Caetano Nigro Neto

Dexmedetomidine as a Sedative Agent in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials

Introduction The effect of dexmedetomidine on length of intensive care unit (ICU) stay and time to extubation is still unclear. Materials and Methods 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. Results 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. Conclusions 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.

Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process

OBJECTIVE Of the 230 million patients undergoing major surgical procedures every year, more than 1 million will die within 30 days. Thus, any nonsurgical interventions that help reduce perioperative mortality might save thousands of lives. The authors have updated a previous consensus process to identify all the nonsurgical interventions, supported by randomized evidence, that may help reduce perioperative mortality. DESIGN AND SETTING A web-based international consensus conference. PARTICIPANTS The study comprised 500 clinicians from 61 countries. INTERVENTIONS A systematic literature search was performed to identify published literature about nonsurgical interventions, supported by randomized evidence, showing a statistically significant impact on mortality. A consensus conference of experts discussed eligible papers. The interventions identified by the conference then were submitted to colleagues worldwide through a web-based survey. MEASUREMENTS AND MAIN RESULTS The authors identified 11 interventions contributing to increased survival (perioperative hemodynamic optimization, neuraxial anesthesia, noninvasive ventilation, tranexamic acid, selective decontamination of the gastrointestinal tract, insulin for tight glycemic control, preoperative intra-aortic balloon pump, leuko-depleted red blood cells transfusion, levosimendan, volatile agents, and remote ischemic preconditioning) and 2 interventions showing increased mortality (beta-blocker therapy and aprotinin). Interventions then were voted on by participating clinicians. Percentages of agreement among clinicians in different countries differed significantly for 6 interventions, and a variable gap between evidence and clinical practice was noted. CONCLUSIONS The authors identified 13 nonsurgical interventions that may decrease or increase perioperative mortality, with variable agreement by clinicians. Such interventions may be optimal candidates for investigation in high-quality trials and discussion in international guidelines to reduce perioperative mortality.

Use of Volatile Anesthetics During Cardiopulmonary Bypass: A Systematic Review of Adverse Events

OBJECTIVES Recently, evidence of reduction in mortality due to the use of volatile agents during cardiac surgery led to an increase in their use during cardiopulmonary bypass (CPB). Because this technique could be beneficial to patients, but might present several hazards to new users, the authors decided to perform a systematic review of the main problems and complications. DESIGN Systematic literature review. SETTING Hospital. PARTICIPANTS Adults undergoing cardiac surgery with use of volatile anesthetic agents during CPB. INTERVENTION Several databases were searched for pertinent studies to identify all reports on the adverse events of using volatile agents during CPB and all randomized controlled trials using volatile agents during CPB. MEASUREMENTS AND MAIN RESULTS Six nonrandomized trials reporting adverse events or complications with the use of volatile agents during CPB for cardiac surgery were identified: 2 reporting low transfer of isoflurane to the blood with diffusion membrane oxygenators; 2 reporting iatrogenic causes of damage after spilling liquid isoflurane onto the surface of the membrane oxygenators while filling the vaporizer; and 2 suggesting that the use of volatile agents during CPB increased the pollution of the room and the risk of occupational exposure of the operating room staff. On the other hand, no adverse event was reported in 19 studies that randomized 1,195 patients to receive isoflurane, desflurane, or sevoflurane during CPB. CONCLUSION It is mandatory for industry to provide safe and easy-to-use devices to administer volatile agents during CPB with the standard membrane oxygenators.

Cardiac Index Assessment by the Pressure Recording Analytic Method in Critically Ill Unstable Patients After Cardiac Surgery

OBJECTIVE The authors measured cardiac index in unstable patients after cardiac surgery with the Pressure Recording Analytic Method (PRAM) and compared it with the reference method of thermodilution (ThD) with the pulmonary artery catheter; using the hypothesis that there were no significant differences between the 2 methods. DESIGN A prospective study. SETTING Cardiac surgery intensive care unit in a teaching hospital. PARTICIPANTS Ninety-four measurements from 59 patients with ongoing high doses of inotropic drugs and/or an intra-aortic balloon pump for low-cardiac-output syndrome after cardiac surgery were studied. INTERVENTIONS The pulmonary artery catheter and the radial or femoral arterial catheter for measuring blood pressure were already in place for standard hemodynamic monitoring. MEASUREMENTS AND MAIN RESULTS The mean of the total CI measurements was 2.94 ± 0.67 L/min/m(2) with PRAM and 2.95 ± 0.63 L/min/m(2) with ThD, with no significant difference according to the linear mixed models analysis. The PRAM and ThD techniques were similar in unstable patients without atrial fibrillation (mean bias 0.047 ± 0.395 L/min/m(2) and a percentage error of 29%), while no agreement between PRAM and ThD was found in unstable patients with atrial fibrillation (mean bias 0.195 ± 0.885 L/min/m(2) and a percentage error of 69%). CONCLUSION Cardiac index measurements after cardiac surgery performed with PRAM and with ThD showed a good agreement in hemodynamically unstable patients given high doses of inotropes and/or an IABP in patients in sinus rhythm, but not in those with atrial fibrillation.

Randomized Trial on the Effect of Sevoflurane on Polypropylene Membrane Oxygenator Performance

OBJECTIVES Volatile anesthetics have cardioprotective properties that improve clinically relevant outcomes in cardiac surgery, and can be used during cardiopulmonary bypass (CPB) through adapted calibrated vaporizers together with air and oxygen (O2). The effect of volatile agents on the membrane oxygenator is unknown. The aim of this study was to evaluate, for the first time, the performance of semiporous polypropylene membrane oxygenators after the use of sevoflurane vaporized during CPB in cardiac surgery. DESIGN A prospective, randomized, controlled trial. SETTING Teaching hospital. PARTICIPANTS Thirty-two consecutive patients scheduled to undergo coronary artery bypass graft with CPB. INTERVENTIONS Patients were allocated randomly to receive either a volatile anesthetic (sevoflurane 1%-3%, 16 patients) or an intravenous hypnotic (midazolam, 16 patients) during CPB. After surgery, the membrane oxygenators used during CPB were tested with regard to O2 transfer, carbon dioxide transfer, and pressure drop. MEASUREMENTS AND MAIN RESULTS The authors observed no protocol deviation or crossover. The performance of the membrane oxygenator was similar between the 2 groups, as documented by O2 transfer (55±6.4 mL/min/L in the sevoflurane group versus 57±4.7 mL/min/L in the midazolam group, p = 0.4), carbon dioxide transfer, and pressure drop. CONCLUSIONS The use of sevoflurane during CPB in cardiac surgery does not affect membrane oxygenator performance.

Use of volatile anesthetics in extracorporeal circulation

BACKGROUND AND OBJECTIVES The 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. CONTENT In 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 specifics in order to solve possible doubts.

Tricks, tips, and literature review on the adapted vaporize system to deliver volatile agents during cardiopulmonary bypass

Background: Recently, evidence of cardio-protection and reduction in mortality due to the use of volatile agents during cardiac surgery led to an increase in their use during cardiopulmonary bypass (CPB). These findings seem to be enhanced when the volatile agents are used during all the surgical procedure, including the CPB period. Aims: Since the administration of volatile agents through CPB can be beneficial to the patients, we decided to review the use of volatile agents vaporized in the CPB circuit and to summarize some tricks and tips of this technique using our 10-year experience of Brazilian and Italian centers with a large volume of cardiac surgeries. Study Setting: Hospital. Methods: A literature review. Results: During the use of the volatile agents in CPB, it is very important to analyze all gases that come in and go out of the membrane oxygenators. The proper monitoring of inhaled and exhaled fraction of the gas allows not only monitoring of anesthesia level, but also the detection of possible leakage in the circuit. Any volatile agent in the membrane oxygenator is supposed to pollute the operating theater. This is the major reason why proper scavenging systems are always necessary when this technique is used. Conclusion: While waiting for industry upgrades, we recommend that volatile agents should be used during CPB only by skilled perfusionists and physicians with the aim to reduce postoperative morbidity and mortality.

Intrathecal sufentanil for coronary artery bypass grafting

CONTEXT Cardiac surgery patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. OBJECTIVE Evaluate the effect of adding intrathecal sufentanil to general anesthesia on hemodynamics. DESIGN Prospective, randomized, not blinded study, after approval by local ethics in Research Committee. SETTING Monocentric study performed at Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil. PATIENTS 40 consenting patients undergoing elective coronary artery bypass, both genders. EXCLUSION CRITERIA Chronic kidney disease; emergency procedures; reoperations; contraindication to spinal block; left ventricular ejection fraction less than 40%; body mass index above 32kg/m(2) and use of nitroglycerin. INTERVENTIONS Patients were randomly assigned to receive intrathecal sufentanil 1μg/kg or not. Anesthesia induced and maintained with sevoflurane and continuous infusion of remifentanil. MAIN OUTCOME MEASURES Hemodynamic variables, blood levels of cardiac troponin I, B-type natriuretic peptide, interleukin-6 and tumor necrosis factor alfa during and after surgery. RESULTS Patients in sufentanil group required less inotropic support with dopamine when compared to control group (9.5% vs 58%, p=0.001) and less increases in remifentanil doses (62% vs 100%, p=0.004). Hemodynamic data at eight different time points and biochemical data showed no differences between groups. CONCLUSIONS Patients receiving intrathecal sufentanil have more hemodynamical stability, as suggested by the reduced inotropic support and fewer adjustments in intravenous opioid doses.

Assessment of sternal closure using titanium plate

INTRODUCTION 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.

Paraplegia após revascularização cirúrgica do miocárdio: relato de caso

JUSTIFICATIVA E OBJETIVOS: Os avancos ocorridos na Anestesiologia permitiram melhores indices de seguranca. Varias tecnicas e agentes sao utilizados visando controlar a resposta hemodinâmica e minimizar os efeitos adversos do estimulo cirurgico em pacientes submetidos a procedimentos cardiacos. 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 hipertensao arterial controladas; tabagismo, enfermidade vascular periferica e historia de infarto agudo do miocardio ha 20 anos. O paciente foi submetido a revascularizacao com arteria mamaria interna esquerda e enxertos de safena com pincamento intermitente da aorta em circulacao extracorporea. Durante as primeiras 24 horas na UTI apresentou eventos de instabilidade hemodinâmica, hipotensao subita e fibrilacao atrial. Apos 26 horas do final do procedimento cirurgico, o paciente estava acordado, hemodinamicamente estavel e com boa dinâmica respiratoria quando foi extubado. O paciente estava comunicativo, orientado, porem com imobilidade e reflexos abolidos nos membros inferiores. Na avaliacao neurologica: pares de nervos cranianos sem alteracao, ausencia de queixa de dor de qualquer tipo da cintura pelvica para baixo, preservacao da sensibilidade superficial e profunda, perfusao distal adequada sem edemas, e paraplegia flacida na regiao abaixo de T8. Exame de ecocardiografia sem alteracoes. A tomografia computadorizada da coluna lombo-sacra, nao mostrou massa compressiva no espaco epidural ou adjacente. CONCLUSAO: A sindrome da arteria espinhal anterior, deve ser sempre considerada nos procedimentos de manipulacao da aorta. A prevencao, particularmente nos pacientes de risco e necessaria. A tomografia computadorizada e importante para o diagnostico diferencial e a ressonância magnetica para a localizacao da lesao.