Pub Date : 2025-03-01DOI: 10.1016/j.bjane.2025.844603
João Victor Galvão Barelli , David D. Araujo , Suely P. Zeferino , Gustavo M. Dantas , Filomena B. Galas
Background
This study aimed to evaluate the effects of the inhalational anesthetic sevoflurane on postoperative myocardial injury and renal function in children under 2 years old with congenital heart disease (RACHS 1, 2, and 3) undergoing cardiac surgery with extracorporeal circulation.
Methods
A randomized clinical trial was conducted with 66 patients divided into two groups: one receiving sevoflurane and the other Total Intravenous Anesthesia (TIVA). The primary outcome was the serum troponin I levels within the first 48 hours postoperatively. Secondary outcomes included urine output and serum urea levels.
Results
The median troponin I levels at 48 hours were 10.5 ng.mL−1 (IQR: 8.2–12.7) in the sevoflurane group and 11.0 ng.mL−1 (IQR: 8.7–13.0) in the TIVA group (p = 0.336). The sevoflurane group showed higher urine output on the second postoperative day (median: 800 mL [IQR: 420–913] vs. 541 mL [IQR: 312–718], p = 0.034) and lower serum urea levels (median: 24 mg.dL−1 [IQR: 16–35] vs. 36 mg.dL−1 [IQR: 23–49], p = 0.030).
Conclusions
While sevoflurane did not significantly impact myocardial injury markers, it demonstrated potential renal protective effects in this patient population. Further research is necessary to confirm these findings across different pediatric age groups and surgical contexts.
背景：本研究旨在评估吸入麻醉剂七氟醚对2岁以下先天性心脏病患儿（RACHS 1、2和3）行体外循环心脏手术后心肌损伤和肾功能的影响。方法：将66例患者随机分为七氟醚组和全静脉麻醉组（TIVA）。主要观察指标是术后48小时内血清肌钙蛋白I水平。次要结局包括尿量和血清尿素水平。结果：48小时肌钙蛋白I水平中位数为10.5 ng。mL-1 （IQR: 8.2-12.7）在七氟醚基团和11.0 ng。TIVA组mL-1 (IQR: 8.7-13.0) （p = 0.336）。七氟醚组术后第2天尿量较高（中位数：800 mL [IQR: 420-913] vs. 541 mL [IQR: 312-718], p = 0.034），血清尿素水平较低（中位数：24 mg）。dL-1 [IQR: 16-35] vs. 36 mg。dL-1 [IQR: 23-49], p = 0.030)。结论：虽然七氟醚对心肌损伤标志物没有显著影响，但在该患者群体中显示出潜在的肾脏保护作用。进一步的研究需要在不同的儿童年龄组和手术环境中证实这些发现。
{"title":"Impact of anesthetic technique on troponin I levels in pediatric cardiac surgery: a randomized clinical trial","authors":"João Victor Galvão Barelli , David D. Araujo , Suely P. Zeferino , Gustavo M. Dantas , Filomena B. Galas","doi":"10.1016/j.bjane.2025.844603","DOIUrl":"10.1016/j.bjane.2025.844603","url":null,"abstract":"<div><h3>Background</h3><div>This study aimed to evaluate the effects of the inhalational anesthetic sevoflurane on postoperative myocardial injury and renal function in children under 2 years old with congenital heart disease (RACHS 1, 2, and 3) undergoing cardiac surgery with extracorporeal circulation.</div></div><div><h3>Methods</h3><div>A randomized clinical trial was conducted with 66 patients divided into two groups: one receiving sevoflurane and the other Total Intravenous Anesthesia (TIVA). The primary outcome was the serum troponin I levels within the first 48 hours postoperatively. Secondary outcomes included urine output and serum urea levels.</div></div><div><h3>Results</h3><div>The median troponin I levels at 48 hours were 10.5 ng.mL−1 (IQR: 8.2–12.7) in the sevoflurane group and 11.0 ng.mL<sup>−1</sup> (IQR: 8.7–13.0) in the TIVA group (p = 0.336). The sevoflurane group showed higher urine output on the second postoperative day (median: 800 mL [IQR: 420–913] vs. 541 mL [IQR: 312–718], p = 0.034) and lower serum urea levels (median: 24 mg.dL<sup>−1</sup> [IQR: 16–35] vs. 36 mg.dL<sup>−1</sup> [IQR: 23–49], p = 0.030).</div></div><div><h3>Conclusions</h3><div>While sevoflurane did not significantly impact myocardial injury markers, it demonstrated potential renal protective effects in this patient population. Further research is necessary to confirm these findings across different pediatric age groups and surgical contexts.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844603"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143538015","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-03-01DOI: 10.1016/j.bjane.2025.844602
Guozhen Xie , Maria Estevez , Kiyan Heybati , Matthew Vogt , Michael Smith , Christine Moshe , Johanna Chan , Vivek Kumbhari , Ryan Chadha
Background
Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy.
Methods
We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO2 < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals.
Results
Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05).
Conclusions
With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.
{"title":"Single-agent versus combination regimens containing propofol: a retrospective cohort study of recovery metrics and complication rates in a hospital-based endoscopy suite","authors":"Guozhen Xie , Maria Estevez , Kiyan Heybati , Matthew Vogt , Michael Smith , Christine Moshe , Johanna Chan , Vivek Kumbhari , Ryan Chadha","doi":"10.1016/j.bjane.2025.844602","DOIUrl":"10.1016/j.bjane.2025.844602","url":null,"abstract":"<div><h3>Background</h3><div>Anesthesiologists are often tasked with overseeing sedation in non-surgical settings. We aim to determine whether adding adjuvant sedatives to propofol affects the recovery times and complication rates after endoscopy.</div></div><div><h3>Methods</h3><div>We conducted a retrospective cohort study of adults (≥18) who received propofol while undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy (COL) at a large academic institution over a four-year period. Patients receiving propofol alone were compared against patients receiving propofol in combination with midazolam, fentanyl, ketamine, or dexmedetomidine. The primary outcome was PACU length of stay, adjusted for age, sex, and ASA Score. Secondary outcomes included incidence of PACU postoperative nausea and vomiting, hypoxemia (SpO<sub>2</sub> < 90%), bradycardia (HR < 60 bpm), and escalation of care (hospital admission), reported in adjusted odds ratios and their 95% confidence intervals.</div></div><div><h3>Results</h3><div>Across the study period, 28,532 cases were included. Colonoscopies performed under propofol+fentanyl sedation were associated with significantly longer PACU LOS compared to propofol alone. Adjusted mean PACU LOS was significantly longer in patients receiving adjuvant fentanyl, compared to propofol alone (p < 0.01) and propofol + dexmedetomidine (p < 0.01). Patients receiving propofol alone exhibited a 9.4% incidence of bradycardia, 16.0% hypoxia, 0.89% PONV, and 0.40% hospitalization. Adjuvant fentanyl use was associated with higher odds of hypoxia across all procedure types (p < 0.05). Adjuvant dexmedetomidine was associated with higher rates of bradycardia, but lower rates of hypoxia, PONV, and hospitalization (p < 0.05).</div></div><div><h3>Conclusions</h3><div>With the exception of fentanyl, combining propofol with other sedatives was not associated with longer recovery times. The incidence of complications differed significantly with the use of adjuvant fentanyl or dexmedetomidine.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844602"},"PeriodicalIF":1.7,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143538098","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-28DOI: 10.1016/j.bjane.2025.844604
Gustavo R.M. Wegner , Bruno F.M. Wegner , Henrik G. Oliveira , Luis A. Costa , Luigi W. Spagnol , Valentine W. Spagnol , Jorge R.M. Carlotto , Eugénio Pagnussatt Neto
Background
The impact of choosing between inhalational anesthetics and propofol for maintenance anesthesia in liver transplantation or liver resections remains uncertain.
Methods
A systematic search was conducted on PubMed, Scopus, Embase, Web of Science, and the Cochrane Library on September 5, 2023, adhering to the Cochrane Handbook and PRISMA guidelines.
Results
Fifteen randomized controlled trials and five observational studies, comprising 1,602 patients, were included. The statistical analysis was categorized into three groups: liver transplantation (four studies), living donor hepatectomy (four studies), and liver mass hepatectomy (twelve studies). The liver mass hepatectomy group was further subdivided based on the performance of the Pringle maneuver and the use of pharmacological preconditioning. Statistically significant results are described below. In liver transplant recipients, propofol anesthesia was associated with lower AST levels on the first postoperative day. Hepatic donors anesthetized with propofol had higher total infusion volumes and intraoperative urine output. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher peak AST and ALT levels compared to those who received pharmacological preconditioning. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher AST and ALT levels on both the first and third postoperative days, increased total infusion volumes, and shorter hospital stays, when compared to pharmacological conditioning.
Conclusions
Our findings do not offer sufficient evidence to inform clinical practice. The choice between propofol-based and inhalational anesthesia should be tailored to the individual patient's condition and the nature of the procedure being performed.
Registration
PROSPERO ID: CRD42023460715.
背景：在肝移植或肝切除术中选择吸入麻醉剂和异丙酚维持麻醉的影响尚不确定。方法：根据Cochrane Handbook和PRISMA指南，于2023年9月5日对PubMed、Scopus、Embase、Web of Science和Cochrane Library进行系统检索。结果：纳入15项随机对照试验和5项观察性研究，共1602例患者。统计分析分为三组：肝移植（4项研究）、活体供肝切除术（4项研究）和肝块切除术（12项研究）。根据Pringle手法的表现和药物预处理的使用，进一步细分肝肿块肝切除术组。统计上显著的结果如下。在肝移植受者中，异丙酚麻醉与术后第一天较低的AST水平相关。用异丙酚麻醉的肝供者总输注量和术中尿量较高。与接受药物预处理的患者相比，接受Pringle手法和异丙酚麻醉的肝肿块切除术患者的AST和ALT峰值水平更高。与药物治疗相比，接受Pringle手法和异丙酚麻醉的肝肿物切除术患者在术后第一天和第三天的AST和ALT水平较高，总输注量增加，住院时间缩短。结论：我们的研究结果没有提供足够的证据来指导临床实践。丙泊酚为基础麻醉和吸入麻醉之间的选择应根据个别患者的情况和正在进行的手术的性质而定。注册：普洛斯彼罗ID: CRD42023460715。
{"title":"Comparison of total intravenous anesthesia and inhalational anesthesia in patients undergoing liver surgery: a systematic review and meta-analysis","authors":"Gustavo R.M. Wegner , Bruno F.M. Wegner , Henrik G. Oliveira , Luis A. Costa , Luigi W. Spagnol , Valentine W. Spagnol , Jorge R.M. Carlotto , Eugénio Pagnussatt Neto","doi":"10.1016/j.bjane.2025.844604","DOIUrl":"10.1016/j.bjane.2025.844604","url":null,"abstract":"<div><h3>Background</h3><div>The impact of choosing between inhalational anesthetics and propofol for maintenance anesthesia in liver transplantation or liver resections remains uncertain.</div></div><div><h3>Methods</h3><div>A systematic search was conducted on PubMed, Scopus, Embase, Web of Science, and the Cochrane Library on September 5, 2023, adhering to the Cochrane Handbook and PRISMA guidelines.</div></div><div><h3>Results</h3><div>Fifteen randomized controlled trials and five observational studies, comprising 1,602 patients, were included. The statistical analysis was categorized into three groups: liver transplantation (four studies), living donor hepatectomy (four studies), and liver mass hepatectomy (twelve studies). The liver mass hepatectomy group was further subdivided based on the performance of the Pringle maneuver and the use of pharmacological preconditioning. Statistically significant results are described below. In liver transplant recipients, propofol anesthesia was associated with lower AST levels on the first postoperative day. Hepatic donors anesthetized with propofol had higher total infusion volumes and intraoperative urine output. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher peak AST and ALT levels compared to those who received pharmacological preconditioning. Patients undergoing liver mass resection with the Pringle maneuver and propofol anesthesia had higher AST and ALT levels on both the first and third postoperative days, increased total infusion volumes, and shorter hospital stays, when compared to pharmacological conditioning.</div></div><div><h3>Conclusions</h3><div>Our findings do not offer sufficient evidence to inform clinical practice. The choice between propofol-based and inhalational anesthesia should be tailored to the individual patient's condition and the nature of the procedure being performed.</div></div><div><h3>Registration</h3><div>PROSPERO ID: CRD42023460715.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844604"},"PeriodicalIF":1.7,"publicationDate":"2025-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143538012","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-18DOI: 10.1016/j.bjane.2025.844599
Alessandro Scudellari , Federico Bilotta
{"title":"A pragmatic view on general anesthesia in mechanical thrombectomy for acute ischemic stroke","authors":"Alessandro Scudellari , Federico Bilotta","doi":"10.1016/j.bjane.2025.844599","DOIUrl":"10.1016/j.bjane.2025.844599","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844599"},"PeriodicalIF":1.7,"publicationDate":"2025-02-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143469858","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-05DOI: 10.1016/j.bjane.2025.844596
Luciana C. Stefani , Liana M.T.A. Azi , Andre P. Schmidt
{"title":"Transforming perioperative care in Brazil: challenges and opportunities for improving outcomes","authors":"Luciana C. Stefani , Liana M.T.A. Azi , Andre P. Schmidt","doi":"10.1016/j.bjane.2025.844596","DOIUrl":"10.1016/j.bjane.2025.844596","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844596"},"PeriodicalIF":1.7,"publicationDate":"2025-02-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143375056","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-26DOI: 10.1016/j.bjane.2025.844595
Simone Chaves Fagondes , Carmem Lúcia Oliveira da Silva , Anneliese Hoffmann , Rita de Cássia Guedes de Azevedo Barbosa , Daiane Falkembach , Ângela Beatriz John
Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.
{"title":"Home mechanical ventilation: a narrative review and a proposal of practical approach","authors":"Simone Chaves Fagondes , Carmem Lúcia Oliveira da Silva , Anneliese Hoffmann , Rita de Cássia Guedes de Azevedo Barbosa , Daiane Falkembach , Ângela Beatriz John","doi":"10.1016/j.bjane.2025.844595","DOIUrl":"10.1016/j.bjane.2025.844595","url":null,"abstract":"<div><div>Growing evidence of the benefits of home ventilatory support in patients with chronic respiratory failure along with technological advances in ventilators have enabled their use in overly complex situations, shaping a new scenario for physicians. This has further given rise to new challenges related to their incorporation into current medical practice. However, this evolution needs to be coupled with knowledge and skills of physicians who are willing to prescribe Home Mechanical Ventilation (HMV), in order to prevent them from making inappropriate choices or adjustments that may ultimately have ethical and legal implications. This article aims to provide guidance and information to support the indication for HMV and the ventilation modalities to be implemented, review basic ventilation concepts, including the ventilator modes most commonly used in patients outside the hospital setting, list the brands and models available in the Brazilian market, provide the means for obtaining equipment for HMV, and finally, describe the requirements for selection of equipment, taking into account the individual characteristics of the patient to ensure safe perioperative care and earlier dehospitalization.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844595"},"PeriodicalIF":1.7,"publicationDate":"2025-01-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143054410","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an effective intervention for restoring adequate circulatory perfusion after cardiac arrest. Ensuring high-quality Cardiopulmonary Resuscitation (CPR) before initiating Extracorporeal Membrane Oxygenation (ECMO) is critical to mitigate tissue hypoxia and ischemia. This study aimed to evaluate the effect of End-Tidal Carbon Dioxide (ETCO2) Goal-Directed CPR (GDCPR) on neurological function before ECMO using a retrospective case-control analysis.
Methods
The medical records of all patients who received ECPR treated at Zhongshan City People's Hospital were collected between January 2020 and March 2023. In this retrospective cohort study, the patients were divided into Conventional CPR (CCPR) and ETCO2-GDCPR groups based on whether ETCO2 was used as a guide for CPR.
Results
A total of 71 patients were included, of whom 46 comprised the CCPR group and 25 comprised the GDCPR group. Approximately 37% of patients who received ECPR had good cerebral function at discharge, with a higher rate in the GDCPR group (52%) compared with the CCPR group (28%) (p = 0.047). Multivariate analysis showed that the Highest Interleukin-6 (H-IL6) levels after ECMO (Odds Ratio [OR = 1.001], 95% Confidence Interval [95% CI 1.000–1.003], p = 0.005) was a risk factor for neurological function at discharge. The other risk factors for poor prognosis in patients who received ECPR included pre-ECMO CPR protocols (OR = 10.74, 95% CI 1.90–60.48, p = 0.007) and IL6 levels after ECMO (OR = 1.002, 95% CI 1.001–1.003, p = 0.005). ECMO duration (OR = 0.83, 95% CI 0.74–0.94, p = 0.002) was identified as a protective factor. Patients with short ECMO duration have a poor prognosis. The area under the curve for ECMO duration was 0.86 (0.77–0.94, p < 0.01), while that for H-IL6 was 0.19 (0.09–0.29, p < 0.01).
Conclusion
ETCO2-guided ECPR is associated with improved neurological prognosis and patient outcomes. Therefore, monitoring ETCO2 levels should be considered a crucial component of evaluating resuscitation efficacy during CPR.
背景：体外心肺复苏（ECPR）是心脏骤停后恢复充足循环灌注的有效干预措施。在启动体外膜氧合（ECMO）之前确保高质量的心肺复苏（CPR）对于减轻组织缺氧和缺血至关重要。本研究旨在通过回顾性病例对照分析，评估潮末二氧化碳（ETCO2）目标导向CPR （GDCPR）对ECMO前神经功能的影响。方法：收集2020年1月至2023年3月在中山市人民医院接受ECPR治疗的所有患者病历。在本回顾性队列研究中，根据是否使用ETCO2作为CPR指导，将患者分为常规CPR （Conventional CPR， CCPR）组和ETCO2- gdcpr组。结果：共纳入71例患者，其中CCPR组46例，GDCPR组25例。约37%接受ECPR的患者出院时脑功能良好，GDCPR组（52%）高于CCPR组（28%）（p = 0.047）。多因素分析显示，ECMO后最高的白细胞介素-6 （H-IL6）水平（优势比[OR = 1.001]，95%可信区间[95% CI 1.000-1.003], p = 0.005）是出院时神经功能的危险因素。接受ECPR患者预后不良的其他危险因素包括ECMO前CPR方案（OR=10.74, 95% CI 1.90-60.48, p = 0.007）和ECMO后il -6水平（OR = 1.002,95% CI 1.001-1.003, p = 0.005）。ECMO持续时间（OR = 0.83,95% CI 0.74-0.94, p = 0.002）被确定为保护因素。ECMO持续时间短的患者预后较差。ECMO持续时间曲线下面积为0.86 (0.77 ~ 0.94,p < 0.01)， H-IL6曲线下面积为0.19 （0.09 ~ 0.29,p < 0.01）。结论：etco2引导下的ECPR可改善神经系统预后和患者预后。因此，监测ETCO2水平应被视为评估心肺复苏术中复苏效果的重要组成部分。
{"title":"End-tidal carbon dioxide-guided extracorporeal cardiopulmonary resuscitation improves neurological prognosis in patients: a single-center retrospective cohort study","authors":"Xiaozu Liao, Chen Gu, Zhou Cheng, Kepeng Liu, Qing Yin, Binfei Li","doi":"10.1016/j.bjane.2025.844588","DOIUrl":"10.1016/j.bjane.2025.844588","url":null,"abstract":"<div><h3>Background</h3><div>Extracorporeal Cardiopulmonary Resuscitation (ECPR) is an effective intervention for restoring adequate circulatory perfusion after cardiac arrest. Ensuring high-quality Cardiopulmonary Resuscitation (CPR) before initiating Extracorporeal Membrane Oxygenation (ECMO) is critical to mitigate tissue hypoxia and ischemia. This study aimed to evaluate the effect of End-Tidal Carbon Dioxide (ETCO<sub>2</sub>) Goal-Directed CPR (GDCPR) on neurological function before ECMO using a retrospective case-control analysis.</div></div><div><h3>Methods</h3><div>The medical records of all patients who received ECPR treated at Zhongshan City People's Hospital were collected between January 2020 and March 2023. In this retrospective cohort study, the patients were divided into Conventional CPR (CCPR) and ETCO<sub>2</sub>-GDCPR groups based on whether ETCO<sub>2</sub> was used as a guide for CPR.</div></div><div><h3>Results</h3><div>A total of 71 patients were included, of whom 46 comprised the CCPR group and 25 comprised the GDCPR group. Approximately 37% of patients who received ECPR had good cerebral function at discharge, with a higher rate in the GDCPR group (52%) compared with the CCPR group (28%) (p = 0.047). Multivariate analysis showed that the Highest Interleukin-6 (H-IL6) levels after ECMO (Odds Ratio [OR = 1.001], 95% Confidence Interval [95% CI 1.000–1.003], p = 0.005) was a risk factor for neurological function at discharge. The other risk factors for poor prognosis in patients who received ECPR included pre-ECMO CPR protocols (OR = 10.74, 95% CI 1.90–60.48, p = 0.007) and IL6 levels after ECMO (OR = 1.002, 95% CI 1.001–1.003, p = 0.005). ECMO duration (OR = 0.83, 95% CI 0.74–0.94, p = 0.002) was identified as a protective factor. Patients with short ECMO duration have a poor prognosis. The area under the curve for ECMO duration was 0.86 (0.77–0.94, p < 0.01), while that for H-IL6 was 0.19 (0.09–0.29, p < 0.01).</div></div><div><h3>Conclusion</h3><div>ETCO<sub>2</sub>-guided ECPR is associated with improved neurological prognosis and patient outcomes. Therefore, monitoring ETCO<sub>2</sub> levels should be considered a crucial component of evaluating resuscitation efficacy during CPR.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844588"},"PeriodicalIF":1.7,"publicationDate":"2025-01-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143042757","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-22DOI: 10.1016/j.bjane.2025.844589
Jacek B. Cywinski , Yufei Li , Lusine Israelyan , Roshni Sreedharan , Silvia Perez-Protto , Kamal Maheshwari
Background
Extreme hemodynamic changes, especially intraoperative hypotension (IOH), are common and often prolonged during Liver Transplant (LT) surgery and during initial hours of recovery. Hypotension Prediction Index (HPI) software is one of the tools which can help in proactive hemodynamic management. The accuracy of the advanced hemodynamic parameters such as Cardiac Output (CO) and Systemic Vascular Resistance (SVR) obtained from HPI software and prediction performance of the HPI in LT surgery remains unknown.
Methods
This was a retrospective observational study conducted in a tertiary academic center with a large liver transplant program. We enrolled 23 adult LT patients who received both Pulmonary Artery Catheter (PAC) and HPI software monitoring. Primarily, we evaluated agreement between PAC and HPI software measured CO and SVR. A priori, we defined a relative difference of less than 20% between measurements as an adequate agreement for a pair of measurements and estimated the Lin's Concordance Correlation Coefficient and Bland-Altman Limits of Agreement (LOA). Clinically acceptable LOA was defined as ± 1 L.min-1 for CO and ± 200 dynes s.cm-5 for SVR. Secondary outcome was the ability of the HPI to predict future hypotension, defined as Mean Arterial Pressure (MAP) less than 65 mmHg lasting at least one minute. We estimated sensitivity, positive predictive value, and time from alert to hypotensive events for HPI software.
Results
Overall, 125 pairs of CO and 122 pairs of SVR records were obtained from 23 patients. Based on our predefined criteria, only 42% (95% CI 30%, 55%) of CO records and 53% (95% CI 28%, 72%) of SVR records from HPI software were considered to agree with those from PAC. Across all patients, there were a total of 1860 HPI alerts (HPI ≥ 85) and 642 hypotensive events (MAP < 65 mmHg). Out of the 642 hypotensive events, 618 events were predicted by HPI alert with sensitivity of 0.96 (95% CI: 0.95). Many times, the HPI value remained above alert level and was followed by multiple hypotensive events. Thus, to evaluate PPV and time to hypotension metric, we considered only the first HPI alert followed by a hypotensive event (“true alerts”). The “true alert” was the first alert when there were several alerts before a hypotension. There were 614 “true alerts” and the PPV for HPI was 0.33 (95% CI 0.31, 0.35). The median time from HPI alert to hypotension was 3.3 [Q1, Q3: 1, 9.3] mins.
Conclusion
There was poor agreement between the pulmonary artery catheter and HPI software calculated advanced hemodynamic parameters (CO and SVR), in the patients undergoing LT surgery. HPI software had high sensitivity but poor specificity for hypotension prediction, resulting in a high burden of false alarms.
背景：极端的血流动力学变化，特别是术中低血压（IOH），在肝移植（LT）手术和恢复的最初几个小时内是常见的，并且经常延长。低血压预测指数（HPI）软件是主动进行血流动力学管理的工具之一。HPI软件获得的心输出量（CO）和全身血管阻力（SVR）等高级血流动力学参数的准确性以及HPI在LT手术中的预测性能尚不清楚。方法：这是一项回顾性观察性研究，在一个大型肝移植项目的三级学术中心进行。我们招募了23名接受肺动脉导管（PAC）和HPI软件监测的成年LT患者。首先，我们评估了PAC和HPI软件测量CO和SVR之间的一致性。先验地，我们将测量值之间的相对差异小于20%定义为一对测量值的足够一致性，并估计了Lin’s一致性相关系数和Bland-Altman一致性极限（LOA）。临床上可接受的LOA定义为CO为±1 L.min-1， SVR为±200 dynes s.cm-5。次要结果是HPI预测未来低血压的能力，定义为平均动脉压（MAP）低于65 mmHg持续至少一分钟。我们估计了HPI软件的敏感性、阳性预测值和从警报到低血压事件的时间。结果：23例患者共获得125对CO和122对SVR记录。根据我们的预定义标准，HPI软件中只有42% （95% CI 30%, 55%）的CO记录和53% （95% CI 28%, 72%）的SVR记录被认为与PAC的记录一致。在所有患者中，共有1860次HPI警报（HPI≥85）和642次低血压事件（MAP< 65 mmHg）。在642例低血压事件中，HPI预警预测618例事件，敏感性为0.96 （95% CI: 0.95）。许多时候，HPI值保持在警戒水平以上，随后发生多次低血压事件。因此，为了评估PPV和降压时间指标，我们只考虑了第一次HPI警报之后的低血压事件（“真实警报”）。“真正的警报”是在低血压之前有几个警报时的第一个警报。有614例“真实警报”，HPI的PPV为0.33 （95% CI 0.31, 0.35）。从HPI警报到低血压的中位时间为3.3分钟[Q1， Q3: 1,9.3]分钟。结论：在接受LT手术的患者中，肺动脉导管与HPI软件计算的晚期血流动力学参数（CO和SVR）之间的一致性较差。HPI软件对低血压的预测敏感性高，但特异性差，导致虚警负担高。
{"title":"Evaluation of hypotension prediction index software in patients undergoing orthotopic liver transplantation: retrospective observational study","authors":"Jacek B. Cywinski , Yufei Li , Lusine Israelyan , Roshni Sreedharan , Silvia Perez-Protto , Kamal Maheshwari","doi":"10.1016/j.bjane.2025.844589","DOIUrl":"10.1016/j.bjane.2025.844589","url":null,"abstract":"<div><h3>Background</h3><div>Extreme hemodynamic changes, especially intraoperative hypotension (IOH), are common and often prolonged during Liver Transplant (LT) surgery and during initial hours of recovery. Hypotension Prediction Index (HPI) software is one of the tools which can help in proactive hemodynamic management. The accuracy of the advanced hemodynamic parameters such as Cardiac Output (CO) and Systemic Vascular Resistance (SVR) obtained from HPI software and prediction performance of the HPI in LT surgery remains unknown.</div></div><div><h3>Methods</h3><div>This was a retrospective observational study conducted in a tertiary academic center with a large liver transplant program. We enrolled 23 adult LT patients who received both Pulmonary Artery Catheter (PAC) and HPI software monitoring. Primarily, we evaluated agreement between PAC and HPI software measured CO and SVR. A priori, we defined a relative difference of less than 20% between measurements as an adequate agreement for a pair of measurements and estimated the Lin's Concordance Correlation Coefficient and Bland-Altman Limits of Agreement (LOA). Clinically acceptable LOA was defined as ± 1 L.min<sup>-1</sup> for CO and ± 200 dynes s.cm<sup>-5</sup> for SVR. Secondary outcome was the ability of the HPI to predict future hypotension, defined as Mean Arterial Pressure (MAP) less than 65 mmHg lasting at least one minute. We estimated sensitivity, positive predictive value, and time from alert to hypotensive events for HPI software.</div></div><div><h3>Results</h3><div>Overall, 125 pairs of CO and 122 pairs of SVR records were obtained from 23 patients. Based on our predefined criteria, only 42% (95% CI 30%, 55%) of CO records and 53% (95% CI 28%, 72%) of SVR records from HPI software were considered to agree with those from PAC. Across all patients, there were a total of 1860 HPI alerts (HPI ≥ 85) and 642 hypotensive events (MAP < 65 mmHg). Out of the 642 hypotensive events, 618 events were predicted by HPI alert with sensitivity of 0.96 (95% CI: 0.95). Many times, the HPI value remained above alert level and was followed by multiple hypotensive events. Thus, to evaluate PPV and time to hypotension metric, we considered only the first HPI alert followed by a hypotensive event (“true alerts”). The “true alert” was the first alert when there were several alerts before a hypotension. There were 614 “true alerts” and the PPV for HPI was 0.33 (95% CI 0.31, 0.35). The median time from HPI alert to hypotension was 3.3 [Q1, Q3: 1, 9.3] mins.</div></div><div><h3>Conclusion</h3><div>There was poor agreement between the pulmonary artery catheter and HPI software calculated advanced hemodynamic parameters (CO and SVR), in the patients undergoing LT surgery. HPI software had high sensitivity but poor specificity for hypotension prediction, resulting in a high burden of false alarms.</div></div>","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 3","pages":"Article 844589"},"PeriodicalIF":1.7,"publicationDate":"2025-01-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143043236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-14DOI: 10.1016/j.bjane.2025.844586
Andre P. Schmidt , Federico Bilotta
{"title":"Challenges in surgical and perioperative care for Brazil's aging population","authors":"Andre P. Schmidt , Federico Bilotta","doi":"10.1016/j.bjane.2025.844586","DOIUrl":"10.1016/j.bjane.2025.844586","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844586"},"PeriodicalIF":1.7,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11761882/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143017382","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-14DOI: 10.1016/j.bjane.2025.844587
Andre P. Schmidt , Clovis T. Bevilacqua Filho , Eduarda S. Martinelli , Virgínia C. de Moura
{"title":"The pulmonary artery catheter in modern anesthesiology and intensive care: indications, benefits, and limitations","authors":"Andre P. Schmidt , Clovis T. Bevilacqua Filho , Eduarda S. Martinelli , Virgínia C. de Moura","doi":"10.1016/j.bjane.2025.844587","DOIUrl":"10.1016/j.bjane.2025.844587","url":null,"abstract":"","PeriodicalId":32356,"journal":{"name":"Brazilian Journal of Anesthesiology","volume":"75 2","pages":"Article 844587"},"PeriodicalIF":1.7,"publicationDate":"2025-01-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143017384","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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