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1.
Medicine (Baltimore) ; 98(45): e17940, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31702683

RESUMO

Venous air embolism (VAE) can be observed in the right heart system on contrast-enhanced computed tomography (CT), following injection of contrast media with a power injector system. Although most VAEs are mostly asymptomatic, they may result in paradoxical air embolism (PAE).To evaluate whether the incidence of VAE on coronary CT angiography is associated with the process of preparation of the intravenous access route.We retrospectively evaluated 692 coronary CT examinations at 3 institutions. Trained CT nurses placed an intravenous cannula in the forearm. Tubes connected to the cannula were prepared in the following ways: A, using an interposed three-way cock and a 20-mL syringe filled with normal saline to collect air contamination in the tube; B, through direct connection to the power injector system without the interposed 3-way cock; and C, using an interposed three-way cock and a 100-mL normal saline drip infusion bottle system to keep the tube patent. The incidence and location of VAE and preparation of intravenous injection were assessed.The overall incidence of VAE was 55.3% (383/692), most frequently observed in the right atrium (81.5%, 312/383). Its incidence varied significantly across the 3 techniques (A: 21.6% (35/162), B: 63.2% (237/375) and C: 71.6% (111/155); P < .001). No patient demonstrated any symptom associated with VAE.Using a 3-way cock with syringe demonstrated the lowest incidence of VAE on coronary CT angiography. It is thus recommended to reduce potential complication risks related to intravenous contrast media injection.


Assuntos
Angiografia por Tomografia Computadorizada/efeitos adversos , Embolia Aérea/etiologia , Embolia Paradoxal/etiologia , Átrios do Coração/diagnóstico por imagem , Idoso , Meios de Contraste/administração & dosagem , Embolia Aérea/complicações , Embolia Aérea/epidemiologia , Embolia Paradoxal/epidemiologia , Humanos , Injeções Intravenosas/efeitos adversos , Injeções Intravenosas/instrumentação , Injeções Intravenosas/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
2.
Aerosp Med Hum Perform ; 90(6): 524-530, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31101137

RESUMO

INTRODUCTION: The frequency of long-duration, high-altitude missions with fighter aircraft is increasing, which may increase the incidence of decompression sickness (DCS). The aim of the present study was to compare decompression stress during simulated sustained high-altitude flying vs. high-altitude flying interrupted by periods of moderate or marked cabin pressure increase.METHODS: The level of venous gas emboli (VGE) was assessed from cardiac ultrasound images using the 5-degree Eftedal-Brubakk scale. Nitrogen washout/uptake was measured using a closed-circuit rebreather. Eight men were investigated in three conditions: one 80-min continuous exposure to a simulated cabin altitude of A) 24,000 ft, or four 20-min exposures to 24,000 ft interspersed by three 20-min intervals at B) 20,000 ft or C) 900 ft.RESULTS: A and B induced marked and persistent VGE, with peak bubble scores of [median (range)]: A: 2.5 (1-3); B: 3.5 (2-4). Peak VGE score was less in C [1.0 (1-2), P < 0.01]. Condition A exhibited an initially high and exponentially decaying rate of nitrogen washout. In C the washout rate was similar in each period at 24,000 ft, and the nitrogen uptake rate was similar during each 900-ft exposure. B exhibited nitrogen washout during each period at 24,000 ft and the initial period at 20,000 ft, but on average no washout or uptake during the last period at 20,000 ft.DISCUSSION: Intermittent reductions of cabin altitude from 24,000 to 20,000 ft do not appear to alleviate the DCS risk, presumably because the pressure increase is not sufficient to eliminate VGE. The nitrogen washout/uptake rate did not reflect DCS risk in the present exposures.Ånell R, Grönkvist M, Eiken O, Gennser M. Nitrogen washout and venous gas emboli during sustained vs. discontinuous high-altitude exposures. Aerosp Med Hum Perform. 2019; 90(6):524-530.


Assuntos
Medicina Aeroespacial , Altitude , Doença da Descompressão/epidemiologia , Embolia Aérea/epidemiologia , Nitrogênio/sangue , Adulto , Gasometria , Doença da Descompressão/sangue , Doença da Descompressão/etiologia , Embolia Aérea/sangue , Embolia Aérea/etiologia , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Militares , Pilotos , Fatores de Risco , Fatores de Tempo , Veias
3.
Gynecol Oncol ; 150(3): 515-520, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30037490

RESUMO

OBJECTIVE: To evaluate the hospital-acquired condition (HAC) following oophorectomy and/or hysterectomy for gynecologic cancer patients based on clinical outcomes and costs. MATERIALS AND METHODS: Data were obtained from the Nationwide Inpatient Sample from 2005 to 2011. Chi-squared and Wilcoxon rank sum two-sample tests and multivariate logistic regression model were used for statistical analysis. RESULTS: Of 82,304 women (median age: 60 years, range: 1-101), 49,386 (60.0%) had endometrial, 23,510 (28.6%) had ovarian, and 9408 (11.4%) had cervical cancers. Of 135 HAC events, these involved catheter-associated urinary tract infections (n = 47), vascular catheter-associated infection (n = 41), foreign object retained after surgery (n = 19), pressure ulcers (n = 16), manifestation of poor glycemic control (n = 10), and air embolism (n = 2). Older patients (≥60 years) experienced more HACs relative to younger (0.23% vs. 0.09%; OR = 2.13, 95% CI: 1.30-3.50; p = 0.003), and patients with Medicaid experienced more HACs compared to those with private insurance (0.35% vs. 0.10%; OR = 3.09, 95% CI: 1.70-5.62; p < 0.001). Laparoscopic surgeries were associated with less HACs compared to open surgeries (0.05% vs. 0.19%; OR = 0.41, 95% CI: 0.19-0.90; p = 0.03). Length of hospitalization and hospital charges were greater for those with HACs, (12 days vs. 3 days; p < 0.001; $89,324 vs. $31,107; p < 0.001), respectively. CONCLUSION: The odds of hospital-acquired conditions were higher in older patients, open surgery, Medicaid insured with higher associated hospital charges.


Assuntos
Infecções Relacionadas a Cateter/epidemiologia , Infecção Hospitalar/epidemiologia , Corpos Estranhos/epidemiologia , Neoplasias dos Genitais Femininos/cirurgia , Lesão por Pressão/epidemiologia , Infecções Urinárias/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Embolia Aérea/epidemiologia , Feminino , Preços Hospitalares/estatística & dados numéricos , Humanos , Hiperglicemia/epidemiologia , Hipoglicemia/epidemiologia , Histerectomia , Lactente , Laparoscopia/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Pessoa de Meia-Idade , Ovariectomia , Fatores de Risco , Estados Unidos/epidemiologia , Adulto Jovem
4.
Anesth Analg ; 127(2): 420-423, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29933275

RESUMO

BACKGROUND: Known complications of endoscopic retrograde cholangiopancreatography (ERCP) include pancreatitis, bleeding, duodenal perforation, and venous air embolism (VAE). The aim of this study was to determine the incidence of VAE during ERCP and be able to differentiate high-risk versus low-risk ERCP procedures. METHODS: This is a prospective cohort study consisting of patients who underwent ERCP and were monitored with a precordial Doppler ultrasound (PDU) for VAE. PDU monitoring was digitally recorded and analyzed to confirm the suspected VAE. Demographic and clinical data related to the anesthetic care, endoscopic procedure, and intraoperative hemodynamics were analyzed. RESULTS: A total of 843 ERCP procedures were performed over a 15-month period. The incidence of VAE was 2.4% (20 patients). All VAE's occurred during procedures in which stent placement, sphincterotomy, biopsy, duct dilation, gallstone retrieval, cholangioscopy, or necrosectomy occurred. Ten of 20 (50%) of VAEs were associated with hemodynamic alterations. None occurred if the procedure was only diagnostic or for stent removal. Subanalysis for the type of procedure showed that VAE was statistically more frequent when stents were removed and then replaced or if a cholangioscopy was performed. CONCLUSIONS: The high incidence of VAE highlights the need for practitioners to be aware of this potentially serious event. Use of PDU can aid in the detection of VAE during ERCP and should be considered especially during high-risk therapeutic procedures. Detection may allow appropriate interventions before serious adverse events such as cardiovascular collapse occur.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestesia/efeitos adversos , Cateterismo/efeitos adversos , Feminino , Hemodinâmica , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Pancreatite , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Fatores de Risco , Stents/efeitos adversos , Resultado do Tratamento , Ultrassonografia Doppler
5.
ASAIO J ; 64(1): 31-37, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28557862

RESUMO

Prolonged use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may be complicated by end-organ dysfunction. Although gaseous microemboli (GME) are thought to damage end organs during cardiopulmonary bypass, patient exposures to GME have not been well characterized during VA ECMO. We therefore performed an observational study of GME in adult VA ECMO patients, with correlation to clinical events during routine patient care. After institutional review board (IRB) approval, we used two Doppler probes to detect GME noninvasively in extracorporeal membrane oxygenation (ECMO) circuits on four patients for 15 hours total while also recording patient care events. We then conducted in vitro trials to compare Doppler signals with gold-standard measurements using an Emboli Detection and Classification EDAC quantifier (Luna Innnovations, Inc. Roanoke, VA) (Terumo Cardiovascular, Ann Arbor, MI) during simulated clinical interventions. Correlations between Doppler and EDAC data were used to estimate GME counts and volumes represented by clinical Doppler data. A total of 503 groups of Doppler peaks representing GME showers were observed, including 194 statistically larger showers during patient care activities containing 92% of total Doppler peaks. Intravenous injections accounted for an estimated 68% of GME and 88% of GME volume, whereas care involving movement accounted for an estimated 6% of GME and 3% of volume. Overall estimated embolic rates of 24,000 GME totaling 4 µl/hr rivals reported GME rates during cardiopulmonary bypass. Numerous GME are present in the postmembrane circuit during VA ECMO, raising concern for effects on microcirculation and organ dysfunction. Strategies to detect and minimize GME may be warranted to limit embolic exposures experienced by VA ECMO patients.


Assuntos
Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Adulto , Humanos
6.
J Neurosurg ; 128(5): 1560-1569, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-28707996

RESUMO

OBJECTIVE The semisitting position of a patient confers numerous advantages in various neurosurgical procedures, but venous air embolism is one of the associated complications of this position. To date, no prospective studies of the relationship between the degree of head elevation and the rate and severity of venous air embolism for patients undergoing a procedure in this position have been performed. In this study, the authors compared changes in the severity of venous air embolism according to the degree of head elevation (30° or 45°) in patients undergoing an elective cranial neurosurgical procedure in the semisitting position. METHODS One hundred patients undergoing an elective infratentorial craniotomy in the semisitting position were included, and each patient was assigned to 1 of 2 groups. In Group 1, each patient's head was elevated 30° during surgery, and in Group 2, each patient's head elevation was 45°. Patients were assigned to their group according to the location of their lesion. During surgery, the standard anesthetic protocol was used with total intravenous anesthesia, and transesophageal echocardiography was used to detect air in the blood circulation. Any air embolism seen on the echocardiography screen was classified as Grade 0 to 4. If multiple events occurred, the worst graded attack was used for statistical analysis. During hemodynamic changes caused by emboli, fluid and vasopressor requirements were recorded. Surgical and anesthetic complications were recorded also. All results were compared statistically, and a p value of < 0.05 was considered statistically significant. RESULTS There was a statistically significant difference between groups for the total rates of venous air emboli detected on transesophageal echocardiography (22.0% [n = 11] in Group 1 and 62.5% [n = 30] in Group 2; p < 0.0001). The rate and severity of air embolism were significantly lower in Group 1 than in Group 2 (p < 0.001). The rates of clinically important venous air embolism (Grade 2, 3, or 4, venous air embolism with decreased end-tidal carbon dioxide levels and/or hemodynamic changes) were 8.0% (n = 4) in Group 1 and 50.0% (n = 24) in Group 2 (p < 0.0001). There was no association between the rate and severity of venous air embolism with patient demographics (p > 0.05). An association was found, however, between the rate of venous air embolism and the type of surgical pathology (p < 0.001); venous embolism occurred more frequently in patients with a meningioma. There were no major surgical or anesthetic complications related to patient position during the postoperative period. CONCLUSIONS For patients in the semisitting position, an increase in the degree of head elevation is related directly to a higher rate of venous air embolism. With a 30° head elevation and our standardized technique of positioning, the semisitting position can be used safely in neurosurgical practice.


Assuntos
Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Complicações Intraoperatórias/epidemiologia , Procedimentos Neurocirúrgicos/métodos , Posicionamento do Paciente , Adulto , Anestesia/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Embolia Aérea/terapia , Feminino , Cabeça , Humanos , Incidência , Complicações Intraoperatórias/terapia , Masculino , Neoplasias Meníngeas/epidemiologia , Neoplasias Meníngeas/cirurgia , Meningioma/epidemiologia , Meningioma/cirurgia , Posicionamento do Paciente/efeitos adversos , Posicionamento do Paciente/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/terapia , Estudos Prospectivos , Índice de Gravidade de Doença
7.
Undersea Hyperb Med ; 44(6): 509-519, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29281188

RESUMO

Inadvertent exposure to radiation, chemical agents and biological factors are well recognized hazards associated with the health care delivery system. Less well appreciated yet no less harmful is risk of decompression sickness in those who accompany patients as inside attendants (IAs) during provision of hyperbaric oxygen therapy. Unlike the above hazards where avoidance is practiced, IA exposure to decompression sickness risk is unavoidable. While overall incidence is low, when calculated as number of cases over number of exposures or potential for a case during any given exposure, employee cumulative risk, defined here as number of cases over number of IAs, or risk that an IA may suffer a case, is not. Commonly, this unique occupational environmental injury responds favorably to therapeutic recompression and a period of recuperation. There are, however, permanent and career-ending consequences, and at least two nurses have succumbed to their decompression insults. The intent of this paper is to heighten awareness of hyperbaric attendant decompression sickness. It will serve as a review of reported cases and reconcile incidence against largely ignored individual worker risk. Mitigation strategies are summarized and an approach to more precisely identify risk factors that might prompt development of consensus screening standards is proposed.


Assuntos
Doença da Descompressão/etiologia , Pessoal de Saúde , Oxigenação Hiperbárica/efeitos adversos , Doenças Profissionais/etiologia , Intoxicação por Monóxido de Carbono/terapia , Doença da Descompressão/epidemiologia , Doença da Descompressão/prevenção & controle , Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Embolia Aérea/prevenção & controle , Feminino , Humanos , Oxigenação Hiperbárica/métodos , Incidência , Masculino , Doenças Profissionais/epidemiologia , Doenças Profissionais/prevenção & controle , Fatores de Risco
8.
Aerosp Med Hum Perform ; 88(4): 370-376, 2017 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-28517999

RESUMO

INTRODUCTION: Ambulation during extravehicular activity on Mars may increase the risk of decompression sickness through enhanced bubble formation in the lower body. HYPOTHESES: walking effort (ambulation) before an exercise-enhanced denitrogenation (prebreathe) protocol at 14.7 psia does not increase the incidence of venous gas emboli (VGE) at 4.3 psia, but does increase incidence if performed after tissues become supersaturated with nitrogen at 4.3 psia. METHODS: VGE results from 45 control subjects who performed exercise prebreathe without ambulation before or during a 4-h exposure to 4.3 psia were compared to 21 subjects who performed the same prebreathe but ambulated before and during the hypobaric exposure (Group I) and to 41 subjects who only ambulated before the hypobaric exposure (Group II). Monitoring for VGE in the pulmonary artery was for 4 min at about 12-min intervals using precordial Doppler ultrasound (2.5 mHz). Detected VGE were assigned a categorical grade from I to IV. The detection of Grade III or IV was classified as "high VGE grade." RESULTS: The incidence of high VGE grade for Group I (57%) was greater than the control (17%) and Group II (15%). The incidence of pain-only decompression sickness was greater for Group I (20%) than the control (0%) and Group II (5%). CONCLUSIONS: High-grade VGE are increased by mild ambulation conducted under a supersaturated state (Group I vs. II); however, no increase was observed with mild ambulation during the saturated state alone (control vs. Group II).Conkin J, Pollock NW, Natoli MJ, Martina SD, Wessell JH III, Gernhardt ML. Venous gas emboli and ambulation at 4.3 psia. Aerosp Med Hum Perform. 2017; 88(4):370-376.


Assuntos
Doença da Descompressão/epidemiologia , Embolia Aérea/epidemiologia , Caminhada/fisiologia , Adulto , Fatores Etários , Feminino , Humanos , Incidência , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Fatores de Tempo
9.
Oncotarget ; 8(16): 27502-27509, 2017 Apr 18.
Artigo em Inglês | MEDLINE | ID: mdl-28412755

RESUMO

Laparoscopic hepatectomy carries a high risk of gas embolism due to the extensive hepatic transection plane and large hepatic vena cava. Here, we compared the influence of inhaled and intravenous anesthetics on gas embolism during laparoscopic hepatectomy. Fifty patients undergoing laparoscopic hepatectomy were divided into two groups to receive sevoflurane anesthesia (group S, n = 25) or intravenous propofol anesthesia (group p, n = 25). During the operation, gas emboli were detected by transesophageal echocardiography and graded according to their size. Venous CO2 emboli were detected in all patients, and the embolism grades did not differ between the two groups. However, the mean embolism episode duration was longer in group S than group P (51.24±23.59 vs. 34.00±17.13 sec, p < 0.05). At the point of the most severe gas embolism, the PTCO2 was higher in group S than group p (44.00±4.47 vs. 41.36±2.77 mmHg, p < 0.05), while the PO2/FiO2 (450.52±54.08 vs. 503.80±63.18, p < 0.05) and pH values (7.35±0.05 vs. 7.38±0.02, p < 0.05) were lower in group S than group P. Patients with a history of abdominal surgery or liver cirrhosis had higher gas embolism grades. Thus volatile anesthetics may lengthen the duration of embolism episodes and worsen hemodynamics and pulmonary blood gas exchange during surgery.


Assuntos
Dióxido de Carbono/efeitos adversos , Embolia Aérea/etiologia , Hepatectomia/efeitos adversos , Laparoscopia/efeitos adversos , Éteres Metílicos/administração & dosagem , Pneumoperitônio/complicações , Propofol/administração & dosagem , Idoso , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Anestésicos Intravenosos/administração & dosagem , Anestésicos Intravenosos/efeitos adversos , Biomarcadores , Embolia Aérea/diagnóstico , Embolia Aérea/epidemiologia , Feminino , Humanos , Incidência , Masculino , Éteres Metílicos/efeitos adversos , Pessoa de Meia-Idade , Pneumoperitônio/etiologia , Propofol/efeitos adversos , Índice de Gravidade de Doença , Sevoflurano , Ultrassonografia
10.
J Neurosurg Anesthesiol ; 29(3): 236-242, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-26998647

RESUMO

BACKGROUND: Continuous venovenous hemodialysis (CVVHD) may generate microemboli that cross the pulmonary circulation and reach the brain. The aim of the present study was to quantify (load per time interval) and qualify (gaseous vs. solid) cerebral microemboli (CME), detected as high-intensity transient signals, using transcranial Doppler ultrasound. MATERIALS AND METHODS: Twenty intensive care unit (ICU group) patients requiring CVVHD were examined. CME were recorded in both middle cerebral arteries for 30 minutes during CVVHD and a CVVHD-free interval. Twenty additional patients, hospitalized for orthopedic surgery, served as a non-ICU control group. Statistical analyses were performed using the Mann-Whitney U test or the Wilcoxon matched-pairs signed-rank test, followed by Bonferroni corrections for multiple comparisons. RESULTS: In the non-ICU group, 48 (14.5-169.5) (median [range]) gaseous CME were detected. In the ICU group, the 67.5 (14.5-588.5) gaseous CME detected during the CVVHD-free interval increased 5-fold to 344.5 (59-1019) during CVVHD (P<0.001). The number of solid CME was low in all groups (non-ICU group: 2 [0-5.5]; ICU group CVVHD-free interval: 1.5 [0-14.25]; ICU group during CVVHD: 7 [3-27.75]). CONCLUSIONS: This observational pilot study shows that CVVHD was associated with a higher gaseous but not solid CME burden in critically ill patients. Although the differentiation between gaseous and solid CME remains challenging, our finding may support the hypothesis of microbubble generation in the CVVHD circuit and its transpulmonary translocation toward the intracranial circulation. Importantly, the impact of gaseous and solid CME generated during CVVHD on brain integrity of critically ill patients currently remains unknown and is highly debated.


Assuntos
Estado Terminal , Embolia Aérea/diagnóstico por imagem , Hemofiltração , Embolia Intracraniana/diagnóstico por imagem , Adulto , Idoso , Cuidados Críticos , Diagnóstico Diferencial , Embolia Aérea/epidemiologia , Embolia Aérea/terapia , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Unidades de Terapia Intensiva , Embolia Intracraniana/epidemiologia , Embolia Intracraniana/terapia , Masculino , Microbolhas , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Ultrassonografia Doppler Transcraniana
11.
J Neurosurg ; 127(1): 182-188, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-27494821

RESUMO

OBJECTIVE Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series. METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure. RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2-70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12-0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4-39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09-5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery. CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.


Assuntos
Complicações Intraoperatórias/epidemiologia , Procedimentos Neurocirúrgicos/métodos , Posicionamento do Paciente/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Postura Sentada , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Embolia Aérea/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição de Risco , Adulto Jovem
12.
Acta Neurochir (Wien) ; 159(2): 339-346, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27896454

RESUMO

BACKGROUND: There is an ongoing debate about the sitting position (SP) in neurosurgical patients. The SP provides a number of advantages as well as severe complications such as commonly concerning venous air embolism (VAE). The best monitoring system for the detection of VAE is still controversial. METHODS: In this retrospective analysis we compared 208 patients. Transesophageal echocardiography (TEE) or transthoracic Doppler (TTD) were used as monitoring devices to detect VAE; 101 cases were monitored with TEE and 107 with TTD. RESULTS: The overall incidence of VAE was 23% (TTD: 10%; TEE: 37%), but the incidence of clinically relevant VAE (drop in end-tidal carbon dioxide above 3 mmHg) was higher in the TTD group (9 out of 17 VAE, 53%) compared to the TEE group (19 out of 62 VAE, 31%). None of the patients with recorded VAE had clinically significant sequelae. CONCLUSIONS: In this small sample we found more VAE events in the TEE group, but the incidence of clinically relevant VAE was rare and comparable to other data. There is no consensus in the definition of clinically relevant VAE.


Assuntos
Craniotomia/efeitos adversos , Embolia Aérea/etiologia , Posicionamento do Paciente/efeitos adversos , Adulto , Idoso , Veias Cerebrais/patologia , Veias Cerebrais/cirurgia , Craniotomia/métodos , Ecocardiografia Transesofagiana/métodos , Embolia Aérea/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Posicionamento do Paciente/métodos
13.
J Med Assoc Thai ; 99(5): 511-6, 2016 May.
Artigo em Inglês | MEDLINE | ID: mdl-27501605

RESUMO

BACKGROUND: Posterior cranial fossa surgery is commonly performed under sitting and horizontal position in our institution. Venous air embolism is a potentially serious complication of neurosurgery especially in the sitting position. OBJECTIVE: We aim to compare the incidence of severe venous air embolism and other complications of both positions. MATERIAL AND METHOD: A retrospective analysis of medical record was performed in 192 patients undergoing posterior cranial fossa craniotomy from January 2010 to December 2013. Data collected from the records included demographic profile, patient position, hemodynamic changes, venous air embolism (VAE), blood loss/transfusion, duration of surgery, postoperative complications, duration of ICU stay, and postoperative discharge status. The definition of severe air embolism was identified as suspected VAE with decreased systolic blood pressure greater than 20%. RESULTS: There were 92 patients in sitting position (SP) group and 100 patients in horizontal position (HP) group. The incidence of severe venous air embolism was signficantly higher in SP group compared with HP group (41.3% vs. 11.0%, p<0. 001). SP group had more complications than HP group in both central nervous system (71% vs. 34.0%, p = 0.001), and cardiovascular system (17% vs. 6%, p = 0.001). Although postoperative ventilator time in SP group was less than HP group (1.24 vs. 1.60 days, p = 0.029), ICU and hospital stay were not different in either group. CONCLUSION: The incidence of severe venous air embolism detected by end tidal CO2 was significantly higher in SP group. However, 11% of HP group were suspected of severe air embolism.


Assuntos
Fossa Craniana Posterior/cirurgia , Embolia Aérea/etiologia , Complicações Intraoperatórias/etiologia , Posicionamento do Paciente , Adulto , Idoso , Craniotomia/efeitos adversos , Embolia Aérea/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
J Extra Corpor Technol ; 48(1): 5-10, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-27134302

RESUMO

Gaseous microemboli (GME) are known to be delivered to the arterial circulation of patients during cardiopulmonary bypass (CPB). An increased number of GME delivered during adult CPB has been associated with brain injury and postoperative cognitive dysfunction. The GME load in children exposed to CPB and its consequences are not well characterized. We sought to establish a baseline of arterial limb emboli counts during the conduct of CPB for our population of patients requiring surgery for congenital heart disease. We used the emboli detection and counting (EDAC) device to measure GME activity in 103 consecutive patients for which an EDAC machine was available. Emboli counts for GME <40 µ and >40 µ were quantified and indexed to CPB time (minutes) and body surface area (BSA) to account for the variation in patient size and CPB times. Patients of all sizes had a similar embolic burden when indexed to bypass time and BSA. Furthermore, patients of all sizes saw a three-fold increase in the <40 µ embolic burden and a five-fold increase in the >40 µ embolic burden when regular air was noted in the venous line. The use of kinetic venous-assisted drainage did not significantly increase arterial limb GME. Efforts for early identification and mitigation of venous line air are warranted to minimize GME transmission to congenital cardiac surgery patients during CPB.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Embolia Aérea , Extremidades/irrigação sanguínea , Cardiopatias Congênitas/cirurgia , Doença Arterial Periférica , Adulto , Superfície Corporal , Procedimentos Cirúrgicos Cardíacos/instrumentação , Ponte Cardiopulmonar/instrumentação , Criança , Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Desenho de Equipamento , Cardiopatias Congênitas/epidemiologia , Humanos , Doença Arterial Periférica/epidemiologia , Doença Arterial Periférica/etiologia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia
15.
J Clin Neurosci ; 25: 75-8, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26549680

RESUMO

Placing patients who are undergoing neurosurgical procedures to the cervical spine in the sitting position offers significant advantages. These must be counterbalanced against the risk of venous and paradoxical air embolism. This study addresses the role and safety of the sitting position for instrumented cervical surgery. Twenty-five consecutive patients who underwent instrumented cervical surgery in the sitting position were recruited via retrospective analysis. Complications arising from the surgical procedure - specifically venous air embolism - were recorded, as well as pre- and post-operative haemoglobin levels. The incidence of venous air embolism was 0% (97.5% one-sided confidence interval: 0-13.7%). However, five other complications occurred (incidence rate of 20% with a 95% confidence interval of 6.8-40.7%). With appropriate precautions, screening and specific indications, the sitting position can be safely used in more complex instrumented cervical surgery.


Assuntos
Vértebras Cervicais/cirurgia , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/epidemiologia , Postura , Adulto , Embolia Aérea/epidemiologia , Embolia Aérea/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Período Pós-Operatório , Estudos Retrospectivos , Adulto Jovem
16.
J Vasc Interv Radiol ; 26(3): 366-71, 2015 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-25638749

RESUMO

PURPOSE: To determine the impact of the introduction of aerostatic sheaths on air embolism (AE) events during tunneled dialysis catheter (TDC) insertion and to characterize such events occurring during over-the-wire exchange (OTWE). MATERIALS AND METHODS: Between July 2001 and April 2013, 5,789 TDCs were placed, including 3,963 de novo placements, 1,811 OTWEs, and 15 tract recanalizations. There were 15 AE events reported, and the medical records of these patients were reviewed. The effect of aerostatic sheaths, introduced in July 2005, was compared with the period before their introduction; the same TDC design was used throughout. RESULTS: Of the 15 AE events, 10 occurred during de novo placement (10 of 3,963 placement; 0.25%), 4 occurred during OTWE (4 of 1,811 placements; 0.22%), and 1 occurred during tract recanalization. With regard to aerostatic sheaths in de novo TDC placement, 4 of 1,174 (0.34%) AE events occurred before aerostatic sheath introduction, and 6 of 2,789 (0.22%) AE events occurred after aerostatic sheath introduction. These rates did not differ statistically (P = .5). CONCLUSIONS: Use of aerostatic sheaths trended toward reducing AE events during de novo TDC placement. This trend was not statistically significant, probably owing to the rarity of AE despite the large sample size. Air embolism occurs during OTWE at a rate similar to de novo placement with aerostatic sheaths as well as during tract recanalization.


Assuntos
Cateterismo/estatística & dados numéricos , Cateteres de Demora/estatística & dados numéricos , Embolia Aérea/epidemiologia , Embolia Aérea/prevenção & controle , Diálise Renal/instrumentação , Diálise Renal/estatística & dados numéricos , Adulto , Idoso , Cateterismo/efeitos adversos , Cateteres de Demora/efeitos adversos , Remoção de Dispositivo/efeitos adversos , Remoção de Dispositivo/estatística & dados numéricos , Embolia Aérea/etiologia , Análise de Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pennsylvania/epidemiologia , Prevalência , Desenho de Prótese , Diálise Renal/efeitos adversos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
17.
Diving Hyperb Med ; 44(2): 79-85, 2014 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-24986725

RESUMO

BACKGROUND: Scuba diving injuries vary greatly in severity and prognosis. While decompression sickness (DCS) and arterial gas embolism can be tracked easily, other forms of diving injury remain unaccounted for. PURPOSE: The purpose of this paper is to assess rates of overall self-reported scuba-diving-related injuries, self-reported DCS-like symptoms, and treated DCS and their association with diver certification level, diving experience and demographic factors. METHODS: We analyzed self-reported data from a Divers Alert Network membership health survey conducted during the summer of 2011. Poisson regression models with scaled deviance were used to model the relative rates of reported injuries. Models were adjusted for sex, age, body mass index (BMI) and average annual dives, based on the bias-variance tradeoff. RESULTS: The overall rate of diving-related injury was 3.02 per 100 dives, self-reported DCS symptoms was 1.55 per 1,000 dives and treated DCS was 5.72 per 100,000 dives. Diving-related injury and self-reported DCS symptom rates decreased for higher diver certification levels, increasing age, increasing number of average annual dives and for men; they increased for increasing BMI. CONCLUSIONS: Diving injury rates may be higher than previously thought, indicating a greater burden on the diving community. Self-reported DCS-like symptoms are a small fraction of all dive-related injuries and those receiving treatment for DCS are an even smaller fraction. The small number of divers seeking treatment may suggest the mild nature and a tendency towards natural resolution for most injuries.


Assuntos
Doença da Descompressão/epidemiologia , Mergulho/lesões , Embolia Aérea/epidemiologia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Índice de Massa Corporal , Certificação , Redes Comunitárias/estatística & dados numéricos , Doença da Descompressão/terapia , Mergulho/efeitos adversos , Mergulho/normas , Mergulho/estatística & dados numéricos , Feminino , Inquéritos Epidemiológicos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Distribuição de Poisson , Recreação , Estudos Retrospectivos , Autorrelato , Fatores Sexuais , Adulto Jovem
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