RESUMO
Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
Assuntos
Pulmão/fisiopatologia , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Obesidade/fisiopatologia , Ventilação Pulmonar , Respiração , Insuficiência Respiratória/fisiopatologia , Procedimentos Cirúrgicos Operatórios , Humanos , Obesidade/diagnóstico , Obesidade/epidemiologia , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/epidemiologia , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/prevenção & controle , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. METHODS: PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. RESULTS: One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring. CONCLUSIONS: A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
Assuntos
Analgésicos Opioides/efeitos adversos , Capnografia/métodos , Oximetria/métodos , Insuficiência Respiratória/induzido quimicamente , Insuficiência Respiratória/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Algoritmos , Feminino , Humanos , Pacientes Internados , Masculino , Pessoa de Meia-Idade , Modelos Teóricos , Monitorização Fisiológica , Valor Preditivo dos Testes , Estudos Prospectivos , Taxa Respiratória , Fatores de RiscoRESUMO
Background: The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS).Methods: A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations.Recommendations: After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: 1) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, 2) stable ambulatory patients with OHS receive positive airway pressure (PAP), 3) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, 4) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2-3 mo), and 5) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery).Conclusions: Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
Assuntos
Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/terapia , Humanos , Estados UnidosRESUMO
PURPOSE: Adaptive servoventilation (ASV) has been reported to show improvement in patients with sleep-disordered breathing (SDB) and heart failure (HF); however, its role as a second-line or adjunctive treatment is not clear. We conducted a systematic review and meta-analysis of new existing data including cardiac mechanistic factor, geometry, and cardiac biomarkers. METHODS: We systematically searched for randomized controlled trials (RCTs) and cohort studies that assessed the efficacy or effectiveness of ASV compared to conventional treatments for SDB and HF in five research databases from their inception to November 2018. Random-effects meta-analyses using the inverse variance method and stratified by study design were performed. RESULTS: We included 15 RCTs (n = 859) and 5 cohorts (n = 162) that met our inclusion criteria. ASV significantly improved left ventricular ejection fraction (LVEF) in cohorts (MD 6.96%, 95% CI 2.58, 11.34, p = 0.002), but not in RCTs. Also, the ASV group had significantly lower apnea-hypopnea index (AHI) in both cohorts (MD - 26.02, 95% CI - 36.94, - 15.10, p < 0.00001) and RCTs (MD - 21.83, 95% CI - 28.17, - 15.49, p < 0.00001). ASV did not significantly decrease the E/e' ratio in RCTs or in cohorts. Finally, ASV significantly decreased brain natriuretic peptide (BNP) in the cohorts (SMD - 121.99, CI 95% - 186.47, - 57.51, p = 0.0002) but not in RCTs. ASV did not have a significant effect on systolic blood pressure, diastolic blood pressure, and cardiac diameters. CONCLUSIONS: ASV therapy is associated with improvements of AHI in comparison to alternative treatments in patients with SDB and HF. ASV did not improve LVEF or E/e' ratios in randomized trials; other intermediate outcomes did not improve significantly.
Assuntos
Insuficiência Cardíaca/terapia , Respiração com Pressão Positiva/métodos , Síndromes da Apneia do Sono/terapia , Idoso , Estudos de Coortes , Comorbidade , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Síndromes da Apneia do Sono/diagnóstico , Síndromes da Apneia do Sono/fisiopatologia , Volume Sistólico/fisiologia , Resultado do TratamentoRESUMO
OBJECTIVE: Patients undergoing noncardiac surgery are at risk for postoperative cardiovascular complications. Literature regarding the ability of the Revised Cardiac Risk Index (RCRI), functional capacity, and stress testing to predict perioperative cardiac events is scarce. The authors examined the association of these parameters with perioperative cardiac events and their additive ability to predict these outcomes. DESIGN: This was a single-center retrospective study conducted at the Cleveland Clinic. SETTING: Hospital. PARTICIPANTS: Patients undergoing noncardiac surgery. INTERVENTION: Patients underwent stress testing. MEASUREMENTS AND MAIN RESULTS: The primary outcome of interest was major adverse cardiac events (MACE). The study cohort included 509 patients with a predominantly good functional status, as defined by estimated metabolic equivalents (METSe), which was ≥4 in 83% of the patients. The addition of preoperative stress testing, when indicated based on the RCRI and functional class limitation, only modestly improved discrimination of risk for postoperative outcomes (METSeâ¯+â¯RCRIâ¯+â¯positive stress test-C statistic 0.77 for MACE; 0.84 for 1-year mortality) compared with the combination of functional capacity (METSe) and RCRI (C statistic 0.70 for MACE; 0.79 for 1-year mortality). A surprisingly high prevalence of false negative stress tests (negative stress tests in patients who later had presence of obstructive coronary disease on angiography) was noted, but the C statistic for MACE remained unchanged, even when no false negative results were assumed. CONCLUSIONS: In a cohort of patients with predominantly good functional status and intermediate-to-high RCRI scores, addition of a preoperative stress test was of only moderate value in predicting postoperative cardiovascular outcomes compared with a combination of functional class and RCRI.
Assuntos
Teste de Esforço/métodos , Cardiopatias/diagnóstico , Cardiopatias/fisiopatologia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/fisiopatologia , Cuidados Pré-Operatórios/métodos , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de RiscoAssuntos
Oxigenação por Membrana Extracorpórea , Coração Auxiliar , Humanos , Choque Cardiogênico/diagnóstico , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Resultado do Tratamento , Oxigenação por Membrana Extracorpórea/efeitos adversos , Obesidade/complicações , Obesidade/diagnósticoRESUMO
BACKGROUND: Obstructive sleep apnea (OSA) is a common comorbidity in patients undergoing cardiac surgery and may predispose patients to postoperative complications. The purpose of this meta-analysis is to determine the evidence of postoperative complications associated with OSA patients undergoing cardiac surgery. METHODS: A literature search of Cochrane Database of Systematic Reviews, Medline, Medline In-process, Web of Science, Scopus, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL until October 2016 was performed. The search was constrained to studies in adult cardiac surgical patients with diagnosed or suspected OSA. All included studies must report at least 1 postoperative complication. The primary outcome is major adverse cardiac or cerebrovascular events (MACCEs) up to 30 days after surgery, which includes death from all-cause mortality, myocardial infarction, myocardial injury, nonfatal cardiac arrest, revascularization process, pulmonary embolism, deep venous thrombosis, newly documented postoperative atrial fibrillation (POAF), stroke, and congestive heart failure. Secondary outcome is newly documented POAF. The other exploratory outcomes include the following: (1) postoperative tracheal intubation and mechanical ventilation; (2) infection and/or sepsis; (3) unplanned intensive care unit (ICU) admission; and (4) duration of stay in hospital and ICU. Meta-analysis and meta- regression were conducted using Cochrane Review Manager 5.3 (Cochrane, London, UK) and OpenBUGS v3.0, respectively. RESULTS: Eleven comparative studies were included (n = 1801 patients; OSA versus non-OSA: 688 vs 1113, respectively). MACCEs were 33.3% higher odds in OSA versus non-OSA patients (OSA versus non-OSA: 31% vs 10.6%; odds ratio [OR], 2.4; 95% confidence interval [CI], 1.38-4.2; P = .002). The odds of newly documented POAF (OSA versus non-OSA: 31% vs 21%; OR, 1.94; 95% CI, 1.13-3.33; P = .02) was higher in OSA compared to non-OSA. Even though the postoperative tracheal intubation and mechanical ventilation (OSA versus non-OSA: 13% vs 5.4%; OR, 2.67; 95% CI, 1.03-6.89; P = .04) were significantly higher in OSA patients, the length of ICU stay and hospital stay were not significantly prolonged in patients with OSA compared to non-OSA. The majority of OSA patients were not treated with continuous positive airway pressure therapy. Meta-regression and sensitivity analysis of the subgroups did not impact the OR of postoperative complications for OSA versus non-OSA groups. CONCLUSIONS: Our meta-analysis demonstrates that after cardiac surgery, MACCEs and newly documented POAF were 33.3% and 18.1% higher odds in OSA versus non-OSA patients, respectively.
Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Apneia Obstrutiva do Sono/epidemiologia , Procedimentos Cirúrgicos Cardíacos/tendências , Humanos , Estudos Observacionais como Assunto/métodos , Complicações Pós-Operatórias/diagnóstico , Apneia Obstrutiva do Sono/diagnóstico , Resultado do TratamentoRESUMO
PURPOSE OF REVIEW: The purpose of this review is to identify chronic pulmonary conditions which may often not be recognized preoperatively especially before elective noncardiac surgery and which carry the highest risk of perioperative morbidity and mortality. RECENT FINDINGS: This review discusses some of the most recent studies that highlight the perioperative complications, and their prevention and management strategies. SUMMARY: Pulmonary hypertension is a well recognized risk factor for postoperative complications after cardiac surgery but the literature surrounding noncardiac surgery is sparse. Pulmonary hypertension was only recently classified as an independent risk factor for postoperative complications in the American Heart Association/American College of Cardiology Foundation Practice Guideline for noncardiac surgery. Spinal anesthesia should be avoided in most surgeries on patients with pulmonary hypertension because of it's rapid sympatholytic effects. The presence of significant right ventricle dysfunction and marked hypoxemia should prompt re-evaluation of the need for elective surgery. Obesity hypoventilation syndrome is even harder to recognize preoperatively as arterial blood gases are generally not obtained prior to elective noncardiac surgery. Amongst patients with obstructive sleep apnea this group of patients carries much higher risk of postoperative respiratory and congestive heart failure.
Assuntos
Procedimentos Cirúrgicos Eletivos/efeitos adversos , Hipertensão Pulmonar/complicações , Síndrome de Hipoventilação por Obesidade/complicações , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Raquianestesia/efeitos adversos , Doença Crônica , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/prevenção & controle , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Incidência , Seleção de Pacientes , Assistência Perioperatória/normas , Período Perioperatório , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/prevenção & controle , Medição de Risco/métodos , Medição de Risco/normas , Fatores de Risco , Disfunção Ventricular Direita/diagnóstico , Disfunção Ventricular Direita/etiologiaRESUMO
Obstructive sleep apnea (OSA) is a commonly encountered problem in the perioperative setting even though many patients remain undiagnosed at the time of surgery. The objective of this systematic review was to evaluate whether the diagnosis of OSA has an impact on postoperative outcomes. We performed a systematic review of studies published in PubMed-MEDLINE, MEDLINE In-Process, and other nonindexed citations, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Health Technology Assessment up to November 2014. Studies of adult patients with a diagnosis of OSA or high risk thereof, published in the English language, undergoing surgery or procedures under anesthesia care, and reporting ≥1 postoperative outcome were included. Overall, the included studies reported on 413,304 OSA and 8,556,279 control patients. The majority reported worse outcomes for a number of events, including pulmonary and combined complications, among patients with OSA versus the reference group. The association between OSA and in-hospital mortality varied among studies; 9 studies showed no impact of OSA on mortality, 3 studies suggested a decrease in mortality, and 1 study reported increased mortality. In summary, the majority of studies suggest that the presence of OSA is associated with an increased risk of postoperative complications.
Assuntos
Complicações Pós-Operatórias/etiologia , Síndromes da Apneia do Sono/complicações , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Anestesia/efeitos adversos , Mortalidade Hospitalar , Humanos , Complicações Pós-Operatórias/mortalidade , Medição de Risco , Fatores de Risco , Síndromes da Apneia do Sono/diagnóstico , Síndromes da Apneia do Sono/mortalidade , Síndromes da Apneia do Sono/fisiopatologia , Procedimentos Cirúrgicos Operatórios/mortalidade , Fatores de Tempo , Resultado do TratamentoRESUMO
The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients' conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.
Assuntos
Anestesia/normas , Anestesiologia/normas , Cuidados Pré-Operatórios/normas , Apneia Obstrutiva do Sono/diagnóstico , Adulto , Anestesia/efeitos adversos , Anestesia/métodos , Anestesiologia/métodos , Consenso , Procedimentos Cirúrgicos Eletivos , Medicina Baseada em Evidências/normas , Humanos , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Valor Preditivo dos Testes , Cuidados Pré-Operatórios/métodos , Medição de Risco , Fatores de Risco , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/fisiopatologia , Apneia Obstrutiva do Sono/terapia , Resultado do TratamentoRESUMO
BACKGROUND: Obstructive sleep apnea (OSA) is a commonly encountered comorbid condition in patients undergoing surgery and is associated with a greater risk of postoperative adverse events. Our objective in this review was to investigate the effectiveness of continuous positive airway pressure (CPAP) in reducing the risk of postoperative adverse events in patients with OSA undergoing surgery, the perioperative Apnea-Hypopnea Index (AHI), and the hospital length of stay (LOS). METHODS: We performed a systematic search of the literature databases. We reviewed the studies that included the following: (1) adult surgical patients (>18 years old) with information available on OSA; (2) patients using either preoperative and/or postoperative CPAP or no-CPAP; (3) available reports on postoperative adverse events, preoperative and postoperative AHI, and LOS; and (4) all published studies in English including case series. RESULTS: Six studies that included 904 patients were eligible for the meta-analysis. The meta-analysis for postoperative adverse events was performed in 904 patients (CPAP: n = 471 vs no-CPAP: n = 433; adverse events: 134 vs 133; P = 0.19). There was no significant difference in the postoperative adverse events between the 2 groups. The preoperative baseline AHI without CPAP was reduced significantly with postoperative use of CPAP (preoperative AHI versus postoperative AHI, 37 ± 19 vs 12 ± 16 events per hour, P < 0.001). LOS showed a trend toward significance in the CPAP group versus the no-CPAP group (4.0 ± 4 vs 4.4 ± 8 days, P = 0.05). CONCLUSIONS: Our review suggests that there was no significant difference in the postoperative adverse events between CPAP and no-CPAP treatment. Patients using CPAP had significantly lower postoperative AHI and a trend toward shorter LOS. There may be potential benefits in the use of CPAP during the perioperative period.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Apneia Obstrutiva do Sono/terapia , Procedimentos Cirúrgicos Operatórios , Distribuição de Qui-Quadrado , Comorbidade , Humanos , Tempo de Internação , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Fatores de Risco , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Fatores de TempoRESUMO
BACKGROUND: We investigated whether right ventricular dysfunction (RVD) as assessed by echocardiogram can be used as a prognostic factor in hemodynamically stable patients with acute pulmonary embolism (PE). Short-term mortality has been investigated only in small studies and the results have been controversial. METHODS: A PubMed search was conducted using two keywords, "pulmonary embolism" and "echocardiogram", for articles published between January 1st 1998 and December 31st 2011. Out of 991 articles, after careful review, we found 12 articles that investigated the implications of RVD as assessed by echocardiogram in predicting short-term mortality for hemodynamically stable patients with acute PE. We conducted a meta-analysis of these data to identify whether the presence of RVD increased short-term mortality. RESULTS: Among 3283 hemodynamically stable patients with acute PE, 1223 patients (37.3%) had RVD, as assessed by echocardiogram, while 2060 patients (62.7%) had normal right ventricular function. Short-term mortality was reported in 167 (13.7%) out of 1223 patients with RVD and in 134 (6.5%) out of 2060 patients without RVD. Hemodynamically stable patients with acute PE who had RVD as assessed by echocardiogram had a 2.29-fold increase in short-term mortality (odds ratio 2.29, 95% confidence interval 1.61-3.26) compared with patients without RVD. CONCLUSIONS: In hemodynamically stable patients with acute PE, RVD as assessed by echocardiogram increases short-term mortality by 2.29 times. Consideration should be given to obtaining echocardiogram to identify high-risk patients even if they are hemodynamically stable.
Assuntos
Doença Aguda , Embolia Pulmonar/diagnóstico , Disfunção Ventricular Direita/diagnóstico por imagem , Função Ventricular Direita , Distribuição de Qui-Quadrado , Hemodinâmica , Humanos , Razão de Chances , Valor Preditivo dos Testes , Prognóstico , Embolia Pulmonar/mortalidade , Embolia Pulmonar/fisiopatologia , Medição de Risco , Fatores de Risco , Ultrassonografia , Disfunção Ventricular Direita/mortalidade , Disfunção Ventricular Direita/fisiopatologiaRESUMO
BACKGROUND: Despite the concern that sleep apnea (SA) is associated with increased risk for postoperative complications, a paucity of information is available regarding the effect of this disorder on postoperative complications and resource utilization in the orthopedic population. With an increasing number of surgical patients suffering from SA, this information is important to physicians, patients, policymakers, and administrators alike. METHODS: We analyzed hospital discharge data of patients who underwent total hip or knee arthroplasty in approximately 400 U.S. Hospitals between 2006 and 2010. Patient, procedure, and health care system-related demographics and outcomes such as mortality, complications, and resource utilization were compared among groups. Multivariable logistic regression models were fit to assess the association between SA and various outcomes. RESULTS: We identified 530,089 entries for patients undergoing total hip and knee arthroplasty. Of those, 8.4% had a diagnosis code for SA. In the multivariate analysis, the diagnosis of SA emerged as an independent risk factor for major postoperative complications (OR 1.47; 95% confidence interval [CI], 1.39-1.55). Pulmonary complications were 1.86 (95% CI, 1.65-2.09) times more likely and cardiac complications 1.59 (95% CI, 1.48-1.71) times more likely to occur in patients with SA. In addition, SA patients were more likely to receive ventilatory support, use more intensive care, stepdown and telemetry services, consume more economic resources, and have longer lengths of hospitalization. CONCLUSIONS: The presence of SA is a major clinical and economic challenge in the postoperative period. More research is needed to identify SA patients at risk for complications and develop evidence-based practices to aid in the allocation of clinical and economic resources.
Assuntos
Artroplastia de Quadril/métodos , Artroplastia do Joelho/métodos , Síndromes da Apneia do Sono/complicações , Síndromes da Apneia do Sono/cirurgia , Idoso , Comorbidade , Bases de Dados Factuais , Feminino , Lesões do Quadril/complicações , Humanos , Traumatismos do Joelho/complicações , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias , Prevalência , Análise de Regressão , Estudos Retrospectivos , Fatores de Risco , Telemetria , Resultado do TratamentoRESUMO
Modern surgery is faced with the emergence of newer "risk factors" and the challenges associated with identifying and managing these risks in the perioperative period. Obstructive sleep apnea and obesity hypoventilation syndrome pose unique challenges in the perioperative setting. Recent studies have identified some of the specific risks arising from caring for such patients in the surgical setting. While all possible postoperative complications are not yet fully established or understood, the prevention and management of these complications pose even greater challenges. Pulmonary hypertension with its changing epidemiology and novel management strategies is another new disease for the surgeon and the anesthesiologist in the noncardiac surgical setting. Traditionally most such patients were not considered surgical candidates for any required elective surgery. Our review discusses these disease entities which are often undiagnosed before elective noncardiac surgery.
Assuntos
Hipertensão Pulmonar/cirurgia , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/prevenção & controle , Síndrome de Hipoventilação por Obesidade/cirurgia , Apneia Obstrutiva do Sono/cirurgia , Humanos , Hipertensão Pulmonar/epidemiologia , Síndrome de Hipoventilação por Obesidade/epidemiologia , Fatores de Risco , Comportamento de Redução do Risco , Apneia Obstrutiva do Sono/epidemiologiaRESUMO
OBJECTIVE: The current standards of postoperative respiratory monitoring on medical-surgical floors involve spot-pulse oximetry checks every 4-8 h, which can miss the opportunity to detect prolonged hypoxia and acute hypercapnia. Continuous respiratory monitoring can recognize acute respiratory depression episodes; however, the existing evidence is limited. We sought to review the current evidence on the effectiveness of continuous pulse oximetry (CPOX) with and without capnography versus routine monitoring and their effectiveness for detecting postoperative respiratory failure, opioid-induced respiratory depression, and preventing downstream adverse events. METHODS: We performed a systematic literature search on Ovid Medline, Embase, and Cochrane Library databases for articles published between 1990 and April 2023. The study protocol was registered in Prospero (ID: 439467), and PRISMA guidelines were followed. The NIH quality assessment tool was used to assess the quality of the studies. Pooled analysis was conducted using the software R version 4.1.1 and the package meta. The stability of the results was assessed using sensitivity analysis. DESIGN: Systematic Review and Meta-Analysis. SETTING: Postoperative recovery area. PATIENTS: 56,538 patients, ASA class II to IV, non-invasive respiratory monitoring, and post-operative respiratory depression. INTERVENTIONS: Continuous pulse oximetry with or without capnography versus routine monitoring. MEASUREMENTS: Respiratory rate, oxygen saturation, adverse events, and rescue events. RESULTS: 23 studies (17 examined CPOX without capnography and 5 examined CPOX with capnography) were included in this systematic review. CPOX was better at recognizing desaturation (SpO2 < 90%) OR: 11.94 (95% CI: 6.85, 20.82; p < 0.01) compared to standard monitoring. No significant differences were reported for ICU transfer, reintubation, and non-invasive ventilation between the two groups. CONCLUSIONS: Oxygen desaturation was the only outcome better detected with CPOX in postoperative patients in hospital wards. These comparisons were limited by the small number of studies that could be pooled for each outcome and the heterogeneity between the studies.
Assuntos
Analgésicos Opioides , Insuficiência Respiratória , Humanos , Analgésicos Opioides/efeitos adversos , Taxa Respiratória , Capnografia/métodos , Monitorização Fisiológica/métodos , Insuficiência Respiratória/induzido quimicamente , Insuficiência Respiratória/prevenção & controle , Insuficiência Respiratória/diagnóstico , Oximetria/métodos , Complicações Pós-Operatórias/diagnóstico , HospitaisRESUMO
BACKGROUND: Studies have shown inconclusive results on the effectiveness of cerebral protection devices (CPDs) with transcatheter aortic valve replacement. We aimed to analyze the national statistics on stroke and other outcomes with CPD use. METHODS AND RESULTS: The Nationwide Readmissions Database (2017-2020) was queried to obtain data on patients undergoing transcatheter aortic valve replacement. Outcomes were compared between patients with a CPD and patients without a CPD. Of 271 804 patients undergoing transcatheter aortic valve replacement, CPD was used in 7.3% of patients. In a multivariable logistic regression analysis, CPD use was not associated with lower overall stroke rates (1.6% versus 1.9% without CPD; odds ratio, 0.95 [95% CI, 0.84-1.07]; P=0.364), but it was significantly associated with lower major stroke rates (1.2% versus 1.5% without CPD; odds ratio, 0.85 [95% CI, 0.74-0.98]; P=0.02). Patients with a CPD also had a shorter length of stay, higher routine discharges to home/self-care (74.9% versus 70.6%), and lower mortality rates (0.7% versus 1.3%). The 30-day (9.6% versus 11.7%) and 180-day (24.6% versus 28.2%) readmission rates were significantly lower in the CPD cohort. Among patients who developed stroke, patients with a CPD had more frequent routine discharges. Prior valve surgery was associated with the highest risk of overall and major stroke. CONCLUSIONS: CPD use during transcatheter aortic valve replacement was not independently associated with a lower risk of overall stroke but was associated with a lower risk of major stroke in a multivariable model. Data from future randomized trials that may offset any potential confounders in our study are required to help identify patients who would benefit from the use of these devices.
Assuntos
Acidente Vascular Cerebral , Substituição da Valva Aórtica Transcateter , Humanos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/instrumentação , Masculino , Feminino , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Idoso de 80 Anos ou mais , Idoso , Fatores de Risco , Estenose da Valva Aórtica/cirurgia , Estenose da Valva Aórtica/mortalidade , Estados Unidos/epidemiologia , Dispositivos de Proteção Embólica , Medição de Risco/métodos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Resultado do Tratamento , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Bases de Dados Factuais , Incidência , Fatores de TempoRESUMO
INTRODUCTION: We present the proceedings of the second annual meeting of the Society of Anesthesia and Sleep Medicine. The theme of the meeting was "Anesthesia and Sleep Medicine: What Every Health Professional Needs to Know." DISCUSSION: While upper airway obstruction during sleep and anesthesia received concentrated attention, with particular regard to perioperative assessment and managment of obstuctive sleep apnea, a diversity of issues were raised including: the genetic basis for variations in ventilatory control; shared charactertics of sleep and anesthesia; hazards posed by narcotic use in patients with obstructive sleep apnea (OSA); the respiratory complication that follow surgery in such patients; who amongst them is suitable for ambulatory surgery; and the special circumstances that apply to anesthesia for children with OSA. How principles based on these considerations have been applied to protocol development at two major centers was presented towards the end of the meeting. The proceedings highlight issues discussed by each of the invited speakers but do not include the research abstracts discussed during the poster session.
Assuntos
Anestesia , Apneia Obstrutiva do Sono , Medicina do Sono , Sociedades Médicas , Humanos , Estados UnidosRESUMO
Pulmonary hypertension is a well-established independent risk factor for perioperative complications after elective non-cardiac surgery. Patients undergoing cardiac surgery are routinely evaluated for the presence of pulmonary hypertension in the preoperative period. Better monitoring in the postoperative critical care setting leads to more efficient management of potential complications. Data among patients with pulmonary hypertension undergoing elective non-cardiac surgery are scant. Moreover, the condition may be unidentified at the time of surgery. Also, monitoring after non-cardiac surgery can be very limited in the PACU setting, as opposed to the critical care setting. All these factors can result in a higher postoperative complication rate and poor outcomes.
RESUMO
Purpose: To characterize medical and surgical patient characteristics, as well as clinical and economic outcomes, associated with unplanned intensive care unit (ICU) admissions. Patients and Methods: This was a retrospective matched cohort analysis that utilized the PINC AITM Healthcare Database, which collects deidentified data from 25% of United States (US) hospital admissions. Discharge records were assessed for medical and surgical admissions in 2021. An unplanned ICU admission was defined as direct transfer from a medical, surgical, or telemetry unit to the ICU. Patients with and without an unplanned ICU admission were 1:1 propensity score matched. Differences between patients with and without unplanned ICU admissions were assessed using two-sample t-tests for continuous measures and Chi-square tests for categorical measures. Results: A total of 3,807,124 qualifying admissions were identified. Medical admissions with unplanned ICU transfers were more likely to be urgent/emergent (odds ratio [OR] 2.9, 95% confidence interval [CI 2.7-3.0], p<0.0001), with patient characteristics including male sex (1.4, [1.4-1.4], p<0.0001), obesity (1.7, [1.6-1.7], p<0.0001), and increased Charlson Comorbidity Index (CCI=1: 1.8, [1.8-1.9], p<0.0001; CCI≥5: 3.2, [3.1-3.3], p<0.0001). Surgical admissions with unplanned ICU transfers were more likely to be urgent/emergent (3.1, [2.9-3.2], p<0.0001) and with patients of higher CCI (2.5, [2.3-2.6], p<0.0001 to a CCI of≥5 (7.9, [7.4-8.4], p<0.0001). Between matched medical patients, mean differences in length of stay, cost, and mortality were 4.1 days (p<0.0001), $13,424 (p<0.0001), and 21% (p<0.0001), respectively. Between matched surgical patients, mean differences in these outcomes were 6.4 days (p<0.0001), $21,448 (p<0.0001), and 14% (p<0.0001), respectively. Conclusion: Emergency care in patients with a higher co-morbid burden is more likely to lead to unplanned ICU admission, putting patients at a significantly increased chance of mortality, longer length of stay, and increased costs. Improving care and monitoring of patients outside the ICU may help detect early changes in pathophysiology and enable early intervention.