RESUMEN
Tumor staging is critical for the treatment of lung malignancies. Invasive techniques of lung tumor staging can be accomplished via mediastinoscopy, endobronchial ultrasound, and video-assisted thoracoscopy. Anesthesiologists taking care of patients undergoing mediastinal staging procedures might face different challenges. In this narrative review, the authors summarize the literature on the anesthetic considerations for mediastinal staging procedures.
Asunto(s)
Anestesia/métodos , Neoplasias Pulmonares/patología , Mediastino/patología , Humanos , Neoplasias Pulmonares/cirugía , Mediastinoscopía , Estadificación de Neoplasias , Cirugía Torácica Asistida por Video , Ultrasonografía IntervencionalAsunto(s)
Neoplasias de los Genitales Femeninos/cirugía , Procedimientos Quirúrgicos Ginecológicos/métodos , Ginecología/organización & administración , Atención Perioperativa/métodos , Oncología Quirúrgica/organización & administración , Femenino , Humanos , Atención Perioperativa/normas , Guías de Práctica Clínica como Asunto , Desarrollo de ProgramaRESUMEN
Acute pancreatitis is a common and potentially severe disease where nutritional support does affect its development in a way it may be considered a treatment in severe cases. These include around 20% of patients and present mortality rates of 8%-39%. In mild acute pancreatitis patients are prescribed nil per os at admission and advance diet in a progressive manner the following days. Although early introduction of diet has proven to shorten the length of stay, it is still not clear when and how to introduce diet. Severe disease is a hypercatabolic situation which often appears in already malnourished patients. Early enteral nutrition has shown a significative benefit over parenteral nutrition in terms of infection rates, hyperglycemia and mortality rates. This benefit may be related to a decrease in bacterial intestinal translocation. Nasoyeyunal tube feeding is the preferred site, but there are trials supporting nasogastric tubes, a more feasible election. The following lines offer an up to date review of nutritional management in acute pancreatitis, trying to answer in a clear and practical way to the most frequent problems arising in the day to day management of this disease.
Asunto(s)
Apoyo Nutricional , Pancreatitis/dietoterapia , Nutrición Enteral , Humanos , Tiempo de Internación , Pancreatitis/mortalidad , Pancreatitis/terapia , Nutrición ParenteralRESUMEN
La pancreatitis aguda es una patología frecuente y potencialmente grave en la que el manejo nutricional influye de manera importante en su desarrollo, de tal forma que se puede considerar un tratamiento específico en los casos graves. Éstos suponen aproximadamente el 20% de los pacientes y presentan una mortalidad entre el 8-39%. En los casos leves se suele proceder a un ingreso en dieta absoluta y posterior reintroducción progresiva de la dieta. Aunque se ha demostrado que una reintroducción temprana acorta la duración del ingreso, existe incertidumbre acerca del momento y del tipo de dieta idóneos. Las pancreatitis graves son estados hipercatabólicos que se presentan en pacientes que frecuentemente presentan déficits nutricionales basales. El soporte nutricional iniciado precozmente por vía enteral ha demostrado un beneficio significativo respecto a la vía parenteral en cuanto a tasa de infección, control de glucemia y mortalidad. Este beneficio puede relacionarse con una disminución de la traslocación bacteriana. Si bien tradicionalmente se ha empleado la vía nasoyeyunal, existen estudios que apoyan la vía nasogástrica, mucho más accesible. En el siguiente texto ofrecemos una revisión actualizada del manejo nutricional en la pancreatitis aguda, intentando responder de manera clara y con un enfoque práctico a las preguntas que más frecuentemente se presentan en el manejo de esta patología (AU)
Acute pancreatitis is a common and potentially severe disease where nutritional support does affect its development in a way it may be considered a treatment in severe cases. These include around 20% of patients and present mortality rates of 8%-39%. In mild acute pancreatitis patients are prescribed nil per os at admission and advance diet in a progressive manner the following days. Although early introduction of diet has proven to shorten the length of stay, it is still not clear when and how to introduce diet. Severe disease is a hypercatabolic situation which often appears in already malnourished patients. Early enteral nutrition has shown a significative benefit over parenteral nutrition in terms of infection rates, hyperglycemia and mortality rates. This benefit may be related to a decrease in bacterial intestinal translocation. Nasoyeyunal tube feeding is the preferred site, but there are trials supporting nasogastric tubes, a more feasible election. The following lines offer an up to date review of nutritional management in acute pancreatitis, trying to answer in a clear and practical way to the most frequent problems arising in the day to day management of this disease (AU)
Asunto(s)
Humanos , Pancreatitis/dietoterapia , Apoyo Nutricional/métodos , Nutrición Enteral/métodos , Nutrición Parenteral/métodos , Trastornos Nutricionales/dietoterapia , Enfermedad AgudaRESUMEN
Percutaneous coronary interventions (PCI) performed with concomitant use of heparin and platelet inhibitors are safe procedures with reported vascular complication rates of approximately 6.1%. EPILOG investigators demonstrated that utilizing a low-dose heparin regimen with abciximab, along with early sheath removal, vascular access-related bleeding was significantly lower than that reported in EPIC. Recently, a suture-mediated closure (SMC) device has been reported to be safe, appears effective, and may improve patient comfort by allowing early ambulation. We conducted a retrospective analysis (January 1999 to March 2000) of complication frequencies among PCI patients who underwent SMC and those who had manual compression (non-SMC). Furthermore, we compared the overall rates of complications to patients who underwent PCI prior to the introduction of SMC (1995-1998). When comparing the current cohort to the historical cohort, there was a significant decrease in the number of retroperitoneal bleeds (0.3% vs. 0.9%; P = 0.003), hematomas (5% vs. 9%; P < 0.001), pseudoaneurysms (1.2% vs. 2.7%; P < 0.001), and need for vascular surgery (0.9% vs. 2.8%; P < 0.001). There was no difference in the number of arterio-venous fistulas and a slight increase in transfusion needs (12% vs. 10%; P = 0.03). Within the current cohort, there was no difference in the vascular complications between SMC and non-SMC PCI patients, although there were lower rates of pseudoaneurysms (0.5% vs. 1.8%; P = 0.02) and transfusion requirements (72/880 vs. 132/874; P < 0.001). These results suggest that the complication rates for SMC are not different and may be lower when compared to non-SMC patients after PCI. At our institution, the practice of early sheath removal and less aggressive heparin dosing has led to a decrease in vascular complication rates and a 66% reduction in vascular surgeries on post-PCI patients. Because of the limitations of retrospective analyses, further studies will be necessary to confirm these findings.
Asunto(s)
Aneurisma Falso/etiología , Angioplastia Coronaria con Balón , Fístula Arteriovenosa/etiología , Enfermedad Coronaria/terapia , Hematoma/etiología , Hemorragia/etiología , Técnicas de Sutura/efectos adversos , Técnicas de Sutura/instrumentación , Enfermedades Vasculares/etiología , Anciano , Aneurisma Falso/cirugía , Fístula Arteriovenosa/cirugía , Transfusión Sanguínea , Estudios de Cohortes , Ambulación Precoz , Femenino , Hematoma/cirugía , Hemorragia/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Retrospectivos , Resultado del Tratamiento , Enfermedades Vasculares/cirugía , Procedimientos Quirúrgicos VascularesRESUMEN
BACKGROUND: Although clopidogrel is used to prevent subacute stent thrombosis, its safety and efficacy have not been compared with ticlopidine in a randomized manner in the United States. METHODS AND RESULTS: Patients with successful intracoronary stent implantation were randomly assigned to therapy with ticlopidine or clopidogrel. Loading doses were administered immediately after the procedure, and the drugs were prescribed for 2 weeks. One thousand sixteen patients were enrolled: 522 patients were randomly assigned to ticlopidine therapy and 494 to clopidogrel. High-risk characteristics included recent myocardial infarction in 41.4% of the cases, angiographically evident thrombus in 20.9%, and abrupt or threatened closure in 3.64%. An intravenous glycoprotein IIb/IIIa inhibitor was used in 48.2% of the cases, and thrombocytopenia occurred in 1.43% of these patients. Failure to complete 2 weeks of therapy occurred in 3.64% of the patients treated with ticlopidine and in 1.62% of the patients treated with clopidogrel (P=0.043). Within 30 days, thrombosis of the stent occurred in 1.92% of the patients in the ticlopidine group and in 2.02% of the clopidogrel group (P=0.901). A major adverse cardiac event occurred in 4.60% of patients receiving ticlopidine and in 3.85% of patients receiving clopidogrel (P=0.551). CONCLUSIONS: Clopidogrel is better tolerated than ticlopidine during a 2-week regimen after intracoronary stent implantation. Combining either thienopyridine with an intravenous platelet IIb/IIIa inhibitor appears to be safe. When applied to a broad spectrum of patients receiving stent implantation, clopidogrel confers similar protection as ticlopidine against subacute stent thrombosis and major adverse cardiac events.
Asunto(s)
Enfermedad Coronaria/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Stents , Ticlopidina/uso terapéutico , Abciximab , Anticuerpos Monoclonales/uso terapéutico , Clopidogrel , Trombosis Coronaria/etiología , Trombosis Coronaria/prevención & control , Eptifibatida , Exantema/inducido químicamente , Femenino , Enfermedades Gastrointestinales/inducido químicamente , Hemorragia/inducido químicamente , Humanos , Fragmentos Fab de Inmunoglobulinas/uso terapéutico , Masculino , Persona de Mediana Edad , Neutropenia/inducido químicamente , Péptidos/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/antagonistas & inhibidores , Complejo GPIIb-IIIa de Glicoproteína Plaquetaria/metabolismo , Stents/efectos adversos , Trombocitopenia/inducido químicamente , Ticlopidina/efectos adversos , Ticlopidina/análogos & derivados , Tirofibán , Tirosina/análogos & derivados , Tirosina/uso terapéuticoRESUMEN
BACKGROUND: Prolonged intravenous infusions of recombinant tissue factor pathway inhibitor (rTFPI) have been shown to attenuate markedly neointimal formation and stenosis after balloon-induced injury to the carotid arteries in minipigs. DESIGN: Because local delivery of rTFPI to the injury site would be clinically advantageous, we designed this study to compare the local delivery and retention of rTFPI in balloon-injured arteries using three catheter-based systems. METHODS: Similar amounts (range 3-4.5 mg) of a mixture of 125I-labeled and unlabeled rTFPI were delivered by either passive diffusion at moderate pressure (5 x 10(5) Pa with the LocalMed InfusaSleeve, or 4 x 10(5) Pa with the SciMed Dispatch device), or facilitated diffusion combining lower pressure (2 x 10(5) Pa) and electrical current (3.5 mA/cm2; e-MED, iontophoresis) to balloon-injured carotid arteries in anesthetized rabbits. RESULTS: Comparable amounts of rTFPI were retained on the injured vessels immediately after delivery (t = 0) with the LocalMed (628 +/- 68 micrograms/g per cm2, n = 4), SciMed (522 +/- 167 micrograms/g per cm2, n = 4), and e-MED (497 +/- 142 micrograms/g per cm2, n = 4) catheters (NS). However, rTFPI was decreased by 37% after 24 h compared with t = 0 (P < 0.02) in the e-MED group, but was increased 1.5-fold (P = 0.02) and 1.3-fold in the SciMed and LocalMed groups, respectively, presumably because of redistribution of rTFPI from remote endothelial or perivascular sites. Retention of rTFPI was six to nine times higher for injured compared with non-injured arteries, and persisted for at least 48 h after delivery with the LocalMed catheter. CONCLUSIONS: Sustained, marked retention of rTFPI delivered locally at the site of balloon-induced arterial injury appears to result from catheter-based systems that use passive diffusion at moderate pressure.
Asunto(s)
Angioplastia de Balón/efectos adversos , Traumatismos de las Arterias Carótidas , Sistemas de Liberación de Medicamentos/métodos , Fibrinolíticos/administración & dosificación , Lipoproteínas/administración & dosificación , Animales , Cateterismo , Sistemas de Liberación de Medicamentos/instrumentación , Inhibidores del Factor Xa , Conejos , Proteínas Recombinantes/administración & dosificaciónRESUMEN
Over 400,000 percutaneous transluminal coronary angioplasties (PTCAs) are currently performed annually in the United States. Approximately 10% of these procedures include rotational atherectomy, although the national average rate of stent placements continues to increase in some centers to as high as 75%. The combination of rotational atherectomy and intra-coronary stent placement is between 2% and 7.5% of interventional procedures per year in the United States. This article reviews the existing literature on rotational atherectomy and stent implantation for complex lesions and describes the upcoming prospective, multicenter randomized Stent Implantation, Postrotational Atherectomy (SPORT) trial.
Asunto(s)
Aterectomía Coronaria/instrumentación , Implantación de Prótesis Vascular/instrumentación , Enfermedad Coronaria/cirugía , Stents , Diseño de Equipo , Humanos , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del Tratamiento , Estados UnidosRESUMEN
The clinical significance of myocardial bridges (MBs) is variable, and most patients are asymptomatic. However, angina, myocardial infarction, and sudden death have been reported in association with MBs. Here we describe the use of intracoronary stenting for the treatment of a patient with an anterior myocardial infarction due to an MB.
Asunto(s)
Angioplastia Coronaria con Balón/instrumentación , Anomalías de los Vasos Coronarios/terapia , Infarto del Miocardio/terapia , Stents , Angiografía Coronaria , Anomalías de los Vasos Coronarios/complicaciones , Anomalías de los Vasos Coronarios/diagnóstico por imagen , Diagnóstico Diferencial , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico por imagen , Infarto del Miocardio/etiología , Resultado del TratamientoRESUMEN
Intravascular stents are successfully used during coronary revascularization. Subacute stent thrombosis is a rare complication, associated with a 40-60% risk of myocardial infarction, and occurs 5-10 days after implantation. We describe a case of late stent thrombosis potentially due to delayed endothelialization from cancer chemotherapy.
Asunto(s)
Angioplastia de Balón/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/efectos adversos , Enfermedad Coronaria/terapia , Trombosis Coronaria/etiología , Stents/efectos adversos , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/complicaciones , Carcinoma de Células Escamosas/tratamiento farmacológico , Angiografía Coronaria , Enfermedad Coronaria/complicaciones , Enfermedad Coronaria/diagnóstico , Trombosis Coronaria/diagnóstico , Trombosis Coronaria/fisiopatología , Falla de Equipo , Humanos , Neoplasias Pulmonares/complicaciones , Neoplasias Pulmonares/tratamiento farmacológico , Masculino , Persona de Mediana EdadRESUMEN
Serial sampling from the coronary sinus is an attractive technique for drawing blood samples to be used in the characterization of procoagulant activity during coronary interventions. We have developed a modified Simmons catheter for rapid cannulation of the coronary sinus from the femoral approach. The catheter design incorporates heparin bonding and distal side-holes to minimize blood sampling artifacts. Coronary sinus cannulation was performed via the femoral approach in 186 patients by use of a multipurpose catheter (n = 8), an unmodified Simmons I or II catheter (n = 64), or the modified Simmons catheter (n = 114). The coronary sinus was cannulated successfully with the modified Simmons catheter in 97% of patients; the success rate with the unmodified Simmons II catheter was 87% (P = 0.02). The modified Simmons catheter represents an improved technique for cannulation of the coronary sinus from the femoral vein.
Asunto(s)
Cateterismo Periférico/instrumentación , Vasos Coronarios , Vena Femoral , Heparina/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Sangre , Cateterismo Periférico/métodos , Cateterismo Periférico/estadística & datos numéricos , Distribución de Chi-Cuadrado , Diseño de Equipo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Manejo de Especímenes/instrumentación , Manejo de Especímenes/métodos , Manejo de Especímenes/estadística & datos numéricosRESUMEN
BACKGROUND: Acute thrombosis is thought to contribute to abrupt coronary occlusion during percutaneous coronary revascularization despite the administration of heparin and aspirin. This study was designed to detect the presence of heparin-resistant thrombin activity and to define its relationship to the acute ischemic complications of coronary interventions. METHODS AND RESULTS: Plasma levels of fibrinopeptide A (FPA) and prothrombin fragment 1.2 (F1.2), markers of thrombin and factor Xa activity, respectively, were measured in the coronary sinus with heparin-bonded catheters in 58 patients undergoing coronary interventions. Activated coagulation times were maintained > 300 seconds by the Hemochron method. Mean FPA levels decreased significantly, from 7.0 +/- 0.9 nmol/L before the procedure to 5.2 +/- 0.5 nmol/L after the heparin bolus and to 2.9 +/- 0.2 nmol/L after the procedure (P = .0001). In 26 patients (45%), FPA levels remained above the threshold for suppression angioplasty of thrombin activity determined during angiography in 7 patients without coronary artery disease (> 3.0 nmol/L). FPA concentrations after coronary interventions were increased in patients with intracoronary thrombus (P = .01), abrupt coronary occlusion (P = .06), postprocedural non-Q-wave myocardial infarction (P = .04), and clinically unsuccessful procedures (P = .04). F1.2 levels were relatively low before the procedures and did not change significantly. CONCLUSIONS: Heparin administration suppresses thrombin activity in most but not all patients undergoing coronary interventions. Heparin-resistant thrombin activity is associated with angiographic evidence of intracoronary thrombus and ischemic complications of coronary interventions.
Asunto(s)
Cateterismo Cardíaco/efectos adversos , Heparina/farmacología , Isquemia Miocárdica/complicaciones , Trombina/antagonistas & inhibidores , Trombina/metabolismo , Enfermedad Aguda , Anciano , Angiografía , Recolección de Muestras de Sangre , Inhibidores del Factor Xa , Femenino , Fibrinopéptido A/metabolismo , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/etiología , Isquemia Miocárdica/metabolismo , Fragmentos de Péptidos/metabolismo , Protrombina/metabolismo , Reproducibilidad de los Resultados , Trombosis/tratamiento farmacológico , Trombosis/etiología , Tiempo de Coagulación de la Sangre TotalRESUMEN
Circulating antiphospholipid antibodies (aPL) are associated with a syndrome of thrombosis, recurrent fetal loss, and thrombocytopenia. We have demonstrated the activation of cultured human umbilical vein endothelial cells (HUVEC) by IgG from patients with anticardiolipin antibodies (aCL). Incubation of HUVEC for 4 h with purified IgG (100 micrograms/ml) from patients with high-titer aCL induced a 2.3-fold increase in monocyte adhesion over that seen in HUVEC incubated with IgG's from normal subjects. The effect of aCL was not attributable to LPS contamination, Fc receptors, or immune complexes. Monocyte adhesion was not induced when the aCL were added in serum-free media but was restored by the addition of purified beta 2GP1, previously described as a necessary cofactor for aCL reactivity. Purified rabbit polyclonal IgG raised against beta 2GP1 also induced monocyte adhesion when incubated with HUVEC. Preadsorption of patient serum with cardiolipin reduced monocyte adhesion by 60%. Immunofluorescent microscopy demonstrated that endothelial cells incubated with patient IgG expressed cell adhesion molecules, including E-selectin, vascular cell adhesion molecule-1, and intracellular adhesion molecule-1. These data support the hypothesis that aPL activate vascular endothelial cells, thereby leading to a pro-thrombotic state.
Asunto(s)
Anticuerpos Antifosfolípidos/inmunología , Endotelio Vascular/fisiología , Inmunoglobulina G/inmunología , Monocitos/fisiología , Adhesión Celular , Células Cultivadas , Medio de Cultivo Libre de Suero , Femenino , Humanos , MasculinoRESUMEN
Dobutamine stress echocardiography (DSE) was performed after coronary angiography to evaluate the need to perform percutaneous transluminal coronary angioplasty (PTCA) for 46 stenoses of moderate severity (50% to 80%) in 46 patients. Patients were divided into 2 groups according to the DSE results in the distribution of the coronary artery with the lesion of moderate severity: group I (n = 32) were those without inducible myocardial ischemia; PTCA was not performed. Group II (n = 14) were those who exhibited myocardial ischemia; PTCA was performed in 12. The 2 groups were comparable in terms of clinical characteristics. Follow-up DSE was performed < or = 48 hours after PTCA, at 3 months, and 6 to 12 months after the first DSE. In group I at 3 months, DSE results were still negative in the distribution of the vessel with the moderately severe lesion in 24 patients; only 1 patient had a positive result, and 8 patients who refused DSE remained clinically stable. At 6 to 12 months (mean 7 +/- 2), 26 patients had negative study results; 3 patients who refused follow-up DSE remained clinically stable. In group II, 12 of 14 patients with inducible ischemia on the initial DSE underwent PTCA. Early follow-up DSE (< or = 48 hours) was negative in 7, and 4 had persistent inducible wall motion abnormalities in the myocardium subtended by the coronary artery in which the PTCA had been performed; 1 study was not performed.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Angioplastia Coronaria con Balón , Enfermedad Coronaria/diagnóstico por imagen , Dobutamina , Adulto , Anciano , Anciano de 80 o más Años , Angiografía Coronaria , Enfermedad Coronaria/terapia , Ecocardiografía/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Índice de Severidad de la EnfermedadRESUMEN
Although significant left internal mammary artery graft ostial stenosis is extremely rare, the clinical importance can be profound. In this report we describe a case in which a restenotic left internal mammary artery graft ostial lesion was successfully opened with excimer laser coronary angioplasty. A resulting pseudoaneurysm spontaneously closed after conservative therapy.
Asunto(s)
Angioplastia Coronaria con Balón/efectos adversos , Angioplastia de Balón Asistida por Láser/efectos adversos , Aneurisma Coronario/etiología , Oclusión de Injerto Vascular/terapia , Anastomosis Interna Mamario-Coronaria , Anciano , Aneurisma Coronario/terapia , Humanos , MasculinoAsunto(s)
Aorta Torácica/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Ecocardiografía Transesofágica , Procesamiento de Imagen Asistido por Computador , Anciano , Anciano de 80 o más Años , Disección Aórtica/diagnóstico por imagen , Aneurisma de la Aorta Torácica/diagnóstico por imagen , Arteriosclerosis/diagnóstico por imagen , Humanos , Masculino , Trombosis/diagnóstico por imagenAsunto(s)
Angioplastia Coronaria con Balón , Enfermedad de la Arteria Coronaria/terapia , Enfermedad Coronaria/terapia , Anciano , Angiografía , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/patología , Circulación Coronaria , Enfermedad Coronaria/diagnóstico por imagen , Enfermedad Coronaria/fisiopatología , Femenino , HumanosRESUMEN
Coronary angioplasty results in transient coronary artery occlusion. This article reviews with systemic and regional methods aimed at preventing the electrophysiologic and hemodynamic consequences of regional myocardial ischemia.