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1.
Anaesth Crit Care Pain Med ; 43(4): 101388, 2024 May 04.
Artigo em Inglês | MEDLINE | ID: mdl-38710323

RESUMO

BACKGROUND: Whether the optimization of cerebral oxygenation based on regional cerebral oxygen saturation (rSO2) monitoring reduces the occurrence of cerebral ischemic lesions is unknown. METHODS: This multicenter, randomized, controlled trial recruited adults admitted for scheduled carotid endarterectomy. Patients were randomized between the standard of care or optimization of cerebral oxygenation based on rSO2 monitoring using near-infrared spectroscopy. In the intervention group, in case of a decrease in rSO2 in the intervention, the following treatments were sequentially recommended: (1) increasing oxygenotherapy, (2) reducing the tidal volume, (3) legs up-raising, (4) performing a fluid challenge and (5) initiating vasopressor support. The primary endpoint was the number of new cerebral ischemic lesions detected using magnetic resonance imaging pre- and postoperatively. Secondary endpoints included new neurological deficits and mortality on day 120 after surgery. RESULTS: Among the 879 patients who were randomized, 665 (75.7%) were men. There was no statistically significant difference between groups for the mean number of new cerebral ischemic lesions per patient up to 3 days after surgery: 0.35 (±1.05) in the standard group vs. 0.58 (±2.83), in the NIRS group; mean difference, 0.23 [95% CI, -0.06 to 0.52]; estimate, 0.22 [95% CI, -0.06 to 0.50]. New neurological deficits up to day 120 after hospital discharge were not different between the groups: 15 (3,39%) in the standard group vs. 42 (5,49%) in the NIRS group; absolute difference, 2,10 [95% CI, -0,62 to 4,82]. There was no significant difference between groups for the median [IQR] hospital length of stay: 4.0 [4.0-6.0] in the standard group vs. 5.0 [4.0-6.0] in the NIRS group; mean difference, -0.11 [95% CI, -0.65 to 0.44]. The mortality rate on day 120 was not different between the standard group (0.68%) vs. the NIRS group (0.92%); absolute difference = 0.24% [95% CI, -0.94 to 1.41]. CONCLUSIONS: Among patients undergoing carotid endarterectomy, optimization of cerebral oxygenation based on rSO2 did not reduce the occurrence of cerebral ischemic lesions postoperatively compared with controlled hypertensive therapy. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01415648.

2.
Ann Vasc Surg ; 51: 225-233, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29772320

RESUMO

BACKGROUND: The optimization of medical treatment regularly challenges the role of carotid surgery for asymptomatic patients. Current research seeks to determine which of these patients will benefit most from surgery. The goal of this study was to identify in a multicenter study, using magnetic resonance imaging (MRI), the risk factors for postoperative silent cerebral ischemic lesions after carotid surgery for asymptomatic stenosis. METHODS: The multicenter, retrospective study included patients with asymptomatic severe carotid stenosis suitable for surgical treatment and who did not have a history of cerebral ischemia. A diffusion MRI scan was performed the day before and in the 3 days after the procedure. An analysis by an independent neuroradiologist determined the presence of preoperative silent ischemia and the appearance of new lesions postoperatively. The analysis also took into account the plaque type, lesions of supra-aortic trunks, the circle of Willis, the type of surgery, and anesthesia, shunt use, and clamp time. RESULTS: Between April 2011 and November 2015, 141 patients were included. The mean degree of carotid stenosis in the patients who underwent surgery was 78.2% ± 6.5, with 9 (6.4%) cases of contralateral stenosis ≥70% and 6 (4.3%) of which were thrombosis. The circle of Willis was incomplete in 23 (16.3%) patients. Twenty-one (14.9%) plaques were of high embolic risk. The preoperative MRI found 34 (24.1%) patients with embolic ischemic lesions. The majority of procedures were eversions performed under general anesthesia, 7 (5%) required a shunt, and the mean clamp time was 39 ± 16 min. The postoperative MRI revealed that 10 (7%) patients had a new ischemic lesion on the operated side. None of these lesions were symptomatic. On multivariate analysis, the risk factors for appearance of a new ischemic lesion on the operated side were significant severe stenosis of the vertebral artery ipsilateral to the lesion (odds ratio [OR] = 9.2, 95% confidence interval [CI] [2.1-39.8], P = 0.003) and insertion of a shunt (OR = 9.1, 95% CI [1.1-73.1], P = 0.039). The 30-day follow-up showed one death at D4 due to hemorrhagic stroke on the operated side and one contralateral stroke. None of the study patients had a myocardial infarction. CONCLUSIONS: In this multicenter study, the rate of silent ischemic lesions in asymptomatic carotid surgery showed 43.3% of preoperative silent ischemic lesions and 9.2% of new silent lesions after surgery. The use of a shunt and presence of ipsilateral vertebral stenosis are risk factors for perioperative embolism.


Assuntos
Infarto Encefálico/etiologia , Estenose das Carótidas/cirurgia , Endarterectomia das Carótidas/efeitos adversos , Idoso , Doenças Assintomáticas , Infarto Encefálico/diagnóstico por imagem , Infarto Encefálico/mortalidade , Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Distribuição de Qui-Quadrado , Imagem de Difusão por Ressonância Magnética , Endarterectomia das Carótidas/mortalidade , Feminino , França , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
3.
Asian Cardiovasc Thorac Ann ; 25(9): 608-617, 2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-29058970

RESUMO

Spinal cord complications including paraplegia and partial neurologic deficits remain a frequent problem during repair of descending thoracic or thoracoabdominal aortic aneurysms. Effective prevention of this dreaded complication is of paramount importance. Among the many adjuncts that have been proposed to prevent spinal cord complications, spinal fluid drainage is one that has been used by numerous teams. The aim of this review is to answer the following question: does spinal fluid drainage afford spinal cord protection during both open and endovascular repair of thoracic or thoracoabdominal aortic aneurysms?


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular , Drenagem/métodos , Procedimentos Endovasculares , Paraplegia/prevenção & controle , Isquemia do Cordão Espinal/prevenção & controle , Animais , Implante de Prótese Vascular/efeitos adversos , Pressão do Líquido Cefalorraquidiano , Drenagem/efeitos adversos , Procedimentos Endovasculares/efeitos adversos , Humanos , Paraplegia/líquido cefalorraquidiano , Paraplegia/etiologia , Paraplegia/fisiopatologia , Fatores de Risco , Isquemia do Cordão Espinal/líquido cefalorraquidiano , Isquemia do Cordão Espinal/etiologia , Isquemia do Cordão Espinal/fisiopatologia , Resultado do Tratamento
4.
Ann Vasc Surg ; 43: 258-264, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28300680

RESUMO

BACKGROUND: To report the prevalence of silent brain infarcts (SBI) at magnetic resonance imaging (MRI) before and after surgery for asymptomatic high grade carotid stenosis. METHODS: This is a single center retrospective observational study. Asymptomatic patients who underwent carotid endarterectomy between October 2012 and October 2014 were included. The preoperative assessment included a Doppler and a computed tomographic (CT) scan dating less than 3 months. A neurological examination was performed during the anesthesia consultation and in the 15 days before surgery. An MRI angiography was performed the day before and 3 days after surgery and was analyzed by an independent neuroradiologist. Preoperative analysis focused on the presence of ischemic events at MRI. The type of plaque, the supra aortic trunk lesions, and the quality of the circle of Willis were analyzed using Doppler and CT scanning. Postoperatively, we searched for signs of postoperative ischemic events at MRI. RESULTS: Forty-one patients were included (85.4% of men), and the mean age was 72.4 ± 8.3 years. We noted 7 (17.1%) contralateral stenoses (>50%) and 2 (4.9%) contralateral thromboses, 6 (14.6%) vertebral stenoses, and 7 (17.1%) abnormalities of the circle of Willis. The morphological analysis described 6 unstable plaques including 4 ulcerated, 1 pseudodissection, and 1 intraplaque hemorrhage. Preoperatively, we noted the presence of 21 (51.2%) ischemic lesions including 9 (21.9%) multiple lacunar ischemic events and 12 (29.3%) silent arterial territory infarcts. Eversion was performed for all patients except for 6 (14.6%), for whom a bypass was necessary. No deaths or major complications were observed in the 30 postoperative days. Postoperatively, MRI showed 3 (7.3%) asymptomatic recent ischemic strokes, 1 ipsilateral middle cerebral artery (MCA) stroke, and 2 contralateral (cerebellar and MCA) strokes. CONCLUSIONS: Patients with asymptomatic significant carotid stenosis show many preoperative SBI indicating a significant embolic risk. It is difficult to conclude about intraoperative embolic risk, but we hope that more data could demonstrate the importance of MRI for the preoperative evaluation of carotid plaques and brain parenchyma, to identify high-risk embolic patients.


Assuntos
Infarto Encefálico/diagnóstico por imagem , Estenose das Carótidas/cirurgia , Angiografia por Ressonância Magnética , Acidente Vascular Cerebral/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Doenças Assintomáticas , Infarto Encefálico/epidemiologia , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/epidemiologia , Feminino , França/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prevalência , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Índice de Gravidade de Doença , Acidente Vascular Cerebral/epidemiologia , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Transcraniana
5.
Anaesth Crit Care Pain Med ; 35(4): 249-53, 2016 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-26976123

RESUMO

INTRODUCTION: In order to evaluate whether cardiologists follow guidelines, we studied patients who were seen for a preoperative cardiologic consultation prior to surgery. METHODS: This retrospective study took place in two surgical units (Vascular and Orthopaedic) in two different university hospitals in 2013. The patient eligibility criteria were: planned elective surgery, cardiologic consultation prior to anaesthesiology consultation and lack of any unstable cardiac condition. The primary endpoint was determination of appropriate use of preoperative cardiac stress exams (CSE). RESULTS: The study included 238 patients who were seen by 131 different cardiologists. Of 238 patients, 60 had a CSE before surgery, but only 7/60 (12%) were deemed to be necessary. Seven out 15 (47%) patients with an indication for a CSE actually underwent said exam. Sixty-six percent of patients (156/238) had a resting trans-thoracic echocardiography before surgery, while only 27/156 (17%) were considered of appropriate use. Among patients with known coronary arterial disease, 59/73 (81%) received a statin, 60/73 (82%) received an antiplatelet agent, and 38/73 (52%) received a beta-blocker. Among patients with planned arterial surgery, 86/137 (63%) received a statin and 100/137 (73%) patients received an antiplatelet agent. Of the 159 consultation reports that were examined, only 5 (3%) mentioned the Lee score and 117 (74%) were concluded with "no contraindication" or a similar phrase. DISCUSSION: In this study, we found that guidelines were generally not used when cardiologists evaluated patients for non-cardiac surgery. This is evidenced by the number of inappropriate exams performed, the lack of true perioperative risk stratification, and incomplete optimization of long-term treatment regimens.


Assuntos
Cardiologistas , Fidelidade a Diretrizes/estatística & dados numéricos , Cuidados Pré-Operatórios/normas , Procedimentos Cirúrgicos Operatórios/métodos , Idoso , Idoso de 80 Anos ou mais , Anestesiologistas , Determinação de Ponto Final , Feminino , França , Cardiopatias/complicações , Cardiopatias/terapia , Testes de Função Cardíaca , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Ortopédicos/métodos , Cuidados Pré-Operatórios/estatística & dados numéricos , Encaminhamento e Consulta , Estudos Retrospectivos , Medição de Risco , Procedimentos Cirúrgicos Vasculares/métodos
6.
Anesthesiology ; 114(4): 796-806, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21336095

RESUMO

BACKGROUND: There is uncertainty regarding the prognostic value of troponin and creatine kinase muscle and brain isoenzyme measurements after noncardiac surgery. METHODS: The current study undertook a systematic review and meta-analysis. The study used six search strategies and included noncardiac surgery studies that provided data from a multivariable analysis assessing whether a postoperative troponin or creatine kinase muscle and brain isoenzyme measurement was an independent predictor of mortality or a major cardiovascular event. Independent investigators determined study eligibility and abstracted data in duplicate. RESULTS: Fourteen studies, enrolling 3,318 patients and 459 deaths, demonstrated that an increased troponin measurement after surgery was an independent predictor of mortality (odds ratio [OR] 3.4, 95% confidence interval [CI] 2.2-5.2), but there was substantial heterogeneity (I(2) = 56%). The independent prognostic capabilities of an increased troponin value after surgery in the 10 studies that assessed intermediate-term (≤ 12 months) mortality was an OR = 6.7 (95% CI 4.1-10.9, I(2) = 0%) and in the 4 studies that assessed long-term (more than 12 months) mortality was an OR = 1.8 (95% CI 1.4-2.3, I(2) = 0%; P < 0.001 for test of interaction). Four studies, including 1,165 patients and 202 deaths, demonstrated an independent association between an increased creatine kinase muscle and brain isoenzyme measurement after surgery and mortality (OR 2.5, 95% CI 1.5-4.0, I(2) = 4%). CONCLUSIONS: An increased troponin measurement after surgery is an independent predictor of mortality, particularly within the first year; limited data suggest an increased creatine kinase muscle and brain isoenzyme measurement also predicts subsequent mortality. Monitoring troponin measurements after noncardiac surgery may allow physicians to better risk stratify and manage their patients.


Assuntos
Creatina Quinase Forma MB/análise , Procedimentos Cirúrgicos Operatórios/mortalidade , Troponina/análise , Biomarcadores/análise , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/mortalidade , Humanos , Prognóstico
7.
Ann Vasc Surg ; 23(1): 60-6, 2009.
Artigo em Inglês | MEDLINE | ID: mdl-18809288

RESUMO

The purpose of this study was to present a single center's experience with elective treatment of descending thoracic aortic aneurysms (DTAAs) in the endovascular era. From July 1997 to May 2005, we operated on 173 patients for DTAA. A total of 52 patients (30.1%) underwent endovascular stent-graft repair (group I). Endovascular repair was carried out exclusively in high-surgical risk patients in whom preoperative spinal cord arteriography usually demonstrated that the origin of the Adamkiewicz artery was located outside the zone to be covered by the stent graft. The remaining 121 patients (69.9%) underwent open surgical repair (group II), with partial cardiopulmonary bypass in 78 cases (64.5%) and deep hypothermic circulatory arrest in 43 (35.5%). The two treatment groups differed significantly with regard to age, prevalence of chronic obstructive pulmonary disease, number of aneurysms involving the upper segment or full length of the descending thoracic aorta, and percentage of patients in whom spinal cord arteriography was either deemed unnecessary or demonstrated that the origin of the Adamkiewicz artery was located within the coverage zone. In-hospital mortality was 15.4% (8/52) in group I vs. 5.0% (6/121) in group II (p = 0.02). Five deaths after endovascular repair were due to technical causes. All neurological deficits due to spinal cord ischemia (9/121, 7.4%) including 3.3% of irreversible flaccid paraplegia occurred in group II (p = 0.04). The findings of this study show that open surgical repair achieves excellent results when high-risk surgical candidates are recommended for endovascular repair. However, since preoperative spinal cord arteriography was a selection criterion for endovascular repair, the improvement in mortality was accompanied by a concentration of spinal cord ischemic complications in the patients having open surgical repair. The high mortality associated with endovascular repair in our series should decrease as deployment skill and endovascular technology improve.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Implante de Prótese Vascular/métodos , Medula Espinal/irrigação sanguínea , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/diagnóstico por imagem , Aneurisma da Aorta Torácica/mortalidade , Aortografia/métodos , Prótese Vascular , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/instrumentação , Implante de Prótese Vascular/mortalidade , Ponte Cardiopulmonar , Criança , Parada Circulatória Induzida por Hipotermia Profunda , Procedimentos Cirúrgicos Eletivos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Paraplegia/etiologia , Estudos Retrospectivos , Isquemia do Cordão Espinal/etiologia , Stents , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento , Adulto Jovem
8.
Ann Vasc Surg ; 22(6): 822-8, 2008 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-18992667

RESUMO

Our purpose was to identify preoperative and intraoperative predictors of early mortality, spinal cord injury, or acute intestinal ischemia after repair of type IV thoracoabdominal aneurysm (TAA IV) as a basis for optimizing surgical indications and techniques. From January 1991 to June 2006 we operated on 171 patients for TAA IV. There were 149 men (87.1%) and 22 women (12.9%), with a mean age of 65.0 +/- 10.9 years (range 23-82). The underlying etiology was degenerative aneurysmal disease in 143 patients (83.6%). Twenty-two patients (12.8%) underwent emergent operation. Comorbidity included coronary disease in 72 patients (45.6%) including 39 who had undergone a revascularization procedure, arterial hypertension in 121 (70.1%), chronic obstructive pulmonary disease in 81 (47.4%), and chronic kidney insufficiency in 58 (33.9%). Seventy-six patients (44.4%) presented concurrent lesions involving at least one visceral artery. Spinal cord arteriography was performed in 91 patients (53.2%). In 25 cases (27.5%) arteriographic findings demonstrated the need for revascularization of the Adamkiewicz artery due to location of the ostium at or below the T12 level. Repair was carried out with cross-clamping only in 160 cases (93.6%). Partial cardiopulmonary bypass was used in 11 patients (6.4%). A total of 23 patients (13.4%) died postoperatively. The cause of death was acute intestinal ischemia in nine cases, multiple organ failure in seven, coagulation disorder in three, cardiac complications in two, and stroke in two. Spinal cord injury occurred in eight patients (4.7%) including two who died. According to univariate analysis, the significant predictors of early death were age over 70 years, degenerative aneurysmal disease, coronary artery disease, chronic renal insufficiency or visceral artery lesions, operator, duration of intestinal ischemia and use of a "complex" surgical technique. Although the only significant predictor of spinal cord injury was duration of digestive ischemia, an almost significant trend (p < 0.1) was observed for coronary artery disease, coronary bypass, and renal insufficiency. The significant predictors of acute intestinal ischemia were kidney insufficiency and visceral artery lesions, but coronary artery disease and previous coronary bypass were almost significant (p = 0.06). Frequent association of TAA IV with arteriosclerotic disease in elderly patients presenting coronary artery disease and chronic kidney insufficiency partly explains why early postoperative mortality remains high. The incidence of spinal cord injury suggests that preoperative spinal cord arteriography is mandatory for prevention. The frequency of intestinal ischemia is more problematic, but a better understanding of the underlying mechanism should enable development of preventive strategies.


Assuntos
Aneurisma da Aorta Torácica/cirurgia , Intestinos/irrigação sanguínea , Isquemia/etiologia , Traumatismos da Medula Espinal/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Doença Aguda , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Aneurisma da Aorta Torácica/mortalidade , Arteriosclerose/complicações , Competência Clínica , Doença da Artéria Coronariana/complicações , Feminino , Humanos , Isquemia/mortalidade , Masculino , Pessoa de Meia-Idade , Insuficiência Renal Crônica/complicações , Fatores de Risco , Traumatismos da Medula Espinal/mortalidade , Fatores de Tempo , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/mortalidade , Adulto Jovem
10.
Anesth Analg ; 104(6): 1326-33, table of contents, 2007 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-17513620

RESUMO

BACKGROUND: Statins reduce cardiac morbidity in nonsurgical populations, and may benefit surgical patients. We sought to examine cardiac outcome in patients who continued, compared with those who discontinued, statin therapy after major vascular surgery. METHODS: Prospectively collected data were examined for an association between statin therapy and perioperative cardiac morbidity in patients undergoing infrarenal aortic surgery. Between January 2001 and December 2003, there were no guidelines for perioperative continuation of statins (discontinuation group, n = 491). From January 2004, guidelines were instituted whereby statin therapy was continued starting as soon as possible after surgery (continuation group, n = 178). The occurrence of cardiac myonecrosis (defined as an increase of cardiac troponin I more than the 99th percentile or 0.2 ng/mL) was analyzed. Intra-cohort (propensity score) and extra-cohort (Lee score) adjustments of the risk were performed. RESULTS: The median delay between surgery and resumption of statin therapy was 4 days and 1 day in the discontinuation and continuation groups (P < 0.001), respectively. Using propensity score matching for likelihood of preoperative treatment, the odds ratio associated with chronic statin treatment to predict myonecrosis for patients with versus without early postoperative statin resumption (continuation versus discontinuation groups) was 0.38 and 2.1 (relative risk reduction of 5.4; 95% confidence interval: 1.2-25.3, P < 0.001), respectively. The odds ratio after adjustment for the Lee score was 0.38 in the continuation group and 2.1 in the discontinuation group (relative reduction of 5.5; 95% confidence interval: 1.2-26.0, P < 0.001). Postoperative statin withdrawal (>4 days) was an independent predictor of postoperative myonecrosis (OR 2.9, 95% confidence interval 1.6-5.5). CONCLUSIONS: Discontinuation of statin therapy after major vascular surgery is associated with an increased postoperative cardiac risk, suggesting that statin therapy should be resumed early after major vascular surgery.


Assuntos
Doenças Cardiovasculares/epidemiologia , Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Cuidados Pós-Operatórios , Procedimentos Cirúrgicos Vasculares , Idoso , Doenças Cardiovasculares/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cuidados Pós-Operatórios/métodos , Período Pós-Operatório , Estudos Prospectivos , Fatores de Risco , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/efeitos adversos
12.
Anesthesiology ; 102(5): 885-91, 2005 May.
Artigo em Inglês | MEDLINE | ID: mdl-15851872

RESUMO

BACKGROUND: Although postoperative myocardial infarction (PMI) after vascular surgery has been described to be associated with prolonged ischemia, its exact pathophysiology remains unclear. METHODS: The authors used intense cardiac troponin I (cTnI) surveillance after abdominal aortic surgery in 1,136 consecutive patients to better evaluate the incidence and timing of PMI (cTnI > or = 1.5 ng/ml) or myocardial damage (abnormal cTnI < 1.5 ng/ml). RESULTS: Abnormal cTnI concentrations was noted in 163 patients (14%), of which 106 (9%) had myocardial damage and 57 (5%) had PMI. In 34 patients (3%), PMI was preceded by a prolonged (> 24 h) period of increased cTnI (delayed PMI), and in 21 patients (2%), the increase in cTnI lasted less than 24 h (early PMI). The mean times from end of surgery to PMI were 37 +/- 22 and 74 +/- 39 h in the early PMI and delayed PMI groups, respectively (P < 0.001). The mean time between the first abnormal cTnI and PMI in the delayed PMI group was 54 +/- 35 h, during which the cTnI profiles of the myocardial damage and delayed PMI groups were identical. In-hospital mortality rates were 24, 21, 7, and 3% for the early PMI, delayed PMI, myocardial damage, and normal groups, respectively. CONCLUSIONS: Intense postoperative cTnI surveillance revealed two types of PMI according to time of appearance and rate of increase in cTnI. The identification of early and delayed PMI may be suggestive of different pathophysiologic mechanisms. Abnormal but low postoperative cTnI is associated with increased mortality and may lead to delayed PMI.


Assuntos
Aorta Abdominal/cirurgia , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Fatores Etários , Idoso , Biomarcadores , Estudos de Coortes , Feminino , Humanos , Masculino , Monitorização Fisiológica , Infarto do Miocárdio/sangue , Infarto do Miocárdio/epidemiologia , Miocárdio/metabolismo , Miocárdio/patologia , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/epidemiologia , Medição de Risco , Fatores de Tempo , Troponina I/sangue , Troponina I/metabolismo
13.
Anesthesiology ; 102(4): 739-46, 2005 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-15791102

RESUMO

BACKGROUND: Percutaneous coronary intervention (PCI) is performed in patients with coronary artery disease who are undergoing major noncardiac procedures to reduce perioperative cardiac morbidity and mortality. However, the impact of this approach on postoperative outcome remains controversial. METHODS: The authors analyzed a cohort of 1,152 patients after abdominal aortic surgery in which 78 patients underwent PCI. A propensity score analysis was performed. Also, using a logistic regression model, the authors determined variables associated with a severe postoperative coronary event or a death in patients without PCI. Then, in patients with PCI, they compared the expected and observed outcome. RESULTS: Five variables (age > 75 yr, blood transfusion > 3 units, repeated surgery, preoperative hemodialysis, and previous cardiac failure) independently predicted (with 94% correctly classified) a severe postoperative coronary event, and five variables (age > 75 yr, repeated surgery, previously abnormal ST segment/T waves, previous hypertension, and previous cardiac failure) independently predicted (with 97% correctly classified) postoperative death. In the PCI group, the observed percentages of patients with a severe postoperative coronary event (9.0% [95% confidence interval, 4.4-17.4]) or death (5.1% [95% confidence interval, 2.0-12.5]) were not significantly different from the expected percentages (8.2 and 6.9%, respectively). When all patients were pooled together, the odds ratios of PCI were not significant. The propensity score analysis provided a similar conclusion. CONCLUSION: PCI did not seem to limit significantly cardiac risk or death after aortic surgery.


Assuntos
Angioplastia com Balão , Procedimentos Cirúrgicos Cardíacos , Cuidados Pré-Operatórios , Idoso , Algoritmos , Anestesia , Cardiomiopatias/epidemiologia , Cardiomiopatias/etiologia , Morte , Determinação de Ponto Final , Feminino , Humanos , Modelos Logísticos , Masculino , Modelos Estatísticos , Medição da Dor/efeitos dos fármacos , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/epidemiologia , Risco Ajustado , Tamanho da Amostra , Resultado do Tratamento
14.
Anesth Analg ; 97(1): 2-12, table of contents, 2003 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12818934

RESUMO

UNLABELLED: Major surgery evokes a stress response that can produce deleterious consequences, especially in a population at high risk for those complications. We tested the hypothesis that decreasing or eliminating one of the sources of stress by providing intense analgesia in the immediate postoperative period via application of neuraxial opioids would decrease major nonsurgical complications. Two-hundred-seventeen patients scheduled to undergo abdominal aortic surgery were randomly allocated to receive either general anesthesia alone (control) or general anesthesia combined with intrathecal opioid (1 micro g/kg sufentanil with 8 micro g/kg preservative-free morphine injected at the L4-5 interspace). Postoperative care was identical in the two groups, including patient-controlled analgesia. Each patient provided an assessment of postoperative pain using a visual analog scale. Postopera-tive complications were recorded according to criteria established a priori. The administration of intrathecal opioid provided more intense analgesia than patient-controlled analgesia during the first 24 h postoperatively (P < 0.05). There was no difference between groups for the incidence of combined major cardiovascular, respiratory, and renal complications (P > 0.05) or mortality (P > 0.05). The incidence of myocardial damage or infarction, as defined by abnormal plasma concentration of troponin I, did not differ between the two groups (P > 0.05). In patients undergoing major abdominal vascular surgery, decrease of one contributor to postoperative stress, by provision of intense analgesia for the intraoperative and initial postoperative period, via application of neuraxial opioid, does not alter the combined major cardiovascular, respiratory, and renal complication rate. IMPLICATIONS: Provision of intense analgesia for the initial postoperative period after major abdominal vascular surgery, via the administration of neuraxial opioid, does not alter the combined incidence of major cardiovascular, respiratory, and renal complications.


Assuntos
Analgésicos Opioides/uso terapêutico , Aorta Abdominal/cirurgia , Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/etiologia , Nefropatias/epidemiologia , Nefropatias/etiologia , Complicações Pós-Operatórias/epidemiologia , Doenças Respiratórias/epidemiologia , Doenças Respiratórias/etiologia , Procedimentos Cirúrgicos Vasculares/efeitos adversos , Idoso , Analgésicos Opioides/administração & dosagem , Gasometria , Método Duplo-Cego , Eletrocardiografia/efeitos dos fármacos , Feminino , Humanos , Injeções Intravenosas , Injeções Espinhais , Masculino , Pessoa de Meia-Idade , Neurônios Aferentes/efeitos dos fármacos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/epidemiologia , Cuidados Pós-Operatórios , Complicações Pós-Operatórias/etiologia , Estudos Prospectivos , Resultado do Tratamento
16.
Anesthesiology ; 98(6): 1338-44, 2003 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-12766641

RESUMO

BACKGROUND: Terlipressin, a precursor that is metabolized to lysine-vasopressin, has been proposed as a drug for treatment of intraoperative arterial hypotension refractory to ephedrine in patients who have received long-term treatment with renin-angiotensin system inhibitors. The authors compared the effectiveness of terlipressin and norepinephrine to correct hypotension in these patients. METHODS: Among 42 patients scheduled for elective carotid endarterectomy, 20 had arterial hypotension following general anesthesia that was refractory to ephedrine. These patients were the basis of the study. After randomization, they received either 1 mg intravenous terlipressin (n = 10) or norepinephrine infusion (n = 10). Beat-by-beat recordings of systolic arterial blood pressure and heart rate were stored on a computer. The intraoperative maximum and minimum values of blood pressure and heart rate, and the time spent with systolic arterial blood pressure below 90 mmHg and above 160 mmHg, were used as indices of hemodynamic stability. Data are expressed as median (95% confidence interval). RESULTS: Terlipressin and norepinephrine corrected arterial hypotension in all cases. However, time spent with systolic arterial blood pressure below 90 mmHg was less in the terlipressin group (0 s [0-120 s] vs. 510 s [120-1011 s]; P < 0.001). Nonresponse to treatment (defined as three boluses of terlipressin or three changes in norepinephrine infusion) occurred in zero and eight cases (P < 0.05), respectively. CONCLUSIONS: In patients who received long-term treatment with renin-angiotensin system inhibitors, intraoperative refractory arterial hypotension was corrected with both terlipressin and norepinephrine. However, terlipressin was more rapidly effective for maintaining normal systolic arterial blood pressure during general anesthesia.


Assuntos
Anestesia Geral , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Anti-Hipertensivos/uso terapêutico , Hipotensão/tratamento farmacológico , Lipressina/análogos & derivados , Lipressina/uso terapêutico , Norepinefrina/uso terapêutico , Complicações Pós-Operatórias/tratamento farmacológico , Vasoconstritores/uso terapêutico , Idoso , Angiotensina II , Antagonistas de Receptores de Angiotensina , Pressão Sanguínea/efeitos dos fármacos , Eletrocardiografia , Endarterectomia das Carótidas , Feminino , Frequência Cardíaca/efeitos dos fármacos , Humanos , Hipotensão/etiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Terlipressina
18.
Anesth Analg ; 96(1): 33-8, table of contents, 2003 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-12505919

RESUMO

UNLABELLED: Remifentanil is a potent ultra-short-acting opioid, which permits rapid emergence. However, remifentanil is expensive and may have detrimental effects on hemodynamics in case of overdose. Target-controlled infusion (TCI) permits adapting infusion to pharmacokinetic models. In this prospective randomized study, we compared intra- and postoperative hemodynamics, remifentanil requirement during anesthesia, and postoperative morphine requirement in patients scheduled for carotid surgery, and receiving either continuous IV weight-adjusted infusion of remifentanil (RIVA) or TCI for remifentanil (TCIR). Forty-six patients were enrolled in this study: all were anesthetized by using TCI for propofol. Twenty-three received RIVA (0.5 micro g. kg(-1) x min(-1)) for the induction of anesthesia and endotracheal intubation, with the infusion rate decreased to 0.25 micro g x kg(-1) x min(-1) after intubation, then adapted by step of 0.05 micro g x kg(-1) x min(-1) according to hemodynamics. Twenty-three patients received TCIR (Minto model, Rugloop), with an effect-site concentration at 4 ng/mL during induction, then adapted by step of 1 ng/mL according to hemodynamics. All patients received atracurium and a 50% mixture of N(2)O/O(2). Hemodynamic variables were recorded each minute. The number and duration of hemodynamic events were collected, and total doses of anesthetics (remifentanil and propofol) and vasoactive drugs were noted in both groups of patients. Data were analyzed by using unpaired t-tests. RIVA was significantly associated with more frequent episodes of intraoperative hypotension (16 versus 6, P < 0.001) and more frequent episodes of postoperative hypertension and/or tachycardia requiring more frequent administration of beta-adrenergic blockers (16 vs 10, P < 0.04) in comparison with TCIR. The need for morphine titration was not significantly different between groups. TCIR led to a significantly smaller requirement of remifentanil (700 +/- 290 versus 1390 +/- 555 micro g, P < 0.001) without difference in propofol requirement. This prospective randomized study demonstrated that, during carotid endarterectomy, in comparison with patients receiving remifentanil using continuous RIVA, TCI results in less hypotensive episodes during the induction of anesthesia, in fewer episodes of tachycardia and/or hypertension and a smaller beta-adrenergic blocker requirement during recovery, and a decrease in remifentanil requirement. Recommendations to prefer TCI for remifentanil administration during carotid endarterectomy may be justified. IMPLICATIONS: Remifentanil for intraoperative analgesia in carotid artery surgery is associated with a better stability in perioperative hemodynamics when administered in target-controlled infusion compared with continuous weight-adjusted infusion. This may be related to a smaller requirement of this drug when using target-controlled infusion, as well as a smooth mode of administration.


Assuntos
Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Hemodinâmica/efeitos dos fármacos , Piperidinas/administração & dosagem , Piperidinas/uso terapêutico , Procedimentos Cirúrgicos Vasculares , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Analgésicos Opioides/efeitos adversos , Anestesia Geral , Endarterectomia das Carótidas , Determinação de Ponto Final , Feminino , Humanos , Hipotensão/induzido quimicamente , Hipotensão/epidemiologia , Infusões Intravenosas , Masculino , Monitorização Intraoperatória , Dor Pós-Operatória/tratamento farmacológico , Piperidinas/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Remifentanil
19.
Ann Vasc Surg ; 16(6): 679-84, 2002 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-12404045

RESUMO

From January 1, 1995 to July 31, 2000, a total of 133 patients underwent elective surgical treatment for degenerative aneurysm of the descending thoracic (n = 45) or thoracoabdominal (n = 88) aorta. There were 116 men (87%) and 17 women (13%) with a mean age of 66.4 +/- 8.7 years (range, 39 to 84 years). Sixteen patients (12%) died in the immediate postoperative period. Thirteen patients (10%) had already undergone myocardial revascularizaton. Thirty-five patients (26%) presented clinical symptoms of coronary artery disease. Preoperative coronary arteriography was performed in 84 (63%) patients, demonstrating normal findings or clinically insignificant lesions in 48 patients (57%), single-vessel lesions (>70% reduction in diameter) in 19 patients, two-vessel lesions in 12 patients, and three-vessel lesions in 5 patients. On the basis of these findings, myocardial revascularization was performed before aortic repair in 11 patients. The total number of myocardial revascularization procedures in this series was 24 (18%). Four patients had previously undergone a total of 6 carotid endarterectomy procedures. Routine duplex ultrasound demonstrated significant carotid artery lesions in 12 patients (9%). Ten of these patients (8%) underwent carotid endarterectomy. The total number of carotid endarterectomy procedures in this series was 16 in 14 patients. The prevalence of coronary and carotid lesions in patients indicated for elective treatment for degenerative aneurysm of the descending thoracic or thoracoabdominal aorta was similar to that observed in patients presenting degenerative aneurysm of the infrarenal abdominal aorta. Univariate analysis demonstrated that coronary and carotid lesions with or without treatment are a significant risk factor for mortality following surgical repair of degenerative aneurysm of the descending thoracic or thoracoabdominal aorta. This finding suggests that routine preoperative coronary arteriography and duplex ultrasound are warranted.


Assuntos
Aorta Torácica/patologia , Aneurisma da Aorta Abdominal/complicações , Aneurisma da Aorta Torácica/complicações , Doenças das Artérias Carótidas/complicações , Doença da Artéria Coronariana/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Aorta Torácica/cirurgia , Aneurisma da Aorta Abdominal/epidemiologia , Aneurisma da Aorta Abdominal/cirurgia , Aneurisma da Aorta Torácica/epidemiologia , Aneurisma da Aorta Torácica/cirurgia , Doenças das Artérias Carótidas/epidemiologia , Doenças das Artérias Carótidas/cirurgia , Artéria Carótida Primitiva/diagnóstico por imagem , Artéria Carótida Primitiva/cirurgia , Angiografia Coronária , Doença da Artéria Coronariana/epidemiologia , Doença da Artéria Coronariana/cirurgia , Ecocardiografia , Procedimentos Cirúrgicos Eletivos/mortalidade , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica/mortalidade , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Valor Preditivo dos Testes , Prevalência , Reoperação , Análise de Sobrevida , Resultado do Tratamento
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