21 de dezembro de 2012

Artigo recomendado: Preoperative and Intraoperative Predictors of Postoperative Acute Respiratory Distress Syndrome in a General Surgical Population

James M. Blum, Michael J Stentz, Ronald Dechert, Elizabeth Jewell, Milo Engoren, Andrew L. Rosenberg, Pauline K. Park

Anesthesiology 2013; 118:19-29, Blum et al.

Background: Acute respiratory distress syndrome (ARDS) is a devastating condition with an estimated mortality exceeding 30%. There are data suggesting risk factors for ARDS development in high-risk populations, but few data are available in lower incidence populations. Using risk-matched analysis and a combination of clinical and research data sets, we determined the incidence and risk factors for the development of ARDS in this general surgical population.

Methods: We conducted a review of common adult surgical procedures completed between June 1, 2004 and May 31, 2009 using an anesthesia information system. This data set was merged with an ARDS registry and an institutional death registry. Preoperative variables were subjected to multivariate analysis. Matching and multivariate regression was used to determine intraoperative factors associated with ARDS development.

Results: In total, 50,367 separate patient admissions were identified, and 93 (0.2%) of these patients developed ARDS. Preoperative risk factors for ARDS development included American Society of Anesthesiologist status 3–5 (odds ratio [OR] 18.96), emergent surgery (OR 9.34), renal failure (OR 2.19), chronic obstructive pulmonary disease (OR 2.16), number of anesthetics during the admission (OR 1.37), and male sex (OR 1.65). After matching, intraoperative risk factors included drive pressure (OR 1.17), fraction inspired oxygen (OR 1.02), crystalloid administration in liters (1.43), and erythrocyte transfusion (OR 5.36).

Conclusions: ARDS is a rare condition postoperatively in the general surgical population and is exceptionally uncommon in low American Society of Anesthesiologists status patients undergoing scheduled surgery. Analysis after matching suggests that ARDS development is associated with median drive pressure, fraction inspired oxygen, crystalloid volume, and transfusion.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

18 de dezembro de 2012

Artigo recomendado: IV Lidocaine Useful for Ambulatory Surgery Patients

by Kate O'Rourke

Clinical Anesthesiology, ISSUE: NOVEMBER 2012 | VOLUME: 38:11

The use of intravenous lidocaine in patients undergoing outpatient gynecologic laparoscopy improves the quality of recovery after surgery and reduces the need for opioids, according to a randomized, double-blind clinical trial. Investigators at Northwestern University, who conducted the study, said clinicians should consider using IV lidocaine for a variety of ambulatory procedures.

“I would recommend that it [IV lidocaine] be used routinely in outpatient surgeries,” said Gildasio De Oliveira Jr., MD, assistant professor of anesthesiology at Northwestern University Feinberg School of Medicine, in Evanston, Ill., who helped conduct the research. “It should work for surgeries that have the same pain profile.” Dr. De Oliveira’s group presented its findings at the 2012 annual meeting of the Society for Ambulatory Anesthesia (abstract E3) and published their results in Anesthesia and Analgesia (2012;115:262-267).

Although IV lidocaine has been shown to be effective at reducing postoperative pain in patients undergoing inpatient surgeries such as colon resections, it is rarely used for outpatient surgeries. Before this clinical trial, the only study testing perioperative IV lidocaine in ambulatory surgery patients demonstrated that the drug reduced postoperative pain and opioid consumption in the postanesthesia care unit, but did not lead to a faster discharge from the hospital or reduce opioid consumption after discharge (Anesth Analg 2009;109:1805-1808).

Visite o site do Anesthesiology News e leia o artigo completo:

14 de dezembro de 2012

Anesthesiology News - Drug Trials Fail To Ease Postoperative Delirium


Drug Trials Fail To Ease Postoperative Delirium
by Trevor Stokes

Postoperative delirium affects as many as two-thirds of patients over age 65 and increases in-hospital mortality and health care costs. All of which makes the failure of researchers to find a treatment for the complication so frustrating.

Such is the fate of two recent efforts that showed promise in pilot studies but failed to pan out in subsequent Phase III clinical trials. Both trials involved already approved agents for common neurologic conditions.

In one trial, reported at Euroanaesthesia 2012 (7AP4-10), Alan Chaput, MD, an anesthesiology faculty member at the University of Ottawa in Canada, and his colleagues conducted a randomized double-blind, placebo-controlled study to see if the anticonvulsive pregabalin (Lyrica, Pfizer) could alleviate delirium in postoperative patients.

The antidelirium effect from gabapentin was originally identified in a small pilot trial by Jaqueline Leung, MD, MPH, professor of anesthesia and perioperative care at the University of California, San Francisco of 21 patients (Neurology 2006;67:1251-1253). Dr. Chaput decided to follow up with a Phase III clinical trial.

Clinical Anesthesiology - ISSUE: NOVEMBER 2012 | VOLUME: 38:11

Leia o artigo completo no link abaixo:




11 de dezembro de 2012

Artigo recomendado: Are Anesthesia and Surgery during Infancy Associated with Altered Academic Performance during Childhood?

Robert I. Block, Joss J. Thomas, Emine O. Bayman, James Y. Choi, Karolie K. Kimble, Michael M. Todd

Anesthesiology 2012; 117:494 –503, Block et al.

Background: Although studies in neonatal animals show that anesthetics have neurotoxic effects, relevant human evidence is limited. We examined whether children who had surgery during infancy showed deficits in academic achievement.

Methods: We attempted to contact parents of 577 children who, during infancy, had one of three operations typically performed in otherwise healthy children. We compared scores on academic achievement tests with population norms.

Results: Composite scores were available for 287 patients. The mean normal curve equivalent score was 43.0 ± 22.4 (mean ± SD), lower than the expected normative value of 50, P < 0.0001 by one-sample Student t test; and 35 (12%) had scores below the 5th percentile, more than expected, P < 0.00001 by binomial test. Of 133 patients who consented to participate so that their scores could be examined in relation to their medical records, the mean score was 45.9 ± 22.9, P = 0.0411; and 15 (11%) scored below the 5th percentile, P = 0.0039. Of 58 patients whose medical records showed no central nervous system problems/potential risk factors during infancy, 8 (14%) scored below the 5th percentile, P = 0.008; however, the mean score, 47.6 ± 23.4, was not significantly lower than expected, P = 0.441. Duration of anesthesia and surgery correlated negatively with scores (r = -0.34, N = 58, P = 0.0101).

Conclusions: Although the findings are consistent with possible adverse effects of anesthesia and surgery during infancy on subsequent academic achievement, other explanations are possible and further investigations are needed.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

7 de dezembro de 2012

Artigo recomendado: Surgery Reverses Diabetic Nephropathy in Almost 60% of Patients


Researchers, Expecting a Halt in Progression After Bariatric Surgery, Instead See Remission

Christina Frangou
Gereral Surgery News - ISSUE: NOVEMBER 2012 | VOLUME: 39:11

San Diego—Bariatric surgery induces a significant and lasting improvement in diabetic nephropathy, with nearly 60% of patients with this condition achieving remission five years after surgery, according to a study presented at the 2012 annual meeting of the American Society for Metabolic and Bariatric Surgery.

The investigators say that the finding demonstrates a previously unknown microvascular effect of bariatric surgery.

“When we started this study, we thought bariatric surgery may just halt the progression of diabetic nephropathy. Instead, over half the patients who had diabetic nephropathy prior to undergoing bariatric surgery experienced remission,” said lead author Helen M. Heneghan, MD, a bariatric surgery fellow at Cleveland Clinic Bariatric and Metabolic Institute, in Ohio.

Dr. Heneghan said the finding warrants greater consideration of bariatric surgery in patients with diabetic kidney disease. However, she said, more studies with larger numbers of patients are still needed to confirm the results.

Dr. Heneghan and her colleagues examined the five-year outcomes of 52 diabetic patients who underwent bariatric surgery at the Cleveland Clinic. Of these patients, 75% were women. They had a mean age of 51.2 years (±10.1 years) and a preoperative body mass index of 49 kg/m2 (±8.7 kg/m2).

Visite o site do General Surgery News e leia o artigo completo: 


5 de dezembro de 2012

Artigo recomendado: Elderly Age as a Prognostic Marker of 1-year Poor Outcome for Subarachnoid Hemorrhage Patients through Its Interaction with Admission Hydrocephalus


Vincent Degos, Pierre-Antoine Gourraud, Virginie Trehel Tursis, Rachel Whelan, Chantal Colonne, Anne Marie Korinek, Frédéric Clarençon, Anne-Laure Boch, Aurélien Nouet, William L. Young, Christian C. Apfel, Louis Puybasset

Anesthesiology 2012; 117:1289-99, Degos et al.

Background: An increasing number of elderly patients are treated for aneurysmal subarachnoid hemorrhage. Given that elderly age is associated with both poor outcome and an increased risk of hydrocephalus, we sought to investigate the interaction between age and hydrocephalus in outcome prediction.

Methods: We enrolled 933 consecutive patients treated for subarachnoid hemorrhage between 2002 and 2010 and followed them for 1 yr after intensive care unit discharge. We first performed stepwise analyses to determine the relationship among neurologic events, elderly age (60 or more yr old), and 1-yr poor outcome (defined as Rankin 4–6). Within the most parsimonious model, we then tested for interaction between admission hydrocephalus and elderly age. Finally, we tested the association between age as a stratified variable and 1-yr poor outcome for each subgroup of patients with neurologic events.

Results: 24.1% (n = 225) of subarachnoid hemorrhage patients were 60 yr old or more and 19.3% (n = 180) had 1-yr poor outcomes. In the most parsimonious model (area under the receiver operating characteristic curve, 0.84; 95% CI: 0.82 to 0.88; P < 0.001), elderly age and admission hydrocephalus were two independent predictors for 1-yr outcome (P < 0.001 and P = 0.004,  espectively). Including the significant interaction between age and hydrocephalus (P = 0.04) improved the model’s outcome prediction (P = 0.03), but elderly age was no longer a significant predictor. Finally, stratified age was associated with 1-yr poor outcome for hydrocephalus patients (P = 0.007), but not for patients without hydrocephalus (P = 0.87).

Conclusion: In this observational study, elderly age and admission hydrocephalus predicted poor outcome, but elderly age without hydrocephalus did not. An external validation, however, will be needed to generalize this finding.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

30 de novembro de 2012

Artigo recomendado: Impact of Perioperative Bleeding on the Protective Effect of β-Blockers during Infrarenal Aortic Reconstruction


Yannick Le Manach, Gary S. Collins, Cristina Ibanez, Jean Pierre Goarin, Pierre Coriat, Julien Gaudric, Bruno Riou, Paul Landais

Anesthesiology 2012; 117:1203-11, Le Manach et al.

Background: The use of β-blockers during the perioperative period remains controversial. Although some studies have demonstrated their protective effects regarding postoperative cardiac complications, others have demonstrated increased mortality when β-blockers were introduced before surgery.

Methods: In this observational study involving 1,801 patients undergoing aortic reconstruction, we prospectively assessed β-blocker therapy compared with no β-blocker therapy, with regard to cardiac and noncardiac postoperative outcomes using a propensity score approach. The impact of β-blockers was analyzed according to the intraoperative bleeding estimated by transfusion requirements.

Results: In-hospital mortality was 2.5% (n = 45), β-blocker use was associated with a reduced frequency of postoperative myocardial infarction (OR = 0.46, 95% CI [0.26; 0.80]) and myocardial necrosis (OR = 0.62, 95% CI [0.43; 0.88]) in all patients, but also with an increased frequency of multiple organ dysfunction syndromes (OR = 2.78, 95% CI [1.71; 4.61]). In patients with severe bleeding (n = 163; 9.1%), the frequency of in-hospital death (OR = 6.65, 95% CI [1.09; 129]) and/or multiple organ dysfunction syndromes (OR = 4.18, 95% CI [1.81; 10.38]) were markedly increased. Furthermore, no more than 28% of the patients who died presented with postoperative myocardial infarction, whereas 69% of the patient with a postoperative myocardial infarction also presented an excessive bleeding.

Conclusions: Perioperative β-blocker therapy was associated with an overall reduction in postoperative cardiac events. In the vast majority of patients with low perioperative bleeding, the global effect of β-blockers was protective; in contrast, patients given β-blockers who experienced severe bleeding had higher mortality and an increased frequency of multiorgan dysfunction syndrome.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

28 de novembro de 2012

Curso: Cálculo de Retorno Financeiro (ROI) e Planejamento Estratégico de Prevenção de Doenças

Hospital Alemão Oswaldo Cruz

Datas: 04 e 05 de dezembro
Horário: 08h às 17h 
Locais: Rua João Julião, 331, Bloco B, 14ª Andar 
Rua Treze de Maio, 1815, Mezanino

Cálculo de Retorno Financeiro (ROI) e Planejamento Estratégico de Prevenção de Doenças


Objetivo
Capacitar profissionais de saúde para fazer cálculo de ROI das intervenções de prevenção de doenças e desenvolver planos estratégicos de promoção em saúde.

Público Alvo
Profissionais em geral da área de saúde e gestão de saúde interessados em aprimorar seus conhecimentos sobre gestão estratégica na prevenção de doenças.

Método
O treinamento envolve a exposição de conteúdo de maneira dinâmica e com estudos de caso, e a atuação ativa dos participantes em simulações com utilização do sistema Wellcast ROI.

Mais informações, clique aqui.

27 de novembro de 2012

Artigo recomendado: Aerosolized Antibiotics for Ventilator-associated Pneumonia - Lessons from Experimental Studies


Jean-Jacques Rouby, Belaïd Bouhemad, Antoine Monsel, Hélène Brisson, Charlotte Arbelot, Qin Lu, and the Nebulized Antibiotics Study Group

Anesthesiology 2012; 117:1364-80, Rouby et al.

ABSTRACT

The aim of this review is to perform a critical analysis of experimental studies on aerosolized antibiotics and draw lessons for clinical use in patients with ventilator-associated pneumonia. Ultrasonic or vibrating plate nebulizers should be preferred to jet nebulizers. During the nebulization period, specific ventilator settings aimed at decreasing flow turbulence should be used, and discoordination with the ventilator should be avoided. The appropriate dose of aerosolized antibiotic can be determined as the intravenous dose plus extrapulmonary deposition. If these conditions are strictly respected, then high lung tissue deposition associated with rapid and efficient bacterial killing can be expected. For aerosolized aminoglycosides and cephalosporins, a decrease in systemic exposure leading to reduced toxicity is not proven by experimental studies. Aerosolized colistin, however, does not easily cross the alveolar–capillary membrane even in the presence of severe lung infection, and high doses can be delivered by nebulization without significant systemic exposure.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

23 de novembro de 2012

Artigo recomendado: "Prognostic Significance of Blood Lactate and Lactate Clearance in Trauma Patients"


Marie-Alix Régnier, Mathieu Raux, Yannick Le Manach, Yves Asencio, Johann Gaillard, Catherine Devilliers, Olivier Langeron, Bruno Riou

Anesthesiology 2012; 117:1276-88 Régnier et al.

Background: Lactate has been shown to be a prognostic biomarker in trauma. Although lactate clearance has already been proposed as an intermediate endpoint in randomized trials, its precise role in trauma patients remains to be determined.

Methods: Blood lactate levels and lactate clearance (LC) were calculated at admission and 2 and 4 h later in trauma patients. The association of initial blood lactate level and lactate clearance with mortality was tested using receiver-operating characteristics curve, logistic regression using triage scores, Trauma Related Injury Severity Score as a reference standard, and reclassification method.

Results: The authors evaluated 586 trauma patients (mean age 38 ± 16 yr, 84% blunt and 16% penetrating, mortality 13%). Blood lactate levels at admission were elevated in 327 (56%) patients. The lactate clearance should be calculated within the first 2 h after admission as LC0–2 h was correlated with LC0–4 h (R2 = 0.55, P < 0.001) but not with LC2–4 h (R2 = 0.04, not significant). The lactate clearance provides additional predictive information to initial blood lactate levels and triage scores and the reference score. This additional information may be summarized using a categorical approach (i.e., less than or equal to −20 %/h) in contrast to initial blood lactate. The results were comparable in patients with high (5 mM/l or more) initial blood lactate.

Conclusions: Early (0–2 h) lactate clearance is an important and independent prognostic variable that should probably be incorporated in future decision schemes for the resuscitation of trauma patients.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.



19 de novembro de 2012

Artigo recomendado: Metabolomic Profiling of Children’s Brains Undergoing General Anesthesia with Sevoflurane and Propofol

Zvi Jacob, Haifang Li, Rany Makaryus, Shaonan Zhang, Ruth Reinsel, Hedok Lee, Tian Feng, Douglas L. Rothman, Helene Benveniste.

Anesthesiology 2012; 117:1062–71, Jacob et al.

Background: We recently applied proton magnetic resonance spectroscopy (HMRS) to investigate metabolic consequences of general anesthesia in the rodent brain, and discovered that isoflurane anesthesia was characterized by higher concentrations of lactate, glutamate, and glucose in comparison with propofol. We hypothesized that the metabolomic differences between an inhalant and intravenous anesthetic observed in the rodent brain could be reproduced in the human brain.

Methods: HMRS-based metabolomic profiling was applied to characterize the cerebral metabolic status of 59 children undergoing magnetic resonance imaging during anesthesia with either sevoflurane or propofol. HMRS scans were acquired in the parietal cortex after approximately 60 min of anesthesia. Upon emergence the children were assessed using the pediatric anesthesia emergence delirium scale.

Results: With sevoflurane anesthesia, the metabolic signature consisted of higher concentrations of lactate and glucose compared with children anesthetized with propofol. Further, a correlation and stepwise regression analysis performed on emergence delirium scores in relation to the metabolic status revealed that lactate and glucose correlated positively and total creatine negatively with the emergence delirium score.

Conclusions: Our results demonstrating higher glucose and lactate with sevoflurane in the human brain compared with propofol could reflect greater neuronal activity with sevofluane resulting in enhanced glutamate-neurotransmitter cycling, increased glycolysis, and lactate shuttling from astrocytes to neurons or mitochondrial dysfunction. Further, the association between emergence delirium and lactate suggests that anesthesia-induced enhanced cortical activity in the unconscious state may interfere with rapid return to “coherent” brain connectivity patterns required for normal cognition upon emergence of anesthesia.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

14 de novembro de 2012

Artigo recomendado: Intraoperative Neuromuscular Monitoring Site and Residual Paralysis


Stephan R. Thilen, Bradley E. Hansen, Ramesh Ramaiah, Christopher D. Kent, Miriam M. Treggiari, Sanjay M. Bhananker.

Anesthesiology, V 117 • No 5 964 November 2012

Background: Residual paralysis is common after general anesthesia involving administration of neuromuscular blocking drugs (NMBDs). Management of NMBDs and reversal is frequently guided by train-of-four (TOF) monitoring. We hypothesized that monitoring of eye muscles is associated with more frequent residual paralysis than monitoring at the adductor pollicis.

Methods: This prospective cohort study enrolled 180 patients scheduled for elective surgery with anticipated use of NMBDs. Collected variables included monitoring site, age, gender, weight, body mass index, American Society of Anesthesiologists physical status class, type and duration of surgery, type of NMBDs, last and total dose administered, TOF count at time of reversal, dose of neostigmine, and time interval between last dose of NMBDs to quantitative measurement. Upon postanesthesia care unit admission, we measured TOF ratios by acceleromyography at the adductor pollicis. Residual paralysis was defined as a TOF ratio less than 90%. Multivariable logistic regression was used to account for unbalances between the two groups and to adjust for covariates.

Results: 150 patients received NMBDs and were included in the analysis. Patients with intraoperative TOF monitoring of eye muscles had significantly greater incidence of residual paralysis than patients monitored at the adductor pollicis (P < 0.01). Residual paralysis was observed in 51/99 (52%) and 11/51 (22%) of patients, respectively. The crude odds ratio was 3.9 (95% CI: 1.8–8.4), and the adjusted odds ratio was 5.5 (95% CI: 2.1–14.5).

Conclusions: Patients having qualitative TOF monitoring of eye muscles had a greater than 5-fold higher risk of postoperative residual paralysis than those monitored at the adductor pollicis.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

9 de novembro de 2012

Todos Contra a Dor - Entrevista com o Dr. Maurício Nunes Nogueira


Matéria da Revista do Hospital Alemão Oswaldo Cruz (Edição - Outubro 2012)

Mesmo com os inúmeros avanços relacionados aos estudos e ao tratamento, a dor ainda é um fator subestimado por grande parte da população e mesmo por profissionais da saúde. Nesta entrevista, o anestesiologista Dr. Maurício Nunes Nogueira, responsável pelo Serviço de Terapia da Dor no Hospital Alemão Oswaldo Cruz, alerta para a importância deste que é considerado o quinto sinal vital.

Atualmente, quais são as dores que mais levam pessoas aos prontos-socorros ou unidades médicas?
Dr. Maurício Nunes Nogueira – No mundo, as dores relacionadas ao reumatismo e à artrite são as campeãs de queixas. Aqui no Brasil, as dores na coluna lombar, assim como as neuropáticas são as mais relatadas. Pesquisas mostram que, das pessoas que sofrem com dor, uma parcela significativa fica parcial ou totalmente incapacitada de maneira transitória ou permanente, comprometendo de modo significativo sua qualidade de vida. Daí a necessidade 
de se tratar adequadamente a dor.


E como seria este tratamento adequado?
Dr. Maurício Nunes Nogueira – Valorizar a dor é a primeira regra. Quer dizer, não podemos ignorar um sinal claro de que alguma coisa não está bem naquele organismo. Por isso, quando um paciente chega ao serviço médico fazendo qualquer referência a algum tipo de dor, a primeira coisa que devemos fazer é investigar para descartar as causas letais, ou seja, verificar se o paciente não está enfartando ou se não está sofrendo de um acidente vascular cerebral (AVC), por exemplo. Excluindo problemas que podem levar o paciente a óbito, parte-se para uma nova triagem até que se identifique o que está efetivamente causando o incômodo. Mas é importante que, neste momento, possamos oferecer conforto não apenas ao paciente, mas também aos familiares que provavelmente não querem ver um ente sofrer. Tratar a dor de forma agressiva é algo que permite melhorar as condições daquele paciente, até que possamos analisar as causas do incômodo com mais calma e precisão.

Solicite a revista na íntegra e leia toda a entrevista.




8 de novembro de 2012

Artigo recomendado: Anesthesia Depth Not Linked to Post-op Outcomes

David Wild

Clinical Anesthesiology - ISSUE: OCTOBER 2012 | VOLUME: 38:10

Lighter anesthesia does not reduce the incidence of postoperative morbidity and short-term mortality in patients undergoing noncardiac surgery, researchers have found.

The randomized controlled study, which undercuts previous reports, also failed to reveal higher inflammatory levels among more deeply anesthetized patients. The researchers were scheduled to present their results at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 1200).

“While previous work suggests that maintaining a lighter plane of anesthesia provides short-term benefits such as faster recovery, better hemodynamic control and reduced respiratory complications, nausea and vomiting and duration of hospitalization, it does not appear to prevent major morbidity,” said lead investigator Basem Abdelmalak, MD, associate professor in the Department of General Anesthesiology and Outcomes Research at the Cleveland Clinic, in Ohio.

The results are part of the DeLiT (Design and Organization of the Dexamethasone, Light Anesthesia and Tight Glucose Control) trial, a randomized, single-center analysis of the effects that dexamethasone, glucose control and, in this case, depth of anesthesia have on perioperative inflammation and complications in surgery patients.

In examining the effects of anesthesia depth, Dr. Abdelmalak and his colleagues compared a composite of more than one dozen serious outcomes—including myocardial infarction, stroke, sepsis and 30-day mortality—in 194 patients given light anesthesia and 187 given deeper anesthesia. Anesthetic depth was evaluated by bispectral index monitoring (BIS, Covidien). Dr. Abdelmalak and his team also compared plasma concentrations of the inflammatory marker high-sensitivity C-reactive protein (hsCRP).

Visite o site do Anesthesiology News e leia o artigo completo:

17 de outubro de 2012

An Apgar Score for Surgery
Atul A Gawande, Mary R Kwaan, Scott E Regenbogen,
Stuart A Lipsitz, Michael J Zinner.
Department of Health Policy and Management,
Harvard School of Public Health, Boston, MA, USA.
 
2007 Feb;204(2):201-8. Epub 2006 Dec 27.
 
BACKGROUND:

Surgical teams have not had a routine, reliable measure of patient condition at the end of an operation.We aimed to develop an Apgar score for the field of surgery, an outcomes score that teams could calculate at the end of any general or vascular surgical procedure to accurately grade a patient’s condition and chances of major complications or death.


STUDY DESIGN:

We derived our surgical score in a retrospective analysis of data from medical records and the National Surgical Quality Improvement Program for 303 randomly selected patients undergoing colectomy at Brigham and Women’s Hospital, Boston. The primary outcomes measure was incidence of major complication or death within 30 days of operation.We validated the score in two prospective, randomly selected cohorts: 102 colectomy patients and 767 patients undergoing general or vascular operations at the same institution.


RESULTS:

A 10-point score based on a patient’s estimated amount of blood loss, lowest heart rate, and lowest mean arterial pressure during general or vascular operations was significantly associated with major complications or death within 30 days (p < 0.0001; c-index 0.72). Of 767 general and vascular surgery patients, 29 (3.8%) had a surgical score < 4. Major complications or death occurred in 17 of these 29 patients (58.6%) within 30 days. By comparison, among 220 patients with scores of 9 or 10, only 8 (3.6%) experienced major complications or died (relative risk 16.1; 95% CI, 7.6–34.0; p < 0.0001).
 
CONCLUSIONS:

A simple score based on blood loss, heart rate, and blood pressure can be useful in rating the condition of patients after general or vascular operations. 
 
Publicaremos vários artigos relacionados ao Apgar Score for Surgery. Solicite o artigo completo pelo e-mail anestesiasegura@sma.com.br.
 
 
 

11 de outubro de 2012

Artigo recomendado: Regional Anesthesia for Total Joint Arthroplasty

David A. Provenzano, Eugene R. Viscusi

Anesthesiology News Special Edition - October 2012 - P.59-64

Patients undergoing total joint arthroplasty (TJA) experience high levels of pain after surgery that often interferes with their functional recovery and sleep patterns in the postoperative period. In one study, patients undergoing total hip arthroplasty (THA) and total Knee arthroplasty (TKA) reported mean worst pain severities of 7.6 and 8.1 on a 10-point scale, respectively. Numerous techniques have been developed for anesthesia and analgesia in a effort optimize perioperative pain control, patient satisfaction, and functional recovery. Because clinician preference strongly influences patient selection and decision making, anesthesiologists and orthopedic surgeons must understand the current literature and level of evidence for each technique. This article provides and updated review of the evidence for regional anesthesia for TJA surgery with an emphasis on the risks and benefits of each technique for intraoperative anesthesia and postoperative analgesia.

Caso queira, deixe seu e-mail nos comentários abaixo desta postagem ou solicite pelo e-mail anestesiasegura@sma.com.br e lhe enviaremos o artigo completo.

8 de outubro de 2012

Artigo recomendado: For Shoulder Block, Site May Not Matter for Pt Satisfaction

Michael Vlessides

Clinical Anesthesiology ISSUE: SEPTEMBER 2012 | VOLUME: 38:9

San Diego—Brachial plexus blockade is known to provide superior postoperative pain control after shoulder arthroscopy, but few data point to the best approach to the nerve network.

Perhaps it does not matter after all. New evidence shows that patients perceive no difference in pain control or satisfaction with either a supraclavicular or interscalene block. Even so, the investigators, from the Hospital for Special Surgery, in New York City, noted that supraclavicular block might be preferable for its propensity to be less disruptive to hemidiaphragmatic function. Paralysis of the diaphragm during surgery has been linked to increased postoperative morbidity.

“Shoulder surgery is well known to be one of the most painful surgeries, particularly in the ambulatory setting where patients may or may not have appropriate education about when to take pain medications,” said Stephen Haskins, MD, chief resident at NewYork-Presbyterian/Weill Cornell Medical Center in New York City, who helped conduct the study. “At the Hospital for Special Surgery, about 90% of these surgeries are done under brachial plexus block, so we decided to look more closely for any differences in postoperative pain control and patient satisfaction based on the specific approach we utilized.”

Dr. Haskins and his colleagues performed a prospective cohort trial on 100 patients undergoing ambulatory arthroscopic shoulder surgery under brachial plexus block. Patients completed an online or phone survey on postoperative day 2 or 3, during which they assessed postoperative pain, along with their level of satisfaction with the analgesia, the duration of the nerve block and the pain education they received before surgery.

The majority of the blocks—73%—were performed using the supraclavicular approach, which is typical at the researchers’ institution, Dr. Haskins said. Most consisted of a combination of mepivacaine and bupivacaine, he added.

Visite o site do Anesthesiology News e leia o artigo completo:

5 de outubro de 2012

Artigo recomendado: Anesthesia Depth Not Linked to Post-op Outcomes

David Wild

Clinical Anesthesiology, ISSUE: OCTOBER 2012 - VOLUME: 38:10

Lighter anesthesia does not reduce the incidence of postoperative morbidity and short-term mortality in patients undergoing noncardiac surgery, researchers have found.

The randomized controlled study, which undercuts previous reports, also failed to reveal higher inflammatory levels among more deeply anesthetized patients. The researchers were scheduled to present their results at the 2012 annual meeting of the American Society of Anesthesiologists (abstract 1200).

“While previous work suggests that maintaining a lighter plane of anesthesia provides short-term benefits such as faster recovery, better hemodynamic control and reduced respiratory complications, nausea and vomiting and duration of hospitalization, it does not appear to prevent major morbidity,” said lead investigator Basem Abdelmalak, MD, associate professor in the Department of General Anesthesiology and Outcomes Research at the Cleveland Clinic, in Ohio.

The results are part of the DeLiT (Design and Organization of the Dexamethasone, Light Anesthesia and Tight Glucose Control) trial, a randomized, single-center analysis of the effects that dexamethasone, glucose control and, in this case, depth of anesthesia have on perioperative inflammation and complications in surgery patients.

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1 de outubro de 2012

Artigo recomendado: Anesthesia Method Suggests Possible Cure For Post-trauma Stress


Michael Vlessides

Clinical Anesthesiology - ISSUE: SEPTEMBER 2012 | VOLUME: 38:9

Treatment options for patients with post-traumatic stress disorder (PTSD) are by no means universally effective. From yoga to sleep therapy, pharmacotherapy to traditional counseling, reported rates of improvement are only between 20% and 30%. But an Illinois anesthesiologist believes a staple of pain medicine—the stellate ganglion nerve block—may prove to be the standard of care for PTSD.

Eugene Lipov, MD, medical director of Advanced Pain Centers in Hoffman Estates, Ill., said stellate ganglion blocks are effective in the overwhelming majority of patients with PTSD that he has treated.

Dr. Lipov said the genesis of the therapy came in 2004, when he treated a woman with severe hot flashes who also had complex regional pain syndrome (CRPS).

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http://www.anesthesiologynews.com/ViewArticle.aspx?d=Clinical%2bAnesthesiology&d_id=1&i=September+2012&i_id=882&a_id=21544&tab=MostRead



26 de setembro de 2012

Artigo recomendado: Postoperative Urinary Retention


Anesthetic and Perioperative Considerations

Gabriele Baldini, Hema Bagry, Armen Aprikian, Franco Carli

Anesthesiology, V 110, No 5, May 2009

Urinary retention is common after anesthesia and surgery, reported incidence of between 5% and 70%. Comorbidities, type of surgery, and type of anesthesia influence the development of postoperative urinary retention (POUR). The authors review the overall incidence and mechanisms of POUR associated with surgery, anesthesia and analgesia. Ultrasound has been shown to provide an accurate assessment of urinary bladder volume and a guide to the management of POUR. Recommendations for urinary catheterization in the perioperative setting vary widely, influenced by many factors, including surgical factors, type of anesthesia, comorbidities, local policies, and personal preferences. Inappropriate management of POUR may be responsible for bladder overdistension, urinary tract infection, and catheter-related complications. An evidence-based approach to prevention and management of POUR during the perioperative period is proposed.

BLADDER catheterization is a common procedure during inpatient major surgery that allows monitoring of urine output, guides volume resuscitation, and serves as a surrogate marker of hemodynamic stability. With an increase in outpatient and fast-track surgical procedures, perurethral catheterization is restricted to fewer procedures and for a limited time. Awareness and identification of patients at risk of developing postoperative urinary retention (POUR) thus assumes greater significance. POUR has been defined as the inability to void in the presence of a full bladder. The widely varying reported incidence of POUR reflects its multifactorial etiology and the lack of uniform defining criteria. This paper reviews the physiology of micturition and analyzes the perioperative factors that contribute to POUR. Evidence-based guidelines for the management of POUR are also provided.

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21 de setembro de 2012

Artigo recomendado: Prevention of Intraoperative Awareness with Explicit Recall in an Unselected Surgical Population

A Randomized Comparative Effectiveness Trial

George A. Mashour, Amy Shanks, Kevin K. Tremper, Sachin Kheterpal, Christopher R. Turner, Satya Krishna Ramachandran, Paul Picton, Christa Schueller, Michelle Morris, John C. Vandervest, Nan Lin, Michael S. Avidan

Anesthesiology, V 117 • No 4 717 October 2012

ABSTRACT
Background: Intraoperative awareness with explicit recall occurs in approximately 0.15% of all surgical cases. Efficacy trials based on the Bispectral Index® (BIS) monitor (Covidien, Boulder, CO) and anesthetic concentrations have focused on high-risk patients, but there are no effectiveness data applicable to an unselected surgical population.

Methods: We conducted a randomized controlled trial of unselected surgical patients at three hospitals of a tertiary academic medical center. Surgical cases were randomized to alerting algorithms based on either BIS values or anesthetic concentrations. The primary outcome was the incidence of definite intraoperative awareness; prespecified secondary outcomes included postanesthetic recovery variables.

Results: The study was terminated because of futility. At interim analysis the incidence of definite awareness was 0.12% (11/9,376) (95% CI: 0.07–0.21%) in the anesthetic concentration group and 0.08% (8/9,460) (95% CI: 0.04–0.16%) in the BIS group (P=0.48). There was no significant difference between the two groups in terms of meeting criteria for recovery room discharge or incidence of nausea and vomiting. By post hoc secondary analysis, the BIS protocol was associated with a 4.7-fold reduction in definite or possible awareness events compared with a cohort receiving no intervention (P=0.001; 95% CI: 1.7–13.1).

Conclusion: This negative trial could not detect a difference in the incidence of definite awareness or recovery variables between monitoring protocols based on either BIS values or anesthetic concentration. By post hoc analysis, a protocol based on BIS monitoring reduced the incidence of definite or possible intraoperative awareness compared with routine care.

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18 de setembro de 2012

Artigo recomendado: Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia

Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L, Kurz A, Greenwald S.

Anesthesiology, V 116 • No 6 1195 June 2012

ABSTRACT
Background: Low mean arterial pressure (MAP) and deep hypnosis have been associated with complications and mortality. The normal response to high minimum alveolar concentration (MAC) fraction of anesthetics is hypotension and low Bispectral Index (BIS) scores. Low MAP and/or BIS at lower MAC fractions may represent anesthetic sensitivity. The authors sought to characterize the effect of the triple low state (low MAP and low BIS during a low MAC fraction) on duration of hospitalization and 30-day all-cause mortality.

Methods: Mean intraoperative MAP, BIS, and MAC were determined for 24,120 noncardiac surgery patients at the Cleveland Clinic, Cleveland, Ohio. The hazard ratios associated with combinations of MAP, BIS, and MAC values greater or less than a reference value were determined. The authors also evaluated the association between cumulative triple low minutes, and excess length-of-stay and 30-day mortality.

Results: Means (±SD) defining the reference, low, and high states were 87 ± 5 mmHg (MAP), 46 ± 4 (BIS), and 0.56 ± 0.11 (MAC). Triple lows were associated with prolonged length of stay (hazard ratio 1.5, 95% CI 1.3-1.7). Thirty-day mortality was doubled in double low combinations and quadrupled in the triple low group. Triple low duration ≥60 min quadrupled 30-day mortality compared with ≤15 min. Excess length of stay increased progressively from ≤15 min to ≥60 min of triple low.

Conclusions: The occurrence of low MAP during low MAC fraction was a strong and highly significant predictor for mortality. When these occurrences were combined with low BIS, mortality risk was even greater. The values defining the triple low state were well within the range that many anesthesiologists tolerate routinely.

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14 de setembro de 2012

Artigo recomendado: Home Noninvasive Ventilation: What Does the Anesthesiologist Need to Know?

Karen A. Brown, Gianluca Bertolizio, Marisa Leone, Steven L. Dain

Anesthesiology, V 117 • No 3 657 September 2012

ABSTRACT

Treatment of chronic respiratory failure with noninvasive ventilation (NIV) is standard pediatric practice, and NIV systems are commonly used in the home setting. Although practice guidelines on the perioperative management of children supported with home NIV systems have yet to be published, increasingly these patients are referred for consultation regarding perioperative management. Just as knowledge of pharmacology underlies the safe prescription of medication, so too knowledge of biomedical design is necessary for the safe prescription of NIV therapy. The medical device design requirements developed by the Organization for International Standardization provide a framework to rationalize the safe prescription of NIV for hospitalized patients supported at home with NIV systems. This review article provides an overview of the indications for home NIV therapy, an overview of the medical devices currently available to deliver it, and a specific discussion of the management conundrums confronting anesthesiologists.

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5 de setembro de 2012

Artigo recomendado: Developing Leaders in Anesthesiology - A Practical Framework


Pascal H. Scemama, Jeffrey W. Hull

Anesthesiology, V 117 • No 3 651 September 2012

The call for more effective leadership in medicine, and specifically in anesthesiology, is not new. In 1999, Dr. Francis M. James III, in his Rovenstine lecture, outlined both the importance of leadership in medicine as well as the breadth of leadership opportunities available both inside and outside anesthesiology. Eleven years later, Dr. Peter J. Pronovost, also in his Rovenstine lecture, turned up the volume by setting out an agenda focused on accountability, performance measurement, teamwork, peer-to-peer reviews, and the need for participation from anesthesiologist-leaders in change initiatives within and outside the specialty.

Driven by a heightened focus on cost reduction, quality improvement, patient safety, performance measurement, and technological innovation, anesthesiology is going through a period of upheaval. Effective leadership is essential to the success of this transformation, because leadership is all about envisioning and guiding people through change. If anesthesiology is to continue to thrive as a medical specialty within a rapidly evolving healthcare system, anesthesiologists will need to envision and manifest change beyond simply providing efficient care.

The specialty is confronting what has been coined an “adaptive” challenge, i.e., a challenge for which there is no preexisting solution. Furthermore, there is evidence both inside and outside of medicine that organizations that focus exclusively on cost reduction and efficiency during times of rapid change ultimately do not fare well. As a result, anesthesiologists need to become change agents who envision, lead, and implement initiatives that ultimately result in greater patient safety, better patient outcomes, improved quality, and sustainable finances.

Medicine, however, as a whole underinvests in leadership development because, according to Dr. Wiley W. Souba, a surgeon and a prolific writer about leadership, the profession is not sure where to invest or how to “prepare people for the practice of leadership.” He points out that although leadership training is available, the focus on “managerial skills” fails to get at the heart of leadership. More recently, a qualitative study of emergency medicine residents at a major academic center found that the approaches to learning leadership are underdeveloped, resulting in a narrow view of leadership. What is still missing is a roadmap for cultivating leadership behaviors in clinicians and relevant tools to guide their actions. In this article, with the help of a case scenario, we propose a practical framework for turning anesthesiologists into leaders.

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31 de agosto de 2012

Artigo recomendado: Coffee Drinking and Mortality

Scott K. Aberegg, M.D., M.P.H.

n engl j med 367;6 nejm.org august 9, 2012

To the Editor: Freedman et al. (May 17 issue) report the results of a widely publicized study of the association between coffee consumption and mortality. Several limitations and alternative explanations of their findings deserve consideration. The biologic plausibility of a reduction in mortality associated with coffee consumption is inadequately explicated. This is especially noteworthy because coffee consumption appeared to reduce the rate of death from accidents and injuries. In essence, this is a positive result on a negative control embedded within the study, and it undermines the study’s main findings. People frequently drink coffee at work (the proverbial “coffee break”), and the findings of this study could be due to a “healthy worker” effect not captured by other covariates, such as educational attainment and health status. The inclusion of relevant covariates is fraught with difficulty when a plausible mechanism supporting the main study findings is not apparent. The simplest explanation for the aggregate findings seems to be the most likely — in this case, residual confounding from unmeasured behaviors associated with coffee consumption that protect against everything, including accidents and injuries.

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28 de agosto de 2012

Artigo recomendado: Does Rotational Thromboelastometry (ROTEM) Improve Prediction of Bleeding After Cardiac Surgery?

Lee GC et al. – The results suggest that Rotational thromboelastometry (ROTEM) data do not substantially improve a model's ability to predict chest tube drainage, beyond frequently used clinical and laboratory parameters. Although several ROTEM parameters were individually associated with chest tube output (CTO), they did not significantly improve goodness of fit when added to statistical models comprising only clinical and routine laboratory parameters. ROTEM does not seem to improve prediction of chest tube drainage after cardiac surgery involving CPB, although its use in guiding transfusion during cardiac surgery remains to be determined.

Anesthesia & Analgesia, 08/22/2012  Clinical Article

Methods
  • Three hundred twenty-one patients undergoing cardiac surgery involving CPB were enrolled.
  • Patient data were obtained from medical records, including chest tube output (CTO) from post-CPB through the first 8 postoperative hours.
  • Perioperative and postoperative blood samples were collected for ROTEM analysis.
  • Three measures of CTO were used as the primary end points for assessing coagulopathy: continuous CTO; CTO dichotomized at 600mL (75th percentile); and CTO dichotomized at 910mL (90th percentile).
  • Clinical and hematological variables, excluding ROTEM data, that were significantly correlated (P < 0.05) with continuous CTO were included in a stepwise regression model (model 1).
  • An additional model that contained ROTEM variables in addition to the variables from model 1 was created (model 2).
  • Significance in subsequent analyses was declared at P < 0.0167 to account for the 3 CTO end points.
  • Net reclassification index was used to assess overall value of ROTEM data.

Results
  • For continuous CTO, ROTEM variables improved the model's predictive ability (P < 0.0001).
  • For CTO dichotomized at 600mL (75th percentile), ROTEM did not improve the area under the receiver operating characteristic curve (AUC) (P = 0.03).
  • Similarly, for CTO dichotomized at 910mL (90th percentile), ROTEM did not improve the AUC (P = 0.23).
  • Net reclassification index similarly indicated that ROTEM results did not improve overall classification of patients (P = 0.12 for CTO ≥ 600mL; P=0.08 for CTO ≥ 910mL).

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24 de agosto de 2012

Artigo recomendado: Who Is at Risk for Postdischarge Nausea and Vomiting after Ambulatory Surgery?

Christian C. Apfel, Beverly K. Philip, Ozlem S. Cakmakkaya, Ashley Shilling, Yun-Ying Shi, John B. Leslie, Martin Allard, Alparslan Turan, Pamela Windle, Jan Odom-Forren, Vallire D. Hooper, Oliver C. Radke, Joseph Ruiz, Anthony Kovac

Anesthesiology 2012; 117:475– 86 476 Apfel et al.

ABSTRACT

Background: About one in four patients suffers from postoperative nausea and vomiting. Fortunately, risk scores have been developed to better manage this outcome in hospitalized patients, but there is currently no risk score for postdischarge nausea and vomiting (PDNV) in ambulatory surgical patients.

Methods: We conducted a prospective multicenter study of 2,170 adults undergoing general anesthesia at ambulatory surgery centers in the United States from 2007 to 2008. PDNV was assessed from discharge until the end of the second postoperative day. Logistic regression analysis was applied to a development dataset and the area under the receiver operating characteristic curve was calculated in a validation dataset.

Results: The overall incidence of PDNV was 37%. Logistic regression analysis of the development dataset (n=1,913) identified five independent predictors (odds ratio; 95% CI): female gender (1.54; 1.22 to 1.94), age less than 50 yr (2.17; 1.75 to 2.69), history of nausea and/or vomiting after previous anesthesia (1.50; 1.19 to 1.88), opioid administration in the postanesthesia care unit (1.93; 1.53 to 2.43), and nausea in the postanesthesia care unit (3.14; 2.44–4.04). In the validation dataset (n 257), zero, one, two, three, four, and five of these factors were associated with a PDNV incidence of 7%, 20%, 28%, 53%, 60%, and 89%, respectively, and an area under the receiver operating characteristic curve of 0.72 (0.69 to 0.73).

Conclusions: PDNV affects a substantial number of patients after ambulatory surgery. We developed and validated a simplified risk score to identify patients who would benefit from long-acting prophylactic antiemetics at discharge from the ambulatory care center.

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