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(1) Background: The Hypotension Prediction Index (HPI) is an algorithm that predicts hypotension, defined as mean arterial pressure (MAP) less than 65 mmHg for at least 1 min, based on arterial waveform features. We tested the hypothesis that the use of this index reduces the duration and severity of hypotension during noncardiac surgery. (2) Methods: We enrolled adults having moderate- or high-risk noncardiac surgery with invasive arterial pressure monitoring. Participating patients were randomized 1:1 to standard of care or hemodynamic management with HPI guidance with a goal directed hemodynamic treatment protocol. The trigger to initiate treatment (with fluids, vasopressors, or inotropes) was a value of HPI of 85 (range, 0-100) or higher in the intervention group. Primary outcome was the amount of hypotension, defined as time-weighted average (TWA) MAP less than 65 mmHg. Secondary outcomes were time spent in hypertension defined as MAP more than 100 mmHg for at least 1 min; medication and fluids administered and postoperative complications. (3) Results: We obtained data from 99 patients. The median (IQR) TWA of hypotension was 0.16 mmHg (IQR, 0.01-0.32 mmHg) in the intervention group versus 0.50 mmHg (IQR, 0.11-0.97 mmHg) in the control group, for a median difference of -0.28 (95% CI, -0.48 to -0.09 mmHg; p = 0.0003). We also observed an increase in hypertension in the intervention group as well as a higher weight-adjusted administration of phenylephrine in the intervention group. (4) Conclusions: In this single-center prospective study of patients undergoing elective noncardiac surgery, the use of this prediction model resulted in less intraoperative hypotension compared with standard care. An increase in the time spent in hypertension in the treatment group was also observed, probably as a result of overtreatment. This should provide an insight for refining the use of this prediction index in future studies to avoid excessive correction of blood pressure.
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BACKGROUND AND AIMS: Patient-controlled analgesia (PCA) with morphine is commonly used to provide analgesia following major surgery, but is not sufficient as a monotherapy strategy. This study aimed to compare the adjunctive analgesic effect of ketamine versus tramadol on postoperative analgesia provided via PCA-morphine in patients undergoing major upper abdominal surgeries. METHODS: Forty-two patients undergoing elective major upper abdominal surgery under general anesthesia were allocated to receive either ketamine (load dose of 0.5 mg kg-1 followed by a continuous infusion of 0.12 mg kg-1 h-1 up to 48 postoperative hours; ketamine group, n = 21) or tramadol (load dose of 1 mg kg-1 followed by a continuous infusion of 0.2 mg kg-1 h-1 up to 48 postoperative hours; tramadol group, n = 21) in addition to their standard postoperative analgesia with PCA-morphine. Postoperative data included morphine consumption, visual analog scale (VAS) scores, and side effects during the first 48 postoperative hours after PCA-morphine initiation. RESULTS: There were no significant differences in patient demographic and intraoperative data between the two groups. Tramadol group had significantly less total morphine consumption during the first 48 postoperative hours (28.905 [16.504] vs 54.524 [20.846] mg [p < 0.001]) and presented significantly lower VAS scores at rest and mobilization (p < 0.05) than the ketamine group. No statistical difference was recorded between the two groups (p > 0.05) regarding postoperative cough, sedation, hallucinations, pruritus, urine retention, and postoperative nausea and vomiting. However, patients in the ketamine group reported dry mouth more frequently than patients in the tramadol group (p = 0.032). CONCLUSIONS: Postoperative administration of tramadol was superior to ketamine due to significantly reduced opioid consumption and better pain scores in patients receiving PCA-morphine after major upper abdominal surgery.
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BACKGROUND AND AIMS: There is evidence that sugammadex can encapsulate other substances except rocuronium, such as dexamethasone. The aim of this study was to investigate the possible clinical interaction between dexamethasone and sugammadex, in patients undergoing laparoscopic cholecystectomy. MATERIAL AND METHODS: This was a randomized, double-blind controlled trial, performed in patients aged 18-75 years, American Society of Anesthesiologists (ASA) I-III, who underwent a laparoscopic cholecystectomy under deep neuromuscular blockade with rocuronium. Patients received 5 mg of dexamethasone or placebo (N/S 0.9%) during induction of anesthesia. Sugammadex 4 mg/kg was administered at the end of surgery at post-tetanic count 1-2. The outcome measures assessed were the time from sugammadex administration until train-of-four (TOF) 0.9, and until patient's extubation, postoperative pain (measured by numeric rating scale 0-10), nausea and vomiting, as well as rescue analgesics and antiemetics required during the first 24 hours postoperatively. The total dose of rocuronium required in both groups was also recorded. RESULTS: Overall, 44 patients were studied. No difference was detected regarding the demographic and surgical characteristics of patients. The time from sugammadex administration until TOF 0.9 and until patients' extubation did not differ significantly between the groups (P = 0.21 and 0.17). Operating conditions, pain scores, nausea/vomiting, and rescue analgesics and antiemetics during the first 24 hours postoperatively, did not differ between the groups. The total dose of rocuronium, however, was significantly more in patients who received dexamethasone (P = 0.01). CONCLUSION: No significant clinical interaction was revealed between dexamethasone and sugammadex during reversal of deep neuromuscular blockade in patients undergoing laparoscopic cholecystectomy.
