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1.
Lancet ; 395(10217): 33-41, 2020 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-31908284

RESUMO

BACKGROUND: Adhesions are the most common driver of long-term morbidity after abdominal surgery. Although laparoscopy can reduce adhesion formation, the effect of minimally invasive surgery on long-term adhesion-related morbidity remains unknown. We aimed to assess the impact of laparoscopy on adhesion-related readmissions in a population-based cohort. METHODS: We did a retrospective cohort study of patients of any age who had abdominal or pelvic surgery done using laparoscopic or open approaches between June 1, 2009, and June 30, 2011, using validated population data from the Scottish National Health Service. All patients who had surgery were followed up until Dec 31, 2017. The primary outcome measure was the incidence of hospital readmissions directly related to adhesions in the laparoscopic and open surgery cohorts at 5 years. Readmissions were categorised as directly related to adhesions, possibly related to adhesions, and readmissions for an operation that was potentially complicated by adhesions. We did subgroup analyses of readmissions by anatomical site of surgery and used Kaplan-Meier analyses to assess differences in survival across subgroups. We used multivariable Cox-regression analysis to determine whether surgical approach was an independent and significant risk factor for adhesion-related readmissions. FINDINGS: Between June 1, 2009, and June 30, 2011, 72 270 patients had an index abdominal or pelvic surgery, of whom 21 519 (29·8%) had laparoscopic index surgery and 50 751 (70·2%) had open surgery. Of the 72 270 patients who had surgery, 2527 patients (3·5%) were readmitted within 5 years of surgery for disorders directly related to adhesions, 12 687 (17·6%) for disorders possibly related to adhesions, and 9436 (13·1%) for operations potentially complicated by adhesions. Of the 21 519 patients who had laparoscopic surgery, 359 (1·7% [95% CI 1·5-1·9]) were readmitted for disorders directly related to adhesions compared with 2168 (4·3% [4·1-4·5]) of 50 751 patients in the open surgery cohort (p<0·0001). 3443 (16·0% [15·6-16·4]) of 21 519 patients in the laparoscopic surgery cohort were readmitted for disorders possibly related to adhesions compared with 9244 (18·2% [17·8-18·6]) of 50 751 patients in the open surgery cohort (p<0·005). In multivariate analyses, laparoscopy reduced the risk of directly related readmissions by 32% (hazard ratio [HR] 0·68, 95% CI 0·60-0·77), and of possibly related readmissions by 11% (HR 0·89, 0·85-0·94) compared with open surgery. Procedure type, malignancy, sex, and age were also independently associated with risk of adhesion-related readmissions. INTERPRETATION: Laparoscopic surgery reduces the incidence of adhesion-related readmissions. However, the overall burden of readmissions associated with adhesions remains high. With further increases in the use of laparoscopic surgery expected in the future, the effect at the population level might become larger. Further steps remain necessary to reduce the incidence of adhesion-related postsurgical complications. FUNDING: Dutch Adhesion Group and Nordic Pharma.


Assuntos
Laparoscopia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Aderências Teciduais/etiologia , Abdome/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Incidência , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Pelve/cirurgia , Complicações Pós-Operatórias/epidemiologia , Reoperação/efeitos adversos , Estudos Retrospectivos , Aderências Teciduais/cirurgia , Adulto Jovem
2.
Anaesthesia ; 75 Suppl 1: e121-e133, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31903567

RESUMO

The epidemiology of peri-operative acute kidney injury varies depending on the definition, type of surgery and acute and chronic comorbidities. Haemodynamic instability, disturbance of the microcirculation, endothelial dysfunction, inflammation and tubular cell injury are the main factors contributing to the pathogenesis. There are no specific therapies. The most effective strategies to protect renal function during the peri-operative period are: the avoidance of nephrotoxic insults; optimisation of haemodynamics; prevention of hypotension; and meticulous fluid management, including avoidance of both hypovolaemia and hypervolaemia. Peri-operative acute kidney injury is associated with an increased risk of short- and long-term postoperative complications, including a longer stay in hospital, development of premature chronic kidney disease and increased mortality. Resource utilisation and healthcare costs are also higher. In future, the development of advanced clinical prediction scores, new imaging and monitoring techniques and the application of new biomarkers for acute kidney injury have the prospect of identifying acute kidney injury earlier and allowing a more personalised management approach with the aim of reducing the global burden of acute kidney injury.


Assuntos
Lesão Renal Aguda/etiologia , Anestesia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Humanos , Fatores de Risco
3.
JAMA ; 323(3): 225-236, 2020 01 21.
Artigo em Inglês | MEDLINE | ID: mdl-31961418

RESUMO

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.


Assuntos
Abdome/cirurgia , Hidratação/métodos , Derivados de Hidroxietil Amido/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Solução Salina/uso terapêutico , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Lesão Renal Aguda/prevenção & controle , Idoso , Método Duplo-Cego , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/mortalidade , Estatísticas não Paramétricas
4.
J Surg Res ; 245: 629-635, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31522036

RESUMO

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Assuntos
Tratamento de Emergência/efeitos adversos , Disparidades em Assistência à Saúde/economia , Renda/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , População Rural/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , População Urbana/estatística & dados numéricos , Adulto Jovem
5.
Rev. bras. cir. plást ; 34(4): 458-467, oct.-dec. 2019. ilus, tab
Artigo em Inglês, Português | LILACS | ID: biblio-1047901

RESUMO

Introdução: A lipoaspiração tem sido submetida à evolução constante desde a sua consolidação e emprego sistemático. O auxílio de tecnologia ultrassônica de terceira geração, VASER® (Vibration Amplification of Sound Energy at Resonance), se destina a facilitar a execução da lipoaspiração e trazer maior segurança e resultados satisfatórios, especialmente na busca por maior definição e lipoaspiração superficial. Métodos: No período de 2015 a 2017, 76 pacientes foram submetidas à lipoaspiração para melhora de contorno corporal no Centro Hospitalar Santa Mônica em Erechim. Foram avaliados os resultados obtidos, as possíveis complicações e a segurança do emprego do VASER®. Resultados: A utilização rotineira do VASER® gera aperfeiçoamento de resultados em contorno corporal. A emulsificação gerada pelo dispositivo associada à lipoaspiração em diversos níveis permite uma maior definição e evidenciação dos marcos anatômicos. Conclusão: Lipoaspiração associada ao VASER® permite ao cirurgião plástico o refinamento de seus resultados com a preservação da segurança do paciente.


Introduction: Liposuction has been improved continuously since it was first introduced. The third-generation ultrasound technology VASERTM (Vibration Amplification of Sound Energy at Resonance) facilitates liposuction, providing improved safety and satisfactory results, especially in the search for greater definition and superficial liposuction. Methods: From 2015 to 2017, 76 patients underwent liposuction to improve their body contour at the Santa Monica Hospital Center in Erechim, Rio Grande do Sul, Brazil. The results, complications, and the safety of VASERTM were evaluated. Results: The routine use of VASERTM improves body contour. The emulsification generated by the device, along with liposuction, resulted in greater definition and revelation of the anatomical landmarks. Conclusion: Liposuction associated with VASERTM allows plastic surgeons to refine the results better while ensuring patient safety is maintained.


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , História do Século XXI , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Operatórios , Lipectomia , Tecido Adiposo , Gordura Subcutânea/cirurgia , Segurança do Paciente/normas , Contorno Corporal , Lipodistrofia , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Lipectomia/métodos , Tecido Adiposo/cirurgia , Gordura Subcutânea , Segurança do Paciente , Contorno Corporal/efeitos adversos , Contorno Corporal/métodos , Lipodistrofia/cirurgia , Lipodistrofia/complicações
6.
Rev. bras. cir. plást ; 34(4): 436-444, oct.-dec. 2019. ilus, tab
Artigo em Inglês, Português | LILACS | ID: biblio-1047896

RESUMO

Introdução: O número de pacientes classificados com sobrepeso ou obesos e, com isso, dos pacientes pós-bariátricas vem aumentando, gerando uma demanda por ritidoplastias neste perfil de público. O objetivo é expor a rotina e táticas cirúrgicas em um hospital de ensino, o perfil destes pacientes, além de um comparativo superficial histológico da pele, tecido celular subcutâneo e SMAS, entre os pacientes pós e não pós-bariátrica. Métodos: Foi realizado revisão de dados do centro cirúrgico e de prontuário entre os anos de 2012 e 2016 em um hospital público na cidade de Goiânia-GO, com levantamento de 32 casos. Resultados: A tática de ritidoplastia utilizada nos pacientes pós-bariátrica não apresenta grandes diferenças entre a utilizada nos pacientes não pós-bariátrica. A análise histopatológica das amostras colhidas evidenciou diferenças marcantes entre os pacientes pós e não pós-bariátrica. Conclusão: Percebeu-se que a técnica operatória na ritidoplastia do paciente pós-bariátrica sustentou detalhes específicos, com resultado cirúrgico pós-operatório satisfatório, uma pele de pior qualidade histológica, com complicações perioperatórias dentro do esperado e com necessidade de maiores estudos para avaliar durabilidade do procedimento.


Introduction: The number of patients classified as overweight or obese has resulted in an increased number of post-bariatric patients, generating a demand for rhytidoplasty in this public profile. The objective is to expose the routine and surgical tactics in a teaching hospital, patient profiles, subcutaneous cellular tissue, and the superficial musculoaponeurotic system are compared between post-bariatric and non-post-bariatric patients, as well as histological superficial comparison of the skin. Methods: A review of the data of 32 cases treated in 2012­2016 was conducted in a public hospital in Goiânia-GO. Results: The tactics of rhytidoplasty used in post-bariatric patients do not differ significantly from those used in nonpost- bariatric patients. A histopathological analysis of the collected samples showed marked differences between post-bariatric and non-post-bariatric patients. Conclusion: The surgical technique of rhytidoplasty of post-bariatric patients sustained specific details with satisfactory postoperative surgical results, skin with worse histological quality, perioperative complications within the expected range, and the need for further studies to assess the procedure's durability


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , História do Século XXI , Complicações Pós-Operatórias , Pele , Procedimentos Cirúrgicos Operatórios , Estudo Comparativo , Ritidoplastia , Condutas Terapêuticas , Cirurgia Bariátrica , Face , Complicações Pós-Operatórias/cirurgia , Complicações Pós-Operatórias/terapia , Pele/anatomia & histologia , Pele/patologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Ritidoplastia/efeitos adversos , Ritidoplastia/métodos , Condutas Terapêuticas/normas , Cútis Laxa , Cútis Laxa/terapia , Cirurgia Bariátrica/efeitos adversos , Cirurgia Bariátrica/métodos , Face/anatomia & histologia , Face/patologia
7.
Crit Care Resusc ; 21(4): 243-50, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31778630

RESUMO

BACKGROUND: Mechanical ventilation is mandatory in patients undergoing general anaesthesia for major surgery. Tidal volumes higher than 10 mL/kg of predicted body weight have been advocated for intraoperative ventilation, but recent evidence suggests that low tidal volumes may benefit surgical patients. To date, the impact of low tidal volume compared with conventional tidal volume during surgery has only been assessed in clinical trials that also combine different levels of positive end-expiratory pressure (PEEP) in each arm. We aimed to assess the impact of low tidal volume compared with conventional tidal volume during general anaesthesia for surgery on the incidence of postoperative respiratory complications in adult patients receiving moderate levels of PEEP. STUDY DESIGN AND METHODS: Single-centre, two-arm, randomised clinical trial. In total, 1240 adult patients older than 40 years scheduled for at least 2 hours of surgery under general anaesthesia and routinely monitored with an arterial line were included. Patients were ventilated intraoperatively with a moderate level of PEEP (5 cmH2O) and randomly assigned to tidal volume of 6 mL/kg predicted body weight (low tidal volume) or 10 mL/kg predicted body weight (conventional tidal volume in Australia). MAIN OUTCOME MEASURE: The primary outcome is the occurrence of postoperative respiratory complications, recorded as a composite endpoint of adverse respiratory events during the first 7 postoperative days. RESULTS AND CONCLUSIONS: This is the first well powered study comparing the effect of low tidal volume ventilation versus high tidal volume ventilation during surgery on the incidence of postoperative respiratory complications in adult patients receiving moderate levels of PEEP. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614000790640).


Assuntos
Anestesia Geral , Respiração com Pressão Positiva , Volume de Ventilação Pulmonar/efeitos dos fármacos , Adulto , Anestesia Geral/efeitos adversos , Austrália , Humanos , Respiração com Pressão Positiva/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Volume de Ventilação Pulmonar/fisiologia
8.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(11): 1027-1033, 2019 Nov 25.
Artigo em Chinês | MEDLINE | ID: mdl-31770833

RESUMO

Objective: To understand the prevalence, diagnosis and treatment of chronic critical illness (CCI) in China. Methods: The clinical data of 472 adult patients admitted to ICU in 53 hospitals, including basic information, disease-related data, nutrition program, etc., were collected on May 10, 2019, by means of multi-center cross-sectional study. If surgical intervention was needed or the occurrence of the disease was directly related to the surgery, ICU patients were regarded as surgical ICU cases (n=211). In this study, the diagnostic criteria for CCI were: (1) admission to ICU >14 days;(2) combined with persistent organ dysfunction. The prevalence,distribution and treatment of CCI and surgery-related CCI were recorded and analyzed. The Mann-Whitney U test, chi-square test or Fisher exact test were used for comparative analysis. Results: Among the 472 ICU patients from 53 hospitals, 326 were male (69.1%) and 146 were female (30.9%). The prevalence of CCI was 30.7% (145/472). Among 211 surgery-related ICU patients, 57 developed CCI with a prevalence of 27.0%. As compared to non-CCI patients, higher APACHE II score [median (IQR) 13.5 (10.0, 18.3) vs. 11.0 (7.0, 16.0), U=2970.000, P=0.007], higher Charlson comorbidity index [median (IQR) 4.0 (2.0, 7.0) vs. 3.0 (1.0, 5.0), U= 3570.000, P=0.036] and higher ratio of breath dysfunction [68.4% (39/57) vs. 48.1% (74/154), χ(2)=6.939, P=0.008] and renal dysfunction [42.1% (24/57) vs. 18.2% (28/154), χ(2)=12.821, P<0.001] were found in surgery-related CCI patients. While SOFA score, Glasgow coma score and other visceral function were not significantly different between surgery-related CCI and non-CCI patients (all P>0.05). NUTRIC score showed that surgery-related CCI patients had higher nutritional risk [43.9% (25/57) vs. 26.6%(41/154), U=5.750, P=0.016] and higher ratio of mechanical ventilation [66.7% (38/57) vs. 52.3% (79/154), χ(2)=3.977, P=0.046] than non-CCI patients. On the survey day, the daily caloric requirements of 50.2% (106/211) of surgery-related ICU patients were calculated according to the standard adult caloric intake index (104.6 to 125.5 kJ·kg(-1)·d(-1), 1 kJ=0.239 kcal), and the daily caloric requirements of 46.4% (98/211) of patients were calculated by physicians according to the severity of the patient's condition. 60.2% (127/211) of nutritional support therapy was enteral nutrition (including a combination of enteral and parenteral nutrition), while the remaining patients received parenteral nutrition (24.6%, 52/211), simple glucose infusion (9.0%, 19/211), or oral diet (6.2%, 13/211). The target calorie of CCI group was 104.6 (87.9, 125.5) kJ·kg(-1)·d(-1), and the actual calorie intake accounted for 0.98 (0.80, 1.00) of the target calory. In the non-CCI group, the target calorie was 104.6 (87.9, 125.5) kJ·kg(-1)·d(-1), and the actual calorie consumed accounted for 0.91 (0.66, 1.00) of the target calorie. There was no statistically significant difference between two groups (P=0.248, P=0.150). Conclusion: The prevalence of CCI and surgery-related CCI in ICU is high, along with severe complications, respiratory and renal dysfunction and mechanical ventilation. Surgical patients admitted to ICU are at high nutritional risk, and active and correct nutritional support is essential for such patients.


Assuntos
Estado Terminal/epidemiologia , Estado Terminal/terapia , Adulto , China/epidemiologia , Doença Crônica/epidemiologia , Doença Crônica/terapia , Estudos Transversais , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Apoio Nutricional/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/efeitos adversos
9.
Br J Nurs ; 28(21): 1358-1364, 2019 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-31778327

RESUMO

This article describes the development of a scoring system for general surgical patients to highlight those at greater risk of developing acute kidney injury (AKI). Following a search of the literature on current practice, a list of common variables was composed. Hospital Episode Statistics (HES) data from two random hospital trusts was used. With the help of a risk analysis system (CRAB Medical module, CRAB Clinical Informatics Ltd) it was possible to examine the relationship between potential risk factors and the incidence of AKI. Using Analyse-it for Excel a binary logistic model was created, which led to the development of a logistic regression equation and consequently a scoring system. The sensitivity and specificity of the model was tested using the receiver operating characteristic (ROC) curve. There was good correlation across the whole risk spectrum with an area under ROC curve of 0.806 (95% confidence intervals 0.787-0.825). The scoring system was developed into an admission checklist for general surgical patients to highlight a patient's risk of developing AKI. In a ward setting a checklist that immediately assesses the patient and produces a rapid indication as to whether the patient is at high risk or low risk would seem to be the ideal tool.


Assuntos
Lesão Renal Aguda/epidemiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Humanos
10.
Rev Lat Am Enfermagem ; 27: e2939, 2019.
Artigo em Português, Inglês, Espanhol | MEDLINE | ID: mdl-31596404

RESUMO

OBJECTIVE: to estimate the prevalence and avoidability of surgical adverse events in a teaching hospital and to classify the events according to the type of incident and degree of damage. METHOD: cross-sectional retrospective study carried out in two phases. In phase I, nurses performed a retrospective review on a simple randomized sample of 192 records of adult patients using the Canadian Adverse Events Study form for case tracking. Phase II aimed at confirming the adverse event by an expert committee composed of physicians and nurses. Data were analyzed by univariate descriptive statistics. RESULTS: the prevalence of surgical adverse events was 21.8%. In 52.4% of the cases, detection occurred on outpatient return. Of the 60 cases analyzed, 90% (n = 54) were preventable and more than two thirds resulted in mild to moderate damage. Surgical technical failures contributed in approximately 40% of the cases. There was a prevalence of the infection category associated with health care (50%, n = 30). Adverse events were mostly related to surgical site infection (30%, n = 18), suture dehiscence (16.7%, n = 10) and hematoma/seroma (15%, n = 9). CONCLUSION: the prevalence and avoidability of surgical adverse events are challenges faced by hospital management.


Assuntos
Hospitais de Ensino/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Brasil/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Complicações Pós-Operatórias/prevenção & controle , Período Pós-Operatório , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/normas , Deiscência da Ferida Operatória/epidemiologia , Infecção da Ferida Cirúrgica/epidemiologia
11.
Heart Surg Forum ; 22(5): E423-E428, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31596724

RESUMO

Although many believe that the phrase "First, do no harm" was part of the Hippocratic Oath, in fact it was not. This phrase, often written in Latin ("Primum non Nocere"), seems to have first appeared in medical writing in the 17th century. However, it is obvious that many therapeutic interventions do cause at least some harm with hopes of benefitting patients in the long run. This balancing of initial harm in hope of eventual benefit is never more apparent than in the case of invasive procedures, though other examples abound, such as the administration of chemotherapy. The ethical concept of nonmaleficence, which traces its origins to the concept of primum non nocere, accurately acknowledges the concept of the need to strive to do more good than harm. Thus, it is apparent that, in a surgical operation, the surgeon is proposing to cause harm, initially, to the patient in hopes of creating an outcome that results in more good than harm. Therefore, the process of obtaining consent from the patient for a surgical operation acknowledges the fact that harm will, in fact, be inflicted on that patient, with the hope that, on balance, this harm will result in a greater overall good for the patient. It is for this reason that the modern concepts of informed consent have developed.


Assuntos
Juramento Hipocrático , Consentimento Livre e Esclarecido , Procedimentos Cirúrgicos Operatórios , Comunicação , Documentação , Humanos , Consentimento Livre e Esclarecido/ética , Consentimento Livre e Esclarecido/legislação & jurisprudência , Educação de Pacientes como Assunto , Cuidados Pré-Operatórios , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Recusa do Paciente ao Tratamento , Revelação da Verdade
12.
Endocrinology ; 160(12): 2892-2902, 2019 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-31589305

RESUMO

Insulin resistance is an independent negative predictor of outcome after elective surgery and increases mortality among surgical patients in intensive care. The incretin hormone glucagon-like peptide-1 (GLP-1) potentiates glucose-induced insulin release from the pancreas but may also increase insulin sensitivity in skeletal muscle and directly suppress hepatic glucose release. Here, we investigated whether a perioperative infusion of GLP-1 could counteract the development of insulin resistance after surgery. Pigs were randomly assigned to three groups; surgery/control, surgery/GLP-1, and sham/GLP-1. Both surgery groups underwent major abdominal surgery. Whole-body glucose disposal (WGD) and endogenous glucose release (EGR) were assessed preoperatively and postoperatively using D-[6,6-2H2]-glucose infusion in combination with hyperinsulinemic euglycemic step-clamping. In the surgery/control group, peripheral insulin sensitivity (i.e., WGD) was reduced by 44% relative to preoperative conditions, whereas the corresponding decline was only 9% for surgery/GLP-1 (P < 0.05). Hepatic insulin sensitivity (i.e., EGR) remained unchanged in the surgery/control group but was enhanced after GLP-1 infusion in both surgery and sham animals (40% and 104%, respectively, both P < 0.05). Intraoperative plasma glucose increased in surgery/control (∼20%) but remained unchanged in both groups receiving GLP-1 (P < 0.05). GLP-1 diminished an increase in postoperative glucagon levels but did not affect skeletal muscle glycogen or insulin signaling proteins after surgery. We show that GLP-1 improves intraoperative glycemic control, diminishes peripheral insulin resistance after surgery, and suppresses EGR. This study supports the use of GLP-1 to prevent development of postoperative insulin resistance.


Assuntos
Peptídeo 1 Semelhante ao Glucagon/administração & dosagem , Incretinas/administração & dosagem , Resistência à Insulina , Assistência Perioperatória/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Animais , Glicemia , Avaliação Pré-Clínica de Medicamentos , Feminino , Técnica Clamp de Glucose , Glicogênio/metabolismo , Infusões Intravenosas , Insulina/sangue , Fígado/metabolismo , Músculo Esquelético/metabolismo , Período Perioperatório , Distribuição Aleatória , Suínos
13.
Cochrane Database Syst Rev ; 9: CD013438, 2019 09 26.
Artigo em Inglês | MEDLINE | ID: mdl-31556094

RESUMO

BACKGROUND: Randomized controlled trials (RCTs) have yielded conflicting results regarding the ability of beta-blockers to influence perioperative cardiovascular morbidity and mortality. Thus routine prescription of these drugs in an unselected population remains a controversial issue. A previous version of this review assessing the effectiveness of perioperative beta-blockers in cardiac and non-cardiac surgery was last published in 2018. The previous review has now been split into two reviews according to type of surgery. This is an update, and assesses the evidence in non-cardiac surgery only. OBJECTIVES: To assess the effectiveness of perioperatively administered beta-blockers for the prevention of surgery-related mortality and morbidity in adults undergoing non-cardiac surgery. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, CINAHL, Biosis Previews and Conference Proceedings Citation Index-Science on 28 June 2019. We searched clinical trials registers and grey literature, and conducted backward- and forward-citation searching of relevant articles. SELECTION CRITERIA: We included RCTs and quasi-randomized studies comparing beta-blockers with a control (placebo or standard care) administered during the perioperative period to adults undergoing non-cardiac surgery. If studies included surgery with different types of anaesthesia, we included them if 70% participants, or at least 100 participants, received general anaesthesia. We excluded studies in which all participants in the standard care control group were given a pharmacological agent that was not given to participants in the intervention group, studies in which all participants in the control group were given a beta-blocker, and studies in which beta-blockers were given with an additional agent (e.g. magnesium). We excluded studies that did not measure or report review outcomes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We included 83 RCTs with 14,967 participants; we found no quasi-randomized studies. All participants were undergoing non-cardiac surgery, and types of surgery ranged from low to high risk. Types of beta-blockers were: propranolol, metoprolol, esmolol, landiolol, nadolol, atenolol, labetalol, oxprenolol, and pindolol. In nine studies, beta-blockers were titrated according to heart rate or blood pressure. Duration of administration varied between studies, as did the time at which drugs were administered; in most studies, it was intraoperatively, but in 18 studies it was before surgery, in six postoperatively, one multi-arm study included groups of different timings, and one study did not report timing of drug administration. Overall, we found that more than half of the studies did not sufficiently report methods used for randomization. All studies in which the control was standard care were at high risk of performance bias because of the open-label study design. Only two studies were prospectively registered with clinical trials registers, which limited the assessment of reporting bias. In six studies, participants in the control group were given beta-blockers as rescue therapy during the study period.The evidence for all-cause mortality at 30 days was uncertain; based on the risk of death in the control group of 25 per 1000, the effect with beta-blockers was between two fewer and 13 more per 1000 (risk ratio (RR) 1.17, 95% confidence interval (CI) 0.89 to 1.54; 16 studies, 11,446 participants; low-certainty evidence). Beta-blockers may reduce the incidence of myocardial infarction by 13 fewer incidences per 1000 (RR 0.72, 95% CI 0.60 to 0.87; 12 studies, 10,520 participants; low-certainty evidence). We found no evidence of a difference in cerebrovascular events (RR 1.65, 95% CI 0.97 to 2.81; 6 studies, 9460 participants; low-certainty evidence), or in ventricular arrhythmias (RR 0.72, 95% CI 0.35 to 1.47; 5 studies, 476 participants; very low-certainty evidence). Beta-blockers may reduce atrial fibrillation or flutter by 26 fewer incidences per 1000 (RR 0.41, 95% CI 0.21 to 0.79; 9 studies, 9080 participants; low-certainty evidence). However, beta-blockers may increase bradycardia by 55 more incidences per 1000 (RR 2.49, 95% CI 1.74 to 3.56; 49 studies, 12,239 participants; low-certainty evidence), and hypotension by 44 more per 1000 (RR 1.40, 95% CI 1.29 to 1.51; 49 studies, 12,304 participants; moderate-certainty evidence).We downgraded the certainty of the evidence owing to study limitations; some studies had high risks of bias, and the effects were sometimes altered when we excluded studies with a standard care control group (including only placebo-controlled trials showed an increase in early mortality and cerebrovascular events with beta-blockers). We also downgraded for inconsistency; one large, well-conducted, international study found a reduction in myocardial infarction, and an increase in cerebrovascular events and all-cause mortality, when beta-blockers were used, but other studies showed no evidence of a difference. We could not explain the reason for the inconsistency in the evidence for ventricular arrhythmias, and we also downgraded this outcome for imprecision because we found few studies with few participants. AUTHORS' CONCLUSIONS: The evidence for early all-cause mortality with perioperative beta-blockers was uncertain. We found no evidence of a difference in cerebrovascular events or ventricular arrhythmias, and the certainty of the evidence for these outcomes was low and very low. We found low-certainty evidence that beta-blockers may reduce atrial fibrillation and myocardial infarctions. However, beta-blockers may increase bradycardia (low-certainty evidence) and probably increase hypotension (moderate-certainty evidence). Further evidence from large placebo-controlled trials is likely to increase the certainty of these findings, and we recommend the assessment of impact on quality of life. We found 18 studies awaiting classification; inclusion of these studies in future updates may also increase the certainty of the evidence.


Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Anestesia Geral/efeitos adversos , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/prevenção & controle , Bradicardia/prevenção & controle , Causas de Morte , Humanos , Hipotensão/mortalidade , Hipotensão/prevenção & controle , Morbidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/prevenção & controle , Complicações Pós-Operatórias/mortalidade , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Procedimentos Cirúrgicos Operatórios/mortalidade
15.
Zhongguo Yi Xue Ke Xue Yuan Xue Bao ; 41(4): 541-547, 2019 Aug 30.
Artigo em Chinês | MEDLINE | ID: mdl-31484619

RESUMO

Perioperative restrictive red blood cell(RBC)transfusion strategy,in which a trigger of hemoglobin(Hb)<7 g/dl is used,is of great benefits to save blood storage and reduce transfusion-related adverse events including infections,immunologic risks,and circulatory overload.Human body can display a series of compensatory mechanisms to acute anemia,including increased cardiac output,favored oxyhemoglobin dissociation,and lung vascular dilation.Therefore,moderate Hb decrease does not necessarily lead to hypoxemia.Patients undergoing hip surgery or suffering from septic shock and/or upper gastrointestinal bleeding can benefit from restrictive RBC transfusion;however,restrictive transfusion may be associated with adverse outcomes in patients with coronary heart disease or undergoing cardiac surgery.Restrictive RBC transfusion strategies have been included in described in many different guidelines.Most of them recommended Hb<7 g/dl to be a trigger for allogeneic RBC transfusion.For patients with an Hb of 7-10 g/dl,the application of restrictive RBC transfusion should be based on the expected blood loss,compensatory ability,and metabolic rate.


Assuntos
Transfusão de Eritrócitos , Guias de Prática Clínica como Assunto , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Hemoglobinas/análise , Humanos , Assistência Perioperatória
16.
Rev. bras. cir. plást ; 34(3): 405-409, jul.-sep. 2019. tab
Artigo em Inglês, Português | LILACS | ID: biblio-1047164

RESUMO

Introdução: Este estudo se trata de um relato de caso que tem por objetivo alertar os cirurgiões para uma possível complicação em pós-operatório de cirurgias estéticas longas sob anestesia geral. A Síndrome de Boerhaave é uma doença grave que ameaça a vida do paciente e merece um diagnóstico precoce até 12hs e um tratamento adequado. Relato de caso: A paciente no pós-operatório de cirurgia plástica abdominal e mastopexia apresentou, após anestesia geral, crises de vômito e náuseas. Resultados: Paciente com 58 anos do sexo feminino submetida à dermolipectomia abdominal e mastopexia pela a técnica de pedículo inferior sob raquianestesia, onde após um período de quatro horas do término da cirurgia apresentou vários episódios de vômitos. Após 10 horas do ato cirúrgico apresentou queixa de algia ao deglutir, seguida de algia intensa generalizada, dispneia intensa, sudorese, palidez, PA 90x50mmhg. Com a piora do quadro a paciente foi encaminhada para a unidade de terapia intensiva onde foi entubada. Foram realizados exames laboratoriais, toracocentese e exames radiológicos. Atualmente, a paciente encontra-se com prótese esofágica. Conclusões: Fazendo a correlação com a bibliografia, no caso em tela sugere-se evitar cirurgias prolongadas, principalmente sob anestesia geral onde pode ocorrer a retenção de gás carbônico, que pode levar a crise emética no pós-operatório em pacientes com antecedentes de doença esofagiana e estar atentos aos sintomas, não descartando a possibilidade da ocorrência da Síndrome Boerhaave.


Introduction: The objective of this case report is to alert surgeons to a possible postoperative complication of long cosmetic surgery under general anesthesia. Boerhaave syndrome is a serious life-threatening disease that requires diagnosis within 12 hours and proper treatment. Case report: A 58-year-old female patient presented with vomiting and nausea after abdominoplasty and mastopexy under general anesthesia. Results: The patient underwent dermolipectomy and mastopexy using the inferior pedicle technique under spinal anesthesia. Four hours after the operation, she presented several episodes of vomiting. Ten hours after the operation, she reported painful swallowing followed by generalized severe pain and presented severe dyspnea, sweating, pallor, and a 90/50 mmHg blood pressure. As the condition worsened, the patient was referred to the intensive care unit where she was intubated and underwent laboratory tests, thoracentesis, and radiological examinations. The patient currently uses an esophageal prosthesis. Conclusions: The literature suggests avoiding prolonged surgery, especially under general anesthesia, because of the risk of carbon dioxide retention, which may lead to postoperative emetic crisis in patients with a history of esophageal disease. It also suggests paying attention to symptoms, not excluding the possibility of Boerhaave syndrome.


Assuntos
Humanos , Feminino , Pessoa de Meia-Idade , História do Século XXI , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Operatórios , Cirurgia Plástica , Transtornos da Motilidade Esofágica , Esôfago , Abdominoplastia , Anestesia Geral , Ruptura Espontânea/complicações , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Cirurgia Plástica/efeitos adversos , Cirurgia Plástica/métodos , Transtornos da Motilidade Esofágica/cirurgia , Transtornos da Motilidade Esofágica/complicações , Esôfago/cirurgia , Abdominoplastia/efeitos adversos , Abdominoplastia/métodos , Anestesia Geral/métodos
20.
Niger Postgrad Med J ; 26(3): 143-151, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31441451

RESUMO

Introduction: Surgical site infection (SSI) is a major patient safety concern in hospitals. Unlike most developed countries, Nigeria does not yet have an established national system to monitor the occurrence of this infection. This meta-analysis was thus designed to determine the pooled cumulative incidence of SSIs and various determinants of its occurrence in Nigeria. Methods: The electronic databases were systematically searched for articles reporting the occurrence and risk factors associated with SSIs in Nigeria from January 2000 to December 2018. The eligible articles were evaluated using a set of pre-defined criteria. The extracted data were analysed using the comprehensive meta-analysis software. The Begg and Egger's regression tests were used to assess the risk of bias of the included publications. Results: Thirty-two articles emanating from the six geopolitical regions of Nigeria were included in this meta-analysis. The pooled cumulative incidence of SSIs was 14.5% (95% confidence interval [CI]: 0.113-0.184) with the highest incidence reported in the north-eastern region (27.3%, 95% CI: 0.132-0.481) of the country. It was also found to occur more predominantly following colorectal and abdominal surgeries, among elderly patients and in patients with co-morbid conditions. The most frequently reported was the superficial incisional SSIs occurring in 62.5% (95% CI: 0.333-0.848). Higher preponderance was also observed among patients with dirty wounds (52.7%, 95% CI: 0.367-0.682). Conclusion: This meta-analysis documents for the first time the national burden of SSIs in Nigeria. Control measures geared towards its reduction should be strengthened and a national policy on SSI surveillance, prevention and control developed.


Assuntos
Procedimentos Cirúrgicos Operatórios/efeitos adversos , Infecção da Ferida Cirúrgica/epidemiologia , Idoso , Humanos , Incidência , Nigéria/epidemiologia , Segurança do Paciente , Fatores de Risco
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