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1.
Int J Mol Sci ; 20(19)2019 Sep 25.
Artigo em Inglês | MEDLINE | ID: mdl-31557884

RESUMO

Sleep apnea syndrome (SAS) is a very common disease involving intermittent hypoxia (IH), recurrent symptoms of deoxygenation during sleep, strong daytime sleepiness, and significant loss of quality of life. A number of epidemiological researches have shown that SAS is an important risk factor for insulin resistance and type 2 diabetes mellitus (DM), which is associated with SAS regardless of age, gender, or body habitus. IH, hallmark of SAS, plays an important role in the pathogenesis of SAS and experimental studies with animal and cellular models indicate that IH leads to attenuation of glucose-induced insulin secretion from pancreatic ß cells and to enhancement of insulin resistance in peripheral tissues and cells, such as liver (hepatocytes), adipose tissue (adipocytes), and skeletal muscles (myocytes). In this review, we focus on IH-induced dysfunction in glucose metabolism and its underlying molecular mechanisms in several cells and tissues related to glucose homeostasis.


Assuntos
Diabetes Mellitus Tipo 2/etiologia , Diabetes Mellitus Tipo 2/metabolismo , Hipóxia/complicações , Hipóxia/metabolismo , Síndromes da Apneia do Sono/complicações , Tecido Adiposo/metabolismo , Animais , Diabetes Mellitus Tipo 2/epidemiologia , Glucose/metabolismo , Humanos , Hipóxia/epidemiologia , Insulina/metabolismo , Resistência à Insulina , Células Secretoras de Insulina/metabolismo , Fígado/metabolismo , Músculo Esquelético/metabolismo , Tecido Nervoso/metabolismo , Especificidade de Órgãos , Síndromes da Apneia do Sono/epidemiologia
2.
Rev Bras Anestesiol ; 69(4): 390-395, 2019.
Artigo em Português | MEDLINE | ID: mdl-31387740

RESUMO

BACKGROUND: Left double-lumen endotracheal tubes have been widely used in thoracic, esophageal, vascular, and mediastinal procedures to provide lung separation. Lacking clear objective guidelines, anesthesiologists usually select appropriately sized double-lumen endotracheal tubes based on their experience with 35 and 37Fr double-lumen endotracheal tubes, which are the most commonly used. We hypothesized the patients with a left main bronchus of shorter length (<40mm) had a greater chance of experiencing desaturation during one lung ventilation, due to obstruction in the orifice of the left upper lobe with the bronchial tube. METHODS: We included 360 patients with a left double-lumen intubated between September 2014 and August 2015. The patient's age, sex, height, weight, and underlying disease were recorded along with type of surgical procedure and the desaturation episodes. In addition, the width of the trachea and the width and length of the left bronchus were measured using computed tomography. RESULT: Patients with a left main bronchus length of less than 40mm who underwent intubation with a left double-lumen endotracheal tubes had significantly higher incidence of desaturation (Odds Ratio (OR: 8.087)) during one-lung ventilation. Other related factors of patients identified to be at risk of developing hypoxia were diabetes mellitus (OR: 5.368), right side collapse surgery (OR: 4.933), and BMI (OR: 1.105). CONCLUSIONS: We identified that patients with a left main bronchus length of less than 40mm have a great chance of desaturation, especially if other desaturation risk factors are present.


Assuntos
Brônquios/anatomia & histologia , Hipóxia/epidemiologia , Intubação Intratraqueal/métodos , Ventilação Monopulmonar/métodos , Adulto , Idoso , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Tomografia Computadorizada por Raios X
3.
Emerg Med Clin North Am ; 37(3): 431-444, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262413

RESUMO

Acute hypoxemic respiratory failure (AHRF) is a common challenge in emergency medicine. Patient outcomes depend on interventions performed during preintubation, intubation, and postintubation. The article presents recommendations for evidence-based practice to optimally manage patients with AHRF and the acute respiratory distress syndrome.


Assuntos
Hipóxia/terapia , Respiração Artificial , Insuficiência Respiratória/terapia , Algoritmos , Medicina de Emergência , Oxigenação por Membrana Extracorpórea , Hidratação , Glucocorticoides/uso terapêutico , Humanos , Hipóxia/complicações , Hipóxia/epidemiologia , Bloqueadores Neuromusculares/uso terapêutico , Oxigenoterapia , Decúbito Ventral , Síndrome do Desconforto Respiratório do Adulto/terapia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Volume de Ventilação Pulmonar , Vasodilatadores/uso terapêutico , Lesão Pulmonar Induzida por Ventilação Mecânica/prevenção & controle
4.
Emerg Med J ; 36(9): 520-528, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31320332

RESUMO

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.


Assuntos
Protocolos Clínicos/normas , Estado Terminal/terapia , Intubação Intratraqueal/normas , Guias de Prática Clínica como Assunto , Ressuscitação/normas , Adolescente , Bradicardia/epidemiologia , Bradicardia/etiologia , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Hipóxia/epidemiologia , Hipóxia/etiologia , Lactente , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Laringoscópios/efeitos adversos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Estudos Retrospectivos , Gravação em Vídeo , Adulto Jovem
5.
Anesthesiology ; 131(4): 830-839, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31335549

RESUMO

BACKGROUND: The infant airway is particularly vulnerable to trauma from repeated laryngoscopy attempts. Complications associated with elective tracheal intubations in anesthetized infants may be underappreciated. We conducted this study of anesthetized infants to determine the incidence of multiple laryngoscopy attempts during routine tracheal intubation and assess the association of laryngoscopy attempts with hypoxemia and bradycardia. METHODS: We conducted a retrospective cross-sectional cohort study of anesthetized infants (age less than or equal to 12 months) who underwent direct laryngoscopy for oral endotracheal intubation between January 24, 2015, and August 1, 2016. We excluded patients with a history of difficult intubation and emergency procedures. Our primary outcome was the incidence of hypoxemia or bradycardia during induction of anesthesia. We evaluated the relationship between laryngoscopy attempts and our primary outcome, adjusting for age, weight, American Society of Anesthesiologists status, staffing model, and encounter location. RESULTS: A total of 1,341 patients met our inclusion criteria, and 16% (n = 208) had multiple laryngoscopy attempts. The incidence of hypoxemia was 35% (n = 469) and bradycardia was 8.9% (n = 119). Hypoxemia and bradycardia occurred in 3.7% (n = 50) of patients. Multiple laryngoscopy attempts were associated with an increased risk of hypoxemia (adjusted odds ratio: 1.78, 95% CI: 1.30 to 2.43, P < 0.001). There was no association between multiple laryngoscopy attempts and bradycardia (adjusted odds ratio: 1.23, 95% CI: 0.74 to 2.03, P = 0.255). CONCLUSIONS: In a quaternary academic center, healthy infants undergoing routine tracheal intubations had a high incidence of multiple laryngoscopy attempts and associated hypoxemia episodes.


Assuntos
Anestesia/métodos , Bradicardia/epidemiologia , Hipóxia/epidemiologia , Laringoscopia/estatística & dados numéricos , Estudos de Coortes , Estudos Transversais , Humanos , Lactente , Recém-Nascido , Estudos Retrospectivos
6.
Aerosp Med Hum Perform ; 90(8): 720-724, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31331422

RESUMO

INTRODUCTION: The incidence of hypoxia-like symptoms in military aviators is on the rise. Cases can be related to On-Board Oxygen Generating System (OBOGS) malfunction, air contamination, loss of cabin pressurization, hyperventilation, or a combination of these issues simultaneously. Normobaric hypoxia training in tactical fighter simulations has been conducted in the Finnish Air Force since 2008. This training helps aviators to recognize their individual hypoxia symptoms and refreshes hypoxia emergency procedures in a realistic cockpit.METHODS: A flight mission included three set-ups and a return to base (RTB) after the third set-up. In a tactical Hawk simulator, different concentrations of oxygen were used (8%, 7%, and 6% oxygen in nitrogen) to create normobaric hypoxia exposures. During the RTB, the flight instructor evaluated the subjects' flight performance (N = 16) in order to estimate cognitive functions after hypoxia. A control flight was evaluated before or after the flight with normobaric hypoxia exposure.RESULTS: Instrumental flight rule performance during RTB decreased significantly from 4.81 to 3.63 after normobaric hypoxia and emergency procedures. Some pilots reported fatigue, headache, memory problems, and cognitive impairment as adverse effects up to 12 h after normobaric hypoxia training.DISCUSSION: Hypoxia has a significant effect on flight performance during RTB, even 10 min after hypoxia emergency procedures. Since 100% oxygen was used as emergency oxygen, as in a real aircraft, the oxygen paradox may decrease flight performance. Hypoxia training in tactical fighter simulations provides an opportunity for pilots to also understand the effects of the "hypoxia hangover" on their flight performance.Varis N, Parkkola KI, Leino TK. Hypoxia hangover and flight performance after normobaric hypoxia exposure in a Hawk simulator. Aerosp Med Hum Perform. 2019; 90(8):720-724.


Assuntos
Medicina Aeroespacial , Hipóxia/epidemiologia , Militares/estatística & dados numéricos , Pilotos/estatística & dados numéricos , Aeronaves , Altitude , Finlândia , Humanos , Hipóxia/etiologia , Incidência , Masculino , Militares/educação , Pilotos/educação , Treinamento por Simulação
7.
Curr Med Sci ; 39(4): 568-575, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31346992

RESUMO

The possible relationship between lung cancer and nocturnal intermittent hypoxia, apnea and daytime sleepiness, especially the possible relationship between the occurrence and progression of lung cancer and obstructive sleep apnea syndrome (OSAS) was explored. Forty-five cases of primary lung cancer suitable for surgical resection at the Third Affiliated Hospital of Kunming Medical University between January 2017 and December 2017 were recruited (lung cancer group), and there were 45 patients in the control group who had no significant differences in age, sex and other general data from lung cancer group. The analyzed covariates included general situation, snore score, the Epworth Sleeping Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), apnea and hypopneas index (AHI), oxygen desaturation index 4 (ODI4), lowest arterial oxygen saturation [LSpO2 (%)], oxygen below 90% of the time [T90% (min)], the percentage of the total recorded time spend below 90% oxygen saturation (TS90%), to explore the possible relationship between lung cancer and above indicators. The participants were followed up for one year. The results showed that: (1) There was significant difference in body mass index (BMI), ESS, AHI, T90% (min), TS90%, ODI4, snore score and LSpO2 (%) between lung cancer group and control group (P<0.05). There was no statistically significant difference in age, gender, PSQI score, incidence of concurrent hypertension, diabetes and coronary heart disease (CHD), and smoking history between the two groups (P>0.05); (2) Patients in the lung cancer group were divided into OSAS subgroup and non-OSAS subgroup according to the international standard for the diagnosis of OSAS. There was significant difference in BMI, age, staging, incidence of concurrent hypertension and concurrent CHD, snore score, ESS score, T90% (min), TS90%, ODI4 and LSpO2 (%) between OSAS subgroup and non-OSAS subgroup (P<0.05). There was no statistically significant difference in gender, PSQI score, incidence of concurrent diabetes, smoking history and lung cancer type between the two groups (P>0.05); (3) AHI was strongly negatively correlated with the LSpO2 (%) and positively with ESS, staging, snoring score, T90% (min), TS90%, ODI4 and BMI (P<0.05); (4) There were 3 deaths, 5 cases of recurrence, and 4 cases of metastasis in OSAS subgroup; and there was 1 death, 4 cases of recurrence and 2 cases of metastasis in non-OSAS subgroup during the follow-up period of one year, respectively. There was no significant difference in mortality, recurrence rate and metastasis rate between the two subgroups, and the total rate of deterioration in OSAS subgroup was significantly increased compared to the non-OSAS subgroup (P<0.05). It was concluded that the patients with lung cancer are prone to nocturnal hypoxemia, apnea, snoring and daytime sleepiness compared to control group. The incidence of OSAS in patients with lung cancer was higher, and the difference in the hypoxemia-related indicators was statistically significant. The mortality, recurrence rate, and metastasis rate increases in lung cancer patients with OSAS during the one-year follow-up period, suggesting that OSAS may be a contributing factor to the occurrence and progression of lung cancer.


Assuntos
Apneia/epidemiologia , Hipóxia/epidemiologia , Neoplasias Pulmonares/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Adulto , Idoso , Apneia/complicações , Apneia/metabolismo , Apneia/patologia , Índice de Massa Corporal , Progressão da Doença , Feminino , Humanos , Hipertensão/complicações , Hipertensão/epidemiologia , Hipertensão/metabolismo , Hipertensão/patologia , Hipóxia/metabolismo , Hipóxia/patologia , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/metabolismo , Neoplasias Pulmonares/patologia , Masculino , Pessoa de Meia-Idade , Oxigênio/metabolismo , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/metabolismo , Apneia Obstrutiva do Sono/patologia , Sonolência
8.
Enferm. intensiva (Ed. impr.) ; 30(2): 92-93, abr.-jun. 2019.
Artigo em Espanhol | IBECS | ID: ibc-182964

RESUMO

Objetivo: Determinar el efecto de la ventilación con mascarilla-bolsa autoinflable (Ambú(R)) sobre la hipoxemia durante la intubación traqueal en pacientes críticos. La hipótesis planteada es que la ventilación con mascarilla-bolsa autoinflable durante el intervalo desde la inducción anestésica hasta la laringoscopia mejora la SpO2 en comparación con la no ventilación. Diseño: Ensayo clínico, pragmático, no ciego, con asignación aleatoria realizado en 7 Unidades de Cuidados Intensivos en EEUU desde marzo de 2017 a mayo de 2018. Dada la naturaleza de la intervención, los pacientes, los clínicos y el personal de investigación conocían el grupo al que el paciente era asignado. Pacientes:Criterios de inclusión: adultos > 18 años que son sometidos a inducción anestésica e intubación traqueal. Criterios de exclusión: necesidad inmediata de intubación que impide la aleatorización; consideración por parte del médico encargado de necesidad de ventilación con mascarilla-bolsa autoinflable por hipoxemia o acidemia muy graves, contraindicación para ventilación por alto riesgo de aspiración debido a vómitos, hematemesis o hemoptisis; embarazadas; presos. Las causas para la exclusión fueron: indicación urgente para ventilación (42%), indicación urgente para intubación (35%), contraindicación para ventilación (22%), otras (1%)


No disponible


Assuntos
Humanos , Adulto , Máscaras/tendências , Intubação Intratraqueal/métodos , Cuidados Críticos/métodos , Respiração Artificial , Manuseio das Vias Aéreas/enfermagem , Unidades de Terapia Intensiva , Hipóxia/epidemiologia , Laringoscopia
9.
Crit Care ; 23(1): 107, 2019 Apr 03.
Artigo em Inglês | MEDLINE | ID: mdl-30944013

RESUMO

BACKGROUND: In patients who recover consciousness after cardiac arrest (CA), a subsequent death from non-neurological causes may confound the assessment of long-term neurological outcome. We investigated the prevalence and causes of death after awakening (DAA) in a multicenter cohort of CA patients. METHODS: Observational multicenter cohort study on patients resuscitated from CA in eight European intensive care units (ICUs) from January 2007 to December 2014. DAA during the hospital stay was extracted retrospectively from patient medical records. Demographics, comorbidities, initial CA characteristics, concomitant therapies, prognostic tests (clinical examination, electroencephalography (EEG), somatosensory evoked potentials (SSEPs)), and cause of death were identified. RESULTS: From a total 4646 CA patients, 2478 (53%) died in-hospital, of whom 196 (4.2%; ranges 0.6-13.0%) had DAA. DAA was less frequent among out-of-hospital than in-hospital CA (82/2997 [2.7%] vs. 114/1649 [6.9%]; p < 0.001). Median times from CA to awakening and from awakening to death were 2 [1-5] and 9 [3-18] days, respectively. The main causes of DAA were multiple organ failure (n = 61), cardiogenic shock (n = 61), and re-arrest (n = 26). At day 3 from admission, results from EEG (n = 56) and SSEPs (n = 60) did not indicate poor outcome. CONCLUSIONS: In this large multicenter cohort, DAA was observed in 4.2% of non-survivors. Information on DAA is crucial since it may influence epidemiology and the design of future CA studies evaluating neuroprognostication and neuroprotection.


Assuntos
Causas de Morte/tendências , Coma/etiologia , Hipóxia/complicações , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Coma/epidemiologia , Coma/mortalidade , Europa (Continente)/epidemiologia , Feminino , Humanos , Hipóxia/epidemiologia , Hipóxia/mortalidade , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estatísticas não Paramétricas , Suspensão de Tratamento
10.
Ann Transplant ; 24: 139-146, 2019 Mar 12.
Artigo em Inglês | MEDLINE | ID: mdl-30858349

RESUMO

BACKGROUND This study was designed to observe incidence and risk factors of low oxygenation after orthotropic liver transplantation (OLT). MATERIAL AND METHODS We retrospectively evaluated all adult patients who underwent living-donor OLT between January 1, 2017 and December 31, 2017. Postoperative low oxygenation was defined as PaO2/FiO2 <300 mmHg within 24 hours after surgery. Early acute kidney injury (AKI) after OLT was also defined when AKI was happened with 24 hours after operative. RESULTS A total of 301 patients, aged 50.35±10.29 years were enrolled. Of these patients, 100 patients (33.2%) suffered postoperative low oxygenation (PaO2/FiO2=251.80±35.84). Compared with the normal oxygenation group, body mass index (BMI) (24.48±3.53 versus 23.1±3.27 kg/m², P=0.001), preoperative hemoglobin (115.79±29.27 versus 111.52±29.80 g/L, P=0.033), preoperative MELD (22.25±6.54 versus 20.24±5.74, P=0.008), and intraoperative urinary volume (1.25 [0.76, 1.89] versus 2.04 [1.49, 3.68] mL/kg/h, P=0.003) were higher in low oxygenation group. There were more cases of earlier AKIs that occurred after OLT in low oxygenation patients than that in normal group (47% versus 23.4%, P<0.001). Logistic analysis showed that the preoperative BMI (hazard ration [HR]=1.107, [1.010, 1.212], P=0.029) and early AKI after OLT (HR=2.115, [1.161, 3.855], P=0.014) were independent risk factors for postoperative low oxygenation. CONCLUSIONS The incidence of postoperative low oxygenation after liver transplantation in adults was 33.2%. BMI and early AKI after OLT were correlated with postoperative hypoxemia.


Assuntos
Doença Hepática Terminal/cirurgia , Hipóxia/epidemiologia , Hipóxia/etiologia , Transplante de Fígado/efeitos adversos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Fatores de Risco
11.
J Clin Nurs ; 28(11-12): 2245-2252, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30790377

RESUMO

AIMS AND OBJECTIVES: To investigate the associations between nurse staffing and the incidence and severity of hypoxaemia, arterial hypotension and bradycardia of postoperative patients during their postanaesthesia care unit stay. BACKGROUND: Nurse understaffing has been associated with adverse patient outcomes in a variety of hospital settings. In the postanaesthesia care unit, nursing shortage is common and can be related to compromised prevention, detection and treatment of adverse events. DESIGN: Observational, single-centre, prospective study that adhered to Strengthening the Reporting of Observational studies in Epidemiology checklist (see Supporting information Appendix S1); 2,207 patients admitted to the postanaesthesia care unit of a tertiary care hospital over a 5-month period were enrolled. METHODS: Incidence of hypoxaemia (arterial oxygen saturation <95%), arterial hypotension (systolic blood pressure <90 mmHg) and bradycardia (heart rate <50 beats per minute), along with episode severity, was recorded. Patients were classified into three groups as follows: sufficient staffing, low and high understaffing. Risk for hypoxaemia, arterial hypotension and bradycardia was adjusted according to patient, anaesthesia and operation characteristics. RESULTS: The incidence of hypoxaemia was significantly higher in the high understaffing group patients, while the incidence of arterial hypotension was significantly higher in both low and high understaffing group patients, compared to sufficient staffing group ones. In the high understaffing group patients, hypoxaemia and arterial hypotension episodes were of significantly higher severity. CONCLUSIONS: These associations between hypoxaemia and arterial hypotension and postanaesthesia care unit understaffing indicate that care quality and patient safety can be compromised in case patient acuity is not matched with sufficient nursing resources. RELEVANCE TO CLINICAL PRACTICE: Higher incidence of hypoxaemia and arterial hypotension advocates for the prevention of imbalances between patient number and care demands and the number of available nurses.


Assuntos
Período de Recuperação da Anestesia , Recursos Humanos de Enfermagem no Hospital/provisão & distribução , Admissão e Escalonamento de Pessoal/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Adulto , Bradicardia/epidemiologia , Feminino , Humanos , Hipotensão/epidemiologia , Hipóxia/epidemiologia , Incidência , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Período Pós-Operatório , Estudos Prospectivos , Qualidade da Assistência à Saúde
12.
BMC Pulm Med ; 19(1): 51, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30808314

RESUMO

BACKGROUND: Bronchoalveolar lavage (BAL) is utilized for diagnosing lung infiltrates in immunocompromised. There is heterogeneity in the data and reported diagnostic yields range from 26 to 69%. Therefore, selection criteria for BAL to maximize yield and minimize complications are unclear. Objectives of this study were to determine the diagnostic yield and complication rate of BAL in immunocompromised patients presenting with lung infiltrates, and identify factors impacting these outcomes. Exploratory aims included characterization of pathogens, rate of treatment modification and mortality. METHODS: Retrospective study from January 2012 to December 2016. Patients on mechanical ventilation were excluded. Positive diagnostic yield was defined as confirmed microbiological or cytological diagnosis. RESULTS: A total of 217 patients were recruited (70.1% male and mean age: 51.7 ± 14.6 years). Diagnostic yield was 60.8% and complication rate 14.7%. Complications (hypoxemia and endobronchial bleeding) were all sell-limiting. Treatment modification based on BAL results was 63.3%. In 97.0% an infectious aetiology was identified. HIV infection (OR 5.304, 95% CI 1.611-17.458, p = 0.006) and severe neutropenia (OR 4.253, 95% CI 1.288-14.045, p = 0.018) were associated with positive yield. Leukemia (OR 0.317, 95% CI 0.102-0.982, p = 0.047) was associated with lower yield. No factors impacted complication rate. Overall mortality (90-day) was 17.5% and in those with hematologic malignancy, it was 28.3%. CONCLUSION: BAL retains utility in diagnosis of immunocompromised patients with lung infiltrates. However, patients with hematologic malignancy have a high mortality and alternative sampling should be considered because of poor results with BAL. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT01374542 . Registered June 16, 2011.


Assuntos
Antineoplásicos/efeitos adversos , Lavagem Broncoalveolar , Infecções por HIV/imunologia , Neoplasias Hematológicas/imunologia , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Neoplasias Pulmonares/diagnóstico , Pneumonia/diagnóstico , Adenocarcinoma de Pulmão/diagnóstico , Adenocarcinoma de Pulmão/imunologia , Adenocarcinoma de Pulmão/patologia , Adulto , Idoso , Líquido da Lavagem Broncoalveolar/citologia , Líquido da Lavagem Broncoalveolar/microbiologia , Broncoscopia , Carcinoma de Células Escamosas/diagnóstico , Carcinoma de Células Escamosas/imunologia , Carcinoma de Células Escamosas/patologia , Estudos Transversais , Feminino , Humanos , Hipóxia/epidemiologia , Leucemia/imunologia , Neoplasias Pulmonares/imunologia , Neoplasias Pulmonares/patologia , Linfoma/imunologia , Masculino , Pessoa de Meia-Idade , Mortalidade , Neutropenia , Razão de Chances , Transplante de Órgãos , Infecções por Picornaviridae/diagnóstico , Infecções por Picornaviridae/imunologia , Pneumonia/imunologia , Pneumonia/microbiologia , Pneumonia por Pneumocystis/diagnóstico , Pneumonia por Pneumocystis/imunologia , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Eosinofilia Pulmonar/diagnóstico , Eosinofilia Pulmonar/imunologia , Estudos Retrospectivos , Tuberculose Pulmonar/diagnóstico , Tuberculose Pulmonar/imunologia
13.
Br J Anaesth ; 122(3): 388-394, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30770057

RESUMO

BACKGROUND: The incidence of hypoxaemia related to airway management is still a matter of concern. Our aim was to determine the factors that contribute to hypoxaemia during induction of anaesthesia after a standardised preoxygenation procedure. METHODS: The study was a multicentre and prospective observational trial. It evaluated the incidence of hypoxaemia at induction of anaesthesia in adult patients. The primary endpoint was the incidence of hypoxaemia defined as pulse oximetry of arterial oxyhaemoglobin saturation (SpO2) <95%. RESULTS: Of 2398 patients, hypoxaemia was observed in 158 (6.6%). We identified five preoperative independent risk factors: chronic obstructive pulmonary disease, hypertension, anticipated difficult mask ventilation and difficult tracheal intubation, and emergency surgery. There were also three pre-induction independent risk factors: difficult preoxygenation, difficult mask ventilation, and difficult tracheal intubation. We found a high negative predictive value of preoperative risk factors for difficult mask ventilation of 0.96 (0.95-0.96), and for difficult tracheal intubation (0.95 [0.94-0.96]). A total of 723 patients (30%) experienced difficult preoxygenation (FeO2 <90% at the end of preoxygenation). Male sex, chronic obstructive pulmonary disease, hypertension, emergency surgery, and predictable difficult mask ventilation were independent patient risk factors for difficult preoxygenation. CONCLUSIONS: Difficult mask ventilation and difficult tracheal intubation are risk factors for hypoxaemia at induction of general anaesthesia. Difficult preoxygenation was observed in 30% of patients and was also identified as a risk factor for hypoxaemia. This suggests that techniques improving preoxygenation should be implemented in daily practice.


Assuntos
Manuseio das Vias Aéreas/métodos , Anestesia Geral/métodos , Hipóxia/epidemiologia , Oxigênio/administração & dosagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Humanos , Hipóxia/diagnóstico , Incidência , Masculino , Pessoa de Meia-Idade , Oximetria , Estudos Prospectivos , Fatores de Risco , Adulto Jovem
14.
Obes Surg ; 29(4): 1268-1275, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30612327

RESUMO

BACKGROUND: In obese patients (OP), the best intraoperative ventilation strategy remains to be defined. Dynamic lung compliance (Cdyn) and dead space fraction are indicators of efficient ventilation at an optimal positive end-expiratory pressure (PEEP). Herein, we investigated whether intraoperative dynamic lung compliance optimization through PEEP manipulations affects the incidence of postoperative hypoxemia (SpO2 < 90%) in OP undergoing laparoscopic bariatric surgery (LBS). METHODS: This was a single-center, prospective, randomized controlled study conducted from July 2013 to December 2015. After obtaining institutional review board approval and informed consent, 100 OP undergoing LBS under volume-controlled ventilation (tidal volume 8 mL/kg of ideal body weight) were randomized according to the PEEP level maintained during the surgery. In the control group, a PEEP of 10 cm H2O was maintained, while in the intervention group, the PEEP was adapted to achieve the best dynamic lung compliance. Anesthesia and analgesia were standardized. The patients received supplemental nasal oxygen on the first postoperative day and were monitored up to the second postoperative day with a portable pulse oximeter. RESULTS: Demographics were similar between groups. There was no difference in the incidence of hypoxemia during the first 2 postoperative days (control: 1.3%; intervention: 2.1%; p = 0.264). CONCLUSIONS: The incidence of postoperative hypoxemia was not reduced by an open-lung approach with protective ventilation strategy in obese patients undergoing LBS. A pragmatic application of a PEEP level of 10 cm H2O was comparable to individual PEEP titration in these patients. TRIAL REGISTRATION: Clinicaltrials.gov identifier, NCT02579798; https://clinicaltrials.gov/ct2/show/NCT02579798.


Assuntos
Cirurgia Bariátrica/efeitos adversos , Hipóxia/epidemiologia , Hipóxia/prevenção & controle , Complacência Pulmonar/fisiologia , Obesidade Mórbida/cirurgia , Respiração com Pressão Positiva , Adulto , Cirurgia Bariátrica/métodos , Feminino , Humanos , Hipóxia/etiologia , Incidência , Laparoscopia/efeitos adversos , Pulmão/fisiologia , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/epidemiologia , Obesidade Mórbida/fisiopatologia , Respiração com Pressão Positiva/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Estudos Prospectivos , Respiração , Volume de Ventilação Pulmonar
15.
J Matern Fetal Neonatal Med ; 32(17): 2889-2896, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29527962

RESUMO

Objective: Optimal management of twin deliveries is controversial. We aimed to assess potential risk factors correlated to the development of hypoxia in the second twin after vaginal delivery of the first twin. Study design: This is a retrospective observational study including diamniotic twin pregnancies delivering at our Institution at 35 weeks of gestational age or more, weighing ≥1800 g. Hypoxia was defined as at least one of the following: Apgar score <5 at 10 minute, neonatal resuscitation for >10 minutes, neonatal acidosis (pH ≤7 and/or BE ≥12 mmol/L). Results: A number of 275 diamniotic twin pregnancies met the inclusion criteria and were divided within the following groups: (1) second twin not developing neonatal hypoxia (n = 265); and (2) second twin developing neonatal hypoxia (n = 10). The rate of second twins with neonatal hypoxia during the study period was 3.6% (10/275). Abnormal cardiotocography during the intertwin delivery interval, defined as ACOG category III, was significantly correlated to second twin hypoxia. Of interest, there was no significant difference in the intertwin delivery interval between the study groups. In addition, breech presentation of the second twin did not show to be a risk factor for neonatal hypoxia. None of the second twins developing neonatal hypoxia was reported to have encephalopathy (follow up of at least 24 months). At multivariate analysis, only abnormal cardiotocography was an independent risk factor for second twin hypoxia (OR 17.8, 95% CI 4.1-77.2). Conclusions: In our study, neonatal hypoxia was significantly correlated to abnormal cardiotocography, while intertwin delivery interval was not correlated to the development of this adverse neonatal outcome.


Assuntos
Parto Obstétrico/estatística & dados numéricos , Frequência Cardíaca Fetal/fisiologia , Hipóxia/epidemiologia , Adulto , Cardiotocografia , Estudos de Casos e Controles , Parto Obstétrico/efeitos adversos , Feminino , Humanos , Hipóxia/etiologia , Recém-Nascido , Masculino , Gravidez , Gravidez de Gêmeos , Estudos Retrospectivos , Fatores de Tempo , Gêmeos , Adulto Jovem
16.
Gastrointest Endosc ; 89(4): 855-862, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30217726

RESUMO

BACKGROUND AND AIMS: ERCP is a complex procedure often performed in patients at high risk for sedation-related adverse events (SRAEs). However, there is no current standard of care with regard to mode of sedation and airway management during ERCP. The aim of this study was to assess the safety of general endotracheal anesthesia (GEA) versus propofol-based monitored anesthesia care (MAC) without endotracheal intubation in patients undergoing ERCP at high risk for SRAEs. METHODS: Consecutive patients undergoing ERCP at high risk for SRAEs at a single center were invited to participate in this randomized controlled trial comparing GEA and MAC. Inclusion criteria were STOP-BANG score ≥3, abdominal ascites, body mass index ≥35, chronic lung disease, American Society of Anesthesiologists class >3, Mallampati class 4 airway, and moderate to heavy alcohol use. Exclusion criteria were preceding EUS, emergent ERCP, tracheostomy, unstable airway, gastric outlet obstruction or delayed gastric emptying, and altered foregut anatomy. The primary endpoint was composite incidence of SRAEs: hypoxemia, use of airway maneuvers, hypotension requiring vasopressors, sedation-related procedure interruption, cardiac arrhythmia, and respiratory failure. Secondary outcomes included procedure duration, cannulation success, in-room time, and immediate adverse events. RESULTS: Two hundred patients (mean age, 61.1 ± 13.6 years; 36.5% women) were randomly assigned to GEA (n = 101) or MAC (n = 99) groups. Composite SRAEs were significantly higher in the MAC group compared with the GEA group (51.5% vs 9.9%, P < .001). This was primarily driven by the frequent need for airway maneuvers in the MAC group. Additionally, ERCP was interrupted in 10.1% of patients in the MAC group to convert to GEA because of respiratory instability refractory to airway maneuvers (n = 8) or significant retained gastric contents (n = 2). There were no statistically significant differences in cannulation, in-room, procedure, or fluoroscopy times between the 2 groups. All patients undergoing GEA were successfully extubated in the procedure room at completion of ERCP, and Aldrete scores in recovery did not differ between the 2 groups. There were no immediate adverse events. CONCLUSION: In patients at high risk for SRAEs undergoing ERCP, sedation with GEA is associated with a significantly lower incidence of SRAEs, without impacting procedure duration, success, recovery, or in-room time. These data suggest that GEA should be used for ERCP in patients at high risk for SRAEs (Clinical trial registration number: NCT02850887.).


Assuntos
Anestesia Endotraqueal/efeitos adversos , Anestesia Geral/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/métodos , Sedação Profunda/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Idoso , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia Endotraqueal/métodos , Anestesia Geral/métodos , Arritmias Cardíacas/epidemiologia , Arritmias Cardíacas/etiologia , Sedação Profunda/métodos , Feminino , Humanos , Hipotensão/tratamento farmacológico , Hipotensão/epidemiologia , Hipotensão/etiologia , Hipóxia/epidemiologia , Hipóxia/etiologia , Incidência , Complicações Intraoperatórias/etiologia , Masculino , Pessoa de Meia-Idade , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Vasoconstritores/uso terapêutico
17.
J Pediatr ; 204: 89-95.e1, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30287066

RESUMO

OBJECTIVE: To determine if late preterm infants are at increased risk of intermittent hypoxemic events compared with term infants. STUDY DESIGN: Prospective, cohort, observational study of late preterm infants (340/7-366/7 weeks gestational age) and term infants (390/7-416/7 weeks gestational age). Overnight pulse oximetry recordings were performed on days 2-3 after birth, at term equivalent age, and at 45 weeks postmenstrual age. The primary outcome was the frequency of intermittent hypoxemic events per hour (desaturation ≥10% below the preceding baseline SpO2) on the oximetry recording on days 2-3 after birth. Data were analyzed by the Student t test and general linear mixed model. RESULTS: Eighty-five infants were enrolled (late preterm n = 43; term infants n = 42). On days 2-3 after birth, late preterm infants had more intermittent hypoxemic events than term infants (events per hour, mean ± standard error of the mean, 2.5 ± 1.2 vs 1.0 ± 1.2; P < .0001). On mixed model analysis, late preterm infants had a higher frequency of intermittent hypoxemic events at term equivalent age, which decreased to a similar frequency as in term infants by 45 weeks postmenstrual age (events per hour; term equivalent age, late preterm: least squares mean, 3.7 [95% CI, 2.7-5.1] vs term: least squares mean, 1.7 [95% CI, 1.2-2.3]; 45 weeks postmenstrual age, late preterm: least squares mean, 1.5 [95% CI, 1.1-2.1] vs term: least squares mean, 1.9 [95% CI, 1.4-2.6]; P < .0005). CONCLUSIONS: Late preterm infants are at greater risk of intermittent hypoxemia than term infants soon after birth. We speculate that preventing intermittent hypoxemia in late preterm infants may improve neurodevelopmental outcomes.


Assuntos
Hipóxia/etiologia , Recém-Nascido Prematuro/sangue , Oximetria/métodos , Estudos de Coortes , Feminino , Humanos , Hipóxia/epidemiologia , Recém-Nascido , Masculino , Gravidez , Estudos Prospectivos , Medição de Risco/métodos
18.
Sleep Breath ; 23(1): 373-378, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30349997

RESUMO

PURPOSE: Growing evidence has revealed that nonalcoholic fatty liver disease (NAFLD) is associated with type 2 diabetes. This study aimed to assess the association between glycometabolism and NAFLD in patients with obstructive sleep apnea (OSA). METHODS: Patients with suspected OSA were enrolled consecutively and then underwent polysomnography, liver ultrasound, and biochemical measurements. Logistic regressions were used to identify factors associated with NAFLD. RESULTS: In total, 415 patients were included. The prevalence of NAFLD in the non-OSA, mild OSA, moderate OSA, and severe OSA groups was 37.21%, 69.09%, 68.34%, and 78.08%, respectively. Stepwise logistic regression suggested that percentage of total sleep time spent with oxygen saturation of < 90% (TS90), lowest oxygen saturation (LaSO2), and homeostatic model assessment of insulin resistance (HOMA-IR) were independently associated with NAFLD in all subjects, after adjusting for confounders (odds ratio [OR] = 1.037, p = 0.014; OR = 1.056, p = 0.004; OR = 0.732, p = 0.009; respectively). TS90, LaSO2, and HOMA-IR were also independent predictors for NAFLD in patients with mild and moderate OSA, whereas TS90, LaSO2, and ODI were independent predictors for NAFLD in patients with severe OSA. CONCLUSIONS: There is a relationship between OSA and NAFLD, and the combination of disordered glycometabolism and intermittent hypoxia may act as a "two hit" mechanism to promote the development of NAFLD. Furthermore, intermittent hypoxia alone was an independent predictor for NAFLD in severe OSA patients.


Assuntos
Diabetes Mellitus Tipo 2/diagnóstico , Glicogênio Hepático/metabolismo , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Apneia Obstrutiva do Sono/diagnóstico , Adulto , Idoso , Correlação de Dados , Estudos Transversais , Diabetes Mellitus Tipo 2/epidemiologia , Feminino , Homeostase/fisiologia , Humanos , Hipóxia/diagnóstico , Hipóxia/epidemiologia , Resistência à Insulina/fisiologia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Oxigênio/sangue , Polissonografia , Fatores de Risco , Apneia Obstrutiva do Sono/epidemiologia
19.
Rev Gastroenterol Peru ; 38(3): 242-247, 2018.
Artigo em Espanhol | MEDLINE | ID: mdl-30540727

RESUMO

INTRODUCTION: Hepatopulmonary syndrome (HPS) is a serious complication of liver disease, which is characterized by the presence of intrapulmonary vasodilation and progressive hypoxemia. Liver transplantation is the only effective treatment. OBJECTIVE: To show our results of patients with hepatopulmonary syndrome undergoing liver transplantation. MATERIALS AND METHODS: Retrospective, descriptive and cross-sectional study. From March 2000 to December 2016; 226 liver transplants were performed. Of the total, 25 patients were excluded: 12 retransplantation, 9 liver-kidney combined transplants, 2 transplants for acute liver failure, 2 transplants in non-cirrhotic patients. Of the 201 patients with pretransplant diagnosis of liver cirrhosis, 19 filled criteria for SHP; who were distributed according to age, sex, hypoxemia level (pO2), Child-Pugh score and MELD score. The reversibility hypoxemia after liver trasplantation was measured with a cut-off of p02 >75 mmHg. RESULTS: The prevalence of SHP in our series was 9.45%. The average age was 41 years (14-65); the M / F ratio of 1.65. The 78.94% (15/19) were adults. 89.5% (17/19) were Score of Child-Pugh B and C, and 68.4% had severe and very severe SHP. In 94.11% of patients, reversibility SHP founded. The early mortality rate (30 days) in patients with SHP was 10.4%. CONCLUSIONS: The prevalence of HPS in our series was 9.45%. Transplanted patients with and without SHP had similar survival.


Assuntos
Síndrome Hepatopulmonar/cirurgia , Transplante de Fígado , Adolescente , Adulto , Idoso , Estudos Transversais , Feminino , Hepatite Autoimune/cirurgia , Síndrome Hepatopulmonar/epidemiologia , Departamentos Hospitalares/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Humanos , Hipóxia/epidemiologia , Hipóxia/etiologia , Transplante de Rim/estatística & dados numéricos , Cirrose Hepática/cirurgia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Índice de Gravidade de Doença , Adulto Jovem
20.
Seizure ; 63: 7-13, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30391664

RESUMO

PURPOSE: To estimate the incidence of ictal hypoxemia (IH) and to identify clinical and study-related factors modulating the estimate. METHODS: We searched articles recording concurrent peri-ictal and ictal EEG and Sp02 in adults and children with epilepsy. Studies reporting the total number of seizures recorded and the number of seizures with IH were included in a random-effects meta-analysis. A random-effects meta-regression was used to identify variables affecting study heterogeneity. RESULTS: Twenty-one studies, including 917 participants and 1840 with SpO2 data available were included. The meta-analysis showed a pooled incidence of IH of 35/100 seizures (95% CI 27-44). Sp02 desaturation threshold was associated with the incidence of IH, with less severe desaturations resulting in higher IH frequencies. The incidence of IH was 41/100 seizures (95% CI 29-54) for adults and 47/100 seizures (95% CI 15-78) for tonic-clonic seizures. The meta-regression showed that SpO2 desaturation severity was the sole variable significantly correlated with the incidence of ictal hypoxemia (p = 0.00). CONCLUSION: In a population with refractory epilepsy IH is a frequent phenomenon, especially in adults and in patients presenting with tonic-clonic seizures. The severity of IH appeared independent from the age group and from seizure type and is probably the major clinical concern for its correlation with potentially life-threatening cardiorespiratory alterations and sudden unexpected death in epilepsy (SUDEP).


Assuntos
Epilepsia/epidemiologia , Hipóxia/epidemiologia , Convulsões/epidemiologia , Epilepsia/fisiopatologia , Humanos , Hipóxia/fisiopatologia , Incidência , Convulsões/fisiopatologia
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