Purpose
This study aimed at investigating the mechanisms underlying the oxygenation response to proning and recruitment maneuvers in coronavirus disease 2019 (COVID-19) pneumonia.
Methods
Twenty-five ...patients with COVID-19 pneumonia, at variable times since admission (from 1 to 3 weeks), underwent computed tomography (CT) lung scans, gas-exchange and lung-mechanics measurement in supine and prone positions at 5 cmH
2
O and during recruiting maneuver (supine, 35 cmH
2
O). Within the non-aerated tissue, we differentiated the atelectatic and consolidated tissue (recruitable and non-recruitable at 35 cmH
2
O of airway pressure). Positive/negative response to proning/recruitment was defined as increase/decrease of PaO
2
/FiO
2
. Apparent perfusion ratio was computed as venous admixture/non aerated tissue fraction.
Results
The average values of venous admixture and PaO
2
/FiO
2
ratio were similar in supine-5 and prone-5. However, the PaO
2
/FiO
2
changes (increasing in 65% of the patients and decreasing in 35%, from supine to prone) correlated with the balance between resolution of dorsal atelectasis and formation of ventral atelectasis (
p
= 0.002). Dorsal consolidated tissue determined this balance, being inversely related with dorsal recruitment (
p
= 0.012). From supine-5 to supine-35, the apparent perfusion ratio increased from 1.38 ± 0.71 to 2.15 ± 1.15 (
p
= 0.004) while PaO
2
/FiO
2
ratio increased in 52% and decreased in 48% of patients. Non-responders had consolidated tissue fraction of 0.27 ± 0.1 vs. 0.18 ± 0.1 in the responding cohort (
p
= 0.04). Consolidated tissue, PaCO
2
and respiratory system elastance were higher in patients assessed late (all
p
< 0.05), suggesting, all together, “fibrotic-like” changes of the lung over time.
Conclusion
The amount of consolidated tissue was higher in patients assessed during the third week and determined the oxygenation responses following pronation and recruitment maneuvers.
BACKGROUND:Continuous infusions of norepinephrine to treat perioperative hypotension are typically administered through a central venous line rather than a peripheral venous catheter to avoid the ...risk of localized tissue necrosis in case of drug extravasation. There is limited literature to estimate the risk of skin necrosis when peripheral norepinephrine is used to counteract anesthesia-associated hypotension in elective surgical cases. This study aimed to estimate the rate of occurrence of drug-related adverse effects, including skin necrosis requiring surgical management when norepinephrine peripheral extravasation occurs.
METHODS:This retrospective cohort study used the perioperative databases of the University Hospitals in Amsterdam and Utrecht, the Netherlands, to identify surgical patients who received norepinephrine peripheral intravenous infusions (20 µg/mL) between 2012 and 2016. The risk of drug-related adverse effects, including skin necrosis, was estimated. Particular care was taken to identify patients who needed plastic surgical or medical attention secondary to extravasation of dilute, peripheral norepinephrine.
RESULTS:A total of 14,385 patients who received norepinephrine peripheral continuous infusions were identified. Drug extravasation was observed in 5 patients (5/14,385 = 0.035%). The 95% confidence interval (CI) for infusion extravasation was 0.011%–0.081%, indicating an estimated risk of 1–8 events per every 10,000 patients. There were zero related complications requiring surgical or medical intervention, resulting in a 95% CI of 0%–0.021% and indicating a risk of approximately 0–2 events per 10,000 patients.
CONCLUSIONS:In the current database analysis, no significant association was found between the use of peripheral intravenous norepinephrine infusions and adverse events.
Low mean arterial pressure (MAP) and deep hypnosis have been associated with complications and mortality. The normal response to high minimum alveolar concentration (MAC) fraction of anesthetics is ...hypotension and low Bispectral Index (BIS) scores. Low MAP and/or BIS at lower MAC fractions may represent anesthetic sensitivity. The authors sought to characterize the effect of the triple low state (low MAP and low BIS during a low MAC fraction) on duration of hospitalization and 30-day all-cause mortality.
Mean intraoperative MAP, BIS, and MAC were determined for 24,120 noncardiac surgery patients at the Cleveland Clinic, Cleveland, Ohio. The hazard ratios associated with combinations of MAP, BIS, and MAC values greater or less than a reference value were determined. The authors also evaluated the association between cumulative triple low minutes, and excess length-of-stay and 30-day mortality.
Means (±SD) defining the reference, low, and high states were 87 ± 5 mmHg (MAP), 46 ± 4 (BIS), and 0.56 ± 0.11 (MAC). Triple lows were associated with prolonged length of stay (hazard ratio 1.5, 95% CI 1.3-1.7). Thirty-day mortality was doubled in double low combinations and quadrupled in the triple low group. Triple low duration ≥60 min quadrupled 30-day mortality compared with ≤15 min. Excess length of stay increased progressively from ≤15 min to ≥60 min of triple low.
The occurrence of low MAP during low MAC fraction was a strong and highly significant predictor for mortality. When these occurrences were combined with low BIS, mortality risk was even greater. The values defining the triple low state were well within the range that many anesthesiologists tolerate routinely.
BACKGROUND:Despite the significant healthcare impact of acute kidney injury, little is known regarding prevention. Single-center data have implicated hypotension in developing postoperative acute ...kidney injury. The generalizability of this finding and the interaction between hypotension and baseline patient disease burden remain unknown. The authors sought to determine whether the association between intraoperative hypotension and acute kidney injury varies by preoperative risk.
METHODS:Major noncardiac surgical procedures performed on adult patients across eight hospitals between 2008 and 2015 were reviewed. Derivation and validation cohorts were used, and cases were stratified into preoperative risk quartiles based upon comorbidities and surgical procedure. After preoperative risk stratification, associations between intraoperative hypotension and acute kidney injury were analyzed. Hypotension was defined as the lowest mean arterial pressure range achieved for more than 10 min; ranges were defined as absolute (mmHg) or relative (percentage of decrease from baseline).
RESULTS:Among 138,021 cases reviewed, 12,431 (9.0%) developed postoperative acute kidney injury. Major risk factors included anemia, estimated glomerular filtration rate, surgery type, American Society of Anesthesiologists Physical Status, and expected anesthesia duration. Using such factors and others for risk stratification, patients with low baseline risk demonstrated no associations between intraoperative hypotension and acute kidney injury. Patients with medium risk demonstrated associations between severe-range intraoperative hypotension (mean arterial pressure less than 50 mmHg) and acute kidney injury (adjusted odds ratio, 2.62; 95% CI, 1.65 to 4.16 in validation cohort). In patients with the highest risk, mild hypotension ranges (mean arterial pressure 55 to 59 mmHg) were associated with acute kidney injury (adjusted odds ratio, 1.34; 95% CI, 1.16 to 1.56). Compared with absolute hypotension, relative hypotension demonstrated weak associations with acute kidney injury not replicable in the validation cohort.
CONCLUSIONS:Adult patients undergoing noncardiac surgery demonstrate varying associations with distinct levels of hypotension when stratified by preoperative risk factors. Specific levels of absolute hypotension, but not relative hypotension, are an important independent risk factor for acute kidney injury.
Purpose
We investigated if the stress applied to the lung during non-invasive respiratory support may contribute to the coronavirus disease 2019 (COVID-19) progression.
Methods
Single-center, ...prospective, cohort study of 140 consecutive COVID-19 pneumonia patients treated in high-dependency unit with continuous positive airway pressure (
n
= 131) or non-invasive ventilation (
n
= 9). We measured quantitative lung computed tomography, esophageal pressure swings and total lung stress.
Results
Patients were divided in five subgroups based on their baseline PaO
2
/FiO
2
(day 1): non-CARDS (median PaO
2
/FiO
2
361 mmHg, IQR 323–379), mild (224 mmHg 211–249), mild-moderate (173 mmHg 164–185), moderate-severe (126 mmHg 114–138) and severe (88 mmHg 86–99,
p
< 0.001). Each subgroup had similar median lung weight: 1215 g 1083–1294, 1153 888–1321, 968 858–1253, 1060 869–1269, and 1127 937–1193 (
p
= 0.37). They also had similar non-aerated tissue fraction: 10.4% 5.9–13.7, 9.6 7.1–15.8, 9.4 5.8–16.7, 8.4 6.7–12.3 and 9.4 5.9–13.8, respectively (
p
= 0.85).
Treatment failure of CPAP/NIV occurred in 34 patients (24.3%). Only three variables, at day one, distinguished patients with negative outcome: PaO
2
/FiO
2
ratio (OR 0.99 0.98–0.99,
p
= 0.02), esophageal pressure swing (OR 1.13 1.01–1.27,
p
= 0.032) and total stress (OR 1.17 1.06–1.31,
p
= 0.004). When these three variables were evaluated together in a multivariate logistic regression analysis, only the total stress was independently associated with negative outcome (OR 1.16 1.01–1.33,
p
= 0.032).
Conclusions
In early COVID-19 pneumonia, hypoxemia is not linked to computed tomography (CT) pathoanatomy, differently from typical ARDS. High lung stress was independently associated with the failure of non-invasive respiratory support.
Patients are often concerned about the effects of smoking on perioperative risk. However, effective advice may be limited by the paucity of information about smoking and perioperative risk. Thus, our ...goal was to determine the effect of smoking on 30-day postoperative outcomes in noncardiac surgical patients.
We evaluated 635,265 patients from the American College of Surgeons National Surgical Quality Improvement Program database; 520,242 patients met our inclusion criteria. Of these patients, 103,795 were current smokers; 82,304 of the current smokers were propensity matched with 82,304 never-smoker controls. Matched current smokers and never-smokers were compared on major and minor composite morbidity outcomes and respective individual outcomes.
Current smokers were 1.38 (95% CI, 1.11-1.72) times more likely to die than never smokers. Current smokers also had significantly greater odds of pneumonia (odds ratio OR, 2.09; 95% CI, 1.80-2.43), unplanned intubation (OR, 1.87; 95% CI, 1.58-2.21), and mechanical ventilation (OR, 1.53; 95% CI, 1.31-1.79). Current smokers were significantly more likely to experience a cardiac arrest (OR, 1.57; 95% CI, 1.10-2.25), myocardial infarction (OR, 1.80; 95% CI, 1.11-2.92), and stroke (OR, 1.73; 95% CI, 1.18-2.53). Current smokers also had significantly higher odds of having superficial (OR, 1.30; 95% CI, 1.20-1.42) and deep (OR, 1.42; 95% CI, 1.21-1.68) incisional infections, sepsis (OR, 1.30; 95% CI, 1.15-1.46), organ space infections (OR, 1.38; 95% CI, 1.20-1.60), and septic shock (OR, 1.55; 95% CI, 1.29-1.87).
Our analysis indicates that smoking is associated with a higher likelihood of 30-day mortality and serious postoperative complications. Quantification of increased likelihood of 30-day mortality and a broad range of serious smoking-related complications may enhance the clinician's ability to motivate smoking cessation in surgical patients.
Anesthesia Awareness and the Bispectral Index Avidan, Michael S; Zhang, Lini; Burnside, Beth A ...
The New England journal of medicine,
03/2008, Letnik:
358, Številka:
11
Journal Article
Recenzirano
Odprti dostop
Anesthesia awareness has potential psychological consequences. Use of the bispectral index (BIS) developed from a processed electroencephalogram has been reported to decrease anesthesia awareness. In ...this randomized, controlled trial comparing a BIS-based protocol with a protocol based on measurement of end-tidal anesthetic gases, two cases of definite anesthesia awareness occurred in each group. This study did not show a benefit of BIS monitoring in reducing the rate of anesthesia awareness.
This trial compared a protocol based on the bispectral index (BIS) with a protocol based on measurement of end-tidal anesthetic gases. Two cases of definite anesthesia awareness occurred in each group. This study did not show a benefit of BIS monitoring in reducing the rate of anesthesia awareness.
Anesthesia awareness, also known as unintended intraoperative awareness, is the explicit recall of sensory perceptions during general anesthesia. Anesthesia awareness is rare,
1
,
2
but the incidence may approach 1% in patients at high risk.
3
–
5
Anesthesia awareness can lead to anxiety and post-traumatic stress disorder.
6
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has recommended that stringent efforts be made to prevent anesthesia awareness,
7
and the American Society of Anesthesiologists (ASA) has published guidelines on the subject.
8
According to a sentinel-event alert disseminated by the JCAHO, between 20,000 and 40,000 cases of anesthesia awareness may occur yearly in the . . .
There is insufficient prospective evidence regarding the relationship between surgical experience and prolonged opioid use and pain. The authors investigated the association of patient ...characteristics, surgical procedure, and perioperative anesthetic course with postoperative opioid consumption and pain 3 months postsurgery. The authors hypothesized that patient characteristics and intraoperative factors predict opioid consumption and pain 3 months postsurgery.
Eleven U.S. and one European institution enrolled patients scheduled for spine, open thoracic, knee, hip, or abdominal surgery, or mastectomy, in this multicenter, prospective observational study. Preoperative and postoperative data were collected using patient surveys and electronic medical records. Intraoperative data were collected from the Multicenter Perioperative Outcomes Group database. The association between postoperative opioid consumption and surgical site pain at 3 months, elicited from a telephone survey conducted at 3 months postoperatively, and demographics, psychosocial scores, pain scores, pain management, and case characteristics, was analyzed.
Between September and October 2017, 3,505 surgical procedures met inclusion criteria. A total of 1,093 cases were included; 413 patients were lost to follow-up, leaving 680 (64%) for outcome analysis. Preoperatively, 135 (20%) patients were taking opioids. Three months postsurgery, 96 (14%) patients were taking opioids, including 23 patients (4%) who had not taken opioids preoperatively. A total of 177 patients (27%) reported surgical site pain, including 45 (13%) patients who had not reported pain preoperatively. The adjusted odds ratio for 3-month opioid use was 18.6 (credible interval, 10.3 to 34.5) for patients who had taken opioids preoperatively. The adjusted odds ratio for 3-month surgical site pain was 2.58 (1.45 to 4.4), 4.1 (1.73 to 8.9), and 2.75 (1.39 to 5.0) for patients who had site pain preoperatively, knee replacement, or spine surgery, respectively.
Preoperative opioid use was the strongest predictor of opioid use 3 months postsurgery. None of the other variables showed clinically significant association with opioid use at 3 months after surgery.
Knowledge of gas volume, tissue mass and recruitability measured by the quantitative CT scan analysis (CT-qa) is important when setting the mechanical ventilation in acute respiratory distress ...syndrome (ARDS). Yet, the manual segmentation of the lung requires a considerable workload. Our goal was to provide an automatic, clinically applicable and reliable lung segmentation procedure. Therefore, a convolutional neural network (CNN) was used to train an artificial intelligence (AI) algorithm on 15 healthy subjects (1,302 slices), 100 ARDS patients (12,279 slices), and 20 COVID-19 (1,817 slices). Eighty percent of this populations was used for training, 20% for testing. The AI and manual segmentation at slice level were compared by intersection over union (IoU). The CT-qa variables were compared by regression and Bland Altman analysis. The AI-segmentation of a single patient required 5–10 s vs. 1–2 h of the manual. At slice level, the algorithm showed on the test set an IOU across all CT slices of 91.3 ± 10.0, 85.2 ± 13.9, and 84.7 ± 14.0%, and across all lung volumes of 96.3 ± 0.6, 88.9 ± 3.1, and 86.3 ± 6.5% for normal lungs, ARDS and COVID-19, respectively, with a U-shape in the performance: better in the lung middle region, worse at the apex and base. At patient level, on the test set, the total lung volume measured by AI and manual segmentation had a
R
2
of 0.99 and a bias −9.8 ml CI: +56.0/−75.7 ml. The recruitability measured with manual and AI-segmentation, as change in non-aerated tissue fraction had a bias of +0.3% CI: +6.2/−5.5% and −0.5% CI: +2.3/−3.3% expressed as change in well-aerated tissue fraction. The AI-powered lung segmentation provided fast and clinically reliable results. It is able to segment the lungs of seriously ill ARDS patients fully automatically.
Abstract Study objective To test the primary hypothesis that forced-air prewarming improves patient satisfaction after outpatient surgery and to evaluate the effect on core temperature and thermal ...comfort. Design Prospective randomized controlled trial. Setting Preoperative area, operating room, and postanesthesia care unit. Patients A total of 115 patients aged 18 to 75 years with American Society of Anesthesiologists status < 4 and body mass index of 15 to 36 kg/m2 who were undergoing outpatient surgery (duration < 4 hours). Interventions Patients were randomized to active prewarming with a Mistral-Air warming system initially set to 43°C or no active prewarming. All patients were warmed intraoperatively. Measurements Demographic and morphometric characteristics, perioperative core temperature, ambient temperature, EVAN-G satisfaction score, thermal comfort via visual analog scales. Main Results Data from 102 patients were included in the final analysis. Prewarming did not significantly reduce redistribution hypothermia, with prewarmed minus not prewarmed core temperature differing by only 0.18°C (95% confidence interval CI, − 0.001 to 0.37) during the initial hour of anesthesia ( P = .052). Prewarming increased the mean EVAN-G satisfaction score, although not significantly, with an overall difference (prewarmed minus not prewarmed) of 5.6 (95% CI, − 0.9 to 12.2; P = .09). Prewarming increased thermal comfort, with an overall difference of 6.6 mm (95% CI, 1.0-12.9; P = .02). Conclusion Active prewarming increased thermal comfort but did not significantly reduce redistribution hypothermia or improve postoperative patient satisfaction.
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