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

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.

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.


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).

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