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.

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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).

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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

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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.

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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).

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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.

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