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1.
Medicine (Baltimore) ; 100(11): e25152, 2021 Mar 19.
Artigo em Inglês | MEDLINE | ID: mdl-33726000

RESUMO

ABSTRACT: Noninvasive continuous arterial pressure monitoring may be clinically useful in patients who require continuous blood pressure monitoring in situations where arterial catheter placement is limited. Many previous studies on the accuracy of the noninvasive continuous blood pressure monitoring method reported various results. However, there is no research on the effectiveness of noninvasive arterial pressure monitoring during one-lung ventilation. The purpose of this study was to compare arterial blood pressure obtained through invasive method and noninvasive method by using ClearSight during one-lung ventilation.In this retrospective observational study, a total of 26 patients undergoing one-lung ventilation for thoracic surgery at a single institution between March and July 2019 were recruited. All patients in this study were cannulated on their radial artery to measure continuously invasive blood pressures and applied ClearSight on the ipsilateral side of the cannulated arm. We compared and analyzed the agreement and trendability of blood pressure recorded with invasive and noninvasive methods during one-lung ventilation.Blood pressure and pulse rate showed a narrower limit of agreement with a percentage error value of around 30%. In addition, the tracking ability of each measurement could be determined by the concordance rate, all of which were below acceptable limits (92%).In noninvasive arterial blood pressure monitoring using ClearSight, mean blood pressure and pulse rate show acceptable agreement with the invasive method.


Assuntos
Determinação da Pressão Arterial/instrumentação , Monitores de Pressão Arterial/estatística & dados numéricos , Monitorização Intraoperatória/instrumentação , Ventilação Monopulmonar , Procedimentos Cirúrgicos Torácicos , Idoso , Pressão Arterial , Determinação da Pressão Arterial/métodos , Feminino , Frequência Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Artéria Radial/fisiopatologia , Reprodutibilidade dos Testes , Estudos Retrospectivos
2.
Medicine (Baltimore) ; 100(12): e24324, 2021 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-33761632

RESUMO

ABSTRACT: To evaluate the feasibility of utilizing ultrasonography to monitor the fracture reduction and elastic intramedullary nail fixation processes in treating children with double forearm fractures. A retrospective analysis of 30 children with double forearm fractures treated at our hospital between January 2016 and July 2018. The children were aged 3 to 10 years. All patients were treated with closed reduction and internal fixation with elastic intramedullary nails using intraoperative ultrasound monitoring and intermittent radiographic imaging. The closed reduction and fixation were successful in all patients. The operation times ranged from 16 to 30 minutes, averaging 21 minutes. No neurovascular injuries occurred during closed reduction and nail insertion. Moreover, closed reduction was successful in the first attempt in 86.7% of patients. All patient outcomes were optimal, lacking serious complications during follow-ups. Intraoperative ultrasound monitoring can clearly show the shape and changes in fracture ends, distal growth plates, and surrounding soft tissues, and fracture reduction and passage of elastic nail processes at fracture ends during closed reduction; therefore, visualizing closed reductions can be achieved. The combination of intraoperative ultrasound and radiographic imaging can ensure operative effects and significantly reduce radiation exposure for both doctors and patients. An adequately powered prospective randomized trial is required to confirm our findings.


Assuntos
Antebraço/diagnóstico por imagem , Fixação Intramedular de Fraturas/instrumentação , Monitorização Intraoperatória/métodos , Fraturas do Rádio/cirurgia , Fraturas da Ulna/cirurgia , Pinos Ortopédicos , Criança , Pré-Escolar , Redução Fechada , Estudos de Viabilidade , Feminino , Humanos , Masculino , Radiografia , Rádio (Anatomia)/diagnóstico por imagem , Rádio (Anatomia)/lesões , Rádio (Anatomia)/cirurgia , Fraturas do Rádio/complicações , Fraturas do Rádio/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento , Ulna/diagnóstico por imagem , Ulna/lesões , Ulna/cirurgia , Fraturas da Ulna/complicações , Fraturas da Ulna/diagnóstico , Ultrassonografia
3.
Laryngoscope ; 131 Suppl 4: S1-S42, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33729584

RESUMO

OBJECTIVES/HYPOTHESIS: Facial nerve monitoring (FNM) has evolved into a widely used adjunct for many surgical procedures along the course of the facial nerve. Even though majority opinion holds that FNM reduces the incidence of iatrogenic nerve injury, there are few if any studies yielding high-level evidence and no practice guidelines on which clinicians can rely. Instead, a review of the literature and medicolegal cases reveals significant variations in methodology, training, and clinical indications. STUDY DESIGN: Literature review and expert opinion. METHODS: Given the lack of standard references to serve as a resource for FNM, we assembled a multidisciplinary group of experts representing more than a century of combined monitoring experience to synthesize the literature and provide a rational basis to improve the quality of patient care during FNM. RESULTS: Over the years, two models of monitoring have become well-established: 1) monitoring by the surgeon using a stand-alone device that provides auditory feedback of facial electromyography directly to the surgeon, and 2) a team, typically consisting of surgeon, technologist, and interpreting neurophysiologist. Regardless of the setting and the number of people involved, the reliability of monitoring depends on the integration of proper technical performance, accurate interpretation of responses, and their timely application to the surgical procedure. We describe critical steps in the technical set-up and provide a basis for context-appropriate interpretation and troubleshooting of recorded signals. CONCLUSIONS: We trust this initial attempt to describe best practices will serve as a basis for improving the quality of patient care while reducing inappropriate variations. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:S1-S42, 2021.


Assuntos
Eletromiografia/métodos , Nervo Facial/fisiologia , Nervo Facial/cirurgia , Monitorização Intraoperatória/instrumentação , Guias de Prática Clínica como Assunto/normas , Idoso , Lista de Checagem , Análise Custo-Benefício , Traumatismos do Nervo Facial/epidemiologia , Traumatismos do Nervo Facial/prevenção & controle , Feminino , Humanos , Doença Iatrogênica/epidemiologia , Doença Iatrogênica/prevenção & controle , Incidência , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Neurofisiologia/métodos , Neurofisiologia/estatística & dados numéricos , Preceptoria/normas , Qualidade da Assistência à Saúde , Reprodutibilidade dos Testes
4.
Br J Anaesth ; 126(4): 808-817, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33558051

RESUMO

BACKGROUND: Intraoperative hypotension is associated with a risk of postoperative organ dysfunction. In this study, we aimed to present deep learning algorithms for real-time predictions 5, 10, and 15 min before a hypotensive event. METHODS: In this retrospective observational study, deep learning algorithms were developed and validated using biosignal waveforms acquired from patient monitoring of noncardiac surgery. The classification model was a binary classifier of a hypotensive event (MAP <65 mm Hg) or a non-hypotensive event by analysing biosignal waveforms. The regression model was developed to directly estimate the MAP. The primary outcome was area under the receiver operating characteristic (AUROC) curve and the mean absolute error (MAE). RESULTS: In total, 3301 patients were included. For invasive models, the multichannel model with an arterial pressure waveform, electrocardiography, photoplethysmography, and capnography showed greater AUROC than the arterial-pressure-only models (AUROC15-min, 0.897 [95% confidence interval {CI}: 0.894-0.900] vs 0.891 [95% CI: 0.888-0.894]) and lesser MAE (MAE15-min, 7.76 mm Hg [95% CI: 7.64-7.87 mm Hg] vs 8.12 mm Hg [95% CI: 8.02-8.21 mm Hg]). For the noninvasive models, the multichannel model showed greater AUROCs than that of the photoplethysmography-only models (AUROC15-min, 0.762 [95% CI: 0.756-0.767] vs 0.694 [95% CI: 0.686-0.702]) and lesser MAEs (MAE15-min, 11.68 mm Hg [95% CI: 11.57-11.80 mm Hg] vs 12.67 [95% CI: 12.56-12.79 mm Hg]). CONCLUSIONS: Deep learning models can predict hypotensive events based on biosignals acquired using invasive and noninvasive patient monitoring. In addition, the model shows better performance when using combined rather than single signals.


Assuntos
Aprendizado Profundo/tendências , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/tendências , Idoso , Humanos , Hipotensão/etiologia , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Valor Preditivo dos Testes , Estudos Retrospectivos
5.
Br J Anaesth ; 126(4): 818-825, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33632521

RESUMO

BACKGROUND: We designed a prospective sub-study of the larger Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial to measure differences in stroke volume and other haemodynamic parameters at the end of the intraoperative fluid protocols. The haemodynamic effects of the two fluid regimens may increase our understanding of the observed perioperative outcomes. METHODS: Stroke volume and cardiac output were measured with both an oesophageal Doppler ultrasound monitor and arterial pressure waveform analysis. Stroke volume variation, pulse pressure variation, and plethysmographic variability index were also obtained. A passive leg raise manoeuvre was performed to identify fluid responsiveness. RESULTS: Analysis of 105 patients showed that the primary outcome, Doppler monitor-derived stroke volume index, was higher in the liberal group: restrictive 38.5 (28.6-48.8) vs liberal 44.0 (34.9-61.9) ml m-2; P=0.043. Similarly, there was a higher cardiac index in the liberal group: 2.96 (2.32-4.05) vs 2.42 (1.94-3.26) L min-1 m-2; P=0.015. Arterial-pressure-based stroke volume and cardiac index did not differ, nor was there a significant difference in stroke volume variation, pulse pressure variation, or plethysmographic variability index. The passive leg raise manoeuvre showed fluid responsiveness in 40% of restrictive and 30% of liberal protocol patients (not significant). CONCLUSIONS: The liberal fluid group from the RELIEF trial had significantly higher Doppler ultrasound monitor-derived stroke volume and cardiac output compared with the restrictive fluid group at the end of the intraoperative period. Measures of fluid responsiveness did not differ significantly between groups. CLINICAL TRIAL REGISTRATION: ACTRN12615000125527.


Assuntos
Débito Cardíaco/fisiologia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Hidratação/métodos , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Volume Sistólico/fisiologia , Adulto , Idoso , Procedimentos Cirúrgicos do Sistema Digestório/tendências , Feminino , Hidratação/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/tendências , Complicações Pós-Operatórias/diagnóstico por imagem , Estudos Prospectivos , Resultado do Tratamento , Ultrassonografia Doppler/métodos , Ultrassonografia Doppler/tendências
6.
Medicine (Baltimore) ; 100(1): e24160, 2021 Jan 08.
Artigo em Inglês | MEDLINE | ID: mdl-33429798

RESUMO

ABSTRACT: Postoperative delirium (PODE) can be associated with severe clinical complications; therefore, preventive measures are important. The objective of this trial was to elucidate whether haemodynamic or electroencephalographic (EEG) monitoring parameters during general anaesthesia or sevoflurane dosage correlate with the incidence of PODE. In addition, sevoflurane dosages and EEG stages during the steady state of anaesthesia were analyzed in patients of different ages.Eighty adult patients undergoing elective abdominal surgery received anaesthesia with sevoflurane and sufentanil according to the clinical routine. Anaesthesiologists were blinded to the EEG. Haemodynamic parameters, EEG parameters, sevoflurane dosage, and occurrence of PODE were analyzed.Thirteen patients (4 out of 33 women, 9 out of 47 men) developed PODE. Patients with PODE had a greater mean arterial pressure (MAP) variance (267.26 (139.40) vs 192.56 (99.64) mmHg2, P = .04), had a longer duration of EEG burst suppression or suppression (27.09 (45.32) vs 5.23 (10.80) minutes, P = .03), and received higher minimum alveolar sevoflurane concentrations (MAC) (1.22 (0.22) vs 1.09 (0.17), P = .03) than patients without PODE. MAC values were associated with wide ranges of EEG index values representing different levels of hypnosis.The results suggest that, in order to prevent PODE, a great variance of MAP, higher doses of sevoflurane, and deep levels of anaesthesia should be avoided. Titrating sevoflurane according to end-tidal gas monitoring and vital signs can lead to unnecessarily deep or light hypnosis. Intraoperative EEG monitoring may help to prevent PODE.


Assuntos
Delírio/classificação , Delírio/etiologia , Monitorização Intraoperatória/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Inalatórios/efeitos adversos , Anestésicos Inalatórios/uso terapêutico , Estudos Transversais , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/estatística & dados numéricos , Complicações Pós-Operatórias/classificação , Complicações Pós-Operatórias/fisiopatologia , Estudos Prospectivos , Sevoflurano/efeitos adversos , Sevoflurano/uso terapêutico , Sufentanil/efeitos adversos , Sufentanil/uso terapêutico
7.
Anticancer Res ; 41(1): 409-415, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33419838

RESUMO

BACKGROUND/AIM: We aimed to evaluate the correlation between stroke volume variation (SVV) and intraoperative blood loss (IBL) in hepatocellular carcinoma (HCC) resection and examine the perioperative utility of SVV-based management. PATIENTS AND METHODS: Ninety-five patients who underwent partial or sub-segmental hepatectomy for HCC between 2013 and 2019 at the University of Yamanashi Hospital were retrospectively analyzed. A correlation analysis between IBL and SVV was performed, and then all cases were divided into three groups: high, middle, and low-SVV groups. Perioperative short-term outcomes based on SVV groups were analyzed. RESULTS: There was a weak but significant negative correlation between SVV and IBL (ρ=-0.372, p<0.001). Comparative analysis revealed that low-SVV was associated with a high incidence of postoperative complications and blood transfusion (p=0.018 and 0.037, respectively), and high-SVV was not related with postoperative complications. CONCLUSION: SVV-based management is a significant and feasible strategy to achieve safe and exact surgical resection of HCC.


Assuntos
Perda Sanguínea Cirúrgica , Carcinoma Hepatocelular/cirurgia , Neoplasias Hepáticas/cirurgia , Monitorização Intraoperatória , Volume Sistólico , Idoso , Biomarcadores , Perda Sanguínea Cirúrgica/prevenção & controle , Transfusão de Sangue , Carcinoma Hepatocelular/diagnóstico , Feminino , Testes de Função Cardíaca , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Humanos , Neoplasias Hepáticas/diagnóstico , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias , Estudos Retrospectivos
8.
Anesthesiology ; 134(2): 179-188, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33326001

RESUMO

BACKGROUND: The optimal method for blood pressure monitoring in obese surgical patients remains unknown. Arterial catheters can cause potential complications, and noninvasive oscillometry provides only intermittent values. Finger cuff methods allow continuous noninvasive monitoring. The authors tested the hypothesis that the agreement between finger cuff and intraarterial measurements is better than the agreement between oscillometric and intraarterial measurements. METHODS: This prospective study compared intraarterial (reference method), finger cuff, and oscillometric (upper arm, forearm, and lower leg) blood pressure measurements in 90 obese patients having bariatric surgery using Bland-Altman analysis, four-quadrant plot and concordance analysis (to assess the ability of monitoring methods to follow blood pressure changes), and error grid analysis (to describe the clinical relevance of measurement differences). RESULTS: The difference (mean ± SD) between finger cuff and intraarterial measurements was -1 mmHg (± 11 mmHg) for mean arterial pressure, -7 mmHg (± 14 mmHg) for systolic blood pressure, and 0 mmHg (± 11 mmHg) for diastolic blood pressure. Concordance between changes in finger cuff and intraarterial measurements was 88% (mean arterial pressure), 85% (systolic blood pressure), and 81% (diastolic blood pressure). In error grid analysis comparing finger cuff and intraarterial measurements, the proportions of measurements in risk zones A to E were 77.1%, 21.6%, 0.9%, 0.4%, and 0.0% for mean arterial pressure, respectively, and 89.5%, 9.8%, 0.2%, 0.4%, and 0.2%, respectively, for systolic blood pressure. For mean arterial pressure and diastolic blood pressure, absolute agreement and trending agreement between finger cuff and intraarterial measurements were better than between oscillometric (at each of the three measurement sites) and intraarterial measurements. Forearm performed better than upper arm and lower leg monitoring with regard to absolute agreement and trending agreement with intraarterial monitoring. CONCLUSIONS: The agreement between finger cuff and intraarterial measurements was better than the agreement between oscillometric and intraarterial measurements for mean arterial pressure and diastolic blood pressure in obese patients during surgery. Forearm oscillometry exhibits better measurement performance than upper arm or lower leg oscillometry.


Assuntos
Cirurgia Bariátrica , Determinação da Pressão Arterial/métodos , Monitorização Intraoperatória/métodos , Obesidade/cirurgia , Pressão Sanguínea , Determinação da Pressão Arterial/estatística & dados numéricos , Cateterismo Periférico/métodos , Cateterismo Periférico/estatística & dados numéricos , Feminino , Dedos , Humanos , Masculino , Pessoa de Meia-Idade , Oscilometria/métodos , Oscilometria/estatística & dados numéricos , Estudos Prospectivos , Reprodutibilidade dos Testes
9.
Anesthesiology ; 134(1): 26-34, 2021 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-33079134

RESUMO

BACKGROUND: Perioperative arterial cannulation in children is routinely performed. Based on clinical observation of several complications related to femoral arterial lines, the authors performed a larger study to further examine complications. The authors aimed to (1) describe the use patterns and incidence of major short-term complications associated with arterial cannulation for perioperative monitoring in children, and (2) describe the rates of major complications by anatomical site and age category of the patient. METHODS: The authors examined a retrospective cohort of pediatric patients (age less than 18 yr) undergoing surgical procedures at a single academic medical center from January 1, 2006 to August 15, 2016. Institutional databases containing anesthetic care, arterial cannulation, and postoperative complications information were queried to identify vascular, neurologic, and infectious short term complications within 30 days of arterial cannulation. RESULTS: There were 5,142 arterial cannulations performed in 4,178 patients. The most common sites for arterial cannulation were the radial (N = 3,395 [66.0%]) and femoral arteries (N = 1,528 [29.7%]). There were 11 major complications: 8 vascular and 3 infections (overall incidence, 0.2%; rate, 2 per 1,000 lines; 95% CI, 1 to 4) and all of these complications were associated with femoral arterial lines in children younger than 5 yr old (0.7%; rate, 7 per 1,000 lines; 95% CI, 4 to 13). The majority of femoral lines were placed for cardiac procedures (91%). Infants and neonates had the greatest complication rates (16 and 11 per 1,000 lines, respectively; 95% CI, 7 to 34 and 3 to 39, respectively). CONCLUSIONS: The overall major complication rate of arterial cannulation for monitoring purposes in children is low (0.2%). All complications occurred in femoral arterial lines in children younger than 5 yr of age, with the greatest complication rates in infants and neonates. There were no complications in distal arterial cannulation sites, including more than 3,000 radial cannulations.


Assuntos
Cateterismo Periférico/efeitos adversos , Monitorização Intraoperatória/efeitos adversos , Adolescente , Fatores Etários , Anestesia , Infecções Relacionadas a Cateter/epidemiologia , Cateterismo Periférico/métodos , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Artéria Femoral , Humanos , Lactente , Recém-Nascido , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/epidemiologia , Artéria Radial , Estudos Retrospectivos
10.
Br J Anaesth ; 126(4): 799-807, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33342539

RESUMO

BACKGROUND: Oliguria is often viewed as a sign of renal hypoperfusion and an indicator for volume expansion during surgery. However, the prognostic association and the predictive utility of intraoperative oliguria for postoperative acute kidney injury (AKI) are unclear. METHODS: We conducted a retrospective cohort study on patients undergoing major thoracic surgery in an academic hospital to assess the association of intraoperative oliguria with postoperative AKI and its predictive value. To contextualise our findings, we included our results in a meta-analysis of observational studies on the importance of oliguria during noncardiac surgery. RESULTS: In our cohort study, 3862 patients were included; 205 (5.3%) developed AKI after surgery. Intraoperative urine output of 0.3 ml kg-1 h-1 was the optimal threshold for oliguria in multivariable analysis. Patients with oliguria had an increased risk of AKI (adjusted odds ratio: 2.60; 95% confidence interval: 1.24-5.05). However, intraoperative oliguria had a sensitivity of 5.9%, specificity of 98%, positive likelihood ratio of 2.74, and negative likelihood ratio of 0.96, suggesting poor predictive ability. Moreover, it did not improve upon the predictive performance of a multivariable model, based on discrimination and reclassification indices. Our findings were generally consistent with the results of a systematic review and meta-analysis, including six additional studies. CONCLUSIONS: Intraoperative oliguria has moderate association with, but poor predictive ability for, postoperative AKI. It remains of clinical interest as a risk factor potentially modifiable to interventions.


Assuntos
Lesão Renal Aguda/diagnóstico , Monitorização Intraoperatória/métodos , Oligúria/diagnóstico , Complicações Pós-Operatórias/diagnóstico , Lesão Renal Aguda/epidemiologia , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oligúria/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos
11.
BMJ Case Rep ; 13(12)2020 Dec 29.
Artigo em Inglês | MEDLINE | ID: mdl-33376091

RESUMO

Transcatheter aortic valve implantation (TAVI) is a rapidly evolving treatment option with an inherent risk of causing cerebral infarctions. The mechanism of cerebral infarction during TAVI mainly involves embolisms from the aortic wall and valve. Transoesophageal echocardiography (TEE) is useful for detecting aortic atheromas. We present the case of a patient in whom the dispersal of aortic atheromas was monitored by TEE during TAVI. This report demonstrates the importance of preoperatively predicting embolisms from aortic atheromas in patients with severe aortic stenosis.


Assuntos
Aorta/diagnóstico por imagem , Estenose da Valva Aórtica , Aterosclerose , Infarto Cerebral , Ecocardiografia Transesofagiana/métodos , Complicações Intraoperatórias/diagnóstico por imagem , Placa Aterosclerótica/diagnóstico por imagem , Substituição da Valva Aórtica Transcateter , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/cirurgia , Aterosclerose/complicações , Aterosclerose/diagnóstico , Infarto Cerebral/diagnóstico por imagem , Infarto Cerebral/etiologia , Humanos , Complicações Intraoperatórias/prevenção & controle , Masculino , Monitorização Intraoperatória/métodos , Cuidados Pré-Operatórios/métodos , Risco Ajustado , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Substituição da Valva Aórtica Transcateter/métodos , Resultado do Tratamento
12.
Anesthesiology ; 133(5): 997-1006, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-33048167

RESUMO

BACKGROUND: In most patients having noncardiac surgery, blood pressure is measured with the oscillometric upper arm cuff method. Although the method is noninvasive and practical, it is known to overestimate intraarterial pressure in hypotension and to underestimate it in hypertension. A high-fidelity upper arm cuff incorporating a hydraulic sensor pad was recently developed. The aim of the present study was to investigate whether noninvasive blood pressure measurements with the new high-fidelity cuff correspond to invasive measurements with a femoral artery catheter, especially at low blood pressure. METHODS: Simultaneous measurements of blood pressure recorded from a femoral arterial catheter and from the high-fidelity upper arm cuff were compared in 110 patients having major abdominal surgery or neurosurgery. RESULTS: 550 pairs of blood pressure measurements (5 pairs per patient) were considered for analysis. For mean arterial pressure measurements, the average bias was 0 mmHg, and the precision was 3 mmHg. The Pearson correlation coefficient was 0.96 (P < 0.0001; 95% CI, 0.96 to 0.97), and the percentage error was 9%. Error grid analysis showed that the proportions of mean arterial pressure measurements done with the high-fidelity cuff method were 98.4% in zone A (no risk), 1.6% in zone B (low risk) and 0% in zones C, D, and E (moderate, significant, and dangerous risk, respectively). The high-fidelity cuff method detected mean arterial pressure values less than 65 mmHg with a sensitivity of 84% (95% CI, 74 to 92%) and a specificity of 97% (95% CI, 95% to 98%). To detect changes in mean arterial pressure of more than 5 mmHg, the concordance rate between the two methods was 99.7%. Comparable accuracy and precision were observed for systolic and diastolic blood pressure measurements. CONCLUSIONS: The new high-fidelity upper arm cuff method met the current international standards in terms of accuracy and precision. It was also very accurate to track changes in blood pressure and reliably detect severe hypotension during noncardiac surgery.


Assuntos
Pressão Arterial/fisiologia , Determinação da Pressão Arterial/métodos , Determinação da Pressão Arterial/normas , Monitorização Intraoperatória/métodos , Monitorização Intraoperatória/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Determinação da Pressão Arterial/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/instrumentação , Oscilometria/instrumentação , Oscilometria/métodos , Oscilometria/normas , Estudos Prospectivos , Adulto Jovem
13.
Anesth Analg ; 131(5): 1540-1550, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079877

RESUMO

BACKGROUND: Continuous blood pressure monitoring may facilitate early detection and prompt treatment of hypotension. We tested the hypothesis that area under the curve (AUC) mean arterial pressure (MAP) <65 mm Hg is reduced by continuous invasive arterial pressure monitoring. METHODS: Adults having noncardiac surgery were randomly assigned to continuous invasive arterial pressure or intermittent oscillometric blood pressure monitoring. Arterial catheter pressures were recorded at 1-minute intervals; oscillometric pressures were typically recorded at 5-minute intervals. We estimated the arterial catheter effect on AUC-MAP <65 mm Hg using a multivariable proportional odds model adjusting for imbalanced baseline variables and duration of surgery. Pressures <65 mm Hg were categorized as 0, 1-17, 18-91, and >91 mm Hg × minutes of AUC-MAP <65 mm Hg (ie, no hypotension and 3 equally sized groups of increasing hypotension). RESULTS: One hundred fifty-two patients were randomly assigned to arterial catheter use and 154 to oscillometric monitoring. For various clinical reasons, 143 patients received an arterial catheter, while 163 were monitored oscillometrically. There were a median [Q1, Q3] of 246 [187, 308] pressure measurements in patients with arterial catheters versus 55 (46, 75) measurements in patients monitored oscillometrically. In the primary intent-to-treat analysis, catheter-based monitoring increased detection of AUC-MAP <65 mm Hg, with an estimated proportional odds ratio (ie, odds of being in a worse hypotension category) of 1.78 (95% confidence interval [CI], 1.18-2.70; P = .006). The result was robust over an as-treated analysis and for sensitivity analyses with thresholds of 60 and 70 mm Hg. CONCLUSIONS: Intraoperative blood pressure monitoring with arterial catheters detected nearly twice as much hypotension as oscillometric measurements.


Assuntos
Pressão Arterial , Cateteres , Hipotensão/diagnóstico , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Área Sob a Curva , Diagnóstico Precoce , Feminino , Humanos , Hipotensão/terapia , Complicações Intraoperatórias/terapia , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Oscilometria , Sensibilidade e Especificidade , Procedimentos Cirúrgicos Operatórios , Resultado do Tratamento
14.
Anesth Analg ; 131(5): 1589-1598, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33079883

RESUMO

BACKGROUND: Intraoperative monitoring with pupillometry has shown promising results for nociception/antinociception balance monitoring. However, its benefits in clinical practice remain unproven. The aim of this study was to evaluate the efficacy of intraoperative pupillometry monitoring on intraoperative opioid consumption and postoperative pain compared to surgical pleth index (SPI), another widely investigated monitoring. METHODS: American Society of Anesthesiologists (ASA) I-II patients scheduled for elective laparoscopic cholecystectomy were included. This prospective, parallel-arm, single-center study was conducted in 2 steps. First, we evaluated the feasibility of using pupillometry and SPI monitoring compared with conventional hemodynamic monitoring. Next, a parallel-arm, double-blind randomized study compared the peak postoperative pain measured with numerical rating scale (NRS) from 0 (no pain) to 10 (extreme pain) as a primary outcome between pupillometry (pupillometry group, n = 43) and SPI monitoring (SPI group, n = 43) using Mann-Whitney U test. Secondary outcomes included intraoperative remifentanil consumption, postoperative opioid responsiveness (a decrease in NRS by ≥1 after fentanyl administrations), number of analgesic administrations, and opioid-related complications. RESULTS: In the preliminary study (n = 50), remifentanil consumption was less under pupillometry monitoring compared to SPI monitoring, and peak postoperative pain was lower under pupillometry compared to conventional monitoring. In the main study (n = 86), peak postoperative pain and intraoperative remifentanil consumption were lower in the pupillometry group (median [first to third quartile], 5 [4-6]; mean ± standard deviation [SD], 0.078 ± 0.019 µg·kg·minute) compared to the SPI group (7 [5-8] and 0.0130 ± 0.051 µg·kg·minute; P < .001), with the median difference in peak postoperative pain of -1 and its 95% confidence interval between -2 and -0.5. The pupillometry group had better responsiveness to fentanyl (84.6% vs 61.0%; P = .005) and lower number of analgesic administrations (2 [1-2] vs 2 [1-3]; P = .048) compared to the SPI group. CONCLUSIONS: Intraoperative pupillometry monitoring reduced intraoperative remifentanil consumption and postoperative pain. It may be an alternative option for intraoperative opioid control under general anesthesia in adult patients.


Assuntos
Analgésicos Opioides/uso terapêutico , Anestesia Intravenosa , Anestésicos Intravenosos , Monitorização Intraoperatória/métodos , Nociceptividade/efeitos dos fármacos , Propofol , Pupila/efeitos dos fármacos , Remifentanil , Adulto , Idoso , Colecistectomia Laparoscópica , Método Duplo-Cego , Estudos de Viabilidade , Feminino , Fentanila/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Período Perioperatório , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento
15.
Cochrane Database Syst Rev ; 10: CD010787, 2020 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-33085088

RESUMO

BACKGROUND: Bilateral neck exploration (BNE) is the traditional approach to sporadic primary hyperparathyroidism. With the availability of the preoperative imaging techniques and intraoperative parathyroid hormone assays, minimally invasive parathyroidectomy (MIP) is fast becoming the favoured surgical approach. OBJECTIVES: To assess the effects of minimally invasive parathyroidectomy (MIP) guided by preoperative imaging and intraoperative parathyroid hormone monitoring versus bilateral neck exploration (BNE) for the surgical management of primary hyperparathyroidism. SEARCH METHODS: We searched CENTRAL, MEDLINE, WHO ICTRP and ClinicalTrials.gov. The date of the last search of all databases was 21 October 2019. There were no language restrictions applied. SELECTION CRITERIA: We included randomised controlled trials comparing MIP to BNE for the treatment of sporadic primary hyperparathyroidism in persons undergoing surgery for the first time. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts for relevance. Two review authors independently screened for inclusion, extracted data and carried out risk of bias assessment. The content expert senior author resolved conflicts. We assessed studies for overall certainty of the evidence using the GRADE instrument. We conducted meta-analyses using a random-effects model and performed statistical analyses according to the guidelines in the latest version of the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS: We identified five eligible studies, all conducted in European university hospitals. They included 266 adults, 136 participants were randomised to MIP and 130 participants to BNE. Data were available for all participants post-surgery up to one year, with the exception of missing data for two participants in the MIP group and for one participant in the BNE group at one year. Nine participants in the MIP group and 11 participants in the BNE group had missing data at five years. No study had a low risk of bias in all risk of bias domains. The risk ratio (RR) for success rate (eucalcaemia) at six months in the MIP group compared to the BNE group was 0.98 (95% confidence interval (CI) 0.94 to 1.03; P = 0.43; 5 studies, 266 participants; very low-certainty evidence). A total of 132/136 (97.1%) participants in the MIP group compared with 129/130 (99.2%) participants in the BNE group were judged as operative success. At five years, the RR was 0.94 (95% CI 0.83 to 1.08; P = 0.38; 1 study, 77 participants; very low-certainty evidence). A total of 34/38 (89.5%) participants in the MIP group compared with 37/39 (94.9%) participants in the BNE group were judged as operative success. The RR for the total incidence of perioperative adverse events was 0.50, in favour of MIP (95% CI 0.33 to 0.76; P = 0.001; 5 studies, 236 participants; low-certainty evidence). Perioperative adverse events occurred in 23/136 (16.9%) participants in the MIP group compared with 44/130 (33.9%) participants in the BNE group. The 95% prediction interval ranged between 0.25 and 0.99. These adverse events included symptomatic hypocalcaemia, vocal cord palsy, bleeding, fever and infection. Fifteen of 104 (14.4%) participants experienced symptomatic hypocalcaemia in the MIP group compared with 26/98 (26.5%) participants in the BNE group. The RR for this event comparing MIP with BNE at two days was 0.54 (95% CI 0.32 to 0.92; P = 0.02; 4 studies, 202 participants). Statistical significance was lost in sensitivity analyses, with a 95% prediction interval ranging between 0.17 and 1.74. Five out of 133 (3.8%) participants in the MIP group experienced vocal cord paralysis compared with 2/128 (1.6%) participants in the BNE group. The RR for this event was 1.87 (95% CI 0.47 to 7.51; P = 0.38; 5 studies, 261 participants). The 95% prediction interval ranged between 0.20 and 17.87. The effect on all-cause mortality was not explicitly reported and could not be adequately assessed (very low-certainty evidence). There was no clear difference for health-related quality of life between the treatment groups in two studies, but studies did not report numerical data (very low-certainty evidence). There was a possible treatment benefit for MIP compared to BNE in terms of cosmetic satisfaction (very low-certainty evidence). The mean difference (MD) for duration of surgery comparing BNE with MIP was in favour of the MIP group (-18 minutes, 95% CI -31 to -6; P = 0.004; 3 studies, 171 participants; very low-certainty evidence). The 95% prediction interval ranged between -162 minutes and 126 minutes. The studies did not report length of hospital stay. Four studies reported intraoperative conversion rate from MIP to open procedure information. Out of 115 included participants, there were 24 incidences of conversion, amounting to a conversion rate of 20.8%. AUTHORS' CONCLUSIONS: The success rates of MIP and BNE at six months were comparable. There were similar results at five years, but these were only based on one study. The incidence of perioperative symptomatic hypocalcaemia was lower in the MIP compared to the BNE group, whereas the incidence of vocal cord paralysis tended to be higher. Our systematic review did not provide clear evidence for the superiority of MIP over BNE. However, it was limited by low-certainty to very low-certainty evidence.


Assuntos
Hiperparatireoidismo Primário/diagnóstico por imagem , Hiperparatireoidismo Primário/cirurgia , Monitorização Intraoperatória/métodos , Hormônio Paratireóideo/sangue , Paratireoidectomia/métodos , Adulto , Viés , Humanos , Hiperparatireoidismo Primário/sangue , Hipocalcemia/epidemiologia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Pescoço/cirurgia , Esvaziamento Cervical/métodos , Duração da Cirurgia , Paratireoidectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Paralisia das Pregas Vocais/epidemiologia
17.
PLoS One ; 15(8): e0238249, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32845935

RESUMO

Spontaneous electroencephalogram (EEG) and auditory evoked potentials (AEP) have been suggested to monitor the level of consciousness during anesthesia. As both signals reflect different neuronal pathways, a combination of parameters from both signals may provide broader information about the brain status during anesthesia. Appropriate parameter selection and combination to a single index is crucial to take advantage of this potential. The field of machine learning offers algorithms for both parameter selection and combination. In this study, several established machine learning approaches including a method for the selection of suitable signal parameters and classification algorithms are applied to construct an index which predicts responsiveness in anesthetized patients. The present analysis considers several classification algorithms, among those support vector machines, artificial neural networks and Bayesian learning algorithms. On the basis of data from the transition between consciousness and unconsciousness, a combination of EEG and AEP signal parameters developed with automated methods provides a maximum prediction probability of 0.935, which is higher than 0.916 (for EEG parameters) and 0.880 (for AEP parameters) using a cross-validation approach. This suggests that machine learning techniques can successfully be applied to develop an improved combined EEG and AEP parameter to separate consciousness from unconsciousness.


Assuntos
Monitores de Consciência , Estado de Consciência/fisiologia , Eletroencefalografia/métodos , Aprendizado de Máquina , Monitorização Intraoperatória/métodos , Algoritmos , Anestesia Geral/métodos , Anestésicos Intravenosos/uso terapêutico , Estado de Consciência/efeitos dos fármacos , Potenciais Evocados Auditivos/fisiologia , Humanos , Monitorização Fisiológica/métodos , Redes Neurais de Computação , Máquina de Vetores de Suporte
19.
Eur J Vasc Endovasc Surg ; 60(5): 647-654, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32819817

RESUMO

OBJECTIVE: The aim was to evaluate the potential of near infrared spectrometry (NIRS) monitoring enhanced by autoregulation parameters to detect clamp ischaemia during awake carotid endarterectomy (CEA). METHODS: This was a prospective, hypothesis generating, single centre observational study. Fifty-nine consecutive patients with carotid artery stenosis, of whom 15 (25%) were symptomatic, were enrolled. The patients underwent awake CEA with NIRS monitoring. Regional oxygen saturation (rSO2), relative tissue haemoglobin concentration (rTHb), and mean arterial blood pressure were captured by ICM + software (University of Cambridge Enterprise, Cambridge, UK). The cerebral oxygenation index (COx) and haemoglobin volume index (HVx) were calculated continuously. Two groups were formed depending on neurological symptoms: a symptomatic group with shunt insertion (shunt) and an asymptomatic group (no shunt). RESULTS: Eight patients (14%) became symptomatic and needed intra-operative shunting. The decrease in ipsilateral rSO2 was higher in the shunt group (13.5% vs. 5.3%) and rTHB increased on the non-operated side (+0.05 ± 0.01; p = .016). In symptomatic patients no significant change in rTHB was found during clamping, whereas in asymptomatic patients there was a bilateral increase (ipsilateral: + 0.06 [p = .022]; contralateral: + 0.06 [p = .010]). In asymptomatic patients, ipsilateral COx decreased after clamping (-0.06 ± 0.02; p = .024), indicating functional autoregulation. In symptomatic patients, ipsilateral COx increased to 0.32 (+0.19 ± 0.05; p = .048), indicating loss of autoregulation. Accordingly, pooled ipsilateral and contralateral data showed increasing HVx and COx in symptomatic patients (HVx, p < .001; COx, p = .039). CONCLUSION: In addition to a drop in rSO2, the loss of autoregulatory capacity may be useful in identifying clinically significant clamping ischaemia during CEA under general anaesthesia and may allow optimisation of blood pressure management during awake CEA.


Assuntos
Isquemia Encefálica/diagnóstico , Estenose das Carótidas/cirurgia , Circulação Cerebrovascular/fisiologia , Endarterectomia das Carótidas/efeitos adversos , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesia Geral/efeitos adversos , Pressão Arterial/fisiologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/fisiopatologia , Isquemia Encefálica/prevenção & controle , Circulação Colateral/fisiologia , Estudos de Viabilidade , Feminino , Homeostase/fisiologia , Humanos , Complicações Intraoperatórias/etiologia , Complicações Intraoperatórias/fisiopatologia , Complicações Intraoperatórias/prevenção & controle , Masculino , Oximetria/métodos , Oxigênio/sangue , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho , Vigília/fisiologia
20.
Ann Surg ; 272(2): 220-226, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32675485

RESUMO

OBJECTIVE: To develop and evaluate a novel instrument to measure SEVERE processes using video data. BACKGROUND: Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available. METHODS: Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained. RESULTS: SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence. CONCLUSION: The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/métodos , Endoscopia Gastrointestinal/métodos , Complicações Intraoperatórias/diagnóstico , Monitorização Intraoperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Gravação em Vídeo , Centros Médicos Acadêmicos , Adulto , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Estudos de Coortes , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Endoscopia Gastrointestinal/efeitos adversos , Feminino , Humanos , Complicações Intraoperatórias/prevenção & controle , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Variações Dependentes do Observador , Ontário , Projetos Piloto , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/fisiopatologia , Prognóstico , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Resultado do Tratamento
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