Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence.

Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Risk of pulmonary aspiration during semaglutide use and anesthesia in a fasting patient: a case report with tomographic evidence

ABSTRACT Pulmonary aspiration of gastric residues during anesthesia is a potentially fatal complication for which no specific treatment is available. The primary way to prevent its occurrence in the context of elective surgeries is adherence to fasting protocols. However, some clinical conditions can prolong the gastric emptying time, and the risk of aspiration may exist despite adequate fasting. Recognizing the risk factors for gastroparesis allows the adoption of preventive methods and is the primary way to reduce morbidity and mortality from pulmonary aspiration. In this scenario, the anesthesiologist can investigate the gastric content by using ultrasound, adjust the anesthetic technique, and even postpone elective surgeries. Here, we describe incidental computed tomography finding of solid contents in the stomach of a patient without prior identification of the risk factors for gastroparesis. The patient underwent elective renal nodule ablation under general anesthesia after fasting for 9 hours. During the procedure, solid contents in the stomach were noted on computed tomography. Subsequently, it was discovered that the patient had been using semaglutide for 6 days and had not disclosed this information. Semaglutide use may represent a new and significant risk factor for anesthesia-related pulmonary aspiration. Until studies provide information on the appropriate perioperative management of patients using semaglutide, anesthesiologists need to adopt preventive measures to avoid aspiration. Awareness of this potential association and open communication among patients, physicians, and anesthesia teams are essential for enhancing patient safety.

Methodological description of clinical research data collection through electronic medical records in a center participating in an international multicenter study.

Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study's case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.

Methodological description of clinical research data collection through electronic medical records in a center participating in an international multicenter study / Abordagem e descrição metodológica do uso do prontuário eletrônico como forma de coleta de dados em pesquisa clínica em centro participante de estudo internacional e multicêntrico

ABSTRACT Data collection for clinical research can be difficult, and electronic health record systems can facilitate this process. The aim of this study was to describe and evaluate the secondary use of electronic health records in data collection for an observational clinical study. We used Cerner Millennium®, an electronic health record software, following these steps: (1) data crossing between the study's case report forms and the electronic health record; (2) development of a manual collection method for data not recorded in Cerner Millennium®; (3) development of a study interface for automatic data collection in the electronic health records; (4) employee training; (5) data quality assessment; and (6) filling out the electronic case report form at the end of the study. Three case report forms were consolidated into the electronic case report form at the end of the study. Researchers performed daily qualitative and quantitative analyses of the data. Data were collected from 94 patients. In the first case report form, 76.5% of variables were obtained electronically, in the second, 95.5%, and in the third, 100%. The daily quality assessment of the whole process showed complete and correct data, widespread employee compliance and minimal interference in their practice. The secondary use of electronic health records is safe and effective, reduces manual labor, and provides data reliability. Anesthetic care and data collection may be done by the same professional.

RESUMO A coleta de dados para pesquisa clínica pode representar um desafio em que sistemas de registro eletrônico em saúde podem facilitar o processo. O objetivo deste estudo foi descrever e avaliar o uso secundário de registros eletrônicos em saúde na coleta de dados para um estudo clínico observacional. Usamos o Cerner Millennium®, software de registro eletrônico em saúde, de acordo com os seguintes passos: (1) cruzamento dos dados das fichas de coleta de dados do estudo e dos registros eletrônicos em saúde; (2) desenvolvimento de método para coleta manual de dados não registrados no Cerner Millennium®; (3) desenvolvimento de interface de estudo para a coleta automática de dados nos registros eletrônicos em saúde; (4) treinamento de colaboradores; (5) avaliação da qualidade dos dados; e (6) preenchimento da ficha eletrônica de coleta de dados no fim do estudo. Três fichas de coleta de dados foram consolidadas em uma ficha eletrônica de coleta de dados no fim do estudo. Os pesquisadores realizaram análise qualitativa e quantitativa de dados diariamente. Foram coletados dados de 94 pacientes. Na primeira ficha de coleta de dados, 76,5% das variáveis foram obtidas eletronicamente, na segunda, 95,5%, e na terceira, 100%. A avaliação diária de qualidade do processo como um todo revelou dados completos e corretos, ampla adesão dos colaboradores e mínima interferência na prática profissional. O uso secundário dos registros eletrônicos em saúde é seguro e efetivo, reduz o trabalho manual e produz dados confiáveis. O cuidado anestésico ao paciente e a coleta de dados podem ser realizados simultaneamente pelo mesmo professional.

Association between viscoelastic tests-guided therapy with synthetic factor concentrates and allogenic blood transfusion in liver transplantation: a before-after study.

BACKGROUND: Perioperative bleeding and transfusion are important causes of morbidity and mortality in patients undergoing liver transplantation. The aim of this study is to assess whether viscoelastic tests-guided therapy with the use of synthetic factor concentrates impact transfusion rates of hemocomponents in adult patients undergoing liver transplantation. METHODS: This is an interventional before-after comparative study. Patients undergoing liver transplantation before the implementation of a protocol using thromboelastometry and synthetic factor concentrates were compared to patients after the implementation. Primary outcome was transfusion of any hemocomponents. Secondary outcomes included: transfusion of red blood cells (RBC), fresh frozen plasma (FFP), cryoprecipitate or platelets, clinical complications, length of stay and in-hospital mortality. RESULTS: A total of 183 patients were included in the control and 54 in the intervention phase. After propensity score matching, the proportion of patients receiving any transfusion of hemocomponents was lower in the intervention phase (37.0 vs 58.4%; OR, 0.42; 95% CI, 0.20-0.87; p = 0.019). Patients in the intervention phase received less RBC (30.2 vs 52.5%; OR, 0.21; 95% CI, 0.08-0.56; p = 0.002) and FFP (5.7 vs 27.3%; OR, 0.11; 95% CI, 0.03-0.43; p = 0.002). There was no difference regarding transfusion of cryoprecipitate and platelets, complications related to the procedure, hospital length of stay and mortality. CONCLUSIONS: Use of a viscoelastic test-guided transfusion algorithm with the use of synthetic factor concentrates reduces the transfusion rates of allogenic blood in patients submitted to liver transplantation. TRIAL REGISTRATION: This trial was registered retrospectively on November 15th, 2018 - clinicaltrials.gov - Identifier: NCT03756948.

International multicenter observational study on assessment of ventilatory management during general anaesthesia for robotic surgery and its effects on postoperative pulmonary complication (AVATaR): study protocol and statistical analysis plan.

INTRODUCTION: Robotic-assisted surgery (RAS) has emerged as an alternative minimally invasive surgical option. Despite its growing applicability, the frequent need for pneumoperitoneum and Trendelenburg position could significantly affect respiratory mechanics during RAS. AVATaR is an international multicenter observational study aiming to assess the incidence of postoperative pulmonary complications (PPC), to characterise current practices of mechanical ventilation (MV) and to evaluate a possible association between ventilatory parameters and PPC in patients undergoing RAS. METHODS AND ANALYSIS: AVATaR is an observational study of surgical patients undergoing MV for general anaesthesia for RAS. The primary outcome is the incidence of PPC during the first five postoperative days. Secondary outcomes include practice of MV, effect of surgical positioning on MV, effect of MV on clinical outcome and intraoperative complications. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Board of the Hospital Israelita Albert Einstein. The study results will be published in peer-reviewed journals and disseminated at international conferences. TRIAL REGISTRATION NUMBER: NCT02989415; Pre-results.

The role of thromboelastometry in the assessment and treatment of coagulopathy in liver transplant patients / O papel da tromboelastometria na avaliação e no tratamento da coagulopatia em pacientes submetidos ao transplante hepático

ABSTRACT Perioperative monitoring of coagulation is vital to assess bleeding risks, diagnose deficiencies associated with hemorrhage, and guide hemostatic therapy in major surgical procedures, such as liver transplantation. Routine static tests demand long turnaround time and do not assess platelet function; they are determined on plasma at a standard temperature of 37°C; hence these tests are ill-suited for intraoperative use. In contrast, methods which evaluate the viscoelastic properties of whole blood, such as thromboelastogram and rotational thromboelastometry, provide rapid qualitative coagulation assessment and appropriate guidance for transfusion therapy. These are promising tools for the assessment and treatment of hyper- and hypocoagulable states associated with bleeding in liver transplantation. When combined with traditional tests and objective assessment of the surgical field, this information provides ideal guidance for transfusion strategies, with potential improvement of patient outcomes.

RESUMO A monitorização perioperatória da coagulação é fundamental para estimar o risco de sangramento, diagnosticar deficiências causadoras de hemorragia e guiar terapias hemostáticas durante procedimentos cirúrgicos de grande porte, como o transplante hepático. Os testes estáticos, comumente usados na prática clínica, são insatisfatórios no intraoperatório, pois demandam tempo e não avaliam a função plaquetária; são determinados no plasma e realizados em temperatura padrão de 37°C. Os métodos que avaliam as propriedades viscoelásticas do sangue total, como o tromboelastograma e a tromboelastometria rotacional, podem suprir as deficiências dos testes estáticos tradicionais, uma vez que permitem avaliar a coagulação de forma rápida e qualitativa, guiando a terapia transfusional de forma adequada. A tromboelastometria rotacional mostrou-se promissora na avaliação e no tratamento de estados de hipercoagulação e hipocoagulação, associados a sangramento no transplante hepático. Estas informações, combinadas com os testes tradicionais e uma avaliação objetiva do campo cirúrgico, promovem um cenário ótimo para guiar as estratégias transfusionais e potencialmente melhorar o desfecho destes pacientes.

The role of thromboelastometry in the assessment and treatment of coagulopathy in liver transplant patients.

Perioperative monitoring of coagulation is vital to assess bleeding risks, diagnose deficiencies associated with hemorrhage, and guide hemostatic therapy in major surgical procedures, such as liver transplantation. Routine static tests demand long turnaround time and do not assess platelet function; they are determined on plasma at a standard temperature of 37°C; hence these tests are ill-suited for intraoperative use. In contrast, methods which evaluate the viscoelastic properties of whole blood, such as thromboelastogram and rotational thromboelastometry, provide rapid qualitative coagulation assessment and appropriate guidance for transfusion therapy. These are promising tools for the assessment and treatment of hyper- and hypocoagulable states associated with bleeding in liver transplantation. When combined with traditional tests and objective assessment of the surgical field, this information provides ideal guidance for transfusion strategies, with potential improvement of patient outcomes. RESUMO A monitorização perioperatória da coagulação é fundamental para estimar o risco de sangramento, diagnosticar deficiências causadoras de hemorragia e guiar terapias hemostáticas durante procedimentos cirúrgicos de grande porte, como o transplante hepático. Os testes estáticos, comumente usados na prática clínica, são insatisfatórios no intraoperatório, pois demandam tempo e não avaliam a função plaquetária; são determinados no plasma e realizados em temperatura padrão de 37°C. Os métodos que avaliam as propriedades viscoelásticas do sangue total, como o tromboelastograma e a tromboelastometria rotacional, podem suprir as deficiências dos testes estáticos tradicionais, uma vez que permitem avaliar a coagulação de forma rápida e qualitativa, guiando a terapia transfusional de forma adequada. A tromboelastometria rotacional mostrou-se promissora na avaliação e no tratamento de estados de hipercoagulação e hipocoagulação, associados a sangramento no transplante hepático. Estas informações, combinadas com os testes tradicionais e uma avaliação objetiva do campo cirúrgico, promovem um cenário ótimo para guiar as estratégias transfusionais e potencialmente melhorar o desfecho destes pacientes.

Early perioperative death associated with reexpansion pulmonary edema during liver transplantation.

Hydrothorax is a frequent finding in patients with end-stage liver disease. During the hepatectomy phase of liver transplantation, it is often needed to evacuate large pleural effusions. The acute expansion of the collapsed lung can cause reexpansion pulmonary edema with variable clinical significance. However, this complication has rarely been reported after liver transplantation. In conclusion, we report on an overwhelming reexpansion pulmonary edema during a liver transplantation that rapidly led to the patient's demise and speculate if this condition has not been under recognized in the transplantation setting.

Efeitos hemodinâmicos da ventilaçäo com alta frequência e ventilaçäo controlada mecânica em cäes submetidos à injeçäo venosa de ácido oleico / Hemodynamic effects of high frequency ventilation and conventional mechanical ventilation in dogs subjected to entravenous injection of oleic acid

Para avaliar-se os efeitos hemodinâmicos da ventilaçäo de alta freqüência em jatos (VAFJ) em relaçäo à ventilaçäo mecânica convencional (VCM), na vigência de insuficiência respiratória aguda, foi estabelecido um modelo experimental de lesäo pulmonar provocada em cäes pela injeçäo venosa de ácido oleico (0,07 ml.kg**-1). Foram estudados 16 cäes (15, 91 + ou - 3,27 kg) divididos em 2 grupos. Grupo I (8 cäes) foram ventilados pelo método convencional (VCM). Grupo II (8 cäes) foram ventilados pela técnica de alta freqüencia em jatos (VAFJ), a uma freqüência ventilatória de 200 vezes por minuto. A avaliaçäo hemodinâmica foi feita através de determinaçäo do débito cardíaco e das pressöes ao nível de átrio direito, ventrículo direito, artéria pulmonar e capilar pulmonar, raiz da aorta e ventrículo esquerdo. Estes cateteres foram conectados a transdutores de pressäo e polígrafo "Hewlett Packard". Foram determinadas as pressöes na traquéia e na pleura, colocando-se um "intracath" próximo à carina e no espaço pleural respectivamente. O estudo foi conduzido em 2 etapas. controle (A) e após injeçäo de ácido oleico (B). Os dados obtidos foram submetidos à análise estatística (análise de variância para medidas repetidas), mostrando näo haver diferenças hemodinâmicas significativas entre (A) e (B) comparando-se VAFJ com VCM. Os autores concluem que, embora no modelo experimental utilizado näo ter havido diferenças significativas quanto a repercussöes hemodinâmicas, mais estudos säo necessários para a extrapolaçäo dos mesmos resultados para seres humanos

Ventriculografia cardíaca em cäes submetidos a ventilaçäo de alta freqüência em jatos e ventilaçäo com pressäo positiva intermitente / Cardiac ventriculography in dogs subjected to high frequency jet ventilation and intermittent positive pressure ventilation

Foram realizadas ventriculografias direita e esquerda durante ventilaçäo de alta freqüência em jatos (VAFJ) e ventilaçäo com pressäo positiva intermitente (VPPI) em 10 cäes machos, com peso médio de 16,8 + ou - 3,9kg, cada um sendo o seu próprio controle. Os parâmetros ventilatórios iniciais foram ajustados em: VAFJ - freqüência respiratória de 200 ciclos por minuto, relaçäo inspiraçäo/expiraçäo 1:2; VPPI - volume corrente de 15 a 20ml/kg, freqüência respiratória de 15 ciclos por minuto, relaçäo inspiraçäo/expiraçäo 1:2; obteve-se o mesmo padräo ventilatório nos dois grupos. A ventriculografia foi feita utilizando-se cateter tipo Angio n§ 7, injetando-se contraste radiopaco na dose de 1,2ml/kg, sob pressäo de 500mmHg e velocidade fixa de 15ml/s. As medidas dos volumes ventriculares esquerdo e direito basearam-se respectivamente nos métodos propostos por Dodge e Ida. A análise estatística näo demonstrou diferença significativa nos volumes ventriculares durante o uso dos dois métodos de ventilaçäo; conclui-se pois que os volumes ventriculares näo diferem em cäes normovolêmicos e normoventilados, nos dois métodos de ventilaçäo empregados