RESUMEN
OBJECTIVE: Postoperative nausea and vomiting (PONV) occurs in up to 30% of patients and its pathophysiology and mechanisms have not been completely described. Hypotension and a decrease in cardiac output are suspected to induce nausea. The hypothesis that intraoperative hypotension might influence the incidence of PONV was investigated. MATERIAL AND METHODS: The study was conducted as a retrospective large single center cohort study. The incidence of PONV was investigated until discharge from post anesthesia care unit (PACU). Surgical patients with general anesthesia during a 2-year period between 2018 and 2019 at a university hospital in Germany were included. Groups were defined based on the lowest documented mean arterial pressure (MAP) with group H50: MAP <50mmHg; group H60: MAP <60mmHg; group H70: MAP <70mmHg, and group H0: no MAP <70mmHg. Decreases of MAP in the different groups were related to PONV. Propensity-score matching was carried out to control for overlapping risk factors. RESULTS: In the 2-year period 18.674 patients fit the inclusion criteria. The overall incidence of PONV was 11%. Patients with hypotension had a significantly increased incidence of PONV (H0 vs. H50: 11.0% vs.17.4%, Risk Ratio (RR): 1.285 (99%CI: 1.102-1.498), p < 0.001; H0 vs. H60: 10.4% vs. 13.5%, RR: 1.1852 (99%CI: 1.0665-1.3172), p < 0.001; H0 vs. H70: 9.4% vs. 11.2%, RR: 1.1236 (99%CI: 1.013 - 1.2454); p = 0.0027). CONCLUSION: The study demonstrates an association between intraoperative hypotension and early PONV. A more severe decrease of MAP had a pronounced effect.
Asunto(s)
Hipotensión , Náusea y Vómito Posoperatorios , Humanos , Hipotensión/epidemiología , Hipotensión/etiología , Náusea y Vómito Posoperatorios/epidemiología , Femenino , Masculino , Estudios Retrospectivos , Persona de Mediana Edad , Anciano , Adulto , Complicaciones Intraoperatorias/epidemiología , Complicaciones Intraoperatorias/etiología , Incidencia , Factores de Riesgo , Alemania/epidemiología , Anestesia General/efectos adversosRESUMEN
PURPOSE: This case-control study investigated the long-term evolution of multidrug-resistant bacteria (MDRB) over a 5-year period associated with the use of selective oropharyngeal decontamination (SOD) in the intensive care unit (ICU). In addition, effects on health care-associated infections and ICU mortality were analysed. METHODS: We investigated patients undergoing mechanical ventilation > 48 h in 11 adult ICUs located at 3 campuses of a university hospital. Administrative, clinical, and microbiological data which were routinely recorded electronically served as the basis. We analysed differences in the rates and incidence densities (ID, cases per 1000 patient-days) of MDRB associated with SOD use in all patients and stratified by patient origin (outpatient or inpatient). After propensity score matching, health-care infections and ICU mortality were compared. RESULTS: 5034 patients were eligible for the study. 1694 patients were not given SOD. There were no differences in the incidence density of MDRB when SOD was used, except for more vancomycin-resistant Enterococcus faecium (0.72/1000 days vs. 0.31/1000 days, p < 0.01), and fewer ESBL-producing Klebsiella pneumoniae (0.22/1000 days vs. 0.56/1000 days, p < 0.01). After propensity score matching, SOD was associated with lower incidence rates of ventilator-associated pneumonia and death in the ICU but not with ICU-acquired bacteremia or urinary tract infection. CONCLUSIONS: Comparisons of the ICU-acquired MDRB over a 5-year period revealed no differences in incidence density, except for lower rate of ESBL-producing Klebsiella pneumoniae and higher rate of vancomycin-resistant Enterococcus faecium with SOD. Incidence rates of ventilator-associated pneumonia and death in the ICU were lower in patients receiving SOD.
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Infección Hospitalaria , Neumonía Asociada al Ventilador , Adulto , Antibacterianos/farmacología , Antibacterianos/uso terapéutico , Bacterias , Estudios de Casos y Controles , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/prevención & control , Descontaminación , Humanos , Unidades de Cuidados Intensivos , Neumonía Asociada al Ventilador/tratamiento farmacológico , Neumonía Asociada al Ventilador/epidemiología , Neumonía Asociada al Ventilador/prevención & control , VancomicinaRESUMEN
Insufficient perioperative pain treatment is known as a highly predictive risk factor for the development of chronic postoperative pain. Remifentanil is an ultrashort-acting opioid that provides quick and efficient analgesia but is associated with the induction of opioid-induced hyperalgesia. Despite these well-known characteristics, this substance is being increasingly used in anesthesia and in a variety of medical fields, such as intensive-care medicine and obstetrics. The aim of our study was to reveal whether remifentanil influences postoperative pain, the requirement for postoperative analgesics, and requirement of antiemetics (as indirect indicator of postoperative nausea and vomiting), as well as the effects on time to extubation and length of stay in the postanesthesia care unit in daily clinical routine. From an electronic medical records database of 55,693 anesthesias, we analyzed data from all patients receiving intraabdominal surgery (visceral, gynecological, and urological) under general anesthesia or combined general-epidural anesthesia by propensity score matching. The administration of remifentanil was associated with higher postoperative pain scores despite a higher requirement of postoperative analgesics. Additional epidural analgesia was not able to avoid this finding. The intraoperative use of remifentanil is associated with a deterioration of pain levels and postoperative analgesic requirement, wherefore the potential benefit of this substance seems to be outweighed by its potential disadvantages. Especially in operative procedures in which high postoperative pain scores are expected, the unreflective use should be critically questioned.
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Analgésicos Opioides/uso terapéutico , Cuidados Intraoperatorios/métodos , Dolor Postoperatorio/fisiopatología , Náusea y Vómito Posoperatorios/epidemiología , Remifentanilo/uso terapéutico , Acetaminofén/uso terapéutico , Adulto , Anciano , Analgésicos/uso terapéutico , Antiinflamatorios no Esteroideos/uso terapéutico , Antieméticos/uso terapéutico , Procedimientos Quirúrgicos del Sistema Digestivo , Dipirona/uso terapéutico , Femenino , Procedimientos Quirúrgicos Ginecológicos , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Dolor Postoperatorio/tratamiento farmacológico , Pirinitramida/uso terapéutico , Náusea y Vómito Posoperatorios/tratamiento farmacológico , Sala de Recuperación/estadística & datos numéricos , Procedimientos Quirúrgicos UrológicosRESUMEN
OBJECTIVES: Aortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome. METHODS: As a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently. RESULTS: During aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid-base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant. CONCLUSIONS: HA significantly reduces the need for vasopressors, the amount of transfusion and improves acid-base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.
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Enfermedades de la Aorta/metabolismo , Enfermedades de la Aorta/cirugía , Paro Circulatorio Inducido por Hipotermia Profunda , Hemabsorción , Hemodinámica , Anciano , Femenino , Humanos , Periodo Intraoperatorio , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
PURPOSE: To evaluate appropriate injection protocols for gadofosveset at 1.5 and 3 T magnetic resonance imaging (MRI) for semiquantitative myocardial perfusion analysis. MATERIALS AND METHODS: Eighteen young healthy volunteers were subjected to first-pass perfusion cardiac scans at 1.5 and 3 T MRI using three different injection protocols for gadofosveset (0.00375, 0.0075, and 0.0150 mmol/kg bodyweight) and two perfusions. At both field strengths a T1-weighted saturation recovery turboFLASH sequence with parallel imaging was employed. Peak signal-to-noise ratio (SNR), maximum contrast enhancement ratio (CER), peak-baseline difference, and upslope values were assessed. Moreover, sectors with dark banding artifacts were evaluated. RESULTS: Significant differences of the upslope values for first compared to second perfusion could be observed for the medium- and high-dose groups at 1.5 T (P < 0.01), but not at 3 T. Sectors with dark banding artifacts during first perfusion occurred significantly more often at the highest dose of gadofosveset compared to the lowest dose at 1.5 T (P = 0.04) and 3 T (P < 0.01). CONCLUSION: The best injection protocol for semiquantitative perfusion analysis at 1.5 T is 0.00375 mmol/kg, as higher doses lead to lower upslope values during the second perfusion. At 3 T 0.0075 mmol/kg should be used to avoid dark banding artifacts.
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Medios de Contraste/administración & dosificación , Gadolinio/administración & dosificación , Imagen por Resonancia Magnética , Miocardio/patología , Compuestos Organometálicos/administración & dosificación , Imagen de Perfusión , Adulto , Artefactos , Peso Corporal , Relación Dosis-Respuesta a Droga , Voluntarios Sanos , Corazón/efectos de los fármacos , Humanos , Masculino , Relación Señal-RuidoRESUMEN
This study was performed to determine the best concentration of gadofosveset at 1.5 and 3 T MRI for quantitative myocardial perfusion analysis. 18 healthy volunteers have been examined at a 1.5 and a 3 T MRI system assigned to one of three dose groups: low dose (0.00375 mmol/kg), medium dose (0.0075 mmol/kg), high dose (0.0150 mmol/kg). A T1-weighted saturation recovery turboFLASH sequence with parallel imaging was used. Two perfusion scans were performed for each field strength and volunteer. Peak signal-to-noise-ratio, maximum contrast-enhancement-ratio and myocardial blood flow (MBF) were calculated. MBF values were significantly higher at 1.5 T in the medium and the high dose groups than in the low dose group (p < 0.001). Higher MBF values could be found at 3 T for the second perfusion scan in the medium and both perfusion scans in the high dose group compared to the low dose group. Optimal dose of gadofosveset for quantitative perfusion analysis at 1.5 T is 0.00375 mmol/kg as higher doses caused overestimation of the MBF. At 3 T 0.0075 mmol/kg seems to be the best dose for a single perfusion scan, while for a second perfusion scan MBF may be overestimated.