71 research outputs found
Evaluation_form_1_-_Supplemental_material – Supplemental material for Development of a prototype anti-pollution filter for volatile anesthetics
No full textSupplemental material, Evaluation_form_1_-_Supplemental_material for Development of a prototype anti-pollution filter for volatile anesthetics by Caetano Nigro Neto, Aron Jose Pazin Andrade, Edir Leal, Francisco Jose Lucena Bezerra, Vladimir Lomivorotov and Giovanni Landoni in The International Journal of Artificial Organs</p
An innovative technique to improve safety of volatile anesthetics suction from the cardiopulmonary bypass circuit
No full textContext: Myocardial injury during cardiac surgery on cardiopulmonary bypass (CPB) is a major determinant of morbidity and mortality. Preclinical and clinical evidence of dose- and time-related cardioprotective effects of volatile anesthetic drugs exist and their use during the whole surgery duration could improve perioperative cardiac protection. Even if administering volatile agents during CPB are relatively easy, technical problems, such as waste gas scavenging, may prevent safe and manageable administration of halogenated vapors during CPB. Aims: The aim of this study is to improve the safe administration of volatile anesthesia during CPB. Settings and Design: Tertiary teaching hospital. Subjects and Methods: We describe an original device that collects and disposes of any volatile anesthetic vapors present in the exit stream of the oxygenator, hence preventing its dispersal into the operating theatre environment and adaptively regulates pressure of oxygenator chamber in the CPB circuit. Results: We have so far applied a prototype of this device in more than 1300 adult cardiac surgery patients who received volatile anesthetics during the CPB phase. Conclusions: Widespread implementation of scavenging system like the one we designed may facilitate the perfusionist and the anesthesiologist in delivering these cardioprotective drugs with beneficial impact on patients' outcome without compromising on safety
Minimum alveolar concentration of sevoflurane for maintaining BIS below 50 in patients undergoing coronary artery bypass grafting during normothermic cardiopulmonary bypass phase
No full textIntrodução: A concentração alveolar mínima (CAM) de anestésico inalatório em que 50% dos pacientes mantêm o valor do índice bispectral (BIS) abaixo de 50 é denominada CAMBIS50. A CAMBIS50 foi determinada em pacientes de diferentes idades e condições clinicas, mas não em cirurgia cardíaca. Objetivo: Determinar a concentração alveolar mínima do sevoflurano para índice bispectral abaixo de 50 durante o reaquecimento na circulação extracorpórea, em pacientes submetidos à revascularização do miocárdio. Métodos: Pacientes com estado físico III ou IV da American Society of Anestesiology, com idade entre 40 e 70 anos e submetidos à revascularização do miocárdio foram recrutados para este estudo. Na fase final de reaquecimento da circulação extracorpórea, durante o estado de equilíbrio, uma concentração expirada final alvo pré-determinada do sevoflurano foi mantida por pelo menos dez minutos. Seguido imediatamente por uma avaliação durante 1 minuto do valor do BIS, consistindo de 6 registros feitos em intervalos de 10 segundos. O vaporizador foi ajustado para atingir uma concentração final do sevoflurano de 1% no primeiro paciente. Se um dado paciente apresentasse uma média de valor do BIS abaixo de 50, a concentração expirada final do sevoflurano era reduzida em 0,1% no paciente subsequente. Enquanto, se o paciente apresentasse uma média de valor do BIS 50, a concentração expirada final do sevoflurano era aumentada em 0,1% no paciente subsequente. A CAMBIS50 foi calculada pela média dos pontos médios de cada par cruzado através da sequência Up-and-Down de Dixon. Esta sequência foi avaliada também pelo Probit test, que nos permitiu obter as probabilidades 50% e 95% do sevoflurano para manter um valor do BIS < 50. Resultado: Dos 18 pacientes que foram recrutados para este estudo, 15 efetivamente continuaram no estudo (9 tiveram valores de BIS < 50 e 6 tiveram valores de BIS 50). A CAMBIS50 do sevoflurano durante o reaquecimento na circulação extracorpórea, em adultos com idade entre 40 e 70 anos submetidos à revascularização do miocárdio, calculada pelo método Up-and-Down de Dixon foi de 0,82% [intervalo de confiança de 95% (IC 95%): 0,47-1,16]. As probabilidades 50% e 95% calculadas pelo Probit test para o mesmo contexto foram respectivamente, 0,73% (IC 95%: 0,45-1,00) e 1,39% (IC 95%: 0,42-2,37). Conclusão: A CAMBIS50 do sevoflurano durante o reaquecimento na circulação extracorpórea, em adultos com idade entre 40 e 70 anos submetidos à revascularização do miocárdio, calculada pelo método Up-and-Down de Dixon foi de 0,82% (IC 95%: 0,47-1,16).Introduction: The minimum alveolar concentration (MAC) of inhalational anesthetic for maintaining bispectral index (BIS) below 50 in 50% of patients is defined MACBIS50. MACBIS50 was determined in different ages groups and clinical conditions of patients, however not in cardiac surgery. Objective: This study aims to determine the minimum alveolar concentration of sevoflurane for maintaining bispectral index below 50 in patients undergoing coronary artery bypass grafting during normothermic cardiopulmonary bypass phase. Method: Patients with physical status III or IV of the American Society of Anestesiology, aged between 40 and 70 years and undergoing myocardial revascularization were enrolled in our study. The predetermined target expired concentration of sevoflurane was maintained for at least ten minutes during normothermic cardiopulmonary bypass phase. BIS values were then recorded at an interval of 10 seconds for 1 minute in the state of equilibio. The dial settings were adjusted to attain an end-tidal sevoflurane concentration of 1% in the first patient. If a given patient had an average BIS of < 50, the sevoflurane concentration was reduced by 0.1% in the subsequent patient, whereas if a given patient had a BIS 50, the sevoflurane concentration was increased by 0.1% in the next patient. MACBIS50 was calculated using the midpoint concentration of patients involving a crossover according to the Dixons Up-and-Down sequence. The Up-and-Down sequences were also analyzed by the probit test, which enabled us to derive the sevoflurane concentration to obtain the 50% and 95% probabilities to maintain a BIS value < 50. Result: Of the 18 patients who were recruited for this study, 15 effectively continued in the study (9 had BIS values < 50 and 6 had BIS values 50). MACBIS50 of sevoflurane was 0.82% (CI 95%: 0.47-1.16) in patients undergoing coronary artery bypass grafting during normothermic cardiopulmonary bypass phase. The 50% and 95% probabilities calculated by the Probit test for the same context were, respectively, 0.73% (95% CI: 0.45-1.00) and 1.39% (95% CI: 0.42-2.37). Conclusion: MACBIS50 of sevoflurane was 0.82% (CI 95%: 0.47-1.16) in patients undergoing coronary artery bypass grafting during normothermic cardiopulmonary bypass phase
Evaluation of the systemic inflammatory response with the use of sevoflurane during cardiopulmonary bypass in myocardial revascularization surgery
No full textIntrodução: Atualmente, a anestesia para cirurgia de revascularização do miocárdio segue uma abordagem que visa combater os processos de lesões causados pela isquemia e reperfusão, por meio do pré-condicionamento cardíaco isquêmico remoto e farmacológico, como o proporcionado pelos anestésicos inalatórios, o que pode gerar uma redução nos processos inflamatórios associados à circulação extracorpóra, conforme modelo experimental. Objetivo: Avaliar o efeito anti-inflamatório do Sevoflurano nos pacientes submetidos a revascularização do miocárdio com CEC. Métodos: Foram incluídos total de 100 pacientes, submetidos a revascularização do miocárdio eletiva com CEC, e foram alocados aleatoriamente em 2 grupos: Grupo SEVO (n=50) e Grupo CONTROLE (n=50), com e sem uso de Sevoflurano durante a CEC, respectivamente. Foram anotadas informações biodemográficas e clínicas do pré e pós-operatório e coletadas também as amostras de sangue periférico para dosagens bioquímicas e análise da biologia molecular. Foram avaliados; PMN-elastase IL-1b, IL-4, IL-6, IL-8, IL-10, TNFa e TGFb, além da expressão gênica e dos microRNAs envolvidos no processo inflamatório. A análise estatística foi feita comparando os dois grupos. Resultados: Os parâmetros biodemográficos e clínicos préoperatórios foram homogêneos entre os grupos. As medicações em uso préoperatório mostraram uma diferença significativa para o uso do inibidor da enzima conversora de angiotensina no grupo SEVO (p=0,046). Os dados pósoperatórios mostraram um tempo de intubação maior no grupo SEVO (p=0,049), no entanto, sem diferença nas complicações e na mortalidade. A maioria das expressões gênicas nos leucócitos não mostraram diferença. As citocinas próinflamatórias circulantes IL-1B (p=0,004) e IL-8 (p=0,029) a IL-6 (p=0,009) estavam diminuídas no grupo SEVO. As citocinas anti-inflamatórias IL-4 (p=0,021) estava diminuída no grupo SEVO e IL10 (p=0,004) aumentada no grupo CONTROLE. Os microRNAs que atuam na regulação destas citocinas foram menos expressos no grupo SEVO. Conclusão: No contexto da cirurgia de revascularização do miocárdio com CEC, o sevoflurano pode diminuir o processo inflamatório, regulando os mecanismos pós-transcricionais mediados pelos microRNAs na síntese de citocinas pró e anti-inflamatórias.Introduction: Currently, anesthesia for myocardial revascularization surgery follows an approach that aims to combat the processes of injuries caused by ischemia and reperfusion, through remote ischemic and pharmacological cardiac preconditioning, such as that provided by inhaled anesthetics, which can generate a reduction in the inflammatory processes associated with extracorporeal circulation, according to the experimental model. Objective: To evaluate the antiinflammatory effect of Sevoflurane in patients undergoing coronary artery bypass graft with CPB. Methods: A total of 100 patients who underwent elective myocardial revascularization with CPB were included, and were randomly allocated to 2 groups: SEVO Group (n = 50) and CONTROL Group (n = 50), with and without the use of Sevoflurane during CEC, respectively. Pre-and postoperative bio-demographic and clinical information were recorded and peripheral blood samples were also collected for biochemical measurements and analysis of molecular biology. Were evaluated; PMN-elastase IL-1b, IL-4, IL-6, IL-8, IL-10, TNFa and TGFb, in addition to gene expression and microRNAs involved in the inflammatory process. Statistical analysis was performed comparing the two groups. Results: The preoperative bioemographic and clinical parameters were homogeneous between the groups. Preoperative medications showed a significant difference for the use of the angiotensin-converting enzyme inhibitor in the SEVO group (p = 0.046). Postoperative data showed a longer intubation time in the SEVO group (p = 0.049), however, with no difference in complications and mortality. Most leukocyte gene expressions showed no difference. Circulating pro-inflammatory cytokines IL-1B (p = 0.004) and IL-8 (p = 0.029) to IL-6 (p = 0.009) were decreased in the SEVO group. The anti-inflammatory cytokines IL- 4 (p = 0.021) was decreased in the SEVO group and IL10 (p = 0.004) increased in the CONTROL group. The microRNAs that act in the regulation of these cytokines were less expressed in the SEVO group. Conclusion: In the context of myocardial revascularization surgery with CPB, sevoflurane can decrease the inflammatory process, regulating microRNA-mediated post-transcriptional mechanisms in the synthesis of pro and anti-inflammatory cytokines
The effects of adding intrathecal sufentanil to general anesthesia in patients undergoing coronary artery bypass grafting
No full textObjetivo: Avaliar os efeitos da associacao de sufentanil intratecal a anestesia geral com relacao as alteracoes hemodinamicas no intraoperatorio, em pacientes submetidos a cirurgia de revascularizacao do miocardio com circulacao extracorporea. Tambem avaliados seus possiveis impactos em resultados pos-operatorios, como tempo para a retirada da canula endotraqueal, analgesia e tempo de permanencia na unidade de terapia intensiva e hospitalar. Metodos: Estudo randomizado e prospectivo, nao encoberto ao regime anestesico utilizado, realizado no Instituto Dante Pazzanese de Cardiologia apos aprovacao pelo Comite de Etica em pesquisa local. Incluidos 40 pacientes de ambos os sexos, divididos em dois grupos, S e N, na dependencia de receberem ou nao 1 μg.kg-1 de sufentanil intratecal, respectivamente. A inducao e manutencao da anestesia , incluindo a CEC, foram feitas com sevoflurano, pancuronio e infusao continua de remifentanil. Obtidas variaveis hemodinamicas, niveis sericos de troponina cardiaca I e peptideo natriuretico tipo B (avaliando cardioprotecao), interleucina 6 e fator de necrose tumoral alfa (avaliando resposta inflamatoria), dados coletados no intra e no pos-operatorio. Na analise estatistica os dados obtidos foram expressos em numero (porcentagem), media (±desvio padrao), ou mediana (variacao interquartil). Os testes compararam os grupos com relacao aos dados demograficos; necessidade do uso de drogas vasoativas; consumo de agentes anestesicos; dados bioquimicos e dados hemodinamicos. Resultados: Os grupos foram comparaveis quanto aos dados demograficos. Os pacientes do grupo S necessitaram de menor suporte inotropico com dopamina quando comparados aos pacientes do grupo N (9,5% vs 58%; p=0,001) e tambem menor consumo de remifentanil (62% vs 100%; p=0,004). Nao houve diferenca estatistica significativa quanto aos dados bioquimicos avaliados. Conclusoes: Os pacientes que receberam sufentanil intratecal apresentaram maior estabilidade hemodinamica quando comparados ao grupo controle. Tal resultado foi demonstrado por um menor suporte inotropico e menor necessidade nas doses de opiodes venosos utilizadas. Estes efeitos nao parecem terem sidos decorrentes de menor resposta inflamatoria, como tambem por maior cardioprotecaoBV UNIFESP: Teses e dissertaçõe
Dexmedetomidine as a Sedative Agent in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials
No full textThe effect of dexmedetomidine on length of intensive care unit (ICU) stay and time to extubation is still unclear.Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and the Cochrane Central Register of clinical trials (updated February first 2013). Randomized studies (dexmedetomidine versus any comparator) were included if including patients mechanically ventilated in an intensive care unit (ICU). Co-primary endpoints were the length of ICU stay (days) and time to extubation (hours). Secondary endpoint was mortality rate at the longest follow-up available.The 27 included manuscripts (28 trials) randomized 3,648 patients (1,870 to dexmedetomidine and 1,778 to control). Overall analysis showed that the use of dexmedetomidine was associated with a significant reduction in length of ICU stay (weighted mean difference (WMD) = −0.79 [−1.17 to −0.40] days, p for effect <0.001) and of time to extubation (WMD = −2.74 [−3.80 to −1.65] hours, p for effect <0.001). Mortality was not different between dexmedetomidine and controls (risk ratio = 1.00 [0.84 to 1.21], p for effect = 0.9). High heterogeneity between included studies was found.This meta-analysis of randomized controlled studies suggests that dexmedetomidine could help to reduce ICU stay and time to extubation, in critically ill patients even if high heterogeneity between studies might confound the interpretation of these results
Paraplegia após revascularização cirúrgica do miocárdio: relato de caso Paraplejia después de la revascularización quirúrgica del miocardio: relato de caso Paraplegia after myocardial revascularization: case report
No full textJUSTIFICATIVA E OBJETIVOS: Os avanços ocorridos na Anestesiologia permitiram melhores índices de segurança. Várias técnicas e agentes são utilizados visando controlar a resposta hemodinâmica e minimizar os efeitos adversos do estimulo cirúrgico em pacientes submetidos a procedimentos cardíacos. RELATO DO CASO: Paciente de 70 anos, masculino, 1,74 m, 75 kg, ASA III, e NYHA II. Portador de dislipidemia, diabetes mellitus tipo II e hipertensão arterial controladas; tabagismo, enfermidade vascular periférica e história de infarto agudo do miocárdio há 20 anos. O paciente foi submetido a revascularização com artéria mamária interna esquerda e enxertos de safena com pinçamento intermitente da aorta em circulação extracorpórea. Durante as primeiras 24 horas na UTI apresentou eventos de instabilidade hemodinâmica, hipotensão súbita e fibrilação atrial. Após 26 horas do final do procedimento cirúrgico, o paciente estava acordado, hemodinamicamente estável e com boa dinâmica respiratória quando foi extubado. O paciente estava comunicativo, orientado, porém com imobilidade e reflexos abolidos nos membros inferiores. Na avaliação neurológica: pares de nervos cranianos sem alteração, ausência de queixa de dor de qualquer tipo da cintura pélvica para baixo, preservação da sensibilidade superficial e profunda, perfusão distal adequada sem edemas, e paraplegia flácida na região abaixo de T8. Exame de ecocardiografia sem alterações. A tomografia computadorizada da coluna lombo-sacra, não mostrou massa compressiva no espaço epidural ou adjacente. CONCLUSÃO: A síndrome da artéria espinhal anterior, deve ser sempre considerada nos procedimentos de manipulação da aorta. A prevenção, particularmente nos pacientes de risco é necessária. A tomografia computadorizada é importante para o diagnóstico diferencial e a ressonância magnética para a localização da lesão.JUSTIFICATIVA Y OBJETIVOS: En las últimas décadas, los avances que se han dado en anestesiología resultaron en una reducción de los indicadores de morbilidad y mortalidad. En ese contexto, varias técnicas y agentes anestésicos han sido utilizados para controlar la respuesta hemodinámica y minimizar los efectos perjudiciales provenientes del estimulo quirúrgico en pacientes sometidos a procedimientos cardíacos. En cirugía cardíaca, la asociación de la anestesia regional a la anestesia general, ha sido motivo de muchas controversias entre los anestesistas, además de haber promovido muchos estudios en los últimos años. El surgimiento de las complicaciones neurológicas, es una situación devastadora que puede ocurrir después de una cirugía cardiovascular. En este artículo, relatamos un caso de paraplejia ocurrida en un paciente de 70 años, del sexo masculino, y después de una cirugía de revascularización del miocardio añadiéndosele opioide subaracnoideo a la anestesia general.BACKGROUND AND OBJECTIVES: Developments in anesthesiology have improved safety indices. Several techniques and agents are used to control the hemodynamic response and minimize adverse effects triggered by surgical stimuli in patients undergoing cardiac procedures. CASE REPORT: This is a 70 years old male patient, 1.74 m, 75 kg, ASA III, and NYHA II. The patient had controlled dyslipedemia, type II diabetes mellitus, and hypertension; history of smoking, peripheral vascular disease, and myocardial infarction 20 years ago. The patient underwent revascularization with the left internal mammary artery and saphenous grafts with extracorporeal circulation with intermittent clamping of the aorta. During the first 24 hours in the ICU, the patient developed hemodynamic instability, sudden hypotension, and atrial fibrillation. Twenty-six hours after the end of the surgery, the patient was awake, hemodynamically stable, and with good respiratory dynamics, being extubated. The patient was talkative and oriented, but immobile and negative reflexes in the lower limbs. Neurological evaluation showed: cranial nerves without changes, no complaints of pain below the hips, preserved superficial and deep sensitivity, adequate distal perfusion without edema, and flaccid paraplegia below T8. The echocardiogram did not show any changes. CT scan of the lumbosacral spine was negative for compressive mass in the epidural space or adjacent to it. CONCLUSION: Anterior spinal artery syndrome should be considered in procedures with manipulation of the aorta. Prevention, especially in patients at risk, is necessary. Computed tomography, for the differential diagnosis, and MRI, to localize the lesion, are important
Assessment of sternal closure using titanium plate
No full textINTRODUCTION: The use of plates and screws for more rigid fixation of the sternum, without maintaining contact between the upper portion of the sternum and mediastinum. The present study seeks new choice of plate with a significant difference, the same does not need to be removed in order to proceed to open when necessary sternal emerging opening of the bone. OBJECTIVE: The current study aims to evaluate the efficacy and safety of this procedure. METHODS: To this end, we selected ten patients with coronary artery disease have shown no significant risk factors for mediastinitis. The surgery was thus performed in the usual way that all patients with coronary artery disease surgeries are done at the institution. Only at the time of sternal closure is that there was a change, with the combination of steel wires and plates. RESULTS: All cases had sternal closure properly with good outcome in the medium term. CONCLUSION: The use of plates ENGIMPLAN proved safe and effective for sternal closure
Use of Volatile Anesthetics in Extracorporeal Circulation
No full textAbstractBackground and objectivesThe use of volatile anesthetics in cardiac surgery is not recent. Since the introduction of halothane in clinical practice, several cardiac surgery centers started to use these anesthetics constantly.ContentIn the last years a great number of studies have shown that the volatile anesthetics have a protecting effect against myocardial ischemic dysfunction. Experimental evidences have shown that the halogenated anesthetics have cardioprotective effects that cannot be only explained by coronary flow alterations or by the balance between myocardium available and consumed oxygen. In addition to that, the use of volatile anesthetics during extracorporeal circulation (ECC) in cardiac surgery plays an important role. Recent studies have proven that these agents have cardioprotective properties and produce better results when the volatile anesthetic is used during the whole surgery procedure, including ECC. The use of halogenated anesthetics through calibrated vaporizers adapted to the ECC circuit via oxygenator membranes has become popular. Therefore, the professionals involved such as anesthesiologists and perfusionists should learn specifcs in order to solve possible doubts
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