Brazilian Journal of Anesthesiology最新文献

Background

There is no consensus on the most effective strategy for Postoperative Pulmonary Complication (PPC) reduction. This study hypothesized that a Goal-Directed Fluid Therapy (GDFT) protocol of infusion of predetermined boluses reduces the occurrence of PPC in patients undergoing elective open abdominal surgeries when compared with Standard of Care (SOC) strategy.

Methods

Randomized, prospective, controlled study, conducted from May 2012 to December 2014, with ASA I, II or III patients undergoing open abdominal surgeries, lasting at least 120 min, under general anesthesia, randomized into the SOC and the GDFT group. In the SOC, fluid administration was according to the anesthesiologist's discretion. In the GDFT, the intervention protocol, based on bolus infusion according to blood pressure and delta pulse pressure, was applied. Patients were postoperatively evaluated by an anesthesiologist blinded to the group allocation regarding PPC incidence, mortality, and Length of Hospital Stay (LOHS).

Results

Forty-two patients in the SOC group and 43 in the GDFT group. Nineteen patients (45%) in the SOC and 6 in the GDFT (14%) had at least one PPC (p = 0.003). There was no difference in mortality or LOHS between the groups. Among the patients with PPC, four died (25%), compared to two deaths in patients without PPC (3%) (p = 0.001). The LOHS had a median of 14.5 days in the group with PPC and 9 days in the group without PPC (p = 0.001).

Conclusion

The GDFT protocol resulted in a lower rate of PPC; however, the LOHS and mortality did not reduce.

Background

Myelomeningocele (MMC) is a neural tube defect disease. Antenatal repair of fetal MMC is an alternative to postnatal repair. Many agents can be used as tocolytics during the in utero fetal repair such as β2-agonists and oxytocin receptor antagonists, with possible maternal and fetal repercussions. This study aims to compare maternal arterial blood gas analysis between terbutaline or atosiban, as tocolytic agents, during intrauterine MMC repair.

Methods

Retrospective cohort study. Patients were divided into two groups depending on the main tocolytic agent used during intrauterine MMC repair: atosiban (16) or terbutaline (9). Maternal arterial blood gas samples were analyzed on three moments: post induction (baseline, before the start of tocolysis), before extubation, and two hours after the end of the surgery.

Results

Twenty-five patients were included and assessed. Before extubation, the terbutaline group showed lower arterial pH (7.347 ± 0.05 vs. 7.396 ± 0.02 for atosiban, p = 0.006) and higher arterial lactate (28.33 ± 12.76 mg.dL⁻¹ vs. 13.06 ± 6.35 mg.dL⁻¹, for atosiban, p = 0.001) levels.

Conclusions

Patients who received terbutaline had more acidosis and higher levels of lactate, compared to those who received atosiban, during intrauterine fetal MMC repair.

Introduction

This study aimed to assess the learning curves of peribulbar anesthesia and estimate the number of blocks needed to attain proficiency.

Methods

Anonymized records of sequential peribulbar blocks performed by first-year anesthesia residents were analyzed. The block sequential number and the outcomes were extracted from each record. Success was defined as a complete sensory and motor block of the eye, and failure was defined as an incomplete block requiring supplemental local anesthetic injections or general anesthesia. Learning curves using the LC-CUSUM method were constructed, aiming for acceptable and unacceptable failure rates of 10% and 20%, and 10% probability of type I and II errors. Simulations were used to determine the proficiency limit h₀. Residents whose curves reached h₀ were considered proficient. The Sequential Probability Ratio Test Cumulative Sum Method (SPRT-CUSUM) was used for follow-up.

Results

Thirty-nine residents performed 2076 blocks (median = 52 blocks per resident; Interquartile Range (IQR) [range] = 27–78 [4–132]). Thirty residents (77%) achieved proficiency after a median of 13 blocks (13–24 [13–24]).

Conclusions

The LC-CUSUM is a robust method for detecting resident proficiency at peribulbar anesthesia, defined as success rates exceeding 90%. Accordingly, 13 to 24 supervised double-injection peribulbar blocks are needed to attain competence at peribulbar anesthesia.

Background

Anemia is common in the preoperative setting and associated with increased postoperative complications and mortality. However, it is unclear if preoperative anemia optimization reduces postoperative complications. We aimed to assess the association between preoperative anemia optimization and a composite endpoint of major cardiovascular, renal, and pulmonary complications and all-cause mortality within 30 days after noncardiac surgery in adult patients.

Methods

In this retrospective analysis preoperative anemia was defined as hemoglobin concentration below 12.0 g.dl⁻¹ in women and 13.0 g.dl⁻¹ in men within 6 months before surgery. A propensity score-based generalized estimating equation analysis was used to determine the association between preoperative anemia optimization and the primary outcome. Moreover, mediation analysis was conducted to investigate whether intraoperative red blood cell transfusion or duration of intraoperative hypotension were mediators of the relation between anemia optimization and the primary outcome.

Results

Fifty-seven hundred anemia optimized, and 8721 non-optimized patients met study criteria. The proportion of patients having any component of the composite of major complications and all-cause mortality was 21.5% in the anemia-optimized versus 18.0% in the non-optimized, with confounder-adjusted odds ratio estimate of 0.99 (95% CI 0.86‒1.15) for anemia optimization versus non-optimization, p = 0.90. Intraoperative red blood cell transfusion had a minor mediation effect on the relationship between preoperative anemia optimization and the primary outcome, whereas duration of intraoperative hypotension was not found to be a mediator.

Conclusion

Preoperative anemia optimization did not appear to be associated with a composite outcome of major in-hospital postoperative cardiovascular, renal, and pulmonary complications and all-cause in-hospital mortality.

Background

The costoclavicular approach to brachial plexus block may have a more favorable anatomy than the classic infraclavicular approach. However, there are conflicting results in the literature regarding the comparative effectiveness of these two techniques.

Methods

We systematically searched for Randomized Controlled Trials (RCTs) comparing costoclavicular with infraclavicular brachial plexus blocks for upper extremity surgeries on MEDLINE, EMBASE, and Ovid. The outcomes of interest were sensory and motor block onset times, performance times, block failure, and complication rate. We performed statistical analyses using RevMan 5.4 and assessed heterogeneity using the Cochran Q test and I² statistics. We appraised the risk of bias according to Cochrane's Risk of Bias 2 tool.

Results

We included 5 RCTs and 374 patients, of whom 189 (50.5%) were randomized to undergo costoclavicular block. We found no statistically significant differences between the two techniques regarding sensory block onset time in minutes (Mean Difference [MD = -0.39 min]; 95% CI -2.46 to 1.68 min; p = 0.71); motor block onset time in minutes (MD = -0.34 min; 95% CI -0.90 to 0.22 min; p = 0.23); performance time in minutes (MD = -0.12 min; 95% CI -0.89 to 0.64 min; p = 0.75); incidence of block failure (RR = 1.59; 95% CI 0.63 to 3.39; p = 0.63); and incidence of complications (RR = 0.60; 95% CI 0.20 to 1.84; p = 0.37).

Conclusion

This meta-analysis suggests that the CCV block may exhibit similar sensory and motor onset times when compared to the classic ICV approach in adults undergoing distal upper extremity surgery, with comparable rates of block failure and complications.

Perioperative Goal-Directed Therapy (PGDT) has significantly showed to decrease complications and risk of death in high-risk patients according to numerous meta-analyses. The main goal of PGDT is to individualize the therapy with fluids, inotropes, and vasopressors, during and after surgery, according to patients’ needs in order to prevent organic dysfunction development. In this opinion paper we aimed to focus a discussion on possible alternatives to invasive hemodynamic monitoring in low resource settings.

Introduction

Methylene Blue (MB) has been shown to attenuate oxidative, inflammatory, myocardial, and neurological lesions during ischemia-reperfusion and has great potential during cardiac arrest. This study aimed to determine the effects of MB combined with epinephrine during cardiac arrest on myocardial and cerebral lesions.

Method

Thirty-eight male Wistar rats were randomly assigned to four groups: the sham group (SH, n = 5), and three groups subjected to cardiac arrest (n = 11/group) and treated with EPI 20 µg.kg⁻¹ (EPI), EPI 20 µg.kg⁻¹ + MB 2 mg.kg⁻¹ (EPI + MB), or saline 0.9% 0.2 ml (CTL). Ventricular fibrillation was induced by direct electrical stimulation in the right ventricle for 3 minutes, and anoxia was maintained for 5 minutes. Cardiopulmonary Resuscitation (CPR) consisted of medications, ventilation, chest compressions, and defibrillation. After returning to spontaneous circulation, animals were observed for four hours. Blood gas, troponin, oxidative stress, histology, and TUNEL staining measurements were analyzed. Groups were compared using generalized estimating equations.

Results

No differences in the Returning of Spontaneous Circulation (ROSC) rate were observed among the groups (EPI: 63%, EPI + MB: 45%, CTL: 40%, p = 0.672). The mean arterial pressure immediately after ROSC was higher in the EPI+MB group than in the CTRL group (CTL: 30.5 [5.8], EPI: 63 [25.5], EPI+MB: 123 [31] mmHg, p = 0.007). Serum troponin levels were high in the CTL group (CTL: 130.1 [333.8], EPI: 3.70 [36.0], EPI + MB: 43.7 [116.31] ng/mL, p < 0.05).

Conclusion

The coadministration of MB and epinephrine failed to yield enhancements in cardiac or brain lesions in a rodent model of cardiac arrest.

Background

The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours.

Methods

In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness.

Results

We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores.

Conclusions

Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.