26 de abril de 2011

9º passo para a Anestesia Segura: Planejando a Reposição Volêmica

Hoje iniciamos o nono passo do programa Segurança no Período Perioperatório: 10 Passos para a Anestesia Segura com uma revista desenvolvida pelo Dr. Milton Carlos Dantonio

Esta é a primeira edição de uma revista que aborda questões relacionadas à Reposição Volêmica. Nós apresentamos aqui apenas uma pequena introdução, mas se você quiser continuar a lê-la, mande-nos um e-mail (anestesiasegura@sma.com.br) ou deixe um comentário logo abaixo desta postagem e enviaremos para você no formato eletrônico.

Boa leitura!

15 de abril de 2011

Optimization of the volemic status of cardiosurgical patients before initial anesthesia

Anesteziol Reanimatol. 2008 Sep-Oct;(5):26-9.
Tolstova IA, Aksel'rod BA, Shmyrin MM, Iavorovskiĭ AG.


Twenty-six patients with coronary heart disease who had undergone aortocoronary bypass surgery were examined. In all the patients, central hemodynamic parameters were monitored by transpulmonary thermodilution. The patients were divided into 2 groups. In Group 1 (n = 14), routine initial anesthesia was made without a preliminary volumetric loading test. In Group 2 (n = 12), a controlled volumetric loading test was carried out before induction; a decision on whether it might be made was taken on the basis of the results of a loading test for passive leg raise. The patients from both groups were hypovolemic at baseline, as suggested by the low values of central venous pressure (CVP) and global end-diastolic volume index (GEDVI). By the initiation of initial anesthesia, in Group 2 the mean blood pressure (BPmean), CVP, stroke index (SI), and GEDVI were significantly higher and total peripheral vascular resistance index (TPVRS) was significantly lower than in Group I (p < 0.05), as achieved via preliminary loading tests. After the maximum hypnotic effect being achieved in Group 1, there were reductions in BPmean, SI, GEDVI, dPmax, and TPVRS (p < 0.05). In Group 1, 50% of the patients were observed to have hypotension episodes requiring the patient to be placed in Trendelenburg's position and to be given colloids as jets, and 3 patients received bolus vasopressors. After achieving the maximum hypnotic effect, BPmean, SI, GEDVI, and dPmax also decreased in Group 2 patients (p < 0.05). However, due to preliminary loading tests, these variables remained to be in the normal ranges and were significantly higher than in Group 1 (p < 0.05). IOPSS objectively reflects the preload status at all stages of initial anesthesia and the leg raising test enables prediction of a cardiovascular response to a volumetric load. When infusion therapy is performed, it is advisable to take into account a relationship between altered preload (GEDVI) and cardiac performance (SI). This volumetric loading testing tactics before induction promotes GEDVI to be maintained in the normal ranges throughout the initial anesthesia and minimizes hemodynamic disorders at this stage.

13 de abril de 2011

Monitoring guidelines: a missed opportunity?

Anaesthesia, 2007, 62, pages 857–858
A. Simpson, N. Levy
West Suffolk Hospital

We read with interest the recent AAGBI recommendations for standards of monitoring during anaesthesia and recovery [1]. We appreciate that the introduction of most routine monitoring during anaesthesia has not been subjected to rigorous randomised controlled investigation. The progressive reduction in anaesthesia-related morbidity and mortality is therefore linked to monitoring by association only. However, more recent developments in monitoring have been subjected to randomised controlled trials. Of particular interest to us is the use of cardiac output monitors during the operative period, for which Grade A evidence is available for their use in reducing hospital length of stay and morbidity [2–7]. No specific recommendation for cardiac output monitoring is made in the AAGBI guidelines. We suggest that this represents a significant missed opportunity for the introduction of such monitoring as standard for major surgical procedures, as this would enable targeted fluid management to optimise tissue perfusion intra-operatively, reduce hospital length of stay after major surgery and lead to a reduction in overall morbidity [2–7].

A number of cardiac output monitoring devices are available [2]. Pulmonary artery catheterisation is still cited as the ‘gold standard’ of cardiac output monitoring, but there are concerns regarding its use and effect on patient outcome [8]. The aim of intra-operative cardiac output monitoring is to optimise tissue perfusion and oxygen delivery to organs during the surgical insult, whilst avoiding the consequences of fluid overload. Conventional monitoring of cardiovascular status including the central venous pressure (CVP) is insufficiently sensitive to detect deficits in perfusion, and in studies comparing the use of cardiac output monitoring verses CVP monitoring, those patients that were optimised with cardiac output monitoring do considerably better than those patients whose treatment was guided using the CVP [5–7].


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7 de abril de 2011

Invasive Intravascular Hemodynamic Monitoring: Technical Issues

Sheldon Magder, MD, FRCP(C)
McGill University Health Centre, Royal Victoria Hospital, 687 Pine Avenue West, Montreal, Quebec, Canada H3A 1A1

Hemodynamics measurements are a fundamental part of the management of critically ill patients. Many millions of dollars are spent on equipment to make these measurements, and many hours are spent arguing over the appropriate algorithms for their use at the bedside. Despite the obvious fact that these measurements can only be useful if they are valid and accurate, studies repeatedly show that there is a lack of knowledge of the basic principles behind these measurements and the important artifacts that can result in unreliable measurements [1,2]. This is especially a problem for measurements of central venous pressure (CVP) and pulmonary artery occlusion pressure (Ppao), because the range of normal clinical values is small and errors can become a large percentage of the true value. In this article, the author reviews the basic principles of making hemodynamic measurements as well as common artifacts and pitfalls.

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