RESUMO
BACKGROUND: Asymptomatic brain ischemic injury detected with diffusion-weighted magnetic resonance imaging (DWI) is reported in more than one-half of patients after cardiac surgery. There are conflicting findings on whether DWI-detected covert stroke is associated with neurocognitive dysfunction after surgery, and it is unclear whether such ischemic injury affects quality of life or behavioral outcomes. The purpose of this study was to perform exploratory analysis on whether covert stroke after cardiac surgery is associated with delayed neurocognitive recovery 1 month after surgery, impaired quality of life, anxiety, or depression. METHODS: Analysis of data collected in a prospectively randomized study in patients undergoing cardiac surgery testing whether basing mean arterial pressure (MAP) targets during cardiopulmonary bypass to be above the lower limit of cerebral autoregulation versus usual practices reduces the frequency of adverse neurological outcomes. A neuropsychological testing battery was administered before surgery and then 1 month later. Patients underwent brain magnetic resonance imaging (MRI) between postoperative days 3 and 5. The primary outcome was DWI-detected ischemic lesion; the primary end point was change from baseline in domain-specific neurocognitive Z scores 1 month after surgery. Secondary outcomes included a composite indicator of delayed neurocognitive recovery, quality of life measures, state and trait anxiety, and Beck Depression Inventory scores. RESULTS: Of the 164 patients with postoperative MRI data, clinical stroke occurred in 10 patients. Of the remaining 154 patients, 85 (55.2%) had a covert stroke. There were no statistically significant differences for patients with or without covert stroke in the change from baseline in Z scores in any of the cognitive domains tested adjusted for sex, baseline cognitive score, and randomization treatment arm. The frequency of delayed neurocognitive recovery (no covert stroke, 15.1%; covert stroke, 17.6%; P = .392), self-reported quality of life measurements, anxiety rating, or depression scores were not different between those with or without DWI ischemic injury. CONCLUSIONS: More than one-half of patients undergoing cardiac surgery demonstrated covert stroke. In this exploratory analysis, covert stroke was not found to be significantly associated with neurocognitive dysfunction 1 month after surgery; evidence of impaired quality of life, anxiety, or depression, albeit a type II error, cannot be excluded.
Assuntos
Ansiedade/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Depressão/etiologia , Transtornos Neurocognitivos/etiologia , Acidente Vascular Cerebral/etiologia , Idoso , Ansiedade/diagnóstico , Ansiedade/psicologia , Doenças Assintomáticas , Circulação Cerebrovascular , Bases de Dados Factuais , Depressão/diagnóstico , Depressão/psicologia , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transtornos Neurocognitivos/diagnóstico , Transtornos Neurocognitivos/psicologia , Testes Neuropsicológicos , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/psicologia , Fatores de Tempo , Resultado do Tratamento , Estados UnidosRESUMO
Neurological complications of cardiac surgery have a large effect on patient outcomes. In this review, the value of several modes of central nervous system monitoring for improving perioperative care is critiqued. The electroencephalogram (EEG) has been used as a means for detecting brain ischemia. Even though EEG changes are specific for ischemia, the reliability is tempered by many confounding factors. The effectiveness of the processed EEG for ensuring amnesia during surgery is controversial, but it may have value for optimizing anesthetic dose and thus reducing the risk for delirium. Transcranial Doppler may be beneficial in confirming flow to both cerebral hemispheres during antegrade cerebral perfusion such as during aortic arch surgery and in detecting cerebral emboli. Transcranial Doppler can be used for monitoring cerebral autoregulation, allowing for individualization of blood pressure targets during surgery. Measures of adequacy of cerebral oxygen balance include jugular bulb venous oxygen saturation and near-infrared spectroscopy monitoring. Both monitors have limitations that reduce the sensitivity for detecting brain ischemia. Because near-infrared spectroscopy-measured regional cerebral oxygen saturation does not distinguish arterial from venous blood, these measurements reflect the adequacy of oxygen delivery versus demand. Over short periods, filtered regional cerebral oxygen saturation data may provide a clinically feasible method of monitoring cerebral autoregulation that overcomes many limitations of transcranial Doppler. Ongoing studies have demonstrated that the latter methodology for determining perioperative blood pressure targets has large potential for reducing organ injury from cardiac surgery.
Assuntos
Procedimentos Cirúrgicos Cardíacos , Circulação Cerebrovascular/fisiologia , Monitorização Intraoperatória/métodos , Espectroscopia de Luz Próxima ao Infravermelho/métodos , HumanosRESUMO
OBJECTIVE: To characterize contemporary practice patterns in the use of transesophageal echocardiography during adult liver transplantation and to identify factors preventing more frequent use. DESIGN: Online questionnaire. SETTING: Liver transplantation centers in the United States performing 12 or more adult liver transplants in 2011. PARTICIPANTS: One representative from each qualifying center: The transplant anesthesiology director, a transplant anesthesiologist personally known to the authors, or the department of anesthesiology chair. INTERVENTIONS: Three e-mail attempts were made to solicit participation in the study between June and August 2012. MEASUREMENTS AND MAIN RESULTS: Of the 97 institutions identified, an anesthesiologist from each of 79 (81.4%) centers completed the questionnaire; 38.0% of centers reported routine use and 57.0% for special circumstances or rescue situations, yielding an overall use rate of 94.9%. This distribution was consistent regardless of operative volume, practice size, or academic affiliation. The sole factor predictive of routine transesophageal echocardiography use was an overlap between an institution's cardiac and transplant anesthesiology teams. In practices not routinely employing the technology, the most compelling reason was a sense that it was not necessary. Although 69.9% of transplant anesthesiologists reportedly were proficient in echocardiography, inadequate anesthesiologist training was also a strongly cited hindrance. CONCLUSIONS: Transesophageal echocardiography during adult liver transplantation in the United States has become widely prevalent, with notable growth in its use as a routine diagnostic and monitoring modality. Almost all institutions now use the technology at least occasionally, with the participation of cardiac anesthesiologists being predictive of a center's routine use.
Assuntos
Ecocardiografia Transesofagiana/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Atitude do Pessoal de Saúde , Pesquisas sobre Atenção à Saúde , Humanos , Internet , Transplante de Fígado/métodos , Monitorização Intraoperatória , Assistência Perioperatória , Inquéritos e Questionários , Resultado do Tratamento , Estados UnidosRESUMO
OBJECTIVE: To evaluate the effect of systemic magnesium on the prevention of postoperative cardiac arrhythmias after coronary artery bypass graft surgery. DESIGN: A meta-analysis. SETTING: Randomized controlled trials evaluating the effect of systemic magnesium on the incidence of postoperative arrhythmias. PARTICIPANTS: Patients undergoing coronary artery bypass graft surgery. INTERVENTIONS: Systemic perioperative administration of magnesium sulfate. MEASUREMENTS AND MAIN RESULTS: Twenty studies evaluating 3,696 subjects were included. The combined effect suggested that systemic magnesium reduced the incidence of supraventricular arrhythmias compared with saline (odds ratio [OR] = 0.69; 95% confidence interval [CI], 0.53-0.90; number needed to treat [NNT] = 14). The effect was present for lower-quality studies (Jadad score ≤3; OR = 0.47; 95% CI, 0.28-0.81; NNT = 8), but it was not detected for higher-quality studies (Jadad >3; OR = 0.85; 95% CI, 0.66-1.11). There was no association between the total dose of magnesium administration and the incidence of supraventricular arrhythmias (p = 0.19). There was no effect of magnesium on the incidence of postoperative stroke, myocardial infarction, and death. In addition, magnesium did not reduce the hospital or intensive care unit lengths of stay (all p > 0.05). CONCLUSIONS: The effect of magnesium sulfate in reducing postoperative supraventricular arrhythmias was significant when examined by lower-quality studies but not when examined by higher-quality studies. This fact probably is responsible for controversial findings reported in the literature. Also, magnesium sulfate did not reduce the incidence of complications associated with the development of postoperative cardiac arrhythmias. More effective strategies should be used to prevent complications caused by arrhythmias in this patient population.
Assuntos
Arritmias Cardíacas/prevenção & controle , Ponte de Artéria Coronária/efeitos adversos , Magnésio/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Fibrilação Atrial/prevenção & controle , Bradicardia/prevenção & controle , Humanos , Infarto do Miocárdio/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Intracardiac thrombosis and pulmonary embolism are uncommon complications during liver transplantation but carry a high mortality rate. We report the successful use of low-dose recombinant tissue plasminogen activator (0.5-4 mg) administration in 4 patients. Early diagnosis through transesophageal echocardiography and pulmonary artery catheterization may have contributed to the rapid thrombolysis.
Assuntos
Fibrinolíticos/administração & dosagem , Cardiopatias/tratamento farmacológico , Transplante de Fígado/efeitos adversos , Pneumopatias/tratamento farmacológico , Terapia Trombolítica , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/administração & dosagem , Cateterismo de Swan-Ganz , Diagnóstico Precoce , Ecocardiografia Transesofagiana , Feminino , Cardiopatias/diagnóstico , Cardiopatias/etiologia , Cardiopatias/fisiopatologia , Hemodinâmica , Humanos , Pneumopatias/diagnóstico , Pneumopatias/etiologia , Pneumopatias/fisiopatologia , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Proteínas Recombinantes/administração & dosagem , Trombose/diagnóstico , Trombose/etiologia , Trombose/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVES: The use of steroid therapy in cardiac surgical patients remains controversial. The aim of this clinical investigation was to determine the effect of small-dose dexamethasone therapy on patient-perceived quality of recovery (QoR) scores in elective cardiac surgical patients. In addition, the authors assessed the impact of dexamethasone on the incidence of common adverse events after cardiopulmonary bypass (CPB). DESIGN: A prospective, randomized study. SETTING: University hospitals. PARTICIPANTS: One hundred seventeen patients undergoing cardiac surgery with CPB and anticipated early tracheal extubation. INTERVENTIONS: Subjects were randomized to receive either dexamethasone (dexamethasone group, 8 mg at the induction of anesthesia and at the initiation of CPB) or placebo (control group, saline). MEASUREMENTS AND MAIN RESULTS: The QoR was assessed using the QoR-40 scoring system preoperatively and on postoperative days (PODs) 1 and 2. Secondary outcome measures assessed in the postoperative period included nausea, vomiting, fatigue, febrile responses, shivering, pulmonary gas exchange, and analgesic requirements. Global QoR-40 scores (median [range]) were higher in the dexamethasone group compared with the control group on POD 1 (167 [133-192] v 157 [108-195]; p < 0.0001) and POD 2 (173 [140-196] v 166 [122-196]; p = 0.001). In the dexamethasone group, improved QoR was observed in the QoR-40 dimensions of emotional state (p = 0.002), physical comfort (p = 0.0001-0.006), and pain (p < 0.0001). The incidences or severity of postoperative fatigue (p < 0.0001), febrile responses (p < 0.0001), and shivering (p = 0.001) were reduced in the dexamethasone group. CONCLUSIONS: Patient-perceived postoperative QoR in cardiac surgical patients is enhanced significantly by small-dose dexamethasone treatment.
Assuntos
Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Idoso , Anestesia , Período de Recuperação da Anestesia , Anestesia Geral , Gasometria , Ponte Cardiopulmonar/efeitos adversos , Método Duplo-Cego , Fadiga/epidemiologia , Fadiga/prevenção & controle , Feminino , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Satisfação do Paciente , Complicações Pós-Operatórias/epidemiologia , Náusea e Vômito Pós-Operatórios/epidemiologia , Náusea e Vômito Pós-Operatórios/prevenção & controle , Qualidade de Vida , Recuperação de Função Fisiológica , EsternotomiaRESUMO
OBJECTIVE: Processed EEG monitoring during cardiopulmonary bypass (CPB) may help determine loss of consciousness and depth of anesthesia. This study compared the SNAP(™) II and BIS Vista monitors in patients undergoing isoflurane anesthesia with normothermic CPB. METHODS: 40 subjects undergoing CPB with isoflurane anesthesia were enrolled. Subjects were premedicated with 1-2 mg midazolam approximately 5 min prior to acquisition of baseline index values and anesthesia induced with midazolam and fentanyl. Anesthesia was maintained with isoflurane, midazolam, and fentanyl and a cis-atracurium infusion. SNAP(™) II (version 1.2.9 algorithm 1.88) and BIS Vista (application version 3.00 platform version 2.03) indices were recorded at baseline, pre-induction, post-intubation, incision, start of CPB, every 15 min during CPB, end of CPB, and end of case. Agreement between methods was determined using Pearson correlation and the Bland-Altman method with repeated observa- tions. RESULTS: Twenty-four male and 12 female subjects completed the analysis. The correlation between SNAP(™) II and BIS Vista index values was 0.61 (P < 0.005). A linear relationship between the difference in the indices and the average index values was observed following the induction of anesthesia. In awake subjects, the bias between the SNAP(™) II and BIS Vista was 5 (95% CI 3-7). The limits of agreement were 23 (95% CI 19-26) and -13 (95% CI -9--16). During anesthesia, the mean difference on a log scale was 0.11 (95% CI 0.09-0.12). The limits of agreement were 0.43 (95% CI 0.40-0.45) and -0.21 (95% CI -0.18--0.24). The antilog of the mean difference demonstrated that the SNAP(™) II value was 28% (95% CI 24-33%) higher than the BIS Vista value following induction of anesthesia. CONCLUSIONS: The SNAP(™) II monitor demonstrates a consistently positive bias during cardiopulmonary bypass under isoflurane anesthesia compared with the BIS Vista.
Assuntos
Ponte Cardiopulmonar/instrumentação , Diagnóstico por Computador/instrumentação , Eletroencefalografia/efeitos dos fármacos , Eletroencefalografia/instrumentação , Isoflurano/administração & dosagem , Monitorização Intraoperatória/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Anestésicos Inalatórios/administração & dosagem , Ponte Cardiopulmonar/métodos , Diagnóstico por Computador/métodos , Desenho de Equipamento , Análise de Falha de Equipamento , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodosRESUMO
BACKGROUND: Experimental and clinical data suggest that morphine possesses unique cardioprotective and antiinflammatory properties. In this clinical investigation, we sought to determine whether the choice of intraoperative opioid (morphine or fentanyl) influences early recovery after cardiac surgery. METHODS: Ninety patients undergoing cardiac surgery with cardiopulmonary bypass were randomized to receive either morphine (40 mg) or fentanyl (600 mug) as part of a standardized opioid-isoflurane anesthetic. Quality of recovery was assessed using the QoR-40 questionnaire administered preoperatively and daily on postoperative days 1-3. During the first three postoperative days, pain was measured using a 100-mm visual analog scale, and the use of IV and oral pain medications (morphine or acetaminophen/hydrocodone) was quantified. Hemodynamic variables, duration of tracheal intubation, postoperative febrile reactions, organ morbidities, and intensive care unit (ICU) and hospital length of stay were evaluated. RESULTS: Compared with patients given fentanyl, those receiving morphine had higher global QoR-40 scores on postoperative days 1 (173 vs 160, P < 0.0001), 2 (174 vs 164, P < 0.0001), and 3 (177 vs 167, P < 0.001). Differences between the groups were observed in the QoR-40 dimensions of emotional state, physical comfort, and pain (all P < 0.01-0.0001). Postoperative visual analog scale pain scores, use of pain medication in the ICU and surgical ward, and postoperative febrile reactions were reduced significantly in the morphine group (all P < 0.01). No differences between the groups were noted in duration of tracheal intubation, ICU and hospital length of stay, or postoperative complications. CONCLUSIONS: In patients undergoing elective cardiac surgery with cardiopulmonary bypass, postoperative quality-of-life measures and pain control during recovery were enhanced when morphine (40 mg) was administered intraoperatively as part of a balanced anesthetic technique compared with fentanyl.
Assuntos
Analgésicos Opioides , Anestesia Intravenosa , Anestésicos Intravenosos , Procedimentos Cirúrgicos Cardíacos , Fentanila , Morfina , Idoso , Período de Recuperação da Anestesia , Método Duplo-Cego , Procedimentos Cirúrgicos Eletivos , Feminino , Hemodinâmica/efeitos dos fármacos , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Medição da Dor/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Complicações Pós-Operatórias/epidemiologiaRESUMO
OBJECTIVE: Transcatheter aortic valve replacement is a safe, minimally invasive treatment for severe aortic stenosis in patients with moderate-to-high surgical risk. Monitored anesthesia is administered by an anesthesiologist. This study compares transcatheter aortic valve outcomes under monitored anesthesia vs general anesthesia. METHODS: Data were prospectively collected for 286 patients undergoing transcatheter aortic valve replacement at a single academic hospital from March 2012 to August 2016. The patients were grouped by type of anesthesia: monitored vs general. A propensity score match was performed to compare intraoperative and post-operative outcomes between groups. RESULTS: General anesthesia was used in 102 patients and moderate sedation in 184. Propensity score matching produced 80 pairs. Compared to procedures under general anesthesia, patients receiving monitored anesthesia had shorter procedure (1.6 [1.4, 2.0] vs 2.0 [1.6, 2.5] hours;P < 0.001) and fluoroscopy times (17 [14.5, 22.5] vs 25 [17.9, 30.3] minutes;P < 0.001) and shorter hospital length-of-stay (3 [2.0, 4.0] vs 5 [3.0, 7.0] days;P < 0.001) but no difference in intensive care unit length-of-stay. Blood transfusion was more common in patients undergoing general anesthesia, but there was no difference in stroke, renal failure, postoperative atrial fibrillation, or need for permanent pacemaker. More patients were discharged to home after monitored anesthesia (90% vs 64%;P < 0.001). There was no difference in 30-day mortality (0% vs 3%;P = 0.15). CONCLUSIONS: Transcatheter aortic valve replacement under monitored anesthesia provides the safety of anesthesia-led sedation without intubation and general anesthetic. We found no compromise in patient safety or clinical outcomes.
Assuntos
Anestesia Geral/métodos , Sedação Consciente/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Anestesia Geral/mortalidade , Anestesia Intravenosa/métodos , Sedação Consciente/mortalidade , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Monitorização Intraoperatória/métodos , Pontuação de Propensão , Análise de Sobrevida , Substituição da Valva Aórtica Transcateter/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Epidural analgesia initiated early in labor (when the cervix is less than 4.0 cm dilated) has been associated with an increased risk of cesarean delivery. It is unclear, however, whether this increase in risk is due to the analgesia or is attributable to other factors. METHODS: We conducted a randomized trial of 750 nulliparous women at term who were in spontaneous labor or had spontaneous rupture of the membranes and who had a cervical dilatation of less than 4.0 cm. Women were randomly assigned to receive intrathecal fentanyl or systemic hydromorphone at the first request for analgesia. Epidural analgesia was initiated in the intrathecal group at the second request for analgesia and in the systemic group at a cervical dilatation of 4.0 cm or greater or at the third request for analgesia. The primary outcome was the rate of cesarean delivery. RESULTS: The rate of cesarean delivery was not significantly different between the groups (17.8 percent after intrathecal analgesia vs. 20.7 percent after systemic analgesia; 95 percent confidence interval for the difference, -9.0 to 3.0 percentage points; P=0.31). The median time from the initiation of analgesia to complete dilatation was significantly shorter after intrathecal analgesia than after systemic analgesia (295 minutes vs. 385 minutes, P<0.001), as was the time to vaginal delivery (398 minutes vs. 479 minutes, P<0.001). Pain scores after the first intervention were significantly lower after intrathecal analgesia than after systemic analgesia (2 vs. 6 on a 0-to-10 scale, P<0.001). The incidence of one-minute Apgar scores below 7 was significantly higher after systemic analgesia (24.0 percent vs. 16.7 percent, P=0.01). CONCLUSIONS: Neuraxial analgesia in early labor did not increase the rate of cesarean delivery, and it provided better analgesia and resulted in a shorter duration of labor than systemic analgesia.
Assuntos
Analgesia Epidural , Analgesia Obstétrica , Analgésicos Opioides/administração & dosagem , Cesárea/estatística & dados numéricos , Trabalho de Parto/efeitos dos fármacos , Dor/tratamento farmacológico , Adulto , Analgesia Epidural/efeitos adversos , Analgesia Obstétrica/efeitos adversos , Analgésicos Opioides/farmacologia , Analgésicos Opioides/uso terapêutico , Feminino , Fentanila/administração & dosagem , Fentanila/farmacologia , Fentanila/uso terapêutico , Humanos , Hidromorfona/farmacologia , Hidromorfona/uso terapêutico , Recém-Nascido , Injeções Intravenosas , Injeções Espinhais , Análise Multivariada , Dor/etiologia , Gravidez , Resultado da Gravidez , Risco , Fatores de TempoAssuntos
Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Dexametasona/administração & dosagem , Dexametasona/uso terapêutico , Cuidados Pós-Operatórios/métodos , Complicações Pós-Operatórias/prevenção & controle , Feminino , Humanos , MasculinoAssuntos
Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Coração Auxiliar , Choque Cardiogênico/diagnóstico por imagem , Choque Cardiogênico/terapia , Ultrassonografia de Intervenção/métodos , Adulto , Humanos , Masculino , Miocardite/complicações , Valor Preditivo dos Testes , Desenho de Prótese , Choque Cardiogênico/etiologiaRESUMO
PURPOSE: The main objective of the current investigation was to compare a single wall puncture to vessel transfixing on the success of radial artery cannulation by resident physicians. MATERIAL AND METHODS: The study was a prospective and randomized investigation. Twelve anesthesiology residents performed radial arterial insertions in 126 patients using both the single wall and vessel transfixing technique in random order. The primary outcome was successful cannulation of the radial artery in 4 or less attempts. Other data collected included the total number of attempts and total time to catheter cannulation. RESULTS: Successful radial artery cannulation was achieved in 88% and 86% of patients using the transfixing technique and single wall group, respectively (difference 2%; 95% CI, 14-9, P=0.8, Fisher exact test). Cannulation was successfully on the first attempt in 38% of the transfixing compared to 54% using the single wall technique (difference--16%; 95% CI, 32-2, P=0.1, Fisher Exact test). The median (interquartile range) time to successful cannulation was longer in the transfixing group, 105 (69-176) seconds compared to 65 (25-114) seconds in the single puncture group (P=.009, log-rank test). CONCLUSIONS: Our findings suggest that there does not appear to be an advantage of the transfixing technique over the single wall puncture method for cannulating the radial artery by resident physicians. Cannulation was achieved in shorter time using the single wall puncture technique even after accounting for differences between residents and prior levels of experience.
Assuntos
Anestesiologia , Cateterismo Periférico/métodos , Internato e Residência , Punções/métodos , Artéria Radial , Idoso , Anestesiologia/estatística & dados numéricos , Cateterismo Periférico/estatística & dados numéricos , Feminino , Humanos , Internato e Residência/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Punções/estatística & dados numéricos , Fatores de TempoRESUMO
We present a case of brachial plexus injury in a living-related liver donor, most likely caused by compression of the plexus between the 1st rib and clavicle, the result of rib retraction for surgical exposure.
Assuntos
Plexo Braquial/lesões , Hepatectomia/efeitos adversos , Coleta de Tecidos e Órgãos/efeitos adversos , Adulto , Humanos , Transplante de Fígado , MasculinoRESUMO
BACKGROUND: Postdural puncture headache (PDPH) occurs in up to 80% of parturients who experience inadvertent dural puncture during epidural catheter placement. The authors performed a randomized double blind study to assess the effect of prophylactic epidural blood patch on the incidence of PDPH and the need for therapeutic epidural blood patch. METHODS: Sixty-four parturients who incurred inadvertent dural puncture were randomized to receive a prophylactic epidural blood patch with 20 ml autologous blood (prophylactic epidural blood patch group) or a sham patch (sham group). Subjects were evaluated daily for development of PDPH for a minimum of 5 days after dural puncture. Those who developed a PDPH were followed daily for a minimum of 3 days after resolution of the headache. Subjects with moderate headaches who reported difficulties performing childcare activities and all those with severe headaches were advised to receive a therapeutic epidural blood patch. RESULTS: Eighteen of 32 subjects in each group (56%) developed PDPH. Therapeutic blood patch was recommended in similar numbers of patients in each group. The groups had similar onset time of PDPH, median peak pain scores, and number of days spent unable to perform childcare activities as a result of postural headache. The median duration of PDPH, however, was shorter in the prophylactic epidural blood patch group. CONCLUSIONS: A decrease in the incidence of PDPH or the need for criteria-directed therapeutic epidural patch was not detected when a prophylactic epidural blood patch was administered to parturients after inadvertent dural puncture. However, prophylactic epidural blood patch did shorten the duration of PDPH symptoms.