RESUMEN

BACKGROUND: Postoperative hypoxemia and pulmonary complications remain a frequent event after on-pump cardiac surgery and mostly characterized by pulmonary atelectasis. Surfactant dysfunction or hyposecretion happens prior to atelectasis formation, and sigh represents the strongest stimulus for surfactant secretion. The role of sigh breaths added to conventional lung protective ventilation in reducing postoperative hypoxemia and pulmonary complications among cardiac surgery is unknown. METHODS: The perioperative sigh ventilation in cardiac surgery (E-SIGHT) trial is a single-center, two-arm, randomized controlled trial. In total, 192 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, besides conventional lung protective ventilation, sigh volumes producing plateau pressures of 35 cmH2O (or 40 cmH2O for patients with body mass index > 35 kg/m2) delivered once every 6 min from intubation to extubation. In the control group, conventional lung protective ventilation without preplanned recruitment maneuvers is used. Lung protective ventilation (LPV) consists of low tidal volumes (6-8 mL/kg of predicted body weight) and positive end-expiratory pressure (PEEP) setting according to low PEEP/FiO2 table for acute respiratory distress syndrome (ARDS). The primary endpoint is time-weighted average SpO2/FiO2 ratio during the initial post-extubation hour. Main secondary endpoint is the severity of postoperative pulmonary complications (PPCs) computed by postoperative day 7. DISCUSSION: The E-SIGHT trial will be the first randomized controlled trial to evaluate the impact of perioperative sigh ventilation on the postoperative outcomes after on-pump cardiac surgery. The trial will introduce and assess a novel perioperative ventilation approach to mitigate the risk of postoperative hypoxemia and PPCs in patients undergoing cardiac surgery. Also provide the basis for a future larger trial aiming at verifying the impact of sigh ventilation on postoperative pulmonary complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT06248320. Registered on January 30, 2024. Last updated February 26, 2024.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Hipoxia , Respiración con Presión Positiva , Complicaciones Posoperatorias , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Hipoxia/etiología , Hipoxia/prevención & control , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Respiración con Presión Positiva/métodos , Puente Cardiopulmonar/efectos adversos , Resultado del Tratamiento , Atelectasia Pulmonar/etiología , Atelectasia Pulmonar/prevención & control , Factores de Tiempo , Atención Perioperativa/métodos , Persona de Mediana Edad , Femenino , Masculino , Adulto , Pulmón/fisiopatología , Pulmón/cirugía , Anciano , Respiración Artificial/efectos adversos , Enfermedades Pulmonares/etiología , Enfermedades Pulmonares/prevención & control , Enfermedades Pulmonares/diagnóstico

RESUMEN

STUDY OBJECTIVE: Hypoxemia is the most frequent adverse event observed during gastrointestinal endoscopy under procedural sedation. An optimum oxygen therapy has still not been conclusively determined. DESIGN: A systematic review and network meta-analysis of randomized clinical trials. SETTING: Digestive Endoscopy Center. PATIENTS: Adults (≥18 years old and of both sexes) during gastrointestinal endoscopy under procedural sedation. INTERVENTIONS: Pubmed, MEDLINE, Web of Science, Embase, and Clinicaltrials.gov. were searched until June 30, 2023. Randomized clinical trials (RCTs) comparing any oxygen therapy with another oxygen therapy or with placebo (nasal cannula, NC) were included. MEASUREMENT: The primary outcome was the incidence of hypoxemia, defined as the pulse oxygen saturation (SpO2). Random-effects network meta-analyses were performed. Data are reported as odds ratios (OR), prediction intervals (PrI) and 95% CI. Bias risk was evaluated following the guidelines outlined by the Cochrane Collaboration. The quality of evidence was evaluated through the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. MAIN RESULTS: We included 27 RCTs with a total of 7552 patients. Compared to the use of NC, non-invasive positive pressure ventilation (NIPPV) demonstrated superior efficacy in mitigating hypoxemia (NIPPV vs. NC, OR = 0.16, 95% CI: 0.08-0.31, 95% PrI: 0.06-0.41), followed by Wei nasal jet tube (WNJT) (WNJT vs. NC, OR = 0.17, 95% CI: 0.10-0.30, 95% PrI: 0.07-0.42). The efficacy for preventing hypoxemia was ranked as follows: NIPPV > WNJT > oropharynx/nasopharyngeal catheter > high-flow nasal oxygenation > nasal mask > NC. CONCLUSIONS: During gastrointestinal endoscopy under procedural sedation, all other advanced oxygen therapies were found to be more efficacious than nasal cannula. NIPPV and WNJT appear to be the most efficacious oxygen therapy for preventing hypoxemia. Additionally, clinicians should make a choice regarding the most suitable oxygen therapy based on the risk population, type of endoscopy and adverse events.

Asunto(s)

Endoscopía Gastrointestinal , Hipoxia , Metaanálisis en Red , Terapia por Inhalación de Oxígeno , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Hipoxia/prevención & control , Hipoxia/etiología , Terapia por Inhalación de Oxígeno/métodos , Endoscopía Gastrointestinal/efectos adversos , Endoscopía Gastrointestinal/métodos , Sedación Consciente/métodos , Sedación Consciente/efectos adversos , Respiración con Presión Positiva/métodos , Respiración con Presión Positiva/efectos adversos

RESUMEN

INTRODUCTION: Achieving simultaneous cerebral blood flow (CBF) and oxygenation measures, specifically for point-of-care injury monitoring in prolonged field care, requires the implementation of appropriate methodologies and advanced medical device design, development, and evaluation. The near-infrared spectroscopy (NIRS) method measures the absorbance of light whose attenuation is related to cerebral blood volume and oxygenation. By contrast, diffuse correlation spectroscopy (DCS) allows continuous noninvasive monitoring of microvascular blood flow by directly measuring the degree of light scattering because of red blood cell (RBC) movement in tissue capillaries. Hence, this study utilizes these two optical approaches (DCS-NIRS) to obtain a more complete hemodynamic monitoring by providing cerebral microvascular blood flow, hemoglobin oxygenation and deoxygenation in hemorrhage, and hypoxia-induced injuries. MATERIALS AND METHODS: Piglet models of hemorrhage and hypoxia-induced brain injury were used with DCS and NIRS sensors placed over the preorbital to temporal skull regions. To induce hemorrhagic shock, up to 70% of the animal's total blood volume was withdrawn through graded hemorrhage serially via a syringe from a femoral artery cannula in 10 mL/kg aliquots over 1 minute every 10 minutes. A second group of animals was subjected to hypoxia for ∼1 hour through graded hypoxia by serial titration from normoxic fraction inspired oxygen of 21% to hypoxic fraction inspired oxygen of 6%. A subset of animals served as sham-controls undergoing anesthesia, instrumentation, and ventilation as the injury groups, yet experiencing no blood loss or hypoxia. RESULTS: We first investigated the relationship between hemorrhagic shock and no shock by using measured biomarkers, including blood flow index from DCS associated with CBF and oxygenated (HbO) and de-oxygenated hemoglobin from NIRS. The statistical analysis revealed a significant difference between no shock and hemorrhagic shock (P < .01). The HbO decreased with each blood loss as expected, yet the de-oxygenated hemoglobin was slightly changed. During hypoxia-induced global hypoxic-ischemic injury tests, the CBF results from graded hypoxia were consistent with the response previously measured during hemorrhagic shock. Moreover, HbO decreased when the animal was hypoxic, as expected. A statistical analysis was also conducted to compare the results with those of the sham controls. CONCLUSIONS: There is a consistency in blood flow measures in both injury mechanisms (hemorrhagic shock and hypoxia), which is significant as the new prototype system provides similar measures and trends for each brain injury type, suggesting that the optical system can be used in response to different injury mechanisms. Notably, the results support the idea that this optical system can probe the hemodynamic status of local cerebral cortical tissue and provide insight into the underlying changes of cerebral tissue perfusion at the microvascular level. These measurement capabilities can improve shock identification and monitoring of medical management of injuries, particularly hemorrhagic shock, in prolonged field care.

Asunto(s)

Circulación Cerebrovascular , Hipoxia , Choque Hemorrágico , Espectroscopía Infrarroja Corta , Animales , Choque Hemorrágico/fisiopatología , Choque Hemorrágico/complicaciones , Choque Hemorrágico/diagnóstico , Choque Hemorrágico/terapia , Choque Hemorrágico/etiología , Porcinos , Espectroscopía Infrarroja Corta/métodos , Espectroscopía Infrarroja Corta/instrumentación , Circulación Cerebrovascular/fisiología , Hipoxia/fisiopatología , Hipoxia/etiología , Hipoxia/complicaciones , Monitoreo Fisiológico/métodos , Monitoreo Fisiológico/instrumentación , Hemodinámica/fisiología , Modelos Animales de Enfermedad

RESUMEN

OBJECTIVE: Back to the sources, postoperative nausea and vomiting, hypo- and hypertension, heart rate alterations, and hypoxemia due to laryngospasm might be considered perioperative complications. METHODS: This cross-sectional study was conducted at an Education and Research Hospital between January 2018 and June 2023. The study included a total of 437 cases of thyroid surgery. The demographic data such as age, sex, co-morbidities of the instances, hypotension, hypertension, bradycardia, hypoxemia, and postoperative nausea and vomiting, as well as laboratory data were obtained and analyzed. RESULTS: Of 437 cases, 334 (76%) were females and 103 (24%) were males, with a mean age of 51.83±11.91 years and 55.32±11.87 years, respectively. No statistical significance was realized between the complications, co-morbid diseases, and age. Notably, no liaison between the complications after awakening from the anesthesia and preoperative laboratory parameters was discerned. However, a high but no significant relationship was revealed between the platelet-to-lymphocyte ratio (P/L) in cases with hypoxemia and hypotension. Finally, no significance between laboratory values, bradycardia, hypertension, and postoperative nausea and vomiting was distinguished. CONCLUSION: We postulate that the so-called inflammatory biomarkers measured at the time of preoperative examination in the blood count concept selectively do not enrich for anticipating complications that arise in the perioperative echelon.

Asunto(s)

Biomarcadores , Complicaciones Posoperatorias , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Transversales , Biomarcadores/sangre , Adulto , Anciano , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/sangre , Tiroidectomía/efectos adversos , Náusea y Vómito Posoperatorios/etiología , Náusea y Vómito Posoperatorios/sangre , Hipoxia/sangre , Hipoxia/etiología , Enfermedades de la Tiroides/cirugía , Enfermedades de la Tiroides/sangre , Hipertensión

RESUMEN

BACKGROUND: Hypoxaemia occurs frequently during paediatric laryngeal microsurgery. OBJECTIVE: The oxygen reserve index is a noninvasive and continuous parameter to assess PaO2 levels in the range of 100 to 200 mmHg. It ranges from 0 to 1.0. We investigated whether monitoring the oxygen reserve index can reduce the incidence of SpO2 90% or less. DESIGN: Randomised controlled trial. SETTING: A tertiary care paediatric hospital. PARTICIPANTS: Paediatric patients aged 18 years or less scheduled to undergo laryngeal microsurgery. INTERVENTION: The patients were randomly allocated to the oxygen reserve index or control groups, and stratified based on the presence of a tracheostomy tube. Rescue intervention was performed when the oxygen reserve index was 0.2 or less and the SpO2 was 94% or less in the oxygen reserve index and control groups, respectively. MAIN OUTCOME MEASURE: The primary outcome was the incidence of SpO2 90% or less during the surgery. RESULTS: Data from 88 patients were analysed. The incidence of SpO2 ≤ 90% did not differ between the oxygen reserve index and control groups [P = 0.114; 11/44, 25% vs. 18/44, 40.9%; relative risk: 1.27; and 95% confidence interval (CI): 0.94 to 1.72]. Among the 128 rescue interventions, SpO2 ≤ 90% event developed in 18 out of 75 events (24%) and 42 out of 53 events (79.2%) in the oxygen reserve index and control groups, respectively (P < 0.001; difference: 55.2%; and 95% CI 38.5 to 67.2%). The number of SpO2 ≤ 90% events per patient in the oxygen reserve index group (median 0, maximum 3) was less than that in the control group (median 0, maximum 8, P = 0.031). CONCLUSION: Additional monitoring of the oxygen reserve index, with a target value of greater than 0.2 during paediatric airway surgery, alongside peripheral oxygen saturation, did not reduce the incidence of SpO2 ≤ 90%.

Asunto(s)

Hipoxia , Saturación de Oxígeno , Humanos , Masculino , Femenino , Hipoxia/prevención & control , Hipoxia/sangre , Hipoxia/etiología , Preescolar , Oxígeno/sangre , Niño , Lactante , Microcirugia/métodos , Laringe , Oximetría/métodos , Monitoreo Intraoperatorio/métodos , Adolescente

RESUMEN

Pulmonary benign metastasizing leiomyoma is an uncommon condition, predominantly affecting women of childbearing age with a history of uterine smooth muscle tumors and uterine leiomyoma surgery for uterine leiomyoma. The progression of PBML is often unpredictable and depends on the extent of lung involvement. Generally, most patients remain asymptomatic, but a minority may experience coughing, wheezing, or shortness of breath, which are frequently misdiagnosed as pneumonia. consequently, this presents significant challenges in both treatment and nursing care before diagnosis. This paper reports the case of a 35-year-old woman primarily diagnosed with acute hypoxic respiratory failure who was transferred from the emergency room to the intensive care unit. The initial computed tomography scan of the patient's lungs indicated diffuse interstitial pneumonia, but the sequencing of the alveolar lavage fluid pathogen macro did not detect any bacteria, fungi, or viruses. Moreover, the patient remained in a persistent hypoxic state before the definitive diagnosis. Therefore, our focus was on maintaining the airway patency of the patient, using prone ventilation, inhaling nitric oxide, monitoring electrical impedance tomography, and preventing ventilator-associated pneumonia to improve oxygenation, while awaiting immunohistochemical staining of the patient's biopsied lung tissue. This would help us clarify the diagnosis and treat it based on etiology. After meticulous treatment and nursing care, the patient was weaned off the ventilator after 26 days and transferred to the respiratory ward after 40 days. This case study may serve as a reference for clinical practice and assist patients suffering from PBML.

Asunto(s)

Leiomioma , Neoplasias Pulmonares , Insuficiencia Respiratoria , Neoplasias Uterinas , Humanos , Femenino , Adulto , Leiomioma/patología , Leiomioma/complicaciones , Leiomioma/diagnóstico , Insuficiencia Respiratoria/etiología , Neoplasias Pulmonares/secundario , Neoplasias Pulmonares/complicaciones , Neoplasias Pulmonares/patología , Neoplasias Uterinas/patología , Neoplasias Uterinas/complicaciones , Neoplasias Uterinas/diagnóstico , Tomografía Computarizada por Rayos X , Hipoxia/etiología , Diagnóstico Diferencial

Asunto(s)

Hipoxia , Intubación Intratraqueal , Ketamina , Heridas y Lesiones , Humanos , Ketamina/administración & dosificación , Hipoxia/etiología , Hipoxia/prevención & control , Intubación Intratraqueal/métodos , Intubación Intratraqueal/efectos adversos , Heridas y Lesiones/complicaciones , Incidencia , Intubación e Inducción de Secuencia Rápida/métodos , Masculino , Anestésicos Disociativos/administración & dosificación , Femenino , Factores de Tiempo

RESUMEN

STUDY OBJECTIVE: Hindsight bias is the tendency to overestimate the predictability of an event after it has already occurred. We aimed to evaluate whether hindsight bias influences the retrospective interpretation of clinical scenarios in the field of anesthesiology, which relies on clinicians making rapid decisions in the setting of perioperative adverse events. DESIGN: Two clinical scenarios were developed (intraoperative hypotension and intraoperative hypoxia) with 3 potential diagnoses for each. Participants completed a crossover study reviewing one case without being informed of the supposed ultimate diagnosis (i.e., no 'anchor' diagnosis), referred to as their foresight case, and the other as a hindsight case wherein they were informed in the leading sentence of the scenario that 1 of the 3 conditions provided was the ultimate diagnosis (i.e., the diagnosis the participant might 'anchor' to if given this information at the start). Participants were randomly assigned to (1) which scenario (hypotension or hypoxia) was presented as the initial foresight case and (2) which of the 3 potential diagnoses for the second case (the hindsight case, which defaulted to whichever case the participant was not assigned for the first case) was presented as the ultimate diagnosis in the leading sentence in a 2 (scenario order) x 3 (hindsight case anchor) between-subjects factorial design (6 possible randomization assignments). SETTING: Two academic medical centers. PARTICIPANTS: Faculty, fellow, and resident anesthesiologists and certified nurse anesthetists (CRNAs). INTERVENTIONS: None. MEASUREMENTS: After reading each clinical scenario, participants were asked to rate the probability (%) of each of three potential diagnoses to have caused the hypotension or hypoxia. Compositional data analysis (CoDA) was used to compare whether diagnosis probabilities differ between the hindsight and the foresight case. MAIN RESULTS: 113 participants completed the study. 59 participants (52%) were resident anesthesiologists. Participants randomized to the hypotension scenario as a hindsight case were 2.82 times more likely to assign higher probability to the pulmonary embolus diagnosis if provided as an anchor (95% CI, 1.35-5.90; P = 0.006) and twice as likely to assign higher probability to the myocardial infarction diagnosis if provided as an anchor (95% CI, 1.12-3.58; P = 0.020). Participants randomized to the hypoxia scenario as a hindsight case were 1.78 times more likely to assign higher probability to the mainstem bronchus intubation diagnosis if provided in the anchor statement (95% CI, 1.00-3.14; P = 0.048) and 3.72 times more likely to assign higher probability to the pulmonary edema diagnosis if provided as an anchor (95% CI, 1.88-7.35; P < 0.001). CONCLUSIONS: Hindsight bias influences the clinical diagnosis probabilities assigned by anesthesia providers. Clinicians should be educated on hindsight bias in perioperative medicine and be cognizant of the effect of hindsight bias when interpreting clinical outcomes.

Asunto(s)

Estudios Cruzados , Hipotensión , Hipoxia , Humanos , Hipotensión/diagnóstico , Hipotensión/etiología , Femenino , Hipoxia/etiología , Hipoxia/diagnóstico , Hipoxia/prevención & control , Masculino , Adulto , Anestesiólogos , Anestesiología/métodos , Anestesiología/normas , Complicaciones Intraoperatorias/diagnóstico , Complicaciones Intraoperatorias/etiología , Complicaciones Intraoperatorias/prevención & control , Persona de Mediana Edad , Sesgo , Estudios Retrospectivos

Asunto(s)

Hipoxia , Triaje , Humanos , Triaje/métodos , Hipoxia/diagnóstico , Hipoxia/etiología , Choque/diagnóstico , Masculino , Femenino , Anciano , Servicio de Urgencia en Hospital , Persona de Mediana Edad , Índice de Severidad de la Enfermedad

RESUMEN

BACKGROUND: Nasal cannulas and face masks are common oxygenation tools used in conventional oxygen therapy for patients undergoing endoscopic surgery with sedation. However, as a novel supraglottic ventilation technique, the application of supraglottic jet oxygenation and ventilation (SJOV) in endoscopic surgery has not been well established. METHOD: We searched six electronic databases from inception to January 16, 2024, to assess the oxygenation/ventilation efficacy and side effects of the of SJOV in endoscopic surgery. The primary outcome was the incidence of hypoxemia. The secondary outcomes were the incidence of respiratory depression and adverse effects (nasal bleeding, sore throat, and dry mouth). RESULTS: Nine trials involving 2017 patients were included. The results demonstrated that the incidence of hypoxemia was lower in the SJOV group compared with the conventional oxygen therapy (COT) group [9 trails; 2017 patients; risk ratio (RR) = 0.18; 95% confidence interval (CI), (0.11-0.28)]. Subgroup analyses showed that SJOV reduced the incidence of hypoxemia in the high-risk group but had no effect on the low-risk group. The incidence of respiratory depression is lower in SJOV than in COT, but has increased side effects such as dry mouth. There was no statistically significant difference in nose bleeding or sore throat between the two groups. CONCLUSION: Compared with the COT, the SJOV decreased the incidence of hypoxemia in high-risk patients during endoscopic surgery with sedation. There was an increased risk of dry mouth, but not of nose bleeding or sore throat, during endoscopic surgery under sedation.

Asunto(s)

Endoscopía , Ventilación con Chorro de Alta Frecuencia , Hipoxia , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Hipoxia/prevención & control , Hipoxia/etiología , Hipoxia/epidemiología , Endoscopía/efectos adversos , Endoscopía/métodos , Ventilación con Chorro de Alta Frecuencia/métodos , Ventilación con Chorro de Alta Frecuencia/efectos adversos , Sedación Consciente/efectos adversos , Sedación Consciente/métodos , Incidencia , Insuficiencia Respiratoria/prevención & control , Insuficiencia Respiratoria/etiología , Terapia por Inhalación de Oxígeno/métodos , Resultado del Tratamiento

RESUMEN

OBJECTIVE: This study aimed to compare the effects of patient-controlled intravenous analgesia (PCIA) with and without low-basal infusion on postoperative hypoxaemia. DESIGN: A randomised parallel-group non-inferiority trial. SETTING: The trial was conducted at a grade-A tertiary hospital from December 2021 to August 2022. PARTICIPANTS: 160 adults undergoing gastrointestinal tumour surgery and receiving postoperative PCIA. INTERVENTIONS: Participants randomly received a low-basal (0.1 mg/hour of hydromorphone) or no-basal infusion PCIA for postoperative 48 hours. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was area under curve (AUC) per hour for hypoxaemia, defined as pulse oxygen saturation (SpO2) <95%. Secondary outcomes included: AUC per hour at SpO2<90% and <85%, hydromorphone consumption, ambulation time and analgesic outcomes up to 48 hours after surgery. RESULTS: Among 160 randomised patients, 159 completed the trial. An intention-to-treat analysis showed that AUC per hour (SpO2<95%) was greater in the low-basal infusion group compared with the no-basal infusion group, with a median difference of 0.097 (95% CI 0.001 to 0.245). Non-inferiority (margin: ratio of means (ROM) of 1.25) was not confirmed since the ROM between the two groups was 2.146 (95% CI 2.138 to 2.155). Hydromorphone consumption was higher in the low-basal group than in the no-basal group (median: 5.2 mg versus 1.6 mg, p<0.001). Meanwhile, there were no differences in the AUC values at the other two hypoxaemia thresholds, in ambulation time, or pain scores between the groups. CONCLUSIONS: Among the patients receiving hydromorphone PCIA after gastrointestinal tumour resection, low-basal infusion was inferior to no-basal infusion PCIA for postoperative hypoxaemia at SpO2<95% up to 48 hours after surgery. TRIAL REGISTRATION NUMBER: ChiCTR2100054317.

Asunto(s)

Analgesia Controlada por el Paciente , Analgésicos Opioides , Hidromorfona , Hipoxia , Dolor Postoperatorio , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Analgesia Controlada por el Paciente/métodos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Neoplasias Gastrointestinales/cirugía , Neoplasias Gastrointestinales/complicaciones , Hidromorfona/administración & dosificación , Hipoxia/prevención & control , Hipoxia/etiología , Infusiones Intravenosas , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control

RESUMEN

A 71-year-old woman with coronary artery disease presented for carotid artery revascularization. After general anesthesia, the patient arrived in stable condition to the postanesthesia care unit. While awaiting transfer to her inpatient room, telemetry alarms alerted her nurse, who found the patient unresponsive, cyanotic, and pulseless. Advanced cardiovascular life support was initiated, with return of spontaneous circulation obtained after 1 round of chest compressions. On oropharyngeal examination, food particles were observed and suctioned. The patient then coughed up additional cracker pieces. This case highlights the risk of aspiration from dry, solid foods in the elderly during the postanesthesia recovery period.

Asunto(s)

Paro Cardíaco , Humanos , Femenino , Anciano , Paro Cardíaco/etiología , Hipoxia/etiología , Anestesia General

RESUMEN

Massive pulmonary embolism is a common cause of morbidity and mortality. For patients presenting with massive pulmonary embolism, severe hypoxia is usually associated with severe hypotension. These patients should be considered for thrombectomy should thrombolysis and respiratory support fail to improve their condition. Should thrombectomy not be available or suitable, consideration should be given to offering mechanical chest compressions to 'break up the clot'. We describe a case in which this seemingly led to survival and full recovery.

Asunto(s)

Hipoxia , Embolia Pulmonar , Humanos , Embolia Pulmonar/terapia , Embolia Pulmonar/complicaciones , Hipoxia/terapia , Hipoxia/etiología , Masculino , Reanimación Cardiopulmonar/métodos , Persona de Mediana Edad

RESUMEN

BACKGROUND: Cardiac surgery involving cardiopulmonary bypass induces a significant systemic inflammatory response, contributing to various postoperative complications, including pulmonary dysfunction, myocardial and kidney injuries. OBJECTIVE: To investigate the effect of Nitric Oxide delivery via the cardiopulmonary bypass circuit on various postoperative outcomes. DESIGN: A prospective, single-centre, double-blinded, randomised controlled trial. SETTING: Rabin Medical Centre, Beilinson Hospital, Israel. PATIENTS: Adult patients scheduled for elective cardiac surgery were randomly allocated to one of the study groups. INTERVENTIONS: For the treatment group, 40 ppm of nitric oxide was delivered via the cardiopulmonary bypass circuit. For the control group, nitric oxide was not delivered. OUTCOME MEASURES: The primary outcome was the incidence of hypoxaemia, defined as a p a O2 /FiO 2 ratio less than 300 within 24 h postoperatively. The secondary outcomes were the incidences of low cardiac output syndrome and acute kidney injury within 72 h postoperatively. RESULTS: Ninety-eight patients were included in the final analysis, with 47 patients allocated to the control group and 51 to the Nitric Oxide group. The Nitric Oxide group exhibited significantly lower hypoxaemia rates at admission to the cardiothoracic intensive care unit (47.1 vs. 68.1%), P  = 0.043. This effect, however, varied in patients with or without baseline hypoxaemia. Patients with baseline hypoxaemia who received nitric oxide exhibited significantly lower hypoxaemia rates (61.1 vs. 93.8%), P  = 0.042, and higher p a O2 /FiO 2 ratios at all time points, F (1,30) = 6.08, P  = 0.019. Conversely, this benefit was not observed in patients without baseline hypoxaemia. No significant differences were observed in the incidence of low cardiac output syndrome or acute kidney injury. No substantial safety concerns were noted, and toxic methaemoglobin levels were not observed. CONCLUSIONS: Patients with baseline hypoxaemia undergoing cardiac surgery and receiving nitric oxide exhibited lower hypoxaemia rates and higher p a O2 /FiO 2 ratios. No significant differences were found regarding postoperative pulmonary complications and overall outcomes. TRIAL REGISTRATION: NCT04807413.

Asunto(s)

Procedimientos Quirúrgicos Cardíacos , Puente Cardiopulmonar , Óxido Nítrico , Complicaciones Posoperatorias , Humanos , Óxido Nítrico/administración & dosificación , Masculino , Femenino , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Puente Cardiopulmonar/efectos adversos , Puente Cardiopulmonar/métodos , Estudios Prospectivos , Persona de Mediana Edad , Método Doble Ciego , Anciano , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Hipoxia/etiología , Hipoxia/prevención & control , Hipoxia/epidemiología , Lesión Renal Aguda/etiología , Lesión Renal Aguda/prevención & control , Lesión Renal Aguda/epidemiología , Resultado del Tratamiento , Oxígeno/administración & dosificación , Oxígeno/sangre , Gasto Cardíaco Bajo/prevención & control , Gasto Cardíaco Bajo/etiología

RESUMEN

BACKGROUND: Pleural effusions in post-operative thoracic surgery patients are common. Effusions can result in prolonged hospitalizations or readmissions, with prior studies suggesting mixed effects of pleural drainage on hypoxia. We aimed to define the impact of pleural drainage on pulse oximetry (SpO2) in post-thoracic surgery patients. METHODS: A retrospective study of post-operative thoracic surgery patients undergoing pleural drainage was performed. SpO2 and supplemental oxygen (FiO2) values were recorded at pre- and post-procedure. The primary outcome was difference in pre-procedural and post-procedural SpO2. RESULTS: We identified 95 patients with a mean age of 65 (SD - 13.8) years undergoing 122 pleural drainage procedures. Mean drainage volume was 619 (SD-423) mL and the majority of procedures (88.5 %) included a drainage of <1000 mL. SpO2 was associated with an increase from 94.0 % (SD-2.6) to 97.3 % (SD-2.0) at 24-h (p < 0.0001). FiO2 was associated with a decrease from 0.31 (SD-0.15) to 0.29 (SD-0.12) at 24-h (p = 0.0081). SpO2/FiO2 was associated with an increase from 344.5 (SD-99.0) to 371.9 (SD-94.7) at 24-h post-procedure (p < 0.0001). CONCLUSIONS: Pleural drainage within post-operative thoracic surgery patients offers statistically significant improvements in oxygen saturation by peripheral pulse oximetry and oxygen supplementation; however the clinical significance of these changes remains unclear. Pleural drainage itself may be requested for numerous reasons, including diagnostic (fevers, leukocytosis, etc.) or therapeutic (worsening dyspnea) evaluation. However, pleural drainage may offer minimal clinical impact on pulse oximetry in post-operative thoracic surgery patients.

Asunto(s)

Drenaje , Oximetría , Derrame Pleural , Procedimientos Quirúrgicos Torácicos , Humanos , Oximetría/métodos , Drenaje/métodos , Masculino , Femenino , Estudios Retrospectivos , Anciano , Persona de Mediana Edad , Derrame Pleural/etiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/diagnóstico , Cuidados Posoperatorios/métodos , Hipoxia/etiología , Periodo Posoperatorio

RESUMEN

PURPOSE: Although noninvasive ventilation (NIV) may reduce reintubation in patients with acute hypoxemic respiratory failure following abdominal surgery, this strategy has not been specifically assessed in patients with obesity. METHODS: We conducted a post hoc analysis of a multicenter randomized controlled trial comparing NIV delivered via facial mask to standard oxygen therapy among patients with obesity and acute hypoxemic respiratory failure within 7 days after abdominal surgery. The primary outcome was reintubation within 7 days. Secondary outcomes were invasive ventilation-free days at day 30, intensive care unit (ICU)-acquired pneumonia and 30-day survival. RESULTS: Among 293 patients with hypoxemic respiratory failure following abdominal surgery, 76 (26%) patients had obesity and were included in the intention-to-treat analysis. Reintubation rate was significantly lower with NIV (13/42, 31%) than with standard oxygen therapy (19/34, 56%) within 7 days (absolute difference: - 25%, 95% confidence interval (CI) - 49 to - 1%, p = 0.03). NIV was associated with significantly more invasive ventilation-free days compared with standard oxygen therapy (27.1 ± 8.6 vs 22.7 ± 11.1 days; p = 0.02), while fewer patients developed ICU-acquired pneumonia (1/42, 2% vs 6/34, 18%; p = 0.04). The 30-day survival was 98% in the NIV group (41/42) versus 85% in the standard oxygen therapy (p = 0.08). In patients with body mass index (BMI) < 30 kg/m2, no significant difference was observed between NIV (36/105, 34%) and standard oxygen therapy (47/109, 43%, p = 0.03). An interaction test showed no statistically significant difference between the two subsets (BMI ≥ 30 kg/m2 and BMI < 30 kg/m2). CONCLUSIONS: Among patients with obesity and hypoxemic respiratory failure following abdominal surgery, use of NIV compared with standard oxygen therapy reduced the risk of reintubation within 7 days, contrary to patients without obesity. However, no interaction was found according to the presence of obesity or not, suggesting either a lack of power to conclude in the non-obese subgroup despite existing differences, or that the statistical difference found in the overall sample was driven by a large effect in the obese subsets.

Asunto(s)

Ventilación no Invasiva , Obesidad , Insuficiencia Respiratoria , Humanos , Masculino , Ventilación no Invasiva/métodos , Ventilación no Invasiva/estadística & datos numéricos , Femenino , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/etiología , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/terapia , Anciano , Intubación Intratraqueal/estadística & datos numéricos , Intubación Intratraqueal/efectos adversos , Abdomen/cirugía , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Complicaciones Posoperatorias/epidemiología , Hipoxia/etiología , Hipoxia/terapia , Terapia por Inhalación de Oxígeno/métodos , Terapia por Inhalación de Oxígeno/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos

RESUMEN

PURPOSE: Skin pigmentation influences peripheral oxygen saturation (SpO2) compared to arterial saturation of oxygen (SaO2). Occult hypoxemia (SaO2 ≤ 88% with SpO2 ≥ 92%) is associated with increased in-hospital mortality in venovenous-extracorporeal membrane oxygenation (VV-ECMO) patients. We hypothesized VV-ECMO cannulation, in addition to race/ethnicity, accentuates the SpO2-SaO2 discrepancy due to significant hemolysis. METHODS: Adults (≥ 18 years) supported with VV-ECMO with concurrently measured SpO2 and SaO2 measurements from over 500 centers in the Extracorporeal Life Support Organization Registry (1/2018-5/2023) were included. Multivariable logistic regressions were performed to examine whether race/ethnicity was associated with occult hypoxemia in pre-ECMO and on-ECMO SpO2-SaO2 calculations. RESULTS: Of 13,171 VV-ECMO patients, there were 7772 (59%) White, 2114 (16%) Hispanic, 1777 (14%) Black, and 1508 (11%) Asian patients. The frequency of on-ECMO occult hypoxemia was 2.0% (N = 233). Occult hypoxemia was more common in Black and Hispanic patients versus White patients (3.1% versus 1.7%, P < 0.001 and 2.5% versus 1.7%, P = 0.025, respectively). In multivariable logistic regression, Black patients were at higher risk of pre-ECMO occult hypoxemia versus White patients (adjusted odds ratio [aOR] = 1.55, 95% confidence interval [CI] = 1.18-2.02, P = 0.001). For on-ECMO occult hypoxemia, Black patients (aOR = 1.79, 95% CI = 1.16-2.75, P = 0.008) and Hispanic patients (aOR = 1.71, 95% CI = 1.15-2.55, P = 0.008) had higher risk versus White patients. Higher pump flow rates (aOR = 1.29, 95% CI = 1.08-1.55, P = 0.005) and on-ECMO 24-h lactate (aOR = 1.06, 95% CI = 1.03-1.10, P < 0.001) significantly increased the risk of on-ECMO occult hypoxemia. CONCLUSION: SaO2 should be carefully monitored if using SpO2 during ECMO support for Black and Hispanic patients especially for those with high pump flow and lactate values at risk for occult hypoxemia.

Asunto(s)

Oxigenación por Membrana Extracorpórea , Hipoxia , Sistema de Registros , Humanos , Oxigenación por Membrana Extracorpórea/efectos adversos , Hipoxia/terapia , Hipoxia/sangre , Hipoxia/etiología , Masculino , Femenino , Persona de Mediana Edad , Adulto , Saturación de Oxígeno , Hispánicos o Latinos/estadística & datos numéricos , Mortalidad Hospitalaria , Población Blanca , Anciano , Estados Unidos/epidemiología , Negro o Afroamericano , Hemólisis

RESUMEN

Humidified high-flow nasal oxygen therapy (HFNO) has, in recent years, come to assume a key role in the management of hypoxemic acute respiratory failure (ARF). While non-invasive ventilation (NIV) currently represents the first-line ventilatory strategy in patients exhibiting hypercapnic ARF, the operating principles and physiological effects of HFNO could be interesting and useful in the initial management of hypercapnic ARF and/or after extubation, particularly in acute exacerbations of chronic obstructive pulmonary disease. Under these conditions, HFNO could be used either alone continuously or in combination with NIV during breaks in spontaneous breathing, depending on the severity and etiology of the underlying hypercapnic ARF.

Asunto(s)

Hipercapnia , Ventilación no Invasiva , Terapia por Inhalación de Oxígeno , Insuficiencia Respiratoria , Humanos , Terapia por Inhalación de Oxígeno/métodos , Hipercapnia/terapia , Hipercapnia/etiología , Insuficiencia Respiratoria/terapia , Insuficiencia Respiratoria/etiología , Enfermedad Aguda , Ventilación no Invasiva/métodos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Enfermedad Pulmonar Obstructiva Crónica/complicaciones , Hipoxia/terapia , Hipoxia/etiología

RESUMEN

BACKGROUND: Closed-loop oxygen control systems automatically adjust the fraction of inspired oxygen (FiO2) to maintain oxygen saturation (SpO2) within a predetermined target range. Their performance with low and high-flow oxygen therapies, but not with non-invasive ventilation, has been established. We compared the effect of automated oxygen on achieving and maintaining a target SpO2 range with nasal high flow (NHF), bilevel positive airway pressure (bilevel) and continuous positive airway pressure (CPAP), in stable hypoxaemic patients with chronic cardiorespiratory disease. METHODS: In this open-label, three-way cross-over trial, participants with resting hypoxaemia (n=12) received each of NHF, bilevel and CPAP treatments, in random order, with automated oxygen titrated for 10 min, followed by 36 min of standardised manual oxygen adjustments. The primary outcome was the time taken to reach target SpO2 range (92%-96%). Secondary outcomes included time spent within target range and physiological responses to automated and manual oxygen adjustments. RESULTS: Two participants were randomised to each of six possible treatment orders. During automated oxygen control (n=12), the mean (±SD) time to reach target range was 114.8 (±87.9), 56.6 (±47.7) and 67.3 (±61) seconds for NHF, bilevel and CPAP, respectively, mean difference 58.3 (95% CI 25.0 to 91.5; p=0.002) and 47.5 (95% CI 14.3 to 80.7; p=0.007) seconds for bilevel and CPAP versus NHF, respectively. Proportions of time spent within target range were 68.5% (±16.3), 65.6% (±28.7) and 74.7% (±22.6) for NHF, bilevel and CPAP, respectively.Manually increasing, then decreasing, the FiO2 resulted in similar increases and then decreases in SpO2 and transcutaneous carbon dioxide (PtCO2) with NHF, bilevel and CPAP. CONCLUSION: The target SpO2 range was achieved more quickly when automated oxygen control was initiated with bilevel and CPAP compared with NHF while time spent within the range across the three therapies was similar. Manually changing the FiO2 had similar effects on SpO2 and PtCO2 across each of the three therapies. TRIAL REGISTRATION NUMBER: ACTRN12622000433707.

Asunto(s)

Presión de las Vías Aéreas Positiva Contínua , Estudios Cruzados , Hipoxia , Ventilación no Invasiva , Terapia por Inhalación de Oxígeno , Saturación de Oxígeno , Humanos , Masculino , Femenino , Terapia por Inhalación de Oxígeno/métodos , Hipoxia/terapia , Hipoxia/etiología , Persona de Mediana Edad , Ventilación no Invasiva/métodos , Anciano , Presión de las Vías Aéreas Positiva Contínua/métodos , Oxígeno/administración & dosificación , Enfermedades Cardiovasculares/terapia , Adulto

Asunto(s)

Procedimiento de Fontan , Hipoxia , Humanos , Circulación Colateral/fisiología , Procedimiento de Fontan/efectos adversos , Hipoxia/etiología , Complicaciones Posoperatorias/etiología