limiting sedation during spinal anaesthesia decreases in-hospital postoperative delirium after hip fracture repair. This manuscript reports the secondary outcomes of this trial, including mortality and function. METHODS: Two hundred patients (≥65 yr) undergoing hip fracture repair with spinal anaesthesia were randomised to heavier [modified Observer's Assessment of Alertness/Sedation score (OAA/S) 0-2] or lighter (OAA/S 3-5) sedation, and were assessed for postoperative delirium. Secondary outcomes included mortality and return to pre-fracture ambulation level at 1 yr. Kaplan-Meier analysis, multivariable Cox proportional hazard model, and logistic regression were used to evaluate intervention effects on mortality and odds of ambulation return. RESULTS: One-year mortality was 14% in both groups (log rank P=0.96). Independent risk factors for 1-yr mortality included: Charlson comorbidity index [hazard ratio (HR)=1.23, 95% confidence interval (CI), 1.02-1.49; P=0.03], instrumental activities of daily living [HR=0.74, 95% CI, 0.60-0.91; P=0.005], BMI [HR=0.91, 95% CI 0.84-0.998; P=0.04], and delirium severity [HR=1.20, 95% CI, 1.03-1.41; P=0.02]. Ambulation returned to pre-fracture levels, worsened, or was not obtained in 64%, 30%, and 6% of 1 yr survivors, respectively. Lighter sedation did not improve odds of ambulation return at 1 yr [odds ratio (OR)=0.76, 95% CI, 0.24-2.4; P=0.63]. Independent risk factors for ambulation return included Charlson comorbidity index [OR=0.71, 95% CI, 0.53-0.97; P=0.03] and delirium [OR=0.32, 95% CI, 0.10-0.97; P=0.04]. CONCLUSIONS: This study found that in elderly patients having hip fracture surgery with spinal anaesthesia supplemented with propofol sedation, heavier intraoperative sedation was not associated with significant differences in mortality or return to pre-fracture ambulation up to 1 yr after surgery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00590707.


Assuntos
Sedação Consciente/métodos , Sedação Profunda/métodos , Delírio do Despertar/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Raquianestesia , Sedação Consciente/efeitos adversos , Relação Dose-Resposta a Droga , Delírio do Despertar/etiologia , Delírio do Despertar/mortalidade , Feminino , Força da Mão , Fraturas do Quadril/mortalidade , Fraturas do Quadril/cirurgia , Humanos , Hipnóticos e Sedativos/administração & dosagem , Hipnóticos e Sedativos/efeitos adversos , Estimativa de Kaplan-Meier , Masculino , Maryland/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Propofol/administração & dosagem , Propofol/efeitos adversos , Recuperação de Função Fisiológica
7.
Curr Opin Anaesthesiol ; 32(1): 92-100, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30507679

RESUMO

PURPOSE OF REVIEW: Neurocognitive dysfunction after surgery is highly relevant in the elderly. The multifactorial manner of this syndrome has made it hard to define an ideal biomarker to predict individual risk and assess diagnosis and severity of delirium [postoperative delirium (POD)] and subsequent postoperative cognitive decline (POCD). This review summarizes recent literature on blood biomarkers for POD/POCD. RECENT FINDINGS: Markers for delirium have been searched for in the cerebrospinal fluid to examine the pathologic cascade. However, cerebrospinal fluid cannot be easily obtained in the perioperative setting. Thus, attention shifts toward prediction markers from patients' blood to determine the individual risk. In this regard, three major groups of peripheral blood markers could be distinguished: first, global, but unspecific markers associated with POD/POCD; second, specific and established markers related to neurocognitive function; and third, upcoming or newly described markers with less evidence. Solely neuron-specific enolase is an adequate biomarker based on recent literature. SUMMARY: Single markers for postoperative cognitive impairment cannot predict POD/POCD in geriatric patients. However, a wisely arranged battery of promising biomarkers might achieve a satisfying sensitivity and specificity for the preoperative assessment of subsequent cognitive decline. Adequately powered studies to prove this hypothesis are required.


Assuntos
Anestesia/efeitos adversos , Disfunção Cognitiva/diagnóstico , Delírio do Despertar/diagnóstico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores Etários , Idoso , Envelhecimento/fisiologia , Biomarcadores/análise , Cognição/efeitos dos fármacos , Disfunção Cognitiva/etiologia , Delírio do Despertar/etiologia , Estudos de Viabilidade , Humanos , Período Pós-Operatório , Valor Preditivo dos Testes , Prognóstico , Sensibilidade e Especificidade , Índice de Gravidade de Doença
8.
Curr Opin Anaesthesiol ; 32(1): 101-107, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30507680

RESUMO

PURPOSE OF REVIEW: To summarize recent recommendations on intraoperative electroencephalogram (EEG) neuromonitoring in the elderly aimed at the prevention of postoperative delirium and long-term neurocognitive decline. We discuss recent perioperative EEG investigations relating to aging and cognitive dysfunction, and their implications on intraoperative EEG neuromonitoring in elderly patients. RECENT FINDINGS: The incidence of postoperative delirium in elderly can be reduced by monitoring depth of anesthesia, using an index number (0-100) derived from processed frontal EEG readings. The recently published European Society of Anaesthesiology guideline on postoperative delirium in elderly now recommends guiding general anesthesia with such indices (Level A). However, intraoperative EEG signatures are heavily influenced by age, cognitive function, and choice of anesthetic agents. Detailed spectral EEG analysis and research on EEG-based functional connectivity provide new insights into the pathophysiology of neuronal excitability, which is seen in elderly patients with postoperative delirium. SUMMARY: Anesthesiologists should become acquainted with intraoperative EEG signatures and their relation to age, anesthetic agents, and the risk of postoperative cognitive complications. A working knowledge would allow an optimized and individualized provision of general anesthesia for the elderly.


Assuntos
Anestesia Geral/efeitos adversos , Disfunção Cognitiva/prevenção & controle , Delírio do Despertar/prevenção & controle , Monitorização Neurofisiológica Intraoperatória/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores Etários , Idoso , Envelhecimento/fisiologia , Anestésicos/efeitos adversos , Cognição/efeitos dos fármacos , Cognição/fisiologia , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Monitores de Consciência , Eletroencefalografia/métodos , Eletroencefalografia/normas , Delírio do Despertar/diagnóstico , Delírio do Despertar/epidemiologia , Delírio do Despertar/etiologia , Humanos , Incidência , Monitorização Neurofisiológica Intraoperatória/instrumentação , Monitorização Neurofisiológica Intraoperatória/normas , Guias de Prática Clínica como Assunto
9.
J Clin Anesth ; 53: 35-38, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30292069

RESUMO

BACKGROUND: While the incidence of postoperative delirium is high in aged hospitalized patients undergoing major surgery, little is known concerning patients undergoing ambulatory surgery. OBJECTIVE: To determine the incidence of postoperative delirium in aged patients after hospital discharge from an ambulatory surgery unit. DESIGN: Prospective observational study. PATIENTS: Elderly patients (≥75 years) scheduled for a surgical procedure on an ambulatory basis. INTERVENTIONS: Filling of the Family Confusion Assessment Method (FAM-CAM) questionnaire (11 items) during a phone interview of family caregivers on two separate occasions: five to three days before surgery, and three to five days after surgery. MAIN OUTCOME MEASURES: The detection of acute onset and fluctuating course inattention, disorganized thinking, altered level of consciousness, disorientation, perceptual disturbances, and psychomotor agitation from the observations of family caregivers. RESULTS: Signs of delirium appeared de novo in 2 of 141 patients (incidence 1.4%) in the postoperative period: a 80-years old man who was disoriented and had incoherent and illogical speech on postoperative day 1 of resection of a cephalic cutaneous melanoma under local anesthesia and sedation (midazolam, sufentanil, and propofol), and a 83-years old woman with a pre-existing mental confusion, who experienced visual and hearing hallucinations and had inappropriate behaviour on postoperative day 2 of cataract surgery performed under episcleral block. Both patients returned to their preoperative states within a few days. CONCLUSIONS: Using the FAM-CAM instrument for the detection of postoperative delirium in ambulatory patients, the study showed that the incidence of cognitive changes in the ambulatory setting is very low. Among several putative factors, the lightness of the surgical procedure, the wide use of regional anesthesia, and the short hospital stay may be contributing factors to this result. The findings of this study need to be confirmed in a larger sample of patients.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Anestesia por Condução/efeitos adversos , Delírio do Despertar/epidemiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Cuidadores/estatística & dados numéricos , Delírio do Despertar/diagnóstico , Delírio do Despertar/etiologia , Feminino , Humanos , Incidência , Tempo de Internação/estatística & dados numéricos , Masculino , Estudos Prospectivos , Psicometria , Inquéritos e Questionários/estatística & dados numéricos
10.
Curr Opin Anaesthesiol ; 32(1): 116-119, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30543554

RESUMO

PURPOSE OF REVIEW: There is an urge to improve care for patients with hip fracture. The present review will compare the efficacy of spinal versus general anesthesia for patients requiring hip fracture surgery. RECENT FINDINGS: The present review gives an overview with particular emphasis on literature published during the past 24 months. SUMMARY: So far, no clear evidence form randomized trials exists to identify the best anesthesia technique for hip fracture surgery. However, several large-scale pragmatic trials are ongoing and will provide future guidance.


Assuntos
Anestesia Geral/efeitos adversos , Raquianestesia/efeitos adversos , Delírio do Despertar/epidemiologia , Fixação de Fratura/efeitos adversos , Fraturas do Quadril/cirurgia , Fatores Etários , Idoso , Anestesia Geral/normas , Raquianestesia/normas , Anestésicos/efeitos adversos , Tomada de Decisão Clínica , Delírio do Despertar/etiologia , Delírio do Despertar/prevenção & controle , Humanos , Equipe de Assistência ao Paciente/normas , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento
11.
Mil Med ; 184(1-2): e284-e286, 2019 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-29901770

RESUMO

Serotonin syndrome (SS) is a life-threatening condition, usually precipitated by a combination of serotonergic agents. Data regarding the incidence and management of SS in obstetrics are limited. This study presents a case of SS provoked by an atypical antipsychotic in a second trimester, singleton gestation, and reviews the management of SS in an obstetric patient. We present a case of a schizophreniform, pregnant patient with a singleton gestation admitted to a community, military hospital for serotonin syndrome. The patient was admitted to the intensive care unit (ICU) by the obstetrics team, where she was managed conservatively. The cornerstones of therapy were as follows: discontinuation of offending agent, intravenous fluids, supplemental oxygen, telemetry, and hourly neurological assessments. Fetal status was monitored daily. After stabilization, the patient was transferred from the ICU to inpatient psychiatry for continued care. Although serotonin syndrome is infrequently encountered in obstetrics, it is paramount that all obstetricians are familiar with its recognition and management, particularly in community hospital settings. The low incidence of reported SS is largely attributed to under-recognition, as the syndrome can mimic other more common obstetric diagnoses such as preeclampsia. Given the increasing prevalence of mental health disorders, it is essential for obstetricians to be aware of the potential for SS in our patient population.


Assuntos
Transtornos Psicóticos/diagnóstico , Síndrome da Serotonina/complicações , Adulto , Antipsicóticos/uso terapêutico , Delírio do Despertar/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Cloridrato de Lurasidona/uso terapêutico , Gravidez , Transtornos Psicóticos/tratamento farmacológico , Transtornos Psicóticos/etiologia , Síndrome da Serotonina/diagnóstico , Síndrome da Serotonina/tratamento farmacológico
12.
Anasthesiol Intensivmed Notfallmed Schmerzther ; 53(11-12): 793-796, 2018 Nov.
Artigo em Alemão | MEDLINE | ID: mdl-30458577

RESUMO

Postoperative delirium (POD) is an acute change in the mental state with consciousness and attention deficits. It is a common complication after surgical procedures and can have serious consequences. Thus, the evidence- and consensus-based guidelines for POD appeals with the highest recommendation level that patients be regularly screened for delirium in the postoperative phase, from the recovery room to the fifth postoperative day and at least once per shift, using a validated test instrument for the detection of POD. In 2014, Marcantonio et al. published the 3D-CAM (3-Minute Diagnostic Interview for CAM-defined Delirium). In the 3D-CAM, the algorithm of the Confusion Assessment Method (CAM) is maintained by using individual elements that operationalize the evaluation of the criteria. Therefore, it requires less training, be faster to use, and, due to a standardized approach, has less interrater variability than the CAM, whereas the high sensitivity and specificity are maintained. Our goal was to translate the 3D-CAM from English to German, so as to make this instrument available to German-speaking countries. The translation of the 3D-CAM was based on the 2005 published guideline on Translation and Cultural Adaptation of Patient Reported Outcome Measures of the International Society for Pharmacoeconomics and Outcome Research. Three independent forward translations were harmonized to a preliminary translation, which then was translated back into the original language. Original authors reviewed the back translation. According to a cognitive debriefing, the translation was revised and in addition was adapted for use in the recovery room. Due to close contact with the original authors during the translation process, it was possible to ensure that the contents of the test instrument were remained intact during the translation process.


Assuntos
Anestesia Geral/efeitos adversos , Delírio do Despertar/diagnóstico , Entrevista Psicológica/métodos , Complicações Pós-Operatórias/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Confusão/diagnóstico , Confusão/psicologia , Delírio do Despertar/etiologia , Humanos , Complicações Pós-Operatórias/psicologia , Complicações Pós-Operatórias/terapia , Reprodutibilidade dos Testes , Traduções
14.
Int J Pediatr Otorhinolaryngol ; 110: 12-15, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29859572

RESUMO

OBJECTIVE: Medical acupuncture is increasingly recognized for reducing postoperative pain, nausea and emergence agitation. Anesthetic induction is an ideal time to perform acupuncture in an effort to reduce the adverse side effects of surgery. Acupuncture is safe, inexpensive and does not lengthen the duration of anesthesia. There are however no published reports of how often patients will choose intraoperative acupuncture when given the opportunity to do so. METHODS: A retrospective review of all surgical procedures performed by one surgeon over 12 months was done. This yielded 401 unique patients ranging in age from 3 months to 21 years with a mean of 6 years. Five of these patients had emergent surgery and 396 patients had scheduled surgery; there were a total of 822 surgical procedures performed on these individuals. Intraoperative acupuncture was offered only to the scheduled surgical patients. RESULTS: 388 of 396 (98%) parents chose to have intraoperative acupuncture done for their child. No complications of acupuncture were encountered. CONCLUSION: These results demonstrate strong acceptance of intraoperative acupuncture by parents. We hope this report encourages surgeons to become trained in medical acupuncture.


Assuntos
Terapia por Acupuntura , Delírio do Despertar/prevenção & controle , Cuidados Intraoperatórios , Dor Pós-Operatória/prevenção & controle , Aceitação pelo Paciente de Cuidados de Saúde , Náusea e Vômito Pós-Operatórios/prevenção & controle , Adolescente , Criança , Pré-Escolar , Delírio do Despertar/etiologia , Feminino , Humanos , Lactente , Masculino , Procedimentos Cirúrgicos Otorrinolaringológicos/efeitos adversos , Dor Pós-Operatória/etiologia , Pais/psicologia , Náusea e Vômito Pós-Operatórios/etiologia , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
15.
Anesthesiology ; 129(3): 417-427, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29912008

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Postoperative delirium complicates approximately 15 to 20% of major operations in patients at least 65 yr old and is associated with adverse outcomes and increased resource utilization. Furthermore, patients with postoperative delirium might also be at risk of developing long-term postoperative cognitive dysfunction. One potentially modifiable variable is use of intraoperative processed electroencephalogram to guide anesthesia. This systematic review and meta-analysis examines the relationship between processed electroencephalogram monitoring and postoperative delirium and cognitive dysfunction. METHODS: A systematic search for randomized controlled trials was conducted using Ovid MEDLINE, PubMed, EMBASE, Cochrane Library, and Google search using the keywords processed electroencephalogram, Bispectral Index, postoperative delirium, postoperative cognitive dysfunction. Screening and data extraction were conducted by two independent reviewers, and risk of bias was assessed. Postoperative delirium combined-effect estimates calculated with a fixed-effects model were expressed as odds ratios with 95% CIs. RESULTS: Thirteen of 369 search results met inclusion criteria. Postoperative cognitive dysfunction data were excluded in meta-analysis because of heterogeneity of outcome measurements; results were discussed descriptively. Five studies were included in the quantitative postoperative delirium analysis, with data pooled from 2,654 patients. The risk of bias was low in three studies and unclear for the other two. The use of processed electroencephalogram-guided anesthesia was associated with a 38% reduction in odds for developing postoperative delirium (odds ratio = 0.62; P < 0.001; 95% CI, 0.51 to 0.76). CONCLUSIONS: Processed electroencephalogram-guided anesthesia was associated with a decrease in postoperative delirium. The mechanism explaining this association, however, is yet to be determined. The data are insufficient to assess the relationship between processed electroencephalogram monitoring and postoperative cognitive dysfunction.


Assuntos
Anestesia Geral/efeitos adversos , Eletroencefalografia/métodos , Delírio do Despertar/diagnóstico , Delírio do Despertar/fisiopatologia , Monitorização Intraoperatória/métodos , Delírio do Despertar/etiologia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos
16.
J Clin Anesth ; 50: 33-42, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29958125

RESUMO

STUDY OBJECTIVE: To evaluate the efficiency of dexmedetomidine on the incidence of delirium in patients after cardiac surgery. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Operating room and Intensive Care Unit (ICU). PATIENTS: Ten trials with a total of 1387 patients undergoing cardiac surgery met the inclusion criteria. INTERVENTION: Randomized controlled trials (RCTs) comparing the effect of dexmedetomidine versus non-treatment of dexmedetomidine (normal saline (NS), propofol and other anesthetic drugs) on delirium in patients undergoing cardiac surgery were retrieved from PubMed/Medline, Embase, the Cochrane Library and Web of science. The primary outcome was the incidence of delirium. The secondary outcomes were the rate of bradycardia and hypotension, the duration of mechanical ventilation and the length of ICU and hospital stay. MAIN RESULTS: Compared with the control group, Dexmedetomidine significantly decreased the incidence of postoperative delirium, (risk ratio 0.46; 95% confidence intervals, 0.34 to 0.62; P < 0.00001), while the incidence of bradycardia was increased in dexmedetomidine group (risk ratio 1.86; 95% confidence intervals, 1.16 to 2.99; P = 0.01). There was no significant difference between groups with regarding to the occurrence of hypotension (risk ratio 0.90; 95% confidence intervals, 0.59 to 1.38; P = 0.63), the duration of mechanical ventilation (Mean Difference 0.21; 95% confidence intervals, -0.70 to 1.12; P = 0.65), and the length of ICU (Standard Mean Difference - 0.07; 95% confidence intervals, -0.19 to 0.06; P = 0.3) and hospital stay (Mean Difference - 0.13; 95% confidence intervals, -0.56 to 0.30; P = 0.56). CONCLUSION: Perioperative dexmedetomidine administration decreased the incidence of delirium in patients after cardiac surgery, but might increase the rate of bradycardia. Furthermore, we did not observe significant differences in the incidence of hypotension, the duration of mechanical ventilation and length of ICU and hospital stay between groups. Future studies are needed to ascertain the effect of dexmedetomidine on the incidence of delirium after coronary artery bypass grafting (CABG) and in patient with cognitive disorder at baseline, whether intraoperative dexmedetomidine infusion could reduce postoperative delirium and the optimal dose of dexmedetomidine.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Dexmedetomidina/administração & dosagem , Delírio do Despertar/prevenção & controle , Hipnóticos e Sedativos/administração & dosagem , Assistência Perioperatória/métodos , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Dexmedetomidina/efeitos adversos , Delírio do Despertar/epidemiologia , Delírio do Despertar/etiologia , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Incidência , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/estatística & dados numéricos , Fatores de Tempo
17.
Anesthesiology ; 129(3): 406-416, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29771710

RESUMO

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Cardiac surgery is associated with cognitive decline and postoperative delirium. The relationship between postoperative delirium and cognitive decline after cardiac surgery is unclear WHAT THIS ARTICLE TELLS US THAT IS NEW: The development of postoperative delirium is associated with a greater degree of cognitive decline 1 month after cardiac surgery. The development of postoperative delirium is not a predictor of cognitive decline 1 yr after cardiac surgery. BACKGROUND: Delirium is common after cardiac surgery and has been associated with morbidity, mortality, and cognitive decline. However, there are conflicting reports on the magnitude, trajectory, and domains of cognitive change that might be affected. The authors hypothesized that patients with delirium would experience greater cognitive decline at 1 month and 1 yr after cardiac surgery compared to those without delirium. METHODS: Patients who underwent coronary artery bypass and/or valve surgery with cardiopulmonary bypass were eligible for this cohort study. Delirium was assessed with the Confusion Assessment Method. A neuropsychologic battery was administered before surgery, at 1 month, and at 1 yr later. Linear regression was used to examine the association between delirium and change in composite cognitive Z score from baseline to 1 month (primary outcome). Secondary outcomes were domain-specific changes at 1 month and composite and domain-specific changes at 1 yr. RESULTS: The incidence of delirium in 142 patients was 53.5%. Patients with delirium had greater decline in composite cognitive Z score at 1 month (greater decline by -0.29; 95% CI, -0.54 to -0.05; P = 0.020) and in the domains of visuoconstruction and processing speed. From baseline to 1 yr, there was no difference between delirious and nondelirious patients with respect to change in composite cognitive Z score, although greater decline in processing speed persisted among the delirious patients. CONCLUSIONS: Patients who developed delirium had greater decline in a composite measure of cognition and in visuoconstruction and processing speed domains at 1 month. The differences in cognitive change by delirium were not significant at 1 yr, with the exception of processing speed.


Assuntos
Ponte Cardiopulmonar/efeitos adversos , Disfunção Cognitiva/diagnóstico , Disfunção Cognitiva/etiologia , Delírio do Despertar/diagnóstico , Delírio do Despertar/etiologia , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/tendências , Disfunção Cognitiva/psicologia , Delírio do Despertar/psicologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos
18.
Paediatr Anaesth ; 28(4): 332-337, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29508484

RESUMO

BACKGROUND: Emergence delirium and emergence agitation have been a subject of interest since the early 1960s. This behavior has been associated with increased risk of injury in children and dissatisfaction with anesthesia care in their parents. The Pediatric Anesthesia Emergence Delirium Scale is a commonly used instrument for codifying and recording this behavior. AIMS: The aim of this study was to psychometrically evaluate the Pediatric Anesthesia Emergence Delirium scale, focusing on the factor structure, in a sample of children recovering from anesthesia after surgery or diagnostic procedures. The reliability of the Pediatric Anesthesia Emergence Delirium scale was also tested. METHODS: One hundred and twenty-two children younger than seven years were observed at postoperative care units during recovery from anesthesia. Two or 3 observers independently assessed the children using the Pediatric Anesthesia Emergence Delirium scale. RESULTS: The factor analysis clearly revealed a one-factor solution, which accounted for 82% of the variation in the data. Internal consistency, calculated with Cronbach's alpha, was good (0.96). The Intraclass Correlation Coefficient, which was used to assess interrater reliability for the Pediatric Anesthesia Emergence Delirium scale sum score, was 0.97 (P < .001). The weighted kappa statistics were almost perfect in 4 of 5 items, with substantial agreement in the fifth (P < .001). CONCLUSION: The one-factor solution and the satisfactory reliability in terms of internal consistency and stability support the use of the Pediatric Anesthesia Emergence Delirium scale for assessing emergence delirium in children recovering from anesthesia after surgery or diagnostic procedures. The kappa statistics for the Pediatric Anesthesia Emergence Delirium scale items essentially indicated good agreement between independent raters, supporting interrater reliability.


Assuntos
Anestesia/efeitos adversos , Delírio do Despertar/etiologia , Delírio do Despertar/psicologia , Complicações Pós-Operatórias/psicologia , Psicometria , Período de Recuperação da Anestesia , Criança , Pré-Escolar , Delírio do Despertar/diagnóstico , Análise Fatorial , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Variações Dependentes do Observador , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Reprodutibilidade dos Testes
19.
Aesthetic Plast Surg ; 42(3): 847-853, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29464385

RESUMO

BACKGROUND: Emergence agitation (EA), defined as restlessness, disorientation, excitation, and/or inconsolable crying, is a common phenomenon during early recovery from general anesthesia. In this study, we aimed to determine the (1) EA incidence after rhinoplasty operations in adults; (2) the effects of ketamine administered at sub-anesthetic doses just 20 min before the end of the surgery in rhinoplasty operations on agitation level, postoperative pain, side effects, and complications; and (3) to determine the risk factors for EA in adults after rhinoplasty. MATERIALS AND METHODS: Totally 140 patients scheduled to undergo elective rhinoplasty were enrolled in this prospective study. Patients were equally and randomly divided into two groups: saline group (control group) (n = 70) and ketamine group (n = 70). Twenty minutes before surgery completion, 1 ml saline was administered via the intravenous (i.v.) route to the saline group, while 0.5 mg/kg ketamine was administered via i.v. patients in the ketamine group. The emergence agitation level of the patients was evaluated using the Richmond Agitation-Sedation Scale just after extubation and in the post-anesthesia care unit (PACU). For postoperative pain evaluation, the Numerical Rating Scale (NRS) was scored (from 0 to 10) every 10 min until the patients were discharged from PACU. RESULTS: EA incidence in the control group was as high as 54.3%, while in the ketamine group it was 8.6% just after extubation (p < 0.001). In the PACU, EA incidence was 28.6% in the control group, while none of the patients had EA in the PACU in the ketamine group (p < 0.001). Male gender, severe pain (NRS ≥ 5), and smoking were defined as significant risk factors for EA both after extubation and during follow-ups in the PACU (p < 0.001). CONCLUSIONS: Emergence agitation after rhinoplasty is a common complication, likely disturbing operative outcomes in adults. Ketamine at sub-anesthetic doses is highly effective in preventing EA. Further, larger-scale prospective studies are warranted to determine preventive measures for EA development in rhinoplasty. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .


Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Delírio do Despertar/prevenção & controle , Ketamina/administração & dosagem , Rinoplastia/efeitos adversos , Adulto , Período de Recuperação da Anestesia , Anestesia Geral/efeitos adversos , Anestesia Geral/métodos , Distribuição de Qui-Quadrado , Método Duplo-Cego , Delírio do Despertar/etiologia , Feminino , Humanos , Infusões Intravenosas , Masculino , Prognóstico , Estudos Prospectivos , Valores de Referência , Rinoplastia/métodos , Medição de Risco , Resultado do Tratamento , Adulto Jovem
20.
J Clin Monit Comput ; 32(6): 1033-1040, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29404892

RESUMO

This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO2), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO2 was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO2 was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO2 values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO2 was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO2 nadir values were also significant lower (p = 0.047). Low ScO2 during initial resuscitation (defined as ScO2 < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO2 was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.


Assuntos
Encéfalo/metabolismo , Fraturas do Quadril/metabolismo , Fraturas do Quadril/cirurgia , Oximetria/métodos , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular , Dinamarca/epidemiologia , Delírio do Despertar/etiologia , Feminino , Hemodinâmica , Fraturas do Quadril/mortalidade , Humanos , Masculino , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/estatística & dados numéricos , Oximetria/estatística & dados numéricos , Projetos Piloto , Período Pós-Operatório , Período Pré-Operatório , Estudos Prospectivos , Ressuscitação , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Espectroscopia de Luz Próxima ao Infravermelho/estatística & dados numéricos
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