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sábado, 16 de septiembre de 2017

Anestesia en cirugía cardiaca / Cardiac anaesthesia

Septiembre 13, 2017. No. 2810

Ensayo clínico aleatorizado que compara las respuestas hemodinámicas a ketamina-propofol ón (Ketofol) versus etomidato durante la inducción de la anestesia en pacientes con disfunción ventricular izquierda sometidos a cirugía de bypass coronario.

A randomized clinical trial comparing hemodynamic responses to ketamine-propofol combination (ketofol) versus etomidate during anesthesia induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft surgery.

Baradari AG1, Alipour A2, Habibi MR1, Rashidaei S3, Emami Zeydi A4,5.

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Arch Med Sci. 2017 Aug;13(5):1102-1110. doi: 10.5114/aoms.2016.63193. Epub 2016 Oct 25.

Abstract

INTRODUCTION: Anesthesia induction is often accompanied by a period of hemodynamic instability, which could be a significant problem in patients with compromised ventricular function. The aim of this study is to compare the hemodynamic responses to etomidate versus a combination of ketamine and propofol (ketofol) for anesthetic induction in patients with left ventricular dysfunction undergoing coronary artery bypass graft (CABG) surgery. MATERIAL AND METHODS: In a double-blind randomized clinical study, a total of 84 patients with ischemic left ventricular dysfunction (EF < 40%) were randomly assigned to two groups (A and B). Patients in group A received etomidate 0.2 mg/kg and a placebo (normal saline); group B received a combination of ketamine (1 mg/kg) and propofol (1.5 mg/kg) at the induction of anesthesia. Two minutes after induction, hemodynamic variables, including systolic, diastolic, mean arterial pressure (SAP, DAP, MAP) and heart rate (HR), were measured immediately before and after the laryngoscopy, and before intubation and post-intubation at 1, 2, and 3 min. RESULTS: The decrease in all hemodynamic parameters (SBP, DBP, MAP and HR) from induction time to laryngoscopy was greater in the ketofol group (group B) than in the etomidate group (group A) (p < 0.05). The ephedrine prescription rate due to hemodynamic changes was 24.4% (10 patients) and 5% (2 patients) in group B and group A, respectively (p = 0.03). CONCLUSIONS: We found that etomidate provides superior hemodynamic stability as compared to ketofol in patients with left ventricular dysfunction undergoing CABG surgery under general anesthesia.

KEYWORDS: etomidate; hemodynamics; ketamine; ketofol; propofol; ventricular dysfunction

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Leucocitosis asintomática preoperatoria y evolución postoperatoria en pacientes con cirugía cardíaca.

Preoperative asymptomatic leukocytosis and postoperative outcome in cardiac surgery patients.

Mahmood E1,2, Knio ZO3, Mahmood F1, Amir R1, Shahul S1, Mahmood B1,4, Baribeau Y1, Mueller A1, Matyal R1.

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PLoS One. 2017 Sep 5;12(9):e0182118. doi: 10.1371/journal.pone.0182118. eCollection 2017.

Abstract

BACKGROUND: Despite showing a prognostic value in general surgical patients, preoperative asymptomatic elevated white blood cell (WBC) count is not considered a risk factor for cardiac surgery. Whereas there is sporadic evidence of its value as a preoperative risk marker, it has not been looked at methodically as a specific index of outcome during cardiac surgery. Using a national database we sought to determine the relationship between preoperative WBC count and postoperative outcome in cardiac surgical patients. METHODS: Cardiac surgeries were extracted from the 2007-2013 American College of Surgeons National Surgical Quality Improvement Program database. Leukocytosis was defined by a preoperative WBC count greater than 11,000 cells/μL. A univariate analysis compared the incidence of adverse outcomes for patients with and without leukocytosis. A multivariate logistic regression model was constructed in order to test whether leukocytosis was an independent predictor of morbidity and mortality. RESULTS: Out of a total of 10,979 cardiac surgery patients 863 (7.8%) had preoperative leukocytosis. On univariate analysis, patients with leukocytosis experienced greater incidences of 30-day mortality, wound complications, and medical complications. Wound complications included surgical site infection as well as wound dehiscence. The medical complications included all other non-surgical causes of increased morbidity and infection leading to urinary tract infection, pneumonia, ventilator dependence, sepsis and septic shock. After stepwise model adjustment, leukocytosis was a strong predictor of medical complications (OR 1.22, 95% CI: 1.09-1.36, p = 0.002) with c-statistic of 0.667. However, after stepwise model adjustment leukocytosis was not a significant predictor of 30-day mortality and wound complications. CONCLUSION: Preoperative leukocytosis is associated with adverse postoperative outcome after cardiac surgery and is an independent predictor of infection-related postoperative complications.

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