21 de outubro de 2015

Artigo recomendado: Best position and depth of anaesthesia for laryngeal mask airway removal in children

A prospective randomised controlled trial

George Thomas-Kattappurathu, Ananth Kasisomayajula and Judith Short

BACKGROUND: There is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable.

OBJECTIVES: We wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake.

DESIGN: A prospective randomised trial.

SETTING: A tertiary children’s hospital.

PATIENTS: The study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery.

INTERVENTION: We randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA.

MAIN OUTCOME MEASURES: The primary outcome measure was the number of patients experiencing one or more complication in each group. We also devised a novel ‘Clinical Importance’ score on the basis of the clinical relevance of airway complications.

RESULTS: There were significant differences among groups (P¼0.001); the fewest complications occurred when the LMA was removed in a deep plane of anaesthesia in the lateral position. There was a significant difference among groups in the "Clinical Importance" scores (P < 0,001); the greatest risk occurred when the LMA was removed in deeply anaesthetised supine patients.

CONCLUSION: The results of the present study suggest that lateral positioning of children for removal of the LMA provides the safest conditions if the LMA is to be removed at a deep plane of anaesthesia.

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2 de outubro de 2015

Artigo recomendado: Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy

A Randomized Control Trial

Naveed Siddiqui, Cristian Arzola, Zeev Friedman, Laarni Guerina, Kong Eric You-Ten

Background: Misidentification of the cricothyroid membrane in a “cannot intubate-cannot oxygenate” situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy.

Methods: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex® device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1—easy = visual landmarks; 2—moderate = requires light palpation of landmarks; 3—difficult = requires deep palpation of landmarks; and 4—impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time.

Results: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult–impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001).

Conclusion: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

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24 de setembro de 2015

Artigo recomendado: Practice Guidelines for Central Venous Access

A Report by the American Society of Anesthesiologists Task Force on Central Venous Access

Anesthesiology 2012; 116:539 –73

Practice Guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, Practice Guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.

Practice Guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.

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21 de agosto de 2015

Artigo recomendado: Protective versus Conventional Ventilation for Surgery

A Systematic Review and Individual Patient Data Meta-analysis

Ary Serpa Neto, Sabrine N. T. Hemmes, Carmen S. V. Barbas, Martin Beiderlinden, Michelle Biehl, Jan M. Binnekade, Jaume Canet, Ana Fernandez-Bustamante, Emmanuel Futier, Ognjen Gajic, Göran Hedenstierna, Markus W. Hollmann, Samir Jaber, Alf Kozian, Marc Licker, Wen-Qian Lin, Andrew D. Maslow, Stavros G. Memtsoudis, Dinis Reis Miranda, Pierre Moine,Thomas Ng, Domenico Paparella, M.D., Christian Putensen, Marco Ranieri, Federica Scavonetto, Thomas Schilling, Werner Schmid, Gabriele Selmo, Paolo Severgnini, Juraj Sprung, Sugantha Sundar, Daniel Talmor, Tanja Treschan, Carmen Unzueta, Toby N. Weingarten, Esther K. Wolthuis, Hermann Wrigge, Marcelo Gama de Abreu, Paolo Pelosi, Marcus J. Schultz

Anesthesiology 2015; 123:66-78

Background: Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end–expiratory pressure (PEEP) level and occurrence of PPC.

Methods: Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression.

Results: Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose–response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08).

Conclusions: These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.

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Anaesthesia-Database: The Anesthesia Guide

Anaesthesia-Database: The Anesthesia Guide: A PRACTICAL QUICK-REFERENCE GUIDE TO CLINICAL ANESTHESIOLOGY--PERFECT FOR THE OR AND ICU This carry-anywhere handbook is concise yet...

18 de junho de 2015

Artigo recomendado: Apnea after Awake Regional and General Anesthesia in Infants

The General Anesthesia Compared to Spinal Anesthesia Study - Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial

Andrew J. Davidson, Neil S. Morton, Sarah J. Arnup, Jurgen C. de Graaff, Nicola Disma, Davinia E. Withington, Geoff Frawley, Rodney W. Hunt, Pollyanna Hardy, Magda Khotcholava, Britta S. von Ungern Sternberg, Niall Wilton, Pietro Tuo, Ida Salvo, Gillian Ormond, Robyn Stargatt, Bruno Guido Locatelli, Mary Ellen McCann

Anesthesiology 2015; 123:38-54


Background: Postoperative apnea is a complication in young infants. Awake regional anesthesia (RA) may reduce the risk; however, the evidence is weak. The General Anesthesia compared to Spinal anesthesia study is a randomized, controlled trial designed to assess the influence of general anesthesia (GA) on neurodevelopment. A secondary aim is to compare rates of apnea after anesthesia.

Methods: Infants aged 60 weeks or younger, postmenstrual age scheduled for inguinal herniorrhaphy, were randomized to RA or GA. Exclusion criteria included risk factors for adverse neurodevelopmental outcome and infants born less than 26 weeks gestation. The primary outcome of this analysis was any observed apnea up to 12 h postoperatively. Apnea assessment was unblinded.

Results: Three hundred sixty-three patients were assigned to RA and 359 to GA. Overall, the incidence of apnea (0 to 12 h) was similar between arms (3% in RA and 4% in GA arms; odds ratio [OR], 0.63; 95% CI, 0.31 to 1.30, P = 0.2133); however, the incidence of early apnea (0 to 30 min) was lower in the RA arm (1 vs. 3%; OR, 0.20; 95% CI, 0.05 to 0.91; P = 0.0367). The incidence of late apnea (30 min to 12 h) was 2% in both RA and GA arms (OR, 1.17; 95% CI, 0.41 to 3.33; P = 0.7688). The strongest predictor of apnea was prematurity (OR, 21.87; 95% CI, 4.38 to 109.24), and 96% of infants with apnea were premature.

Conclusions: RA in infants undergoing inguinal herniorrhaphy reduces apnea in the early postoperative period. Cardiorespiratory monitoring should be used for all ex-premature infants.

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10 de junho de 2015

Artigo recomendado: Comparison of Surgical Pleth Index–guided Analgesia with Conventional Analgesia Practices in Children

A Randomized Controlled Trial

Ji Hye Park, Byung Gun Lim, Heezoo Kim, Il Ok Lee, Myoung Hoon Kong, Nan Suk Kim

Anesthesiology 2015;122:1280-7


Background: To compare surgical pleth index (SPI)-guided analgesia with conventional analgesia by evaluating intraoperative analgesic requirements, postoperative pain, and emergence agitation in children.

Methods: This study was designed as a parallel, two-arm, double-blind, randomized controlled trial. Forty-five children undergoing elective adenotonsillectomy were randomly allocated to SPI-guided group (SPI-guided analgesia group, n = 21) or control group (conventional analgesia group, n = 24). Anesthesia was maintained with sevoflurane 2 to 3 vol% in 50% nitrous oxide and oxygen to achieve state entropy between 40 and 60. Intraoperative fentanyl 0.5 μg/kg was administered for the first event persisting 3 min and subsequent events persisting 5 min. An event was defined as an SPI over 50 (SPI-guided group) or a blood pressure or heart rate 20% above the baseline (control group). The primary outcome was intraoperative fentanyl requirement. Secondary outcomes included intraoperative sevoflurane consumption, postoperative emergence agitation and pain score, and postoperative rescue analgesic requirements.

Results: Intraoperative fentanyl requirement was lower in SPI-guided group than in control group (0.43 ± 0.53 vs. 1.73 ± 0.59 μg/kg; P < 0.001). Intraoperative sevoflurane consumption was similar. The proportion of patients with high emergence agitation scores (4 to 5) was greater in SPI-guided group (61.9 vs. 25.0%; P = 0.01). The postoperative pain score and rescue fentanyl consumption were higher in SPI-guided group (7 [4.5; 9] vs. 3 [2; 6.75]; P = 0.002; 0.50 ± 0.34 vs. 0.29 ± 0.30 μg/kg; P = 0.04).

Conclusions: As currently constructed, SPI does not appear to be valid in children. This may be due to both differences in blood vessel distensibility and baseline increased heart rates in children versus adults.

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15 de maio de 2015

Artigo recomendado: Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

Tong J. Gan, Pierre Diemunsch, Ashraf S. Habib, Anthony Kovac, Peter Kranke, Tricia A. Meyer, Mehernoor Watcha,  Frances Chung, Shane Angus, Christian C. Apfel, Sergio D. Bergese, Keith A. Candiotti, Matthew TV Chan, Peter J. Davis, Vallire D. Hooper, Sandhya Lagoo-Deenadayalan, Paul Myles, Greg Nezat, Beverly K. Philip and Martin R. Tramèr

Anesth Analg 2014;118:85–113

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. 

The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

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23 de março de 2015

Artigo recomendado: Postoperative Opioid-induced Respiratory Depression

A Closed Claims Analysis

Lorri A. Lee, Robert A. Caplan, Karen L. Posner, Gregory W. Terman, Terri Voepel-Lewis e  Karen B. Domino

Anesthesiology 2015; 122:659-65)

Background: Postoperative opioid-induced respiratory depression (RD) is a significant cause of death and brain damage in the perioperative period. The authors examined anesthesia closed malpractice claims associated with RD to determine whether patterns of injuries could guide preventative strategies.

Methods: From the Anesthesia Closed Claims Project database of 9,799 claims, three authors reviewed 357 acute pain claims that occurred between 1990 and 2009 for the likelihood of RD using literature-based criteria. Previously cited patient risk factors for RD, clinical management, nursing assessments, and timing of events were abstracted from claim narratives to identify recurrent patterns.

Results: RD was judged as possible, probable, or definite in 92 claims (? = 0.690) of which 77% resulted in severe brain damage or death. The vast majority of RD events (88%) occurred within 24 h of surgery, and 97% were judged as preventable with better monitoring and response. Contributing and potentially actionable factors included multiple prescribers (33%), concurrent administration of nonopioid sedating medications (34%), and inadequate nursing assessments or response (31%). The time between the last nursing check and the discovery of a patient with RD was within 2 h in 42% and within 15 min in 16% of claims. Somnolence was noted in 62% of patients before the event.

Conclusions: This claims review supports a growing consensus that opioid-related adverse events are multifactorial and potentially preventable with improvements in assessment of sedation level, monitoring of oxygenation and ventilation, and early response and intervention, particularly within the first 24 h postoperatively.

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27 de janeiro de 2015

Artigo recomendado: The role of the anesthesiologist in perioperative patient safety

Johannes Wacker; Sven Staender
2014 Wolters Kluwer Health/Lippincott Williams & Wilkins

Purpose of review
Despite the benefits of rapidly advancing therapeutic and diagnostic possibilities, the perioperative setting still exposes patients to significant risks of adverse events and harm. Anesthesiologists are in midstream of perioperative care and can make significant contributions to patient safety and patient outcomes. This article reviews recent research results outlining the current trends of perioperative patient harm and summarizes the evidence in favor of patient safety practices.

Recent findings
Adverse events and patient harm continue to be frequent in the perioperative period. Adverse events occur in about 30% of hospital admissions, are associated with higher mortality, and may be preventable in more than 50%. Evidence-based recommendations are available for many patient safety issues. No magic bullet practices exist, but promising targets include the prevention and limitation of perioperative infections and of complications of airway and respiratory management, the maintenance of achieved safety standards, the use of checklists, and others.

Current research provides growing evidence for the effectiveness of several patient safety practices designed to prevent or diminish perioperative adverse events and patient harm. Future investigations will hopefully fill the numerous persisting knowledge gaps.

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12 de janeiro de 2015

Artigo Recomendado: Transfusion Requirements in Surgical Oncology Patients

A Prospective, Randomized Controlled Trial

Juliano Pinheiro de Almeida; Jean-Louis Vincent; Filomena Regina Barbosa Gomes Galas; Elisangela Pinto Marinho de Almeida; Julia T. Fukushima; Eduardo A. Osawa; Fabricio Bergamin; Clarice Lee Park; Rosana Ely Nakamura; Silvia M. R. Fonseca; Guilherme Cutait; Joseane Inacio Alves; Mellik Bazan; Silvia Vieira; Ana C. Vieira Sandrini; Henrique Palomba; Ulysses Ribeiro Jr.; Alexandre Crippa; Marcos Dalloglio; Maria del Pilar Estevez Diz; Roberto Kalil Filho; Jose Otavio Costa Auler; Andrew Rhodes; Ludhmila Abrahao Hajjar

Anesthesiology 2015; 122:29-38

Background: Several studies have indicated that a restrictive erythrocyte transfusion strategy is as safe as a liberal one in critically ill patients, but there is no clear evidence to support the superiority of any perioperative transfusion strategy in patients with cancer.

Methods: In a randomized, controlled, parallel-group, double-blind (patients and outcome assessors) superiority trial in the intensive care unit of a tertiary oncology hospital, the authors evaluated whether a restrictive strategy of erythrocyte transfusion (transfusion when hemoglobin concentration < 7 g/dl) was superior to a liberal one (transfusion when hemoglobin concentration < 9 g/dl) for reducing mortality and severe clinical complications among patients having major cancer surgery. All adult patients with cancer having major abdominal surgery who required postoperative intensive care were included and randomly allocated to treatment with the liberal or the restrictive erythrocyte transfusion strategy. The primary outcome was a composite endpoint of mortality and morbidity.

Results: A total of 198 patients were included as follows: 101 in the restrictive group and 97 in the liberal group. The primary composite endpoint occurred in 19.6% (95% CI, 12.9 to 28.6%) of patients in the liberal-strategy group and in 35.6% (27.0 to 45.4%) of patients in the restrictive-strategy group (P = 0.012). Compared with the restrictive strategy, the liberal transfusion strategy was associated with an absolute risk reduction for the composite outcome of 16% (3.8 to 28.2%) and a number needed to treat of 6.2 (3.5 to 26.5).

Conclusion: A liberal erythrocyte transfusion strategy with a hemoglobin trigger of 9 g/dl was associated with fewer major postoperative complications in patients having major cancer surgery compared with a restrictive strategy.

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