Browsing by Author "Nunes, C."
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- [CR-POSSUM and Surgical Apgar Score as predictive factors for patients' allocation after colorectal surgery]Publication . Pinho, S.; Lagarto, F.; Gomes, B.; Costa, L.; Nunes, C.; Oliveira, C.Background and objectives: Surgical patients frequently require admission in high-dependency units or intensive care units. Resources are scarce and there are no universally accepted admission criteria, so patients' allocation must be optimized. The purpose of this study was to investigate the relationship between postoperative destination of patients submitted to colorectal surgery and the scores ColoRectal Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity (CR-POSSUM) and Surgical Apgar Score (SAS) and, secondarily find cut-offs to aid this allocation. Methods: A cross-sectional prospective observational study, including all adult patients undergoing colorectal surgery during a 2 years period. Data collected from the electronic clinical process and anesthesia records. Results: A total of 358 patients were included. Median score for SAS was 8 and CR-POSSUM had a median mortality probability of 4.5%. Immediate admission on high-dependency units/intensive care units occurred in 51 patients and late admission in 18. Scores from ward and high-dependency units/intensive care units patients were statistically different (SAS: 8 vs. 7, p<0.001; CR-POSSUM: 4.4% vs. 15.9%, p<0.001). Both scores were found to be predictors of immediate postoperative destination (p<0.001). Concerning immediate high-dependency units/intensive care units admission, CR-POSSUM showed a strong association (AUC 0.78, p=0.034) with a ≥9.16 cut-off point (sensitivity: 62.5%; specificity: 75.2%), outperforming SAS (AUC 0.67, p=0.048), with a ≤7 cut-off point (sensitivity: 67.3%; specificity: 56.1%). Conclusions: Both CR-POSSUM and SAS were associated with the clinical decision to admit a patient to the high-dependency units/intensive care units immediately after surgery. CR-POSSUM alone showed a better discriminative capacity.
- ESTACIONARIDADE DURANTE ANESTESIA GERALPublication . Castro, A.; Nunes, C.; Almeida, F.; Amorim, P.
- Increased lung inflammation with oxygen supplementation in tracheotomized spontaneously breathing rabbits: an experimental prospective randomized studyPublication . Machado, H.; Nunes, C.; Sá, P.; Couceiro, A.; Moreira-Silva, A.; Águas, A.BACKGROUND: Mechanical ventilation is a well-known trigger for lung inflammation. Research focuses on tidal volume reduction to prevent ventilator-induced lung injury. Mechanical ventilation is usually applied with higher than physiological oxygen fractions. The purpose of this study was to investigate the after effect of oxygen supplementation during a spontaneous ventilation set up, in order to avoid the inflammatory response linked to mechanical ventilation. METHODS: A prospective randomised study using New Zealand rabbits in a university research laboratory was carried out. Rabbits (n = 20) were randomly assigned to 4 groups (n = 5 each group). Groups 1 and 2 were submitted to 0.5 L/min oxygen supplementation, for 20 or 75 minutes, respectively; groups 3 and 4 were left at room air for 20 or 75 minutes. Ketamine/xylazine was administered for induction and maintenance of anaesthesia. Lungs were obtained for histological examination in light microscopy. RESULTS: All animals survived the complete experiment. Procedure duration did not influence the degree of inflammatory response. The hyperoxic environment was confirmed by blood gas analyses in animals that were subjected to oxygen supplementation, and was accompanied with lower mean respiratory rates. The non-oxygen supplemented group had lower mean oxygen arterial partial pressures and higher mean respiratory rates during the procedure. All animals showed some inflammatory lung response. However, rabbits submitted to oxygen supplementation showed significant more lung inflammation (Odds ratio = 16), characterized by more infiltrates and with higher cell counts; the acute inflammatory response cells was mainly constituted by eosinophils and neutrophils, with a relative proportion of 80 to 20% respectively. This cellular observation in lung tissue did not correlate with a similar increase in peripheral blood analysis. CONCLUSIONS: Oxygen supplementation in spontaneous breathing is associated with an increased inflammatory response when compared to breathing normal room air. This inflammatory response was mainly constituted with polymorphonuclear cells (eosinophils and neutrophils). As confirmed in all animals by peripheral blood analyses, the eosinophilic inflammatory response was a local organ event.
- Patient-controlled analgesia com morfina endovenosa no tratamento da dor agudaPublication . Figueira, H.; Araújo, M.; Nunes, C.; Machado, S.; Santos, A. R.INTRODUÇÃO: O manuseio da dor aguda (DA) é um desafio na Anestesiologia. PCA (patient-controlled analgesia) com opióide endovenoso (ev) permite administração de opióide on-demand, de forma intermitente, controlada pelo doente. No nosso serviço é usada PCA de morfina ev (protocolo mais usado: bólus 1mg, lockout 7 minutos, sem perfusão contínua). O conhecimento da forma como é utilizada permite-nos melhorar protocolos. OBJETIVOS: Avaliar o uso de PCA com morfina ev no nosso hospital e caraterizar a população de doentes considerando três grupos no que respeita ao consumo total de morfina. MATERIAL E MÉTODOS: Avaliação retrospetiva do processo clínico eletrónico dos doentes referenciados à Unidade de Dor Aguda (UDA) do nosso hospital nos últimos 2 anos. Consulta dos registos da UDA e fichas anestésicas de todos os doentes com analgesia com morfina ev por PCA. Registo de sexo, idade, estado físico ASA, tipo de dor, intervenção cirúrgica, perfusão contínua e total de morfina considerando grupos: 1 (<20mg); 2 (20-40mg); 3 (>40mg). Excluídos doentes com registos incompletos. Aplicados teste Qui quadrado e índice de correlação de Pearson. Resultados apresentados em percentagem (%) e média ± desvio padrão. Significância estatística P<0.05. RESULTADOS E DISCUSSÃO: Excluídos 3 doentes por registos incompletos. Analisados 930. Masculino (M) 51.1%, Idade - 50.7± 19.6 anos, maioritariamente ASA II - 46.1%. Tempo com PCA 2.7 ± 2.5 dias. Dor pós-operatória (DPO) - 95.5%, dor isquémica (DI) - 1.8%, dor traumática (DT) - 1.2%, outra (O) - 1.6%. Ratio bólus pedidos/administrados (P/A) 2.08 ± 3 (50%), encontrando-se relação com a idade: R=0.128 (P<0.01). Perfusão contínua - 4.2% dos casos sendo GRUPO 1- 2.7%; GRUPO 2 - 5.4% e GRUPO 3 - 91.9%. Consumo de morfina - GRUPO 1: DPO - 31.2%, mais frequente cirurgia membro superior - 67.4%; DI - 6.3%; DT - 9.1%; O - 8.3%. GRUPO 2: DPO - 25.4%, mais frequente cirurgia cabeça e pescoço - 40.0%; DI - 6.3%; DT - 18.2%; O - 16.7%. GRUPO 3: DPO - 43.4%, mais frequente cirurgia vascular membro inferior - 82.1% e cirurgia de escoliose - 74.2%; DI - 87.5%; DT - 72.7%; O - 75%. As diferenças de consumos são estatisticamente significativas entre o tipo de dor, intervenção cirúrgica, presença ou não perfusão contínua e classificação ASA (P<0.001). Não existe diferença entre sexo. Dias com PCA, perfusão contínua e intervenção cirúrgica têm importância preditiva no consumo total de morfina (aplicação do modelo linear). CONCLUSÃO: Os resultados mostram maior utilização da PCA na DPO. DI e DT surgem associadas a maior consumo total de morfina. Na DPO, o maior consumo de morfina verifica-se na cirurgia vascular do membro inferior e cirurgia de escoliose; cirurgias de cabeça e pescoço e membro superior estão associadas a menor consumo. O aumento do ratio P/A com a idade
- Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohortsPublication . Jácome, C.; Pereira, A.; Almeida, R.; Ferreira-Magalhães, Manuel; Couto, M.; Araujo, L.; Pereira, M.; Correia, M.; Loureiro, C.; Catarata, M.; Maia Santos, L.; Pereira, J.; Ramos, B.; Lopes, C.; Mendes, A.; Cidrais Rodrigues, J.; Oliveira, G.; Aguiar, A.; Afonso, I.; Carvalho, J.; Arrobas, A.; Coutinho Costa, J.; Dias, J.; Todo Bom, A.; Azevedo, J.; Ribeiro, C.; Alves, M.; Leiria Pinto, P.; Neuparth, N.; Palhinha, A.; Gaspar Marques, J.; Pinto, N.; Martins, P.; Todo Bom, F.; Alvarenga Santos, M.; Gomes Costa, A.; Silva Neto, A.; Santalha, M.; Lozoya, C.; Santos, N.; Silva, D.; Vasconcelos, M.; Taborda-Barata, L.; Carvalhal, C.; Teixeira, M.; Alves, R.; Moreira, A.; Sofia Pinto, C.; Morais Silva, P.; Alves, C.; Câmara, R.; Coelho, D.; Bordalo, D.; Fernandes, R.; Ferreira, R.; Menezes, F.; Gomes, R.; Calix, M.; Marques, A.; Cardoso, J.; Emiliano, M.; Gerardo, R.; Nunes, C.; Câmara, R.; Ferreira, J.; Carvalho, A.; Freitas, P.; Correia, R.; Fonseca, J.Objective: We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance. Design: Baseline data from two prospective multicentre observational studies. Setting: 29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal. Participants: 395 patients (≥13 years old) with persistent asthma. Measures: Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation. Results: High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (rs=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV1 ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R2=44%). Conclusion: Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.
- Practical aspects of the use of target controlled infusion with remifentanil in neurosurgical patients: predicted cerebral concentrations at intubation, incision and extubationPublication . Ferreira, D.; Nunes, C.; Antunes, L.; Lobo, F.; Amorim, P.Abstract Remifentanil has important side effects and it is not easy to know what remifentanil concentrations should be used during different endpoints of anaesthesia. We analyzed the remifentanil predicted effect-site concentrations (RemiCe) at different events during neurosurgical procedures and assessed if the concentrations used were clinically adequate. BIS and haemodynamic parameters were collected every 5 seconds. Predicted cerebral concentration of propofol (PropCe) and RemiCe were analyzed immediately prior to respective stimulus, and 30, 60 and 90 seconds after. RemiCe were 2.2 +/- 0.3, 6 +/- 2.6 and 2.2 +/- 0.9 ng ml(-1) at intubation, incision and extubation, respectively. PropCe observed in the same periods were 5 +/- 1, 2.6 +/- 0.9 and 1 +/- 0.3 microg ml(-1), also respectively. The remifentanil concentrations used in our patients were lower than reported concentrations, while being clinically adequate to minimize the haemodynamic response to stimulation.