30 de setembro de 2011

Artigo recomendado: Estudo Comparativo entre o Uso de Laringoscópio e Estilete Luminoso para Intubação Traqueal


Matheus Felipe de Oliveira Salvalaggio, Rogério Rehme, TSA, Robson Fernandez, Suelen Vieira, Paulo Nakashima

Revista Brasileira de Anestesiologia
Vol. 60, No 2, Março-Abril, 2010

JUSTIFICATIVA E OBJETIVOS: A abordagem das vias aéreas com o uso do laringoscópio pode causar diversos tipos de traumatismos. Este estudo teve como objetivo tentar esclarecer se o método de intubação que utiliza o estilete luminoso pode ser uma alternativa menos traumática para o paciente em comparação ao método por laringoscopia direta.

MÉTODO: O presente estudo envolveu 98 pacientes de 16 a 88 anos, estado físico ASA I e II. Os pacientes foram divididos em dois grupos: Grupo L, submetido à intubação com laringoscópio, com 54 pacientes, e Grupo E, intubado com estilete luminoso, com 44 pacientes. Foram avaliados o número de tentativas para intubação, tempo de intubação, variação de pressão arterial e frequência cardíaca, dor de garganta (odinofagia), disfagia e rouquidão pós-operatória.

RESULTADOS: Os dados demográficos e os parâmetros hemodinâmicos foram semelhantes entre os grupos. Não houve diferença estatística significativa na pesquisa de dor de garganta e disfagia entre os dois grupos. A rouquidão foi o único dado estudado em que se observou diferença estatística significativa, mais predominante no grupo E (p = 0,05).

CONCLUSÕES: Ambas as técnicas de intubação são semelhantes em relação ao comportamento hemodinâmico dos dois grupos. No entanto, o grupo com estilete luminoso apresentou maior frequência do sintoma rouquidão.

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27 de Outubro: 2º SISEPA - Simpósio Interdisciplinar de Segurança do Paciente

Tema Central: Segurança e Qualidade no atendimento perioperatório: Como Melhorar?

27 de setembro de 2011

Artigo recomendado: Thoracic sympathetic block reduces respiratory system compliance


Fábio Ely Martins Benseñor, Joaquim Edson Vieira, José Otávio Costa Auler Júnior (Anesthesia Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil)

Sao Paulo Med J. 2007;125(1):9-14


CONTEXT AND OBJECTIVE
Thoracic epidural anesthesia (TEA) following thoracic surgery presents known analgesic and respiratory benefi ts. However, intraoperative thoracic sympathetic block may trigger airway hyperreactivity. This study weighed up these benefi cial and undesirable effects on intraoperative respiratory mechanics.

DESIGN AND SETTING
Randomized, doubleblind clinical study at a tertiary public hospital.

METHODS
Nineteen patients scheduled for partial lung resection were distributed using a random number table into groups receiving active TEA (15 ml 0.5% bupivacaine, n = 9) or placebo (15 ml 0.9% saline, n = 10) solutions that also contained 1:200,000 epinephrine and 2 mg morphine. Under general anesthesia, fl ows and airway and esophageal pressures were recorded. Pressure-volume curves, lower inflection points (LIP), resistance and compliance at 10 ml/kg tidal volume were established for respiratory system, chest wall and lungs. Student’s t test was performed, including confidence intervals (CI).

RESULTS
Bupivacaine rose 5 ± 1 dermatomes upwards and 6 ± 1 downwards. LIP was higher in the bupivacaine group (6.2 ± 2.3 versus 3.6 ± 0.6 cmH2O, p = 0.016, CI = -3.4 to -1.8). Respiratory system and lung compliance were higher in the placebo group (respectively 73.3 ± 10.6 versus 51.9 ± 15.5, p = 0.003, CI = 19.1 to 23.7; 127.2 ± 31.7 versus 70.2 ± 23.1 ml/cmH2O, p < 0.001, CI = 61 to 53). Resistance and chest wall compliance showed no difference.

CONCLUSION
TEA decreased respiratory system compliance by reducing its lung component. Resistance was unaffected. Under TEA, positive end-expiratory pressure and recruitment maneuvers are advisable.

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23 de setembro de 2011

Artigo recomendado: Clinical consequences of red cell storage in the critically ill


Alan Tinmouth, Dean Fergusson, Ian Chin Yee, and Paul C. Hébert for the ABLE Investigators and the Canadian Critical Care Trials Group

TRANSFUSION 2006;46:2014-2027

Over the past 25 years, we have witnessed a dramatic “paradigm shift” whereby red blood cell (RBC) transfusions, once regarded as “one of the great advances in modern medicine,” are now considered harmful in some clinical situations. This paradigm shift has focused attention on the quality of stored transfused blood. Changes accompanying the storage of red cells (RBCs) are known as the “storage lesion,” which can be defined as a series of biochemical and biomechanical changes in the RBC and storage media during ex vivo preservation that reduce RBC survival and function. Although the storage lesion has been well documented for decades,1 our understanding of the mechanisms involved in these changes and clinical consequences remains incomplete. Recent clinical trials and animal experiments have raised fundamental questions about the efficacy of stored RBCs, 2,3 which may haveimportant implications for the future of transfusion research.

In critically ill patients, clinical studies have reported an association between RBC transfusions and increased morbidity and mortality, an effect that may increase with the age of the transfused RBCs. Anemia is very common in the critically ill with 95 percent of patients admitted to the intensive care unit (ICU) experiencing a hemoglobin (Hb) level below normal by the third day 4,5 and 40 percent to 45 percent of critically ill patients receive 5 units of RBCs during their ICU admission.4,5 More recently, a seminal multicenter randomized controlled clinical trial in critically ill patients (TRICC, Transfusion Requirements in Critical Care) demonstrated a lower 30-day mortality rate in the patients randomly assigned to the restrictive transfusion strategy6 (23.3% vs. 18.7%, p = 0.11; Fig. 1). Plausible explanations for the increased morbidity and mortality seen in TRICC may be that prolonged storage renders RBCs ineffective oxygen (O2) carriers and/or modifies RBCs, which cause harm when transfused into vulnerable patients via either a proinflammatory effect or the direct toxic effects of by-products of RBC storage. To date, the mechanisms of action accounting for increased morbidity and mortality remain unknown. In this article, we will review the laboratory and clinical studies evaluating changes to RBCs with prolonged storage followed by a review of studies evaluating the clinical consequences of prolonged RBC storage.

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20 de setembro de 2011

Artigo recomendado: Hemorrhage and operation cause a contraction of the extracellular space needing replacement—evidence and implications?

A systematic review

Birgitte Brandstrup, MD, PhD, Christer Svensen, MD, PhD, and Allan Engquist, MD.

Surgery 2006;139:419-32.

Background
Hemorrhagic hypotension or operative trauma is believed to cause a contraction of the extracellular fluid volume (ECV) beyond the measured fluid losses. The aim of this review was to explore the evidence and implications of ECV loss.

Methods
We performed a systematic review of original trials measuring ECV changes during hemorrhage or operation. PubMed, relevant periodicals, and reference lists were searched until no further original articles appeared. The quality of both the scientific and the technical methods of the trials were evaluated.

Results
A total of 61 original articles were found. The pattern appeared that all investigators reporting shock or operation to cause a disparate reduction of the ECV had measured the ECV with the same method. The ECV was calculated from very few blood samples that were withdrawn after 20 to 30 minutes of equilibration of a tracer (the 35SO4-tracer). Trials calculating ECV from multiple blood samples, after longer equilibration times, or using other tracers did not find a contraction of the ECV. On the contrary, trials using a bromide tracer found the ECV to be expanded after operation.

Conclusions
The evidence supporting the idea that hemorrhage or operation cause a contraction of the ECV is weak, and probably a result of flawed methodology.

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19 de setembro de 2011

23 de Setembro: Seminário sobre "Erro médico e as consequências administrativas e judiciais"


Este evento será promovido pela Central Prática no dia 23 de setembro, das 9h às 17h55, no auditório da instituição, em São Paulo na Rua Frei Caneca, 159.
A proposta do seminário é promover a discussão entre médicos, advogados, diretores, gerentes e empresários do setor hospitalar e clínico.


16 de setembro de 2011

Artigo recomendado: Assessing the risk of surgery in patients with liver disease


Amitabh Suman, MD, William D. Carey, MD

Cleveland Clinic Journal of Medicine V.73 n.4 April 2006

ABSTRACT
Recent studies have defined objective criteria for determining whether surgery is safe for patients with liver disease. Using these criteria, we may extend the benefit of surgery to more patients with liver disease without increasing the risk.

KEY POINTS
  • Patients with liver disease are at higher risk of death and hepatic decompensation if they undergo surgery than people without liver disease.
  • Liver disease is often undiagnosed before surgery unless it is specifically looked for.
  • Liver disease does not exclude surgery; certain types of surgery can be undertaken safely if patients are chosen carefully.
  • A recent study has suggested a Child-Pugh score of 8 and a Model for End-Stage Liver Disease (MELD) score of 14 as the cutoff values above which surgery poses too much risk for patients with cirrhosis.
  • Surgery is usually not advisable in patients with acute hepatitis, but it appears safe in mild chronic hepatitis.
Because Liver Disease is common, many patients undergoing surgery have it. Patients with liver disease face a higher risk of surgical complications, including death from surgery and anesthesia, but the level of risk is hard to assess because all liver disease is not the same, and neither is all surgery. Uncertainty has led some physicians to be reluctant to send any patient with liver disease to surgery, and others to take unjustified risks.

Although risk assessment has often been based on anecdote, a number of studies can provide guidance in this respect. The goal is to avoid surgery in patients at high risk without denying the benefits of surgery to those at reasonable risk. This review provides the clinician an up-to-date guide to risk assessment for anesthesia and surgery in patients with liver disease.

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13 de setembro de 2011

Artigo recomendado: Fluid Therapy and Surgical Outcomes in Elective Surgery: A Need for Reassessment in Fast-Track Surgery


Kathrine Holte, MD, Henrik Kehlet, MD, PhD, FACS(HON)

J Am Coll Surg Vol. 202, No. 6, June 2006

Principles in perioperative fluid management and their implications for outcomes in elective surgery are controversial because there are limited data from randomized studies.1,2 Although numerous previous studies and several systematic reviews have compared different types of fluids for resuscitation, the results so far have been inconclusive.3-8 Importantly, the vast majority of studies included in these reviews focused on critically ill patients, with conclusions not necessarily applicable for patients undergoing elective surgical procedures.

Recent data suggest that not only the type of fluid, but also the amount of fluid administered perioperatively may influence surgical outcomes,1,2,9-12 a factor not often recognized in previous studies on perioperative fluid management. Recent data have demonstrated that amultimodal revision of principles for postoperative caremay improve outcomes after major surgical procedures (eg, fast-track surgery),13-15 findings that might also have implications for fluid management practices.

We conducted a systematic review of randomized, controlled trials with a focus on the influence of the types of fluid (eg, crystalloids, colloids, and hypertonic solutions) and the amounts of fluid administered perioperatively for fluid resuscitation purposes on surgical outcomes in elective noncardiac surgical procedures. The aim of this review was to examine the evidence from randomized trials concerning the effects of perioperative fluid administration (type and amounts) on surgical outcomes in elective surgical procedures.

These results are discussed within the concept of fast-track surgery, with proposals for improved design of future studies of perioperative fluid management to determine its role in postoperative recovery.

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8 de setembro de 2011

Artigo recomendado: The Influence of Propofol Versus Sevoflurane Anesthesia on Outcome in 10.535 Cardiac Surgical Procedures

Carl-Johan Jakobsen, MD, Henrik Berg, MD, Karsten B. Hindsholm, MD, Nicolas Faddy, RN, and Erik Sloth, MD

Journal of Cardiothoracic and Vascular Anesthesia, Vol 21, No 5 (October), 2007: pp 664-671

Objective: The purpose of this study was to evaluate the possible cardioprotective effect of sevoflurane versus propofol anesthesia in patients undergoing cardiac surgery.

Methods: Ten thousand five hundred thirty-five consecutive single cardiac surgical procedures from 3 cardiac centers were reported to a common registry from 1999 to 2005. The registry was established by the National Board of Health, and reporting was obligatory for all public heart centers in Denmark. The patients were stratified according to preoperative risk factors (EuroSCORE parameters). The outcome parameters were 30-day mortality, the incidence of postoperative myocardial infarction, and the incidence of postoperative arrhythmias.

Results: Overall, the 30-day mortality was lower after sevoflurane (2.84%) versus propofol (3.30%), although not significantly so (p 0.18). No difference was found in the incidence of postoperative myocardial infarction (sevoflurane, 7.76%/propofol, 7.47%). Patients with preoperative unstable angina and/or recent myocardial infarction, and thus already “preconditioned,” did not show any difference in mortality between anesthetic groups, whereas patients without these predictors showed a lower postoperative mortality after sevoflurane (2.28% v 3.14%, p 0.015), which can at least partly be explained by a preconditioning-like effect. The data suggest that patients suffering relatively severe preoperative ischemic stress benefited from propofol anesthesia, which can be related to the antioxidant effects of propofol. Patients in the sevoflurane group had a higher incidence of postoperative atrial fibrillation (28.75% v 24.87%, p < 0.001), whereas patients in the propofol group showed a higher incidence of all other arrhythmias.

Conclusion: Sevoflurane and propofol both possess some, although different, cardioprotective properties. Sevoflurane appears to be superior to propofol in patients with little or no ischemic heart disease, such as noncoronary artery bypass graft (CABG) surgery and CABG surgery without severe preoperative ischemia, whereas propofol seems superior in patients with severe ischemia, cardiovascular instability, or in acute/urgent surgery.

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5 de setembro de 2011

Artigo: Effect of aprotinin on renal dysfunction in patients undergoing on-pump and off -pump cardiac surgery: a retrospective observational study

Ronelle Mouton, David Finch, Ian Davies, Andrea Binks, Kai Zacharowski

Lancet 2008; 371: 475–82

SUMMARY

Background: Aprotinin is used during cardiac surgery for its blood-saving eff ects. However, reports suggest a possible association between use of this drug and increased renal dysfunction and mortality. We investigated the eff ect of aprotinin on renal dysfunction in cardiac surgery, considering the cofactors on-pump versus off -pump surgery and co-medication with angiotensin-converting enzyme (ACE) inhibitors.

Methods: Our analysis included 9875 patients undergoing on-pump or off -pump cardiac surgery from Jan 1, 2000, to Sept 30, 2007. Of these patients, 9106 were included in the retrospective observational study analysis. With propensity-adjusted, multivariate staged logistic regression, we analysed separately the incidence of renal dysfunction in patients receiving aprotinin, tranexamic acid, or no antifi brinolytic treatment in the presence or absence of preoperative ACE inhibitor treatment, for both on-pump and off -pump surgical techniques.

Findings: In 5434 patients undergoing on-pump cardiac surgery, the odds ratio (OR) between aprotinin and an increased risk of renal dysfunction without ACE inhibitor was 1·81 (95% CI 0·79–4·13, p=0·162) and with ACE inhibitor 1·73 (0·56–5·32, p=0·342). In the 848 patients taking ACE inhibitors and undergoing off -pump cardiac surgery, aprotinin was associated with a greater than two-fold increase in the risk of renal dysfunction after off -pump cardiac surgery (OR 2·87 [1·25–6·58], p=0·013).

Interpretation: Our results have shown that aprotinin seems to be safe during on-pump cardiac surgery. However, the combination of aprotinin and ACE inhibitors during off -pump cardiac surgery is associated with a signifi cant risk of postoperative renal dysfunction.

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2 de setembro de 2011

Artigo recomendado: Anaesthesia chapter from Saving Mothers’ Lives: reviewing maternal deaths to make pregnancy safer


G. M. Cooper and J. H. McClure

Br J Anaesth 2008; 100: 17–22

INTRODUCTION
This chapter concerning maternal mortality due to anaesthesia, reprinted with permission from Saving Mothers’ Lives, is the 18th in a series of reports within the Confidential Enquiries into Maternal and Child Health (CEMACH) in the UK. In the years 2003–05 there were six women who died from problems directly related to anaesthesia, which is the same as the 2000–02 triennium.

Obesity was a factor in four of these women who died. Two of these deaths were in women in early pregnancy, who received general anaesthesia for gynaecological surgery by inexperienced anaesthetists who failed to manage the airway and ventilation adequately. When trainee anaesthetists are relatively inexperienced their consultants must know the limits of their competence and when close supervision and help may be needed. One death was due to bupivacaine toxicity due to a drug administration error when a bag of dilute local anaesthetic was thought to be intravenous fluid. In a further 31 cases poor perioperative management may have contributed to death.

Obesity was again a relevant factor. Other cases could be categorized into poor recognition of women being sick and poor clinical management of haemorrhage, sepsis and of pre-eclampsia. Early warning scores of vital signs may help identify the mother who is seriously ill. Learning points are highlighted in relation to the clinical management of these obstetric complications.

Anaesthesia: specific recommendations
All patients, including women in early pregnancy whose treatment is generally managed by gynaecological services, require the same high standard of anaesthetic care. This includes early recovery from anaesthesia for which anaesthetic services have full responsibility. Recovery staff must be able to receive immediate effective assistance from an anaesthetist until the woman is fully conscious and has stable vital signs.

Trainee anaesthetists must be able to obtain prompt advice and help from a designated consultant anaesthetist at all times. They and their consultants must know the limits of their competence and when close supervision and help are needed. Morbidly obese women should not be anaesthetized by trainees without direct supervision.

Trainees across all specialties may not have the experience or skill to recognize a seriously ill woman. Referral to a consultant or senior trainee should occur if there is any doubt about a woman’s condition. Early warning scores may help identify the mother who is seriously ill. Bedside estimation of haemoglobin concentration is valuable. Many of these points are reiterated in the ‘top-ten’ Recommendations of this Report.



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