Aims
Fibrinogen is the key substrate for coagulation. Fibrinogen pharmacokinetics (PK) after single doses of fibrinogen concentrate (FC), using modelling approaches, has only been evaluated in ...congenital afibrinogenaemic patients. The aims of this study are to characterize the fibrinogen PK in patients with acquired—chronic (cirrhosis) or acute—hypofibrinogenaemia (critical haemorrhage), showing endogenous production. Influencing factors of differences on the fibrinogen PK between subpopulations will be identified.
Methods
A total of 428 time–concentration values from 132 patients were recorded. Eighty‐two out of 428 values were from 41 cirrhotic patients administered with placebo and 90 out of 428 were from 45 cirrhotic patients that were given FC, 161 out of 428 values were from 14 afibrinogenaemic patients and 95 out of 428 values were from 32 severe acute trauma haemorrhagic patients. A turnover model that accounted for endogenous production and exogenous dose was fitted using NONMEM74. The production rate (Ksyn), distribution volume (V), plasma clearance (CL) and concentration yielding to 50% of maximal fibrinogen production (EC50) were estimated.
Results
Fibrinogen disposition was described by a one‐compartment model with CL and V values of 0.0456 L·h−1 and 4.34 L·70 kg−1, respectively. Body weight was statistically significant in V. Three different Ksyn values were identified that increased from 0.00439 g·h−1 (afibrinogenaemia), to 0.0768 g·h−1 (cirrhotics) and 0.1160 g·h−1 (acute severe trauma). EC50 was of 0.460 g·L−1.
Conclusions
This model will be key as a support tool for dose calculation to achieve specified target fibrinogen concentrations, in each of the studied populations.
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There is paucity of data on the impact of surgical incision and analgesia on relevant outcomes.A retrospective STROBE-compliant cohort study was performed between July 2007 and August 2017 of ...patients undergoing lung transplantation. Gender, age, indication for lung transplantation, and the 3 types of surgical access (Thoracotomy (T), Sternotomy (S), and Clamshell (C)) were used, as well as 2 analgesic techniques: epidural and intravenous opioids. Outcome variables were: pain scores; postoperative hemorrhage in the first 24 hours, duration of mechanical ventilation, and length of stay at intensive care unit (ICU).Three hundred forty-one patients were identified. Thoracotomy was associated with higher pain scores than Sternotomy (OR 1.66, 95% CI: 1.01; 2.74, P: .045) and no differences were found between Clamshell and Sternotomy incision. The median blood loss was 800 mL interquartile range (IQR): 500; 1238, thoracotomy patients had 500 mL 325; 818 (P < .001). Median durations of mechanical ventilation in Thoracotomy, Sternotomy, and Clamshell groups were 19 11; 37 hours, 34 IQR 16; 57.5 hours, and 27 IQR 15; 50.5 hours respectively. Thoracotomy group were discharged earlier from ICU (P < .001).Thoracotomy access produces less postoperative hemorrhage, duration of mechanical ventilation, and lower length of stay in ICU, but higher pain scores and need for epidural analgesia.
Bariatric surgery patients are at risk of perioperative airway collapse. Neuromuscular blockade should be fully reversed before tracheal extubation. The optimal dosage of the reversal agent ...sugammadex in the morbidly obese is still unknown. This study explored the sugammadex dose adjusted according to train-of-four ratio (TOFR).
Prospective observational study of consecutive patients scheduled for laparoscopic bariatric surgery. To reverse a deep blockade (2 or fewer posttetanic twitches), a dose of sugammadex of 4 mg/kg ideal body weight (IBW) was followed by a second dose of 2 mg/kg IBW if the TOFR was less than 0.9 after 3 min. To reverse a moderate blockade (reappearance of the second twitch in the TOF), a 2 mg/kg IBW dose of sugammadex was followed by a second dose of 2 mg/kg IBW if the TOFR was less than 0.9 after 2 min. Sugammadex effectiveness was reflected by the time required to obtain a TOFr of 0.9 or more.
A total of 120 patients were included. The blockade was deep at the end of surgery in 43 and moderate in 77. The median times (range) to TOFR of 0.9 or more were 167 (20-460) seconds and 113 (28-300) seconds in deep and moderate blockades, respectively (P < 0.05). The percentage of patients requiring a second dose of sugammadex were larger after deep blockades (39.5% n = 17 vs. 23.4% n = 18 after moderate blockades); the difference was not significant.
A sugammadex dose calculated according to IBW is insufficient for reversing both deep and moderate blockades in morbidly obese patients.
Surgical wound is source of pain in hepatectomy with laparotomy. Continuous wound infusion of ropivacaine may provide effective analgesia.
This prospective, randomized trial, patients scheduled for ...hepatectomy received a 48-h preperitoneal continuous wound infusion of either 0.23% ropivacaine or 0.9% saline at 5 ml/h. Primary endpoint was 48 h morphine consumption.
53 patients included in the ropivacaine group and 46 in the saline group. Morphine consumption was 24.63 mg in the ropivacaine group, and 26.78 mg (p = 0.669) in the saline group. Pain was comparable between groups and there were no differences in solid food intake, ambulation, or length of hospital stay. No local or systemic complications were recorded.
Continuous wound infusion with ropivacaine is safe, but it neither reduced morphine consumption nor enhanced recovery in patients undergoing hepatectomy. Success of enhanced recovery in hepatectomy is not influenced by the analgesic regimen if pain is well controlled.
During the COVID-19 crisis it was necessary to generate a specific care network and reconvert operating rooms to attend emergency and high-acuity patients undergoing complex surgery. The aim of this ...study is to classify postoperative complications and mortality and to assess the impact that the COVID-19 pandemic may have had on the results.
this is a non-inferiority retrospective observational study. Two different groups of surgical patients were created: Pre-pandemic COVID and Pandemic COVID. Severity of illness was rated according to the Diagnosis-related Groups (DRG) score. Comparisons were made between groups and between DRG severity score-matched samples. Non-inferiority was set at up to 10 % difference for grade III to V complications according to the Clavien-Dindo classification, and up to 2 % difference in mortality.
A total of 1649 patients in the PreCOVID group and 763 patients in the COVID group were analysed; 371 patients were matched for DRG severity score 3-4 (236 preCOVID and 135 COVID). No differences were found in relation to re-operation (22.5 % vs. 21.5 %) or late admission to critical care unit (5.1 % vs. 4.5 %). Clavien grade III to V complications occurred in 107 patients (45.3 %) in the PreCOVID group and in 56 patients (41.5 %) in the COVID group, and mortality was 12.7 % and 12.6 %, respectively. During the pandemic, 3 % of patients tested positive for Covid-19 on PCR: 12 patients undergoing elective surgery and 11 emergency surgery; there were 5 deaths, 3 of which were due to respiratory failure following Covid-19-induced pneumonia.
Although this study has some limitations, it has shown the non-inferiority of surgical outcomes during the COVID pandemic, and indicates that resuming elective surgery is safe.
Clinicaltrials.gov identifier: NCT04780594 .
To determine the predictive capacity of baseline haemoglobin and maxim clot firmness (MCF) EXTEM thromboelastometry for intraoperative red blood cell (RBC) requirements and its influence on ...mortality.
591 adult liver transplant (LT) recipients from ten Spanish centres were reviewed. The main outcomes were the percentage of patients who received RBC and massive transfusion (≥ 6 RBC units), RBC units transfused, and mortality.
76 % received a donor after brain death graft and 24 % a controlled donor after circulatory death graft. Median (interquartile ranges) RBC transfusion was 2 (0–4) units, and 63 % of patients were transfused. Comparing transfused and non-transfused patients, mean (standard deviation) for baseline haemoglobin was 10.4 (2.1) vs. 13.0 (1.9) g/dl (p = 0.001), EXTEM MCF was 51(11) vs. 55(9) mm (p = 0.001). Haemoglobin and EXTEM MCF were inversely associated with the need of transfusion odds ratio (OR) of 0.558 (95 % CI 0.497–0.627, p < 0.001) and OR 0.966 (95 % CI0.945–0.987, p = 0.002), respectively. Pre-operative baseline haemoglobin ≤ 10 g/dL predicted RBC transfusion, sensitivity of 93 % and specificity of 47 %. Massive transfusion (MT) was received by 19 % of patients. Haemoglobin ≤10 g/dL predicted MT with sensitivity 73 % and specificity of 52 %. One-year patient and graft survival were significantly lower in patients who required MT (78 % and 76 %, respectively) vs. those who did not (94 % and 93 %, respectively).
whereas EXTEM MCF is less dreterminant predicting RBC requirements, efforts are required to improve preoperative haemoglobin up to 10 g/dl in patients awaiting LT.
Background: The composite variability index (CVI), derived from the bispectral analysis (BIS), has been designed to detect nociception; however, there is no evidence that bilateral BIS and CVI show ...intrapatient reproducibility or variability.
Methods: We conducted an observational study in patients who underwent for total knee arthroplasty. A BIS Bilateral Sensor was applied and continuously recorded at different points of the anesthesia procedure. Bland-Altman limits of agreement and dispersion for BIS and for CVI were applied.
Results: Forty-nine right-handed patients were studied. There were differences between the right and left BIS values after tracheal intubation (which was higher on the right side) and at surgical stimulus (higher on the left side). The maximum BIS and minimum, mean, and maximum CVI scores were higher on the left side for left-side procedures, but there were no differences in any indexes for the right-side procedures. Except for the baseline measurements, both CVI and BIS scores presented high interpatient variability. Although the right to left bias was < 3% for the BIS index, dispersion was large at different stages of the anesthesia. The right to left bias for the CVI was 3.8% at tracheal intubation and 5.7% during surgical stimulus.
Conclusions: Our results indicate that the large interindividual variability of BIS and CVI limits their usefulness. We found differences between the left and right measurements in a right-handed series of patients during surgical stimuli though they were not clinically relevant.
Controlled donation after circulatory death (cDCD) has expanded the donor pool for liver transplantation (LT). However, transfusion requirements and perioperative outcomes should be elucidated. The ...aim of this multicenter study was to assess red blood cell (RBC) transfusions, one-year graft and patient survival after LT after cDCD with normothermic regional perfusion (NRP) compared with donors after brain death (DBD).
591 LT carried out in ten centers during 2019 were reviewed. Thromboelastometry was used to manage coagulation and blood product transfusion in all centers. Normothermic regional perfusion was the standard technique for organ recovery.
447 patients received DBD and 144 cDCD with NRP. Baseline MCF Extem was lower in the cDCD group There were no differences in the percentage of patients (63% vs. 61% p = 0.69), nor in the number of RBC units transfused (4.7 (0.2) vs 5.5 (0.4) in DBD vs cDCD, p = 0.11. Twenty-six patients (6%) died during admission for LT in the DBD group compared with 3 patients (2%) in the cDCD group (p = 0.15). To overcome the bias due to a worse coagulation profile in cDCD recipients, matched samples were compared. No differences in baseline laboratory data, or in intraoperative use of RBC or one-year outcome data were observed between DBD and cDCD recipients.
cDCD with NRP is not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found. Donors after controlled circulatory death with NRP can increasingly be utilized with safety, improving the imbalance between organ donors and the ever-growing demand.
•Donations after circulatory death (DCD) are increasingly utilized due to the imbalance between donors and recipients.•Intraoperative transfusion is a known independent risk factor for patient and graft survival in liver transplantation but data comparing the source of donors is scarce.•In a large cohort of liver transplants, cDCD with NRP was not associated with increased RBC transfusion. No differences in graft and patient survival between cDCD and DBD were found.•Our results suggest that cDCD with NRP can safely be used, improving the imbalance between donors and recipients.
A continuous peripheral nerve blockade has proved benefits on reducing postoperative morphine consumption; the combination of a femoral blockade and general anesthesia on reducing intraoperative ...anesthetic requirements has not been studied. The objective of this study was to determine the relevance of timing in the performance of femoral block to intraoperative anesthetic requirements during general anesthesia for total knee arthroplasty.
A single-center, prospective cohort study on patients scheduled for total knee arthroplasty, were sequentially allocated to receive 20mL of 2% mepivacaine throughout a femoral catheter, prior to anesthesia induction (Preoperative) or when skin closure started (Postoperative). An algorithm based on bispectral values guided intraoperative anesthetic management. Postoperative analgesia was done with an elastomeric pump of levobupivacaine 0.125% connected to the femoral catheter and complemented with morphine patient control analgesia for 48hours. The Kruskall Wallis and the chi-square tests were used to compare variables. Statistical significance was set at p<0.05.
There were 94 patients, 47 preoperative and 47 postoperative. Lower fentanyl and sevoflurane were needed intraoperatively in the Preoperative group; median values and range: 250 (100-600) vs 450 (200-600)μg and 21 (12-48) vs 32 (18-67)mL p=0.001, respectively. There were no differences in the median verbal numeric rating scale values 4 (0-10) vs 3 (0-10); and in median morphine consumption 9 (2-73) vs 8 (0-63)mg postoperatively.
A preoperative femoral blockade is useful in decreasing anesthetic requirements in total knee arthroplasty surgery but no added effect in the postoperative analgesic control.
Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors ...associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors.
An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours' care were included from January 1, 2008-December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortality.
Of 899 patients included, 80 (8.9%) died. Seven died within 48 hours of surgery, 18 died between 2 and 7 days, and 55 died after 7 days. Non-survivors were older and had more respiratory comorbidity, chronic liver disease, metastasis, and underwent more palliative procedures. 112 patients underwent emergency surgery; mortality in these patients for resection surgery was 32.5%; in the 787 patients who underwent scheduled surgery, mortality was 4.7% for resection procedures. The estimated odds ratios (95% confidence interval) of preoperative patient factors in emergency surgery confirmed a negative association between survival and older age 0.96 (0.91-1), the presence of respiratory comorbidity 0.14 (0.02-0.77) and metastasis 0.18 (0.05-0.6). After scheduled surgery, survival was negatively associated with age 0.93 (0.90-0.96) and chronic liver disease 0.40 (0.17-0.91). Analysis of complications after emergency surgery also indicated a negative association with sepsis 0.03 (0.003-0.32), respiratory events 0.043 (0.011-0.17) and cardiac events 0.11 (0.027-0.45); after scheduled surgery, respiratory 0.03 (0.01-0.08) and cardiac 0.11 (0.02-0.45) events, renal failure 0.02 (0.006-0.14) and neurological events 0.06 (0.007-0.5).
As most deaths occurred after discharge from the ICU, postoperative sepsis, respiratory and cardiac events should be watched carefully on the ward.
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