Assuntos
Circulação Assistida/instrumentação , Circulação Assistida/normas , Oxigenação por Membrana Extracorpórea/instrumentação , Oxigenação por Membrana Extracorpórea/normas , Coração Auxiliar , Circulação Assistida/métodos , Brasil , Oxigenação por Membrana Extracorpórea/métodos , Insuficiência Cardíaca/terapia , Humanos , Fatores de Risco , Sociedades MédicasRESUMO
PurposeAmbulatory surgery is a major area of surgical and anesthetic practice, and preoperative clinics are being increasingly used for low-risk surgical procedures. This study investigated the impact of preoperative evaluation on perioperative events in patients undergoing cataract surgery.MethodsThis was a retrospective cohort study of 968 consecutive patients undergoing cataract surgery. Details of medical conditions, surgical, anesthetic, and postoperative information were collected from medical records. A logistic regression model was developed using propensity score adjustment for baseline characteristics.ResultsOut 968 patients included, 240 (24.7%) underwent outpatient preoperative evaluation. There were no perioperative major cardiovascular events. Hypertension occurred in 319 (33%) patients, accounting for 79.7% of all adverse events. Preoperative evaluation resulted in a lower hypertension rate after adjustment for propensity score (OR=0.6; 95% CI 0.41-0.93); no effects were observed on posterior capsule rupture and emergency visits/hospitalization within 7 days of surgery. Eighty-nine patients (9.3%) had an initial systolic pressure ≥180 mm Hg, which was not associated with higher risk of posterior capsule rupture (P=0.158) or postoperative adverse events (P=0.902). Median waiting time to surgery was 6 and 2 months for evaluated and non-evaluated patients, respectively (P<0.001).ConclusionsIn the context of low-risk surgery and no major perioperative and postoperative outcomes, it appears that outpatient preoperative evaluation has no role in reducing adverse events in cataract surgery candidates. Despite fewer hypertensive episodes observed in evaluated patients, these episodes were not associated with any medical or surgical outcomes.
Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Extração de Catarata/efeitos adversos , Complicações Intraoperatórias/prevenção & controle , Cuidados Pré-Operatórios/métodos , Idoso , Estudos de Coortes , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosAssuntos
Angina Instável/prevenção & controle , Angina Instável/reabilitação , Infarto do Miocárdio/prevenção & controle , Infarto do Miocárdio/reabilitação , Doenças Cardiovasculares/prevenção & controle , Depressão/prevenção & controle , Humanos , Hiperlipidemias/prevenção & controle , Obesidade/prevenção & controle , Medição de Risco , Prevenção do Hábito de Fumar , Estresse Psicológico/prevenção & controleAssuntos
Anticoagulantes/uso terapêutico , Doenças Cardiovasculares/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Síndrome Coronariana Aguda/tratamento farmacológico , Fibrilação Atrial/tratamento farmacológico , Brasil , Doença de Chagas/tratamento farmacológico , Feminino , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Infarto do Miocárdio/tratamento farmacológico , Período Perioperatório , Sociedades Médicas , Acidente Vascular Cerebral/tratamento farmacológico , Tromboembolia Venosa/tratamento farmacológicoAssuntos
Doenças Cardiovasculares/prevenção & controle , Promoção da Saúde , Aspirina/uso terapêutico , Brasil , Medicina Baseada em Evidências , Feminino , Humanos , Hipertensão/prevenção & controle , Metanálise como Assunto , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
Cardiovascular diseases are responsible for 32% of total mortality in Brazil, mostly due to cerebrovascular and coronary artery disease. Epidemiological and socio-economical factors play a pivotal role on the distribution, severity and management of coronary artery disease, and the burden is greater in the southeast and south regions of the country, with a higher mortality in low-income populations. The Brazilian healthcare structure is divided into two complementary systems-public and private-but 75% of the population is covered exclusively by the public system. Some Brazilian institutions offer state-of-the-art care to patients with acute and chronic coronary artery disease, but regional inequalities in medical care are still significant. National policies will have to be implemented to fight risk factors, to ensure primary prevention strategies, including assistance on drugs with known protective effects, areas to be tackled by both the private and the public health sectors. Finally, large investments will have to be made to improve tertiary care, to reorganise systems of care for acute patients and mainly to ensure prompt access and continuity of cardiac care and secondary prevention strategies for the whole population.
Assuntos
Doença da Artéria Coronariana/terapia , Atenção à Saúde/organização & administração , Síndrome Coronariana Aguda/terapia , Brasil/epidemiologia , Doença Crônica , Doença da Artéria Coronariana/epidemiologia , Atenção à Saúde/tendências , Humanos , Reperfusão Miocárdica/métodosRESUMO
BACKGROUND AND AIMS: The ability of nutritional status assessment methods to predict clinical outcomes in hospitalized patients has not been completely evaluated. This study compared the accuracy of traditionally used nutritional tools and parameters in predicting death, infection, and length of hospital stay (LOS) in hospitalized adults. RESEARCH METHODS & PROCEDURES: Patients admitted at clinical and surgical wards were evaluated by body mass index, percentage of weight loss, Subjective Global Assessment, albumin, lymphocyte count, and followed until discharge. Clinical outcomes considered were in-hospital death, infection, and LOS. Overall accuracy of each method to predict these outcomes was assessed from ROC curves and C-statistic. RESULTS: Among 434 patients evaluated, 51% had a prolonged LOS, 23% developed infection, and 7.8% died during hospitalization. In univariate analysis, serum albumin was the strongest predictive parameter for death (Cstatistic: 0.77; CI95%: 0.69-0.86) and hospital infection (C-statistic: 0.67; CI95%: 0.61-0.74). For longer stay, lymphocyte count (C-statistic: 0.60; CI95%: 0.55-0.65) emerged as the most predictive variable. After adjustment for non-surgical hospitalization and cancer diagnosis, weight loss > 5% (OR: 1.58; CI95%: 1.06-3.35), and serum albumin < 3.5 g/dL (OR: 2.40; CI95%: 1.46-3.94) were associated to LOS. Albumin was the only independent variable related to infection (OR: 5.01; CI95%: 3.06-8.18) and, for hospital death, albumin (OR: 7.20; CI95%: 3.39-15.32) adjusted for age (OR: 1.03; CI95%: 1.01-1.06). CONCLUSIONS: Nutritional assessment methods evaluated were weakly predictors of hospital outcomes. Except for low serum albumin, isolated use of these methods adds little information in identifying the effect of nutritional status on clinically relevant outcomes.
Assuntos
Hospitalização , Avaliação Nutricional , Índice de Massa Corporal , Feminino , Humanos , Contagem de Linfócitos , Masculino , Pessoa de Meia-Idade , Prognóstico , Reprodutibilidade dos Testes , Albumina Sérica/análise , Redução de PesoRESUMO
Febrile neutropenia is associated with significant morbidity and mortality. Managing infectious in neutropenic patients remains a dynamic process, making necessary timely and efficient empirical antibiotic therapy. The implementation of critical pathways has been suggested as a strategy to improve clinical effectiveness. This study evaluated the compliance with an institutional critical pathway for the management of febrile neutropenia and the impact on clinical outcomes at Hospital de Clínicas de Porto Alegre, Brazil (HCPA). We performed a cohort study that prospectively included patients hospitalized from January 2004 to December 2005 and presented febrile neutropenia (190 episodes). Historical controls were selected from March 2001 to April 2003 (193 episodes) before the critical pathway was introduced. This study showed a low rate of full compliance (21.6%; 95% CI 15.7-27.5) with the critical pathway. In most cases, there was partial compliance (67.9%; 95% CI 61.3-74.5). Despite the moderate adherence observed, we recorded a decrease in in-hospital all-cause mortality in the sample studied after protocol implementation (from 24.4 to 14.4%; P = 0.017) and reduction in the length of use of cephalosporin and quinolones. In conclusion, implementation of a critical pathway seems to be an effective strategy to improve clinical outcomes in patients hospitalized with febrile neutropenia.
Assuntos
Antibacterianos/uso terapêutico , Procedimentos Clínicos , Febre/tratamento farmacológico , Fidelidade a Diretrizes , Neutropenia/tratamento farmacológico , Adulto , Brasil , Estudos de Casos e Controles , Feminino , Febre/mortalidade , Hospitais de Ensino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Neutropenia/mortalidade , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Resultado do TratamentoRESUMO
OBJECTIVES: To describe early sequential profiling of circulating levels of tumor necrosis factor alpha (TNF-alpha), TNF-1 and TNF-2 soluble receptors (sTNFR1 and sTNFR2), and of endothelin (ET-1) in patients with severe burn injury, and its association with mortality. DESIGN: Prospective study. SETTING: Intensive Care Burn Unit at a community hospital. PATIENTS: Twenty patients with total burn surface area (TBSA)> or = 30%. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients were enrolled within 6 h from the injury. Blood samples were drawn at zero, 6, 12, and 24 h for sequential ELISA measurement of plasma marker levels. Data are expressed as mean+/-SD. Age, TBSA, and inhalation injury were not significantly different between survivors ( n=9; 30+/-13 years, TBSA 40+/-12%) and nonsurvivors ( n=11, 38+/-15 years, TBSA 56+/-20%). sTNFR1 levels were increased in nonsurvivors (2937+/-1676 pg/ml; 4548+/-1436 pg/ml) as compared to survivors (1313+/-561 pg/ml; 2561+/-804 pg/ml) at 6 h and 24 h, respectively ( P=0.01 and 0.002). sTNFR2 levels were significantly increased in nonsurvivors (4617+/-1,876 pg/ml vs 2611+/-1,326 pg/ml) only at 6 h ( P=0.015). TNF-alpha and ET-1 levels were not different between nonsurvivors and survivors. After adjustment for TBSA, sTNFR1 and sTNFR2 remained significantly higher in nonsurvivors. CONCLUSION: Early and progressive increase in sTNFR1 and sTNFR2 levels is associated with higher risk for poor outcome in severely burned patients.
Assuntos
Queimaduras/sangue , Queimaduras/mortalidade , Endotelina-1/sangue , Receptores do Fator de Necrose Tumoral/sangue , Fator de Necrose Tumoral alfa/análise , APACHE , Adolescente , Adulto , Idoso , Análise de Variância , Biomarcadores/sangue , Feminino , Humanos , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
BACKGROUND: Major surgical procedures are performed with increasing frequency in elderly persons, but the impact of age on resource use and outcomes is uncertain. OBJECTIVE: To evaluate the influence of age on perioperative cardiac and noncardiac complications and length of stay in patients undergoing noncardiac surgery. DESIGN: Prospective cohort study. SETTING: Urban academic medical center. PATIENTS: Consecutive sample of 4315 patients 50 years of age or older who underwent nonemergent major noncardiac procedures. MEASUREMENTS: Major perioperative complications (cardiac and noncardiac), in-hospital mortality, and length of stay. RESULTS: Major perioperative complications occurred in 4.3% (44 of 1015) of patients 59 years of age or younger, 5.7% (93 of 1646) of patients 60 to 69 years of age, 9.6% (129 of 1341) of patients 70 to 79 years of age, and 12.5% (39 of 313) of patients 80 years of age or older (P < 0.001). In-hospital mortality was significantly higher in patients 80 years of age or older than in those younger than 80 years of age (0.7% vs. 2.6%, respectively). Multivariate analyses indicated an increased odds ratio for perioperative complications or in-hospital mortality in patients 70 to 79 years of age (1.8 [95% CI, 1.2 to 2.7]) and those 80 years of age or older (OR, 2.1 [CI, 1.2 to 3.6]) compared with patients 50 to 59 years of age. Patients 80 years of age or older stayed an average of 1 day more in the hospital, after adjustment for other clinical data (P = 0.001). CONCLUSIONS: Elderly patients had a higher rate of major perioperative complications and mortality after noncardiac surgery and a longer length of stay, but even in patients 80 years of age or older, mortality was low.