RESUMO
BACKGROUND: Cardiopulmonary exercise testing (CPET) is increasingly used in the preoperative assessment of patients undergoing major surgery. The objective of this study was to investigate whether CPET can identify patients at risk of reduced survival after abdominal aortic aneurysm (AAA) repair. METHODS: Prospectively collected data from consecutive patients who underwent CPET before elective open or endovascular AAA repair (EVAR) at two tertiary vascular centres between January 2007 and October 2012 were analysed. A symptom-limited maximal CPET was performed on each patient. Multivariable Cox proportional hazards regression modelling was used to identify risk factors associated with reduced survival. RESULTS: The study included 506 patients with a mean age of 73.4 (range 44-90). The majority (82.6%) were men and most (64.6%) underwent EVAR. The in-hospital mortality was 2.6%. The median follow-up was 26 months. The 3-year survival for patients with zero or one sub-threshold CPET value ([Formula: see text] at AT<10.2 ml kg(-1) min(-1), peak [Formula: see text]<15 ml kg(-1) min(-1) or [Formula: see text] at AT>42) was 86.4% compared with 59.9% for patients with three sub-threshold CPET values. Risk factors independently associated with survival were female sex [hazard ratio (HR)=0.44, 95% confidence interval (CI) 0.22-0.85, P=0.015], diabetes (HR=1.95, 95% CI 1.04-3.69, P=0.039), preoperative statins (HR=0.58, 95% CI 0.38-0.90, P=0.016), haemoglobin g dl(-1) (HR=0.84, 95% CI 0.74-0.95, P=0.006), peak [Formula: see text]<15 ml kg(-1) min(-1) (HR=1.63, 95% CI 1.01-2.63, P=0.046), and [Formula: see text] at AT>42 (HR=1.68, 95% CI 1.00-2.80, P=0.049). CONCLUSIONS: CPET variables are independent predictors of reduced survival after elective AAA repair and can identify a cohort of patients with reduced survival at 3 years post-procedure. CPET is a potentially useful adjunct for clinical decision-making in patients with AAA.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Procedimentos Cirúrgicos Eletivos/mortalidade , Teste de Esforço/métodos , Teste de Esforço/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Vasculares/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/diagnóstico , Aneurisma da Aorta Abdominal/mortalidade , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/mortalidade , Procedimentos Endovasculares/estatística & dados numéricos , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios/estatística & dados numéricos , Modelos de Riscos Proporcionais , Estudos Prospectivos , Reprodutibilidade dos Testes , Medição de Risco , Fatores de Risco , Análise de Sobrevida , Procedimentos Cirúrgicos Vasculares/métodos , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricosRESUMO
BACKGROUND: Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity. The aim of this study was to assess whether preoperative CPET identifies patients at risk of early death following elective open and endovascular abdominal aortic aneurysm (AAA) repair. METHODS: Prospective data were collected from a pilot study between September 2005 and February 2007, and from all patients who underwent CPET before elective AAA repair at two vascular centres between February 2007 and November 2011. Symptom-limited, maximal CPET was performed on each patient. Univariable and multivariable analyses were used to identify risk factors for 30- and 90-day mortality. RESULTS: Some 415 patients underwent CPET before elective AAA repair. Anaerobic threshold (AT), peak oxygen consumption (peak V.O(2) ) and ventilatory equivalents for carbon dioxide were associated with 30- and 90-day mortality on univariable analysis. On multivariable analysis, open repair (odds ratio (OR) 4·92, 95 per cent confidence interval 1·55 to 17·00; P = 0·008), AT below 10·2 ml per kg per min (OR 6·35, 1·84 to 29·80; P = 0·007), anaemia (OR 3·27, 1·04 to 10·50; P = 0·041) and inducible cardiac ischaemia (OR 6·16, 1·48 to 23·07; P = 0·008) were associated with 30-day mortality. Anaemia, inducible cardiac ischaemia and peak V.O(2) less than 15 ml per kg per min (OR 8·59, 2·33 to 55·75; P = 0·005) were associated with 90-day mortality on multivariable analysis. Patients with two or more subthreshold CPET values were at increased risk of both 30- and 90-day mortality. CONCLUSION: An AT below 10·2 ml per kg per min, peak V.O(2) less than 15 ml per kg per min and at least two subthreshold CPET values identify patients at increased risk of early death following AAA repair.
Assuntos
Aneurisma da Aorta Abdominal/cirurgia , Teste de Esforço/métodos , Complicações Pós-Operatórias/mortalidade , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Abdominal/mortalidade , Teste de Esforço/mortalidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Consumo de Oxigênio/fisiologia , Projetos Piloto , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/mortalidade , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Adulto JovemRESUMO
BACKGROUND AND OBJECTIVES: Medialization thyroplasty is a surgical technique for improving voice quality, cough effort and laryngeal competence in patients with unilateral vocal fold paralysis. Precision surgery is enabled by operating under total intravenous anaesthesia with controlled ventilation and by using a laryngoscopic video-assisted technique. The anaesthetic challenge is to manage the shared airway with the surgeon, provide a stable operative field and ensure patient safety throughout the procedure. The objective of this case series was to evaluate the use of a modified general anaesthetic technique using the laryngeal mask airway, total intravenous anaesthesia with controlled ventilation. METHODS AND RESULTS: In all, 29 patients underwent medialization thyroplasty using a disposable laryngeal mask airway, total intravenous anaesthesia and controlled ventilation. Standard anaesthetic monitoring including capnography was used intraoperatively. Total intravenous anaesthesia was achieved using effect site target-controlled infusions of propofol and remifentanil. CONCLUSIONS: The technique proved safe with stable haemodynamic observations and only two minor complications. It also provided the surgeon with stable view of the vocal folds in order to perform this precision surgery under an operating microscope.
Assuntos
Anestesia Geral/métodos , Anestésicos Intravenosos/uso terapêutico , Laringoscopia/métodos , Respiração com Pressão Positiva/métodos , Paralisia das Pregas Vocais/cirurgia , Adolescente , Adulto , Idoso , Capnografia , Criança , Feminino , Hemodinâmica , Humanos , Complicações Intraoperatórias/etiologia , Máscaras Laríngeas , Masculino , Microscopia , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Piperidinas/uso terapêutico , Propofol/uso terapêutico , Remifentanil , Cirurgia Vídeoassistida , Qualidade da VozRESUMO
Mitochondrial myopathies are rare complex multisystem disorders, which can present several potential anaesthetic problems. A 49-year-old man with mitochondrial myopathy was anaesthetized successfully for cataract extraction using propofol and alfentanil infusions. Vecuronium sensitivity was apparent, with a prolonged duration of action, despite dosage reduction.
Assuntos
Anestesia Geral , Miopatias Mitocondriais/complicações , Procedimentos Cirúrgicos Oftalmológicos , Extração de Catarata , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
This study compared derived arterial flow waveforms, extracted from pulse oximeter waveforms, with Doppler flow waveforms. Fingertip pulse oximeter waveforms and radial artery Doppler flow waveforms were measured simultaneously in volunteers. The pulse oximeter waveforms were processed to extract the arterial flow waveforms and these were compared with the measured Doppler waveforms. They were very similar.
Assuntos
Monitorização Intraoperatória/métodos , Oximetria/métodos , Artéria Radial/diagnóstico por imagem , Ultrassonografia Doppler , Adulto , Velocidade do Fluxo Sanguíneo , Humanos , Artéria Radial/fisiologiaRESUMO
The long QT syndrome is a disorder of myocardial electrical conduction that leaves the heart vulnerable to the ventricular tachydysrhythmia torsade de pointes. Clinically, this results in syncope or sudden death. The long QT syndrome may be congenital, if caused by abnormal myocardial potassium or sodium ion channels, or acquired, if due to drugs, electrolyte abnormalities or metabolic conditions. Triggers for the development of torsade de pointes include both anaesthesia and surgery. Some anaesthetic agents prolong the QT interval. The condition is reviewed and suggestions are made for the anaesthetic management of affected patients.