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1.
BMC Surg ; 21(1): 1, 2021 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-33388031

RESUMO

BACKGROUND: The effect of low systolic blood pressure and its subsequent postoperative outcome during esophagectomy for esophageal cancer is not well studied. METHODS: A prospective study was conducted and data were collected on patients who underwent esophagectomy and esophagogastric anastomosis for esophageal cancer. Intraoperative hypotension (IOH), defined as systolic blood pressure (SBP) < 90 mm Hg lasting more than 5 min, was recorded. Patients' 30 days post-operative composite outcome of mortality, anastomotic leak, and prolonged hospital stay were analyzed as outcome variables. RESULT: A total of 54 patients underwent esophagectomy for esophageal cancer during the study period. The mean age was 54 years. The mean duration of the surgery was 208 min. Intraoperative mean low SBP was 80 mmHg while the lowest record was 55 mmHg. IOH occurred in 51% (n = 29) of patients. Anastomotic leak occurred in 7% (n = 4) (OR 1.2, 95% CI 0.26-6.3; p = 0.76). In-hospital mortality was 5% (n = 3) (OR 1.44, 95% CI 0.22-9.3; p = 0.7) and 33% (n = 18) had prolonged hospital stay (OR 0.53, 95% CI 0.14-1.9; p = 0.34). The overall anastomotic leak rate was 13% (n = 7). Multivariate analysis (logistic regression model) showed SBP < 90 mmHg for more than 5 min was not significantly associated either with individual or composite outcomes of mortality, anastomotic leak, and prolonged hospital stay (AOR 1.06, 95% CI 0.98-1.14; p = 0.16) CONCLUSION: In patients undergoing esophagectomy for esophageal cancer, a systolic blood pressure < 90 mm Hg for greater than 5 min during surgery has no significant statistical association with composite adverse outcomes of mortality, anastomotic leak, and prolonged hospital stay.


Assuntos
Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Hipotensão/etiologia , Anastomose Cirúrgica , Fístula Anastomótica/epidemiologia , Fístula Anastomótica/etiologia , Fístula Anastomótica/cirurgia , Feminino , Humanos , Hipotensão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos
2.
Artigo em Inglês | MEDLINE | ID: mdl-33477713

RESUMO

Perioperative neurocognitive disorders remain a challenging obstacle in patients after cardiac surgery, as they significantly contribute to postoperative morbidity and mortality. Identifying the modifiable risk factors and mechanisms for postoperative cognitive decline (POCD) and delirium (POD) would be an important step forward in preventing such adverse events and thus improving patients' outcome. Intraoperative hypotension is frequently discussed as a potential risk factor for neurocognitive decline, due to its significant impact on blood flow and tissue perfusion, however the studies exploring its association with POCD and POD are very heterogeneous and present divergent results. This review demonstrates 13 studies found after structured systematic search strategy and discusses the possible relationship between intraoperative hypotension and postoperative neuropsychiatric dysfunction.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Disfunção Cognitiva , Delírio , Hipotensão , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Disfunção Cognitiva/epidemiologia , Disfunção Cognitiva/etiologia , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Complicações Pós-Operatórias/epidemiologia
3.
PLoS One ; 15(8): e0236755, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32790681

RESUMO

BACKGROUND: Spinal anesthesia is a type of regional anesthesia that has been practicing for obstetric anesthesia since the beginning of the 20th century. Despite the simplicity and lower maternal mortality risk, compared to general anesthesia, spinal anesthesia is linked to different adverse effects, of which hypotension is the most common complication. The main aim of this study was to determine the incidence and associated factors of hypotension after spinal anesthesia during cesarean section. METHOD: Institution-based cross-sectional study was conducted with 410 clients. The study was conducted on cesarean section under spinal anesthesia from 5th January to 30th April 2019, at the Gandhi Memorial Hospital, Addis Ababa, Ethiopia. Both bivariable and multivariable logistic regression analysis were done on the associated factors. The level of statistical significance was represented at p<0.05. RESULTS: The incidence of hypotension among mothers who underwent a cesarean section after spinal anesthesia was 64%. Newborn weight ≥4kg (AOR = 5.373; 95%CI: (1.627-17.740)) showed an increase risk of association with hypotension. A baseline systolic blood pressure < 120mmHg (AOR = 6.293; (95%CI: 2.999-13.204)) was found to be associated with increased risk of hypotension. Sensory block height >T6 AOR = 2.230; 95%CI: (1.329-3.741), the time interval between spinal induction and skin incision > 6minutes AOR = 1.803; 95%CI: (1.044-3.114) and anesthetist experience AOR = 5.033(95%CI: 2.144-11.818) were also associated with hypotension. CONCLUSION: The identified risk factors for hypotension, after spinal anesthesia are sensory height block, weight of the baby, the time interval between spinal induction and skin incision, baseline systolic blood pressure, and anesthetist experience.


Assuntos
Raquianestesia/efeitos adversos , Hipotensão/diagnóstico , Adolescente , Adulto , Pressão Sanguínea , Cesárea , Etiópia/epidemiologia , Feminino , Hospitais , Humanos , Hipotensão/epidemiologia , Incidência , Razão de Chances , Gravidez , Fatores de Risco , Adulto Jovem
4.
Medicine (Baltimore) ; 99(28): e20946, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664094

RESUMO

BACKGROUND: The beach chair position (BCP), used during shoulder surgery, is associated with hypotension, bradycardia, and risk of cerebral hypoperfusion. Phenylephrine is commonly used as a first treatment of choice of intraoperative hypotension during surgery. We evaluated the hemodynamic effects of 2 doses of intravenous phenylephrine infusion administered before being placed in BCP for arthroscopic shoulder surgery. The primary endpoint was the incidence of hypotension after positional change. METHODS: Sixty-six patients were randomized to receive either intravenous normal saline (group NS) or intravenous phenylephrine infusion (0.5 µg/kg/min, group LP or 1.0 µg/kg/min, group HP) for 5 minutes before being placed in the BCP. Mean arterial pressure(MAP), heart rate, stroke volume variation, and cardiac index were measured before and after positional change. RESULTS: The total incidence of hypotension after the BCP was 93.65%, but was not significantly different among the 3 groups. However, there was a significant difference in trends between the groups for MAP for 5 minutes after BCP (P = .028). Comparison of changes in MAP at 1 minute compared to post-induction MAP was significantly different between group HP and group NS (P = .014). CONCLUSION: Infusion of 0.5 and 1.0 µg/kg/min of phenylephrine for 5 minutes before the BCP has no preventive effect for incidence of hypotension. However, this study showed that 1.0 µg/kg/min of phenylephrine infusion for 5 minutes can attenuate the severity of hypotension.


Assuntos
Hipotensão/etiologia , Hipotensão/prevenção & controle , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/prevenção & controle , Posicionamento do Paciente/efeitos adversos , Fenilefrina/administração & dosagem , Idoso , Feminino , Humanos , Hipotensão/epidemiologia , Incidência , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Método Simples-Cego
5.
Anesthesiology ; 133(3): 510-522, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32487822

RESUMO

BACKGROUND: Intraoperative hypotension has been associated with postoperative morbidity and early mortality. Postoperative hypotension, however, has been less studied. This study examines postoperative hypotension, hypothesizing that both the degree of hypotension severity and longer durations would be associated with myocardial injury. METHODS: This single-center observational cohort was comprised of 1,710 patients aged 60 yr or more undergoing intermediate- to high-risk noncardiac surgery. Frequent sampling of hemodynamic monitoring on a postoperative high-dependency ward during the first 24 h after surgery was recorded. Multiple mean arterial pressure (MAP) absolute thresholds (50 to 75 mmHg) were used to define hypotension characterized by cumulative minutes, duration, area, and time-weighted-average under MAP. Zero time spent under a threshold was used as the reference group. The primary outcome was myocardial injury (a peak high-sensitive troponin T measurement 50 ng/l or greater) during the first 3 postoperative days. RESULTS: Postoperative hypotension was common, e.g., 2 cumulative hours below a threshold of 60 mmHg occurred in 144 (8%) patients while 4 h less than 75 mmHg occurred in 824 (48%) patients. Patients with myocardial injury had higher prolonged exposures for all characterizations. After adjusting for confounders, postoperative duration below a threshold of 75 mmHg for more than 635 min was associated with myocardial injury (adjusted odds ratio, 2.68; 95% CI, 1.46 to 5.07, P = 0.002). Comparing multiple thresholds, cumulative durations of 2 to 4 h below a MAP threshold of 60 mmHg (adjusted odds ratio, 3.26; 95% CI, 1.57 to 6.48, P = 0.001) and durations of more than 4 h less than 65 mmHg (adjusted odds ratio, 2.98; 95% CI, 1.78 to 4.98, P < 0.001) and 70 mmHg (adjusted odds ratio, 2.18; 95% CI, 1.37 to 3.51, P < 0.001) were also associated with myocardial injury. Associations remained significant after adjusting for intraoperative hypotension, which independently was not associated with myocardial injury. CONCLUSIONS: In this study, postoperative hypotension was common and was independently associated with myocardial injury.


Assuntos
Hipotensão/epidemiologia , Infarto do Miocárdio/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios , Idoso , Causalidade , Estudos de Coortes , Comorbidade , Feminino , Humanos , Masculino , Países Baixos/epidemiologia
6.
Transplant Proc ; 52(6): 1788-1790, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32571703

RESUMO

BACKGROUND: The use of a minimally invasive laparoscopic approach in living donor hepatectomy is increasing with the need for enhanced management of living donors. Hypotensive bradycardia often occurs during abdominal surgery and can be fatal without proper management. We conducted a retrospective study to investigate the incidence and risk factors of symptomatic (hypotensive) bradycardia in laparoscopic living donor hepatectomy. METHODS: Hypotensive bradycardia is defined as the heart rate below 60 beats per minute with simultaneous mean arterial blood pressure (MAP) below 65 mm Hg. Clinical characteristics of liver donors were collected and analyzed from May 2018 to July 2019. RESULTS: This study included 129 cases of living donor hepatectomy; 11 donors of open hepatectomy were excluded, and 118 donors undergoing laparoscopic hepatectomy were analyzed. Hypotensive bradycardia was shown in 27 donors. Hypertension or angiotensin receptor blocker medication were significantly related to hypotensive bradycardia. Hypotensive bradycardia occurred after incision in 22 donors, and the onset time from the incision was 7.5 minutes [first quartile (Q1) 5.75, third quartile (Q3) 11.5, range 0-25], the minimum heart rate was 48.5 beats per minute (Q1 41.5, Q3 53.25, range 25-57), and the minimum MAP was 55 mm Hg (Q1 45, Q3 57.5, range 35-63). It took 132 seconds (Q1 42, Q3 189, range 12-408) to recover MAP over 65 mm Hg. CONCLUSIONS: Hypotensive bradycardia occurred in 22.9% of the laparoscopic living donor hepatectomy cases, and 80.6% of cases occurred after incision. Thorough preoperative evaluation and close monitoring is important even in a healthy donor.


Assuntos
Bradicardia/epidemiologia , Hepatectomia/efeitos adversos , Complicações Intraoperatórias/epidemiologia , Laparoscopia/efeitos adversos , Coleta de Tecidos e Órgãos/efeitos adversos , Adulto , Bradicardia/etiologia , Feminino , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Incidência , Complicações Intraoperatórias/etiologia , Fígado/cirurgia , Transplante de Fígado , Doadores Vivos , Masculino , Estudos Retrospectivos , Fatores de Risco , Ferida Cirúrgica
7.
Arch Gynecol Obstet ; 302(4): 829-836, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32588134

RESUMO

OBJECTIVE: To investigate the efficacy and safety of prophylactic infusion of norepinephrine (NE) versus normal saline in patients undergoing cesarean section. METHODS: Patients (n = 97) were randomized to receive a bolus of NE (6 µg) immediately following spinal anesthesia with maintenance NE (0.05 µg/kg/min IV) or normal saline (n = 98). The primary endpoint was the incidence of postspinal anesthesia hypotension [systolic blood pressure (SBP) < 80% of baseline] at 1-20 min following spinal anesthesia. Secondary outcomes were the overall stability of SBP control versus baseline, inferior vena cava collapsibility index (IVC-CI), other adverse events (bradycardia, nausea, vomiting, and hypertension), and neonatal outcomes (blood gas values and Apgar scores). RESULTS: The rates of postspinal anesthesia hypotension and severe postspinal anesthesia hypotension (SBP < 60% of the baseline) were significantly lower in the NE group (17.5% vs. 62.2%, p < 0.001; 7.2% vs. 17.4%, p = 0.031). In the NE group, SBP remained more stable and closer to baseline (p < 0.001), and IVC-CI values were lower 5 min after spinal anesthesia and 5 min after fetal delivery (p = 0.045; p < 0.001, respectively). Other adverse effects and neonatal outcomes were not different between the two groups. CONCLUSION: Prophylactic NE infusion effectively lowers the incidence of postspinal anesthesia hypotension and does not increase other adverse events in patients or neonates.


Assuntos
Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Cesárea/efeitos adversos , Hipotensão/prevenção & controle , Infusões Parenterais/efeitos adversos , Norepinefrina/administração & dosagem , Profilaxia Pré-Exposição/métodos , Vasoconstritores/administração & dosagem , Adulto , Anestesia Obstétrica/métodos , Raquianestesia/métodos , Pressão Sanguínea , Bradicardia/induzido quimicamente , Bradicardia/epidemiologia , Cesárea/métodos , China/epidemiologia , Feminino , Humanos , Hipertensão/induzido quimicamente , Hipertensão/complicações , Hipotensão/epidemiologia , Recém-Nascido , Infusões Parenterais/métodos , Pessoa de Meia-Idade , Náusea/induzido quimicamente , Náusea/epidemiologia , Norepinefrina/efeitos adversos , Gravidez , Resultado do Tratamento , Vasoconstritores/efeitos adversos , Vômito/induzido quimicamente , Vômito/epidemiologia , Adulto Jovem
8.
PLoS One ; 15(4): e0231172, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32298292

RESUMO

Arterial hypotension during the early phase of anesthesia can lead to adverse outcomes such as a prolonged postoperative stay or even death. Predicting hypotension during anesthesia induction is complicated by its diverse causes. We investigated the feasibility of developing a machine-learning model to predict postinduction hypotension. Naïve Bayes, logistic regression, random forest, and artificial neural network models were trained to predict postinduction hypotension, occurring between tracheal intubation and incision, using data for the period from between the start of anesthesia induction and immediately before tracheal intubation obtained from an anesthesia monitor, a drug administration infusion pump, an anesthesia machine, and from patients' demographics, together with preexisting disease information from electronic health records. Among 222 patients, 126 developed postinduction hypotension. The random-forest model showed the best performance, with an area under the receiver operating characteristic curve of 0.842 (95% confidence interval [CI]: 0.736-0.948). This was higher than that for the Naïve Bayes (0.778; 95% CI: 0.65-0.898), logistic regression (0.756; 95% CI: 0.630-0.881), and artificial-neural-network (0.760; 95% CI: 0.640-0.880) models. The most important features affecting the accuracy of machine-learning prediction were a patient's lowest systolic blood pressure, lowest mean blood pressure, and mean systolic blood pressure before tracheal intubation. We found that machine-learning models using data obtained from various anesthesia machines between the start of anesthesia induction and immediately before tracheal intubation can predict hypotension occurring during the period between tracheal intubation and incision.


Assuntos
Anestesia Geral/efeitos adversos , Anestésicos/efeitos adversos , Hipotensão/epidemiologia , Aprendizado de Máquina , Modelos Cardiovasculares , Adulto , Idoso , Anestesia Geral/instrumentação , Anestésicos/administração & dosagem , Pressão Arterial/efeitos dos fármacos , Teorema de Bayes , Colecistectomia Laparoscópica/efeitos adversos , Sistemas de Liberação de Medicamentos/estatística & dados numéricos , Registros Eletrônicos de Saúde/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Hipotensão/etiologia , Intubação Intratraqueal/efeitos adversos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/estatística & dados numéricos , Redes Neurais de Computação , Curva ROC , Estudos Retrospectivos , Medição de Risco/métodos
9.
Am J Kidney Dis ; 76(3): 331-339, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32331831

RESUMO

BACKGROUND: Most patients receiving maintenance hemodialysis (HD) experience adverse symptoms, which are associated with decreased quality of life. Despite decades of experience, our understanding of causes of HD symptoms remains limited. We aimed to identify modifiable patient- and HD-related predictors of intradialytic symptoms. STUDY DESIGN: Prospective cohort. SETTING & PARTICIPANTS: We leveraged patient-level (n=1,838) and HD session-level (n=64,797) data from the Hemodialysis Trial. EXPOSURE: Pre-HD serum urea nitrogen (SUN) level, pre-HD systolic blood pressure (SBP), intradialytic SBP decline, and ultrafiltration rate (UFR). OUTCOMES: Intra-HD symptoms, including cramps, nausea, chest pain, headache, and lightheadedness. ANALYTICAL APPROACH: Random-effects logistic regression models. RESULTS: Overall, symptoms occurred in 10.7% of HD sessions. Higher pre-HD SUN level (per 10 mg/dL) was associated with higher adjusted odds of muscle cramping and lightheadedness (adjusted ORs [aORs] of 1.20 [95% CI, 1.17-1.22] and 1.13 [95% CI, 1.08-1.18], respectively). SBP decline (from the predialysis value to the dialysis session nadir, per each 10-mm Hg decrease) was associated with greater risk for muscle cramping, headache, chest pain, vomiting, and lightheadedness (the largest aORs were for the 2 latter symptoms: 1.24 [95% CI, 1.20-1.28] and 1.37 [95% CI, 1.33-1.42], respectively). Higher UFR (per 1 mL/kg/h) was associated with greater odds of cramping (aOR, 1.03; 95% CI, 1.02-1.03). Conversely, higher pre-HD SBP (per 10 mm Hg) was associated with reduced risk for vomiting (aOR, 0.88; 95% CI, 0.85-0.92) and lightheadedness (aOR, 0.82; 95% CI, 0.80-0.85). LIMITATIONS: Measured osmolality, dialysate prescription data, and time stamps for symptom occurrence were not available. Clinical trial data may not be broadly generalizable. CONCLUSIONS: Higher pre-HD SUN level, UFR, pre-HD SBP, and SBP decline are independently associated with different patterns of adverse intradialytic symptoms. Recognition that different symptoms may have variable causes may allow tailoring of personalized treatments in future interventional studies.


Assuntos
Diálise Renal/efeitos adversos , Adulto , Idoso , Pressão Sanguínea , Nitrogênio da Ureia Sanguínea , Tontura/epidemiologia , Tontura/etiologia , Feminino , Cefaleia/epidemiologia , Cefaleia/etiologia , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto/estatística & dados numéricos , Cãibra Muscular/epidemiologia , Cãibra Muscular/etiologia , Náusea/epidemiologia , Náusea/etiologia , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos
10.
Obstet Gynecol ; 135(5): 1145-1151, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32282591

RESUMO

OBJECTIVE: To compare the effect of exteriorized with in situ uterine repair on intraoperative nausea and vomiting during elective cesarean delivery under spinal anesthesia using a phenylephrine infusion. METHODS: This study was a randomized double-blinded controlled trial of 180 women undergoing elective cesarean delivery using a standardized anesthetic protocol. Patients were randomized to exteriorization (n=90) or in situ uterine repair (n=90). The spinal anesthetic, phenylephrine infusion, and blood pressure management were all standardized. The primary outcome was postdelivery intraoperative nausea and vomiting using a 4-point scale (0-3). A sample size of 80 patients per group was needed to demonstrate a 50% reduction in intraoperative nausea and vomiting with in situ repair. RESULTS: From November 2015 through July 2018, 180 patients were enrolled. Incidence of postdelivery intraoperative nausea and vomiting was 39% in the exteriorization group compared with 22% in the in situ group (P=.01). Incidence of hypotension (80% vs 50%; P<.001) and tachycardia (33% vs 17%; P=.02) was significantly higher in the exteriorization group, and more phenylephrine boluses were administered to this group (median 4 boluses [first and third quartiles 1.25-7] vs 2 [0-4]; P<.001). The duration of surgery, blood loss, and postoperative hemoglobin decline were similar between groups. CONCLUSION: In situ uterine repair for elective cesarean delivery under spinal anesthesia with a phenylephrine infusion is associated with less postdelivery intraoperative nausea and vomiting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02587013.


Assuntos
Antieméticos/administração & dosagem , Parto Obstétrico/efeitos adversos , Histerotomia/métodos , Complicações Intraoperatórias/prevenção & controle , Fenilefrina/administração & dosagem , Adulto , Raquianestesia , Cesárea/métodos , Método Duplo-Cego , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Incidência , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologia , Náusea/epidemiologia , Náusea/etiologia , Náusea/prevenção & controle , Gravidez , Taquicardia/induzido quimicamente , Taquicardia/epidemiologia , Resultado do Tratamento , Útero/cirurgia , Vômito/epidemiologia , Vômito/etiologia , Vômito/prevenção & controle
11.
Anesthesiology ; 132(6): 1447-1457, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32205546

RESUMO

BACKGROUND: Acute kidney injury (AKI) is a frequent and deadly complication after cardiac surgery. In the absence of effective therapies, a focus on risk factor identification and modification has been the mainstay of management. The authors sought to determine the impact of intraoperative hypotension on de novo postoperative renal replacement therapy in patients undergoing cardiac surgery, hypothesizing that prolonged periods of hypotension during and after cardiopulmonary bypass (CPB) were associated with an increased risk of renal replacement therapy. METHODS: Included in this single-center retrospective cohort study were adult patients who underwent cardiac surgery requiring CPB between November 2009 and April 2015. Excluded were patients who were dialysis dependent, underwent thoracic aorta or off-pump procedures, or died before receiving renal replacement therapy. Degrees of hypotension were defined by mean arterial pressure (MAP) as less than 55, 55 to 64, and 65 to 74 mmHg before, during, and after CPB. The primary outcome was de novo renal replacement therapy. RESULTS: Of 6,523 patient records, 336 (5.2%) required new postoperative renal replacement therapy. Each 10-min epoch of MAP less than 55 mmHg post-CPB was associated with an adjusted odds ratio of 1.13 (95% CI, 1.05 to 1.23; P = 0.002), and each 10-min epoch of MAP between 55 and 64 mmHg post-CPB was associated with an adjusted odds ratio of 1.12 (95% CI, 1.06 to 1.18; P = 0.0001) for renal replacement therapy. The authors did not observe an association between hypotension before and during CPB with renal replacement therapy. CONCLUSIONS: MAP less than 65 mmHg for 10 min or more post-CPB is associated with an increased risk of de novo postoperative renal replacement therapy. The association between intraoperative hypotension and AKI was weaker in comparison to factors such as renal insufficiency, heart failure, obesity, anemia, complex or emergent surgery, and new-onset postoperative atrial fibrillation. Nonetheless, post-CPB hypotension is a potentially easier modifiable risk factor that warrants further investigation.


Assuntos
Lesão Renal Aguda/epidemiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Hipotensão/epidemiologia , Complicações Intraoperatórias/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Terapia de Substituição Renal/estatística & dados numéricos , Idoso , Canadá/epidemiologia , Causalidade , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco
12.
Plast Reconstr Surg ; 145(3): 606-616, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32097291

RESUMO

BACKGROUND: Enhanced recovery after surgery (ERAS) initiatives improve postoperative function and expedite recovery, leading to a decrease in length of stay. The authors noted a high rate of postoperative symptomatic hypotension in patients undergoing abdominal free flap breast reconstruction and wished to explore this observation. METHODS: Subjects undergoing abdominal free flap breast reconstruction at the authors' institution from 2013 to 2017 were identified. The ERAS protocol was initiated in 2015 at the authors' hospital; thus, 99 patients underwent traditional management and 138 patients underwent ERAS management. Demographics and perioperative data were collected and analyzed. Postoperative symptomatic hypotension was defined as mean arterial pressure below 80 percent of baseline with symptoms requiring evaluation. RESULTS: A significantly higher rate of postoperative symptomatic hypotension was observed in the ERAS cohort compared with the traditional management cohort (4 percent versus 22 percent; p < 0.0001). Patients in the ERAS cohort received significantly less intraoperative intravenous fluid (4467 ml versus 3505 ml; p < 0.0001) and had a significantly increased amount of intraoperative time spent with low blood pressure (22 percent versus 32 percent; p =0.002). Postoperatively, the ERAS cohort had significantly lower heart rate (77 beats per minute versus 88 beats per minute; p < 0.0001) and mean arterial pressure (71 mmHg versus 78 mmHg; p < 0.0001), with no difference in urine output or adverse events. CONCLUSIONS: The authors report that ERAS implementation in abdominal free flap breast reconstruction may result in a unique physiologic state with low mean arterial pressure, low heart rate, and normal urine output, resulting in postoperative symptomatic hypotension. Awareness of this early postoperative finding can help better direct fluid resuscitation and prevent episodes of symptomatic hypotension. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Retalhos de Tecido Biológico/transplante , Hipotensão/epidemiologia , Mamoplastia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Adulto , Pressão Arterial/fisiologia , Mama/cirurgia , Feminino , Frequência Cardíaca/fisiologia , Humanos , Hipotensão/etiologia , Hipotensão/fisiopatologia , Tempo de Internação/estatística & dados numéricos , Mamoplastia/métodos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos
13.
J Pediatr Surg ; 55(5): 926-929, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32067810

RESUMO

PURPOSE: Rapid sequence intubation (RSI) drugs, such as propofol, affect clinical outcomes, but this has not been examined in the pediatric population. This descriptive study compares the outcomes associated with intubation drugs used in pediatric traumatic brain injury (TBI) patients. METHODS: A retrospective chart review and descriptive analysis of intubated TBI patients, ages 0-17, admitted to Children's Hospital London Health Sciences Centre (LHSC) from January 2006-December 2016 was performed. RESULTS: Out of 259 patients intubated, complete data was available for 107 cases. Average injury severity score was 28; 46 were intubated at LHSC, 55 at primary care site, and 6 on scene. Intubation attempts were recorded in 87 of 107 paper charts. First-pass intubation success rate was 88.5%. Propofol (n = 21), midazolam (n = 31), etomidate (n = 13), and ketamine (n = 7) were the most commonly used intubation drugs. Paralytics were used in 50% of patients. Following use of propofol, Pediatric Adjusted Shock Index was increased as a result of worsening hypotension. Mean total hospital length of stay was 21 days with 7.5 days in ICU. Survival was 87%. CONCLUSION: Great variability exists in the use of induction agents and paralytics for RSI. Propofol was commonly used and is potentially associated with poorer clinical outcomes. TYPE OF STUDY: Retrospective. LEVEL OF EVIDENCE: IV.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Hipnóticos e Sedativos/administração & dosagem , Propofol/efeitos adversos , Indução e Intubação de Sequência Rápida/métodos , Adolescente , Criança , Pré-Escolar , Etomidato/administração & dosagem , Feminino , Hospitais Pediátricos , Humanos , Hipnóticos e Sedativos/efeitos adversos , Hipotensão/epidemiologia , Lactente , Recém-Nascido , Escala de Gravidade do Ferimento , Ketamina/administração & dosagem , Tempo de Internação , Londres , Masculino , Midazolam/administração & dosagem , Propofol/administração & dosagem , Estudos Retrospectivos , Choque
14.
Crit Care Resusc ; 22(1): 53-62, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32102643

RESUMO

OBJECTIVE: Postprandial hypotension occurs frequently in older survivors of critical illness at 3 months after discharge. We aimed to determine whether postprandial hypotension and its predictors - gastric dysmotility and cardiovascular autonomic dysfunction - persist or resolve as older survivors of critical illness recover, and whether postprandial hypotension after intensive care unit (ICU) discharge is associated with adverse outcomes at 12 months. DESIGN: Prospective observational study. SETTING: Tertiary medical-surgical ICU. PARTICIPANTS: Older adults (aged ≥ 65 years) who had been studied 3 months after ICU discharge and who returned for a follow-up study at 12 months after discharge. MAIN OUTCOME MEASURES: On both occasions after fasting overnight, participants consumed a 300 mL drink containing 75 g glucose, radiolabelled with 20 MBq 99mTcphytate. Blood pressure, heart rate, blood glucose concentration and gastric emptying rate were measured concurrently before and after ingestion of the drink. Falls, quality of life, hospitalisation and mortality rates were also quantified. RESULTS: Out of 35 older adults studied at 3 months, 22 returned for the follow-up study at 12 months. Postprandial hypotension was evident in 29% of participants (95% CI, 14-44%) at 3 months and 10% of participants (95% CI, 1-30%) at 12 months. Postprandial hypotension at 3 months was associated with a more than threefold increase in the risk of falls in the year after ICU discharge (relative risk, 3.7 [95% CI, 1.6-8.8]; P = 0.003). At 12 months, gastric emptying was normal (mean time taken for 50% of gastric contents to empty, 101.6 [SD, 33.3] min) and cardiovascular autonomic dysfunction prevalence was low (9% [95% CI, 1-29%]). CONCLUSIONS: In older adults who were evaluated 3 and 12 months after ICU discharge, postprandial hypotension at 3 months was associated with an increased risk of subsequent falls, but the prevalence of postprandial hypotension decreased with time.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Doenças do Sistema Nervoso Autônomo/fisiopatologia , Sistema Nervoso Autônomo/fisiologia , Estado Terminal , Hipotensão/complicações , Hipotensão/etiologia , Período Pós-Prandial , Idoso , Pressão Sanguínea , Feminino , Seguimentos , Humanos , Hipotensão/epidemiologia , Hipotensão/fisiopatologia , Masculino , Estudos Prospectivos , Qualidade de Vida
15.
J Korean Med Sci ; 35(1): e8, 2020 Jan 06.
Artigo em Inglês | MEDLINE | ID: mdl-31898435

RESUMO

BACKGROUND: There has been no consensus regarding the discontinuation order of vasopressors in patients recovering from septic shock treated with concomitant norepinephrine (NE) and arginine vasopressin (AVP). The aim of this study was to compare the incidence of hypotension within 24 hours based on whether NE or AVP was discontinued first in order to determine the optimal sequence for discontinuation of vasopressors. METHODS: A systematic literature search was conducted in MEDLINE, Embase, and the Cochrane Central Register. The primary end-point was incidence of hypotension within 24 hours after discontinuation of the first vasopressor. RESULTS: We identified five studies comprising 930 patients, of whom 631 (67.8%) discontinued NE first and 299 (32.2%) discontinued AVP first. In pooled estimates, a random-effect model showed that discontinuation of NE first was associated with a significant reduction of the incidence of hypotension compared to discontinuing AVP first (31.8% vs. 54.8%; risk ratios, 0.35; 95% confidence interval, 0.16 to 0.76; P = 0.008; I² = 90.7%). Although a substantial degree of heterogeneity existed among the trials, we could not identify the significant source of bias. In addition, there were no significant differences in intensive care unit (ICU) mortality, in-hospital mortality, 28-day mortality, or ICU length of stay between the groups. CONCLUSION: Discontinuing NE prior to AVP was associated with a lower incidence of hypotension in patients recovering from septic shock. However, our results should be interpreted with caution, due to the considerable between-study heterogeneity.


Assuntos
Arginina Vasopressina/uso terapêutico , Hipotensão/diagnóstico , Norepinefrina/uso terapêutico , Choque Séptico/tratamento farmacológico , Vasoconstritores/uso terapêutico , Humanos , Hipotensão/epidemiologia , Incidência , Adesão à Medicação , Razão de Chances , Choque Séptico/patologia
16.
Geriatr Psychol Neuropsychiatr Vieil ; 18(1): 25-33, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-31908314

RESUMO

Postoperative delirium is common after hip fracture surgery in elderly patients and is associated with poor outcome (higher risk of mortality, institutionalization and length of stay). The relationship between modifiable intra-operative risk factors, such as intra-operative hypotension, and postoperative delirium is unclear. The main objective of this study was to evaluate the association between intra-operative hypotension and the development of a postoperative delirium in older patients with hip fracture. A secondary aim was to assess the impact of other pre- and intra-operative predisposing factors (anaesthetic approaches or specific anaesthetic drugs, surgery duration, timing of surgery, type of implants used as primary treatment, intra-operative blood loss) on developing postoperative delirium in this elderly population. This retrospective monocentric study included 100 consecutive hip fracture patients, aged 75 years and older, admitted to a dedicated ortho-geriatric unit. All patients were screened for post-operative delirium using the confusion assessment method performed by a geriatrician. Intra-operative hypotension was defined as a decrease of more than 30% below the preoperative baseline for systolic blood pressure or a decrease in mean arterial pressure (MAP) below 60 mmHg. Post-operative delirium (n = 37; 37.8%) and intra-operative hypotension (n = 80; 81.6%) are both common in old patients but we did not demonstrate a significant association regardless of the chosen definition. The following risk factors were significantly associated with postoperative delirium: surgical delay (OR 1.47[1.01-2.02]; p = 0.02), institutionalisation (OR 2.25[1.33-3.8]; p = 0.02) and postoperative acute kidney injury (OR 2.34[1.32-4.15]; p = 0.02). Postoperative delirium is common in old patients with hip fracture and is associated with postoperative complications, institutionalisation and surgical delay but not with intra-operative risk factors.


Assuntos
Delírio/epidemiologia , Fraturas do Quadril/complicações , Hipotensão/epidemiologia , Complicações Intraoperatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Anestesia/efeitos adversos , Pressão Sanguínea , Delírio/etiologia , Feminino , Fraturas do Quadril/cirurgia , Hospitalização , Humanos , Masculino , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
17.
Br J Anaesth ; 124(3): e108-e114, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31959386

RESUMO

BACKGROUND: Norepinephrine infusion has been suggested as an effective method for preventing hypotension during spinal anaesthesia for Caesarean delivery. However, optimal dosing regimens for norepinephrine have not been well established. This study aimed to determine the dose-response characteristics of a weight-adjusted fixed-rate infusion of norepinephrine to prevent hypotension during neuraxial anaesthesia for Caesarean delivery. METHODS: In a double-blind, randomised controlled trial, 80 parturients having elective Caesarean delivery received a prophylactic norepinephrine infusion at 0.025 µg kg-1 min-1 (Group N1), 0.05 µg kg-1 min-1 (Group N2), 0.075 µg kg-1 min-1 (Group N3), or 0.10 µg kg-1 min-1 (Group N4), starting immediately after induction of combined spinal-epidural anaesthesia. The primary outcome was non-occurrence of hypotension, defined as a decrease in systolic arterial pressure ≥20% below baseline value or to ≤90 mm Hg, before delivery. Values for 50% effective dose (ED50) and ED90 were calculated using probit regression. RESULTS: The incidence of hypotension was 11/20 (55%), 6/20 (30%), 2/20 (10%), and 1/20 (5%) in Groups N1, N2, N3, and N4, respectively (P<0.0001). The ED50 and ED90 (95% confidence interval) of norepinephrine infusions for preventing hypotension were 0.029 (-0.002 to 0.043) and 0.080 (0.065-0.116) µg kg-1 min-1, respectively. The incidence of reactive hypertension increased with increasing norepinephrine dose (P=0.002). Other adverse effects were similar among groups. CONCLUSIONS: Under the conditions of this study, an infusion of norepinephrine 0.08 µg kg-1 min-1 was effective for preventing hypotension in 90% of patients. This information should provide a guide for initiating norepinephrine infusions. CLINICAL TRIAL REGISTRATION: ChiCTR1900022322 at the Chinese Clinical Trial Registry (http://www.chictr.org.cn/enindex.aspx).


Assuntos
Anestesia Epidural/efeitos adversos , Anestesia Obstétrica/efeitos adversos , Raquianestesia/efeitos adversos , Hipotensão/prevenção & controle , Norepinefrina/administração & dosagem , Adulto , Pressão Sanguínea/efeitos dos fármacos , Cesárea , Relação Dose-Resposta a Droga , Método Duplo-Cego , Feminino , Humanos , Hipotensão/epidemiologia , Gravidez
18.
Pediatr Emerg Care ; 36(2): 63-65, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31929394

RESUMO

OBJECTIVES: To compare timeliness of sepsis recognition and initial treatment in patients with and without high-risk comorbid conditions. METHODS: This was a retrospective cohort study of patients presenting to a pediatric emergency department (ED) who triggered a vital sign-based electronic sepsis alert resulting in bedside "huddle" assessment per institutional practice. A positive sepsis alert was defined as age-specific tachycardia or hypotension, concern for infection, and at least 1 of the following: abnormal capillary refill, abnormal mental status, or a high-risk condition. High-risk conditions were derived from the American Academy of Pediatrics sepsis alert tool. Patients with a positive alert underwent bedside huddle resulting in a decision regarding initiation of sepsis protocol. Placement on the protocol and time to initiation of protocol and individual therapies were compared for patients with and without high-risk conditions. RESULTS: During the 1-year study period, there were 1107 sepsis huddle alerts out of 96,427 ED visits. Of these, 713 (65%) had identified high-risk conditions, and 394 (35%) did not. Among patients with sepsis huddles, there was no difference in sepsis protocol initiation for patients with high-risk conditions compared with those without (24.8% vs 22.0%, P = 0.305). Between patients with high-risk conditions and those without, there were no differences in median time from triage to sepsis protocol activation, triage to initial intravenous antibiotic, triage to initial intravenous fluid therapy, or ED length of stay. CONCLUSIONS: Timeliness of care initiation was no different in high-risk patients with sepsis when using an electronic sepsis alert and protocolized sepsis care.


Assuntos
Serviço Hospitalar de Emergência , Sepse/diagnóstico , Sepse/terapia , Adolescente , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Alarmes Clínicos , Comorbidade , Feminino , Hidratação , Humanos , Hipotensão/epidemiologia , Lactente , Recém-Nascido , Tempo de Internação , Masculino , Medicina de Emergência Pediátrica , Estudos Retrospectivos , Fatores de Risco , Sepse/epidemiologia , Tempo para o Tratamento , Triagem , Sinais Vitais
19.
Eur J Obstet Gynecol Reprod Biol ; 245: 39-44, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31838399

RESUMO

OBJECTIVES: To evaluate the effect of transient fetal bradycardia and other heart rate changes during and after external cephalic version (ECV) on perinatal outcomes. To determine factors associated with a higher risk of occurrence of transient fetal bradycardia during and after ECV. STUDY DESIGN: Prospective study in 286 women after the 36th week of gestation with a fetus in breech presentation who have undergone an ECV attempt. The study analyses the incidence of transient fetal bradycardia during and immediately after ECV, the time interval to complete adjustment of fetal bradycardia, the factors associated with the occurrence of transient fetal bradycardia, cardiotocography (CTG) changes after ECV and perinatal outcomes. All the data were statistically analyzed. RESULTS: The ECV was successful in 51 % (146/286). Transient fetal bradycardia occurred during and after ECV in 81 cases (28.3 %). A successful version was a factor significantly associated with fetal bradycardia (54; 37.0 % versus 27; 19.3 %; p < 0.01). Clinically significant hypotension of the mother was accompanied by transient fetal bradycardia in 12 cases (4.2 %). After the successful ECV there was no significant difference in the percentage of vaginal deliveries between subgroups with and without transient fetal bradycardia (85.2 % versus 83.7 %; p = 1.00). Nor in occurrence of acute fetal distress during labor (18.5 % versus 15.6 %; p = 0.65). In cases of a successful ECV transient CTG changes after ECV had no effect on the incidence of acute fetal distress during labor (23.5 % versus 15.7 %; p = 0.49). CONCLUSIONS: Transient fetal bradycardia and other heart rate changes during and immediately after ECV was not associated with a higher incidence of acute fetal distress during labor and did not affect perinatal outcomes. Higher occurrence of transient bradycardia after ECV was associated only with successful ECV. Transient hypotension of the mother as one of the causes of transient fetal bradycardia during ECV should be considered.


Assuntos
Bradicardia/embriologia , Bradicardia/fisiopatologia , Frequência Cardíaca Fetal/fisiologia , Versão Fetal/efeitos adversos , Adolescente , Adulto , Bradicardia/etiologia , Parto Obstétrico/estatística & dados numéricos , Feminino , Sofrimento Fetal/epidemiologia , Sofrimento Fetal/etiologia , Idade Gestacional , Humanos , Hipotensão/epidemiologia , Hipotensão/etiologia , Recém-Nascido , Gravidez , Complicações Cardiovasculares na Gravidez/epidemiologia , Complicações Cardiovasculares na Gravidez/etiologia , Resultado da Gravidez , Estudos Prospectivos , Adulto Jovem
20.
Anesthesiology ; 132(3): 461-475, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31794513

RESUMO

BACKGROUND: Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk. METHODS: Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline). RESULTS: Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort. CONCLUSIONS: Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.


Assuntos
Lesão Renal Aguda/complicações , Lesão Renal Aguda/epidemiologia , Hipotensão/complicações , Hipotensão/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anemia/complicações , Pressão Arterial , Estudos de Coortes , Feminino , Humanos , Complicações Intraoperatórias/epidemiologia , Masculino , Pessoa de Meia-Idade , Período Pré-Operatório , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
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