Identificação de preditores para prescrição da ventilação não-invasiva no pós-operatório de cirurgia cardíaca em adultos
Identificação de preditores para prescrição da ventilação não-invasiva no pós-operatório de cirurgia cardíaca em adultos
Data
2023
Autores
Lima, Jéssica Gonçalves de
Journal Title
Journal ISSN
Volume Title
Publisher
Instituto Nacional de Cardiologia
Resumo
Introdução: Indivíduos submetidos à cirurgia cardíaca podem apresentar – em decorrência da esternotomia mediana, manipulação cirúrgica, anestesia geral e da circulação extracorpórea (CEC) – algumas complicações pulmonares no decorrer do período pós-operatório (PO). Nesse contexto, a ventilação não-invasiva com pressão positiva (VNIPP) objetiva a manutenção da expansão alveolar a fim de otimizar as trocas gasosas, reduzir atelectasias, reduzir o trabalho respiratório, melhorar a hemodinâmica e reduzir a hipoxemia. Contudo, o uso indiscriminado da VNI de forma profilática rotineiramente em pacientes no PO de cirurgia cardíaca dependeria do aumento de recursos humanos e financeiros. Portanto, definir os critérios para prescrição da VNI nos pacientes em PO de cirurgia cardíaca poderá permitir melhor utilização dos recursos (humanos ou materiais) e ainda a possível redução do tempo de internação hospitalar sendo vantajoso economicamente para o Sistema Único de Saúde (SUS). Objetivo: Revisar, baseado em evidências, o protocolo de aplicação de VNI no pós-operatório de cirurgia cardíaca em adultos. Métodos: Estudo transversal retrospectivo composto por 691 sujeitos que estiveram internados na Unidade de Terapia Cardiointensiva Cirúrgica (UTCIC) após cirurgia cardíaca no Instituto Nacional de Cardiologia (INC), Rio de Janeiro, no período de outubro de 2018 a março de 2020. Do total de pacientes elegíveis (n=691), após a aplicação dos critérios de exclusão, foram analisados 667 prontuários. Os dados foram obtidos por meio do banco de dados do Serviço de Fisioterapia do INC, armazenado na plataforma REDCap (Research Electronic Data Capture) e complementado com base na revisão dos registros em prontuário físico e nos sistemas de armazenamento e gestão de dados hospitalares MV2000 e PAGU. Todas as análises foram realizadas utilizando-se o software de estatística e ciência de dados, STATA 16 (Stata Corp USA). Resultados: A maioria dos pacientes era do sexo masculino (59,6%) e apresentaram uma mediana de idade de 58 anos. A mediana do IMC (kg.m-2) foi de 25,8 [23,2 – 29,1], FEVE (%) 60,0 [48 – 68] e risco pré-operatório (%) 2,1 [1,1 – 4,6]. A maioria dos sujeitos eram da cor branca (52,8%) e o tipo de cirurgia mais realizada foi a Revascularização do miocárdio (CRVM) (42,0%) seguida pelas cirurgias valvares (37,9%). No modelo multivariado do pós-operatório (Pré-EOT) as variáveis que estiveram associadas à indicação da VNI curativa foram CEC, relação PaO2/FiO2 (pré-EOT), idade e classe funcional (NYHA 3 e 4). A P/F pré-EOT mais baixa esteve
associada à VNI enquanto a classe funcional avaliada pela NYHA mostrou-se importante na associação com a necessidade da VNI. O modelo final de análise multivariada, ajustado por idade e sexo e com as variáveis do pré, intra e pós-operatório apresentou somente as variáveis idade e NYHA 4 associadas à necessidade de VNI. Conclusão: Pacientes com idade e um status funcional avançados apresentam maior associação com a necessidade de VNI no pós-operatório de cirurgia cardíaca com esternotomia mediana.
Palavras-chave: Cirurgia torácica. Procedimentos Cirúrgicos Cardiovasculares. Ventilação não invasiva. Pressão Positiva Contínua nas Vias Aéreas
Introduction: Individuals undergoing cardiac surgery may present – as a result of median sternotomy, surgical manipulation, general anesthesia and cardiopulmonary bypass (CPB) – some pulmonary complications during the postoperative period (PO). In this context, non-invasive positive pressure ventilation (NIPPV) aims to maintain alveolar expansion in order to optimize gas exchange, reduce atelectasis, reduce the work of breathing, improve hemodynamics and reduce hypoxemia. However, the indiscriminate use of NIV prophylactically routinely in patients in the postoperative period of cardiac surgery would depend on an increase in human and financial resources. Therefore, defining the criteria for prescribing NIV in patients undergoing cardiac surgery may allow better use of resources (human or material) and also a possible reduction in the length of hospital stay, being economically advantageous for the Unified Health System (SUS). Objective: To review, based on evidence, the NIV application protocol in the postoperative period of cardiac surgery in adults. Methods: Retrospective cross-sectional study comprising 691 subjects who were admitted to the Surgical Cardiointensive Care Unit (UTCIC) after cardiac surgery at the National Institute of Cardiology (INC), Rio de Janeiro, from October 2018 to March 2020 Of the total number of eligible patients (N=691), after applying the exclusion criteria, 667 medical records were analyzed. The data were obtained through the database of the INC Physiotherapy Service, stored on the REDCap platform (Research Electronic Data Capture) and complemented based on the review of records in physical medical records and in the hospital data storage and management systems MV2000 and PAY. All analyzes were performed using the statistics and data science software, STATA 16 (Stata Corp USA). Results: The majority of patients were male (59.6%) and had an average age of 58 years. BMI (kg.m-2) was 25.8 [23.2 – 29.1], LVEF (%) 60.0 [48 – 68] and Preoperative risk (%) 2.1 [1, 1 – 4.6]. The majority of subjects were white (52.8%) and the most commonly performed type of surgery was MVR (42.0%), followed by valve surgeries (37.9%). In the multivariate Postoperative model (Pre-EOT), the variables that presented P<0.05 and were associated with the indication of curative NIV were CPB, P/F (pre-EOT), Age, NYHA 3 and NYHA 4. Lower pre-EOT PaO2/FiO2 ratio was associated with NIV while the functional class assessed by NYHA proved to be important in the association with the need for NIV. In the final multivariate analysis model, adjusted for age and sex and with pre-, intra- and postoperative variables, only the variables age and NYHA 4 were associated with the need for NIV. Conclusion: Patients with advanced age and functional status have a greater association with the need for NIV in the postoperative period of cardiac surgery with median sternotomy. Keywords: Thoracic surgery. Cardiovascular Surgical Procedures. Non-invasive ventilation. Continuous Positive Airway Pressure.
Introduction: Individuals undergoing cardiac surgery may present – as a result of median sternotomy, surgical manipulation, general anesthesia and cardiopulmonary bypass (CPB) – some pulmonary complications during the postoperative period (PO). In this context, non-invasive positive pressure ventilation (NIPPV) aims to maintain alveolar expansion in order to optimize gas exchange, reduce atelectasis, reduce the work of breathing, improve hemodynamics and reduce hypoxemia. However, the indiscriminate use of NIV prophylactically routinely in patients in the postoperative period of cardiac surgery would depend on an increase in human and financial resources. Therefore, defining the criteria for prescribing NIV in patients undergoing cardiac surgery may allow better use of resources (human or material) and also a possible reduction in the length of hospital stay, being economically advantageous for the Unified Health System (SUS). Objective: To review, based on evidence, the NIV application protocol in the postoperative period of cardiac surgery in adults. Methods: Retrospective cross-sectional study comprising 691 subjects who were admitted to the Surgical Cardiointensive Care Unit (UTCIC) after cardiac surgery at the National Institute of Cardiology (INC), Rio de Janeiro, from October 2018 to March 2020 Of the total number of eligible patients (N=691), after applying the exclusion criteria, 667 medical records were analyzed. The data were obtained through the database of the INC Physiotherapy Service, stored on the REDCap platform (Research Electronic Data Capture) and complemented based on the review of records in physical medical records and in the hospital data storage and management systems MV2000 and PAY. All analyzes were performed using the statistics and data science software, STATA 16 (Stata Corp USA). Results: The majority of patients were male (59.6%) and had an average age of 58 years. BMI (kg.m-2) was 25.8 [23.2 – 29.1], LVEF (%) 60.0 [48 – 68] and Preoperative risk (%) 2.1 [1, 1 – 4.6]. The majority of subjects were white (52.8%) and the most commonly performed type of surgery was MVR (42.0%), followed by valve surgeries (37.9%). In the multivariate Postoperative model (Pre-EOT), the variables that presented P<0.05 and were associated with the indication of curative NIV were CPB, P/F (pre-EOT), Age, NYHA 3 and NYHA 4. Lower pre-EOT PaO2/FiO2 ratio was associated with NIV while the functional class assessed by NYHA proved to be important in the association with the need for NIV. In the final multivariate analysis model, adjusted for age and sex and with pre-, intra- and postoperative variables, only the variables age and NYHA 4 were associated with the need for NIV. Conclusion: Patients with advanced age and functional status have a greater association with the need for NIV in the postoperative period of cardiac surgery with median sternotomy. Keywords: Thoracic surgery. Cardiovascular Surgical Procedures. Non-invasive ventilation. Continuous Positive Airway Pressure.
Description
Palavras-chave
Cirurgia torácica, Procedimentos Cirúrgicos Cardiovasculares, Ventilação não invasiva, Pressão Positiva Contínua nas Vias Aéreas, Thoracic surgery, Cardiovascular Surgical Procedures, Non-invasive ventilation, Continuous Positive Airway Pressure
Citação
Lima JG BA. Identificação de preditores para prescrição da ventilação não-invasiva no pós-operatório de cirurgia cardíaca em adultos. Rio de Janeiro. dissertação [Mestrado Profiossional em Ciências Cardiovasculares] Instituto Nacional de Cardiologia - INC; 2023.