Intraoperative fluid management is a crucial aspect of cancer surgery, including colorectal surgery and pancreatoduodenectomy. The study tests if intraoperative multimodal monitoring reduces ...postoperative morbidity and duration of hospitalisation in patients undergoing major abdominal surgery treated by the same anaesthetic protocols with epidural analgesia.
A prospective study was conducted in 2 parallel groups. High-risk surgical patients undergoing major abdominal surgery were randomly selected in the control group (CG), where standard monitoring was applied (44 patients), and the protocol group (PG), where cerebral oxygenation and extended hemodynamic monitoring were used with the protocol for intraoperative interventions (44 patients).
There were no differences in the median length of hospital stay, CG 9 days (interquartile range IQR 8 days), PG 9 (5.5), p = 0.851. There was no difference in postoperative renal of cardiac impairment. Procalcitonin was significantly higher (highest postoperative value in the first 3 days) in CG, 0.75 mcg/L (IQR 3.19 mcg/L), than in PG, 0.3 mcg/L (0.88 mcg/L), p = 0.001. PG patients received a larger volume of intraoperative fluid; median intraoperative fluid balance +1300 ml (IQR 1063 ml) than CG; +375 ml (IQR 438 ml), p < 0.001.
There were significant differences in intraoperative fluid management and vasopressor use. The median postoperative value of procalcitonin was significantly higher in CG, suggesting differences in immune response to tissue trauma in different intraoperative fluid status, but there was no difference in postoperative morbidity or hospital stay.
Local anesthetic wound infusion has become an invaluable technique in multimodal analgesia. The effectiveness of wound infusion of 0.2% ropivacaine delivered by patient controlled analgesia (PCA) ...pump has not been evaluated in minimally invasive cardiac surgery. We tested the hypothesis that 0.2% ropivacaine wound infusion by PCA pump reduces the cumulative dose of opioid needed in the first 48 h after minithoracothomy aortic valve replacement (AVR).
In this prospective, randomized, double-blind, placebo-controlled study, 70 adult patients (31 female and 39 male) were analyzed. Patients were randomized to receive 0.2% ropivacaine or 0.9% saline wound infusion by PCA pump for 48 h postoperatively. PCA pump was programmed at 5 ml h
continuously and 5 ml of bolus with 60 min lockout. Pain levels were assessed and recorded hourly by Numeric Rating Scale (NRS). If NRS score was higher than three the patient was administered 3 mg of opioid piritramide repeated and titrated as needed until pain relief was achieved. The primary outcome was the cumulative dose of the opioid piritramide in the first 48 h after surgery. Secondary outcomes were frequency of NRS scores higher than three, patient's satisfaction with pain relief, hospital length of stay, side effects related to the local anesthetic and complications related to the wound catheter.
The cumulative dose of the opioid piritramide in the first 48 h after minithoracotomy AVR was significantly lower (p < 0.001) in the ropivacaine (R) group median 3 mg (IQR 6 mg) vs. 9 mg (IQR 9 mg). The number of episodes of pain where NRS score was greater than three median 2 (IQR 2), vs 3 (IQR 3), (p = 0.002) in the first 48 h after surgery were significantly lower in the ropivacaine group, compared to control. Patient satisfaction with pain relief in our study was high. There were no wound infections and no side-effects from the local anesthetic.
Wound infusion of local anesthetic by PCA pump significantly reduced opioid dose needed and improves pain control postoperatively. We have also shown that it is a feasible method of analgesia and it should be considered in the multimodal pain control strategy following minimally invasive cardiac surgery.
ClinicalTrials.gov NCT03079830 , date of registration: March 15, 2017. Retrospecitvely registered.
Uvod: O kronični pooperativni bolečini govorimo, kadar ne najdemo drugega vzroka za njen nastanek in ko traja dlje kot 2 meseca po operaciji. Pojavi se pri 10-50 % bolnikov po velikih abdominalnih ...operacijah. Podskupina kronične bolečine, ki jo je najtežje zdraviti, je kronična nevropatska bolečina. Medoperativna epiduralna analgezija in infuzija deksmedetomidina lahko vplivata na incidenco kronične pooperativne bolečine in na incidenco nevropatske bolečine.
Metode: V prospektivno raziskavo smo vključili odrasle kirurške bolnike, sprejete na KO za abdominalno kirurgijo, pri katerih je bila načrtovana operacija želodca, operacija trebušne slinavke ali operacija črevesja. Vsi bolniki so imeli epiduralno analgezijo in medoperativno infuzijo deksmedetomidina. Tri mesece po operaciji smo bolnikom poslali vprašalnike. Ocenjevali smo jakost in vrsto bolečine. Za oceno smo uporabili DN4 (Douleur Neuropathique 4) in vprašalnik painDetect.
Rezultati: Prejeli smo 42 (50 %) pravilno izpolnjenih vprašalnikov DN4 in 45 (53 %) vprašalnikov painDetect. V naši raziskavi je bila incidenca kronične bolečine 25 %, nevropatske bolečine 7,1 % (3 bolniki so izpolnjevali merila za nevropatsko bolečino po vprašalniku DN4).
Zaključek: Rezultati naše prospektivne raziskave nakazujejo, da bi lahko medoperativna uporaba epiduralne analgezije in infuzije deksmedetomidina zmanjšala pojav pooperativne kronične bolečine.
Abstract
Background
Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional ...mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.
Methods
Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.
Results
A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84,
p
= 0.003), heavier (85.2 ± 12.4 vs.72.5 ± 12.9,
p
= 0.002) and had higher body surface area (1.98 ± 0.167 vs. 1.83 ± 0.178,
p
= 0.006). Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy (158 ± 24 vs. 134 ± 30 min,
p
< 0.001, respectively). There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration (5.64, 95%CI 0.677–10.60,
p
= 0.027). Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (
p
= 0.630) (MS: 85.2 ± 9.6 vs. 82.9 ± 11.4,
p
= 0.012; MT: 85.2 ± 9.6 vs. 81.3 ± 8.8,
p
= 0.001).
Conclusion
There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.
Trial registry number
clinicaltrials.gov
,
NCT02697786
14.
Fluid optimisation in pancreas surgery JENKO, MATEJ; POŽAR-LUKANOVIĆ, NEVA; PERIĆ, MLADEN ...
Signa vitae,
01/2019, Letnik:
15, Številka:
2
Journal Article, Paper
Recenzirano
Odprti dostop
Background. Optimal intravascular blood volume, cardiac output and sufficient oxygen supply is a mainstay in major abdominal surgery. Adequate haemodynamic management can improve a favourable outcome ...and shorten the duration of hospital stay.
Our study anticipated different fluid and vasoactive drug consumption and less complications during the pancreatic surgery in the group of patients where extended haemodynamic monitoring was applied.
Materials and methods. 59 adult patients, ASA 2-3, undergoing elective pancreas surgery, were included in the study. In 29 patients in the study group (SG – extended haemodynamic monitoring), cardiac index (CI), mean arterial pressure (MAP) and nominal stroke index (SI) were maintained within 80% of baseline values with actions following study protocol. Patients’ groups were homogenous, even when divided into 4 subgroups (control group (CG) and without epidural catheter (EC), CG and with EC, SG and without EC, SG and with EC).
Intraoperative variables (amount of fluids, vasopressors, surgery duration) and hospitalisation duration, wound healing, reoperation, mortality and other complication were recorded on the postoperative days 3, 5, 8, 15 and on hospital discharge.
Results. There was no difference in ASA health status, intraoperative management and duration of hospitalisation in 4 subgroups. There is a significant difference in intraoperative use of vasopressor support between 4 subgroups (Fisher exact test, p=0,032). All patients in SG with EC required vasopressors. Number of patients with major complications were not statistically different between groups. Pulmonary embolism, postoperative food intolerance and myocardial infarction have occurred only in CG.
Conclusion. In our study there was no difference in overall fluid and vasoactive drug demand. Although in the studied subgroup of patients with additional epidural anaesthesia there was significantly increased demand for vasoactive drugs. The incidence of complication was low in both groups, however, some of major complications occurred only in CG.
•CPB leads to inflammatory responses and oxidative stress.•PON1 is decreased in systemic inflammation and ischemia, like that during CPB is.•Glucocorticoids counteract oxidative stress by up ...regulating PON1 gene expression.•Methylprednisolone doesn't have significant effects on PON1 activity during CPB.
Cardiopulmonary bypass (CPB) is linked to systemic inflammatory responses and oxidative stress. Paraoxonase 1 (PON1) is an antioxidant enzyme with a cardioprotective role whose activity is decreased in systemic inflammation and in patients with acute myocardial and global ischemia. Glucocorticoids counteract the effect of oxidative stress by upregulating PON1 gene expression. The authors aimed to determine the effect of methylprednisolone on PON1 activity during cardiac surgery on CPB.
Prospective, randomized, controlled clinical trial.
The University Medical Center Ljubljana, Slovenia.
Forty adult patients who underwent complex cardiac surgery on CPB between February 2016 and December 2017 were randomized into methylprednisolone and control groups (n = 20 each).
Patients in the methylprednisolone group received 1 g of methylprednisolone in the CPB priming solution, whereas patients in the control group were not given methylprednisolone during CPB.
The effect of methylprednisolone from the CPB priming solution was compared with standard care during CPB on PON1 activity until postoperative day 5. Correlations of PON1 activity with lipid status, mediators of inflammation, and hemodynamics were analyzed also. No significant differences were found between study groups for PON1 activity, high-density lipoprotein, and low-density lipoprotein in any of the measurement intervals (p > 0.016). The methylprednisolone group had significantly lower tumor necrosis factor alpha (p < 0.001) and interleukin-6 (p < 0.001), as well as C-reactive protein and procalcitonin (p < 0.016) after surgery. No significant difference was found between groups for hemodynamic parameters. A positive correlation existed between PON1 and lipid status, whereas a negative correlation was found between PON1 activity and tumor necrosis factor alpha, interleukin-6, and CPB duration.
Methylprednisolone does not influence PON1 activity during cardiac surgery on CPB.
BACKGROUND: Goal-directed fluid therapy (GDFT) with hemodynamic monitoring may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in enhanced ...recovery after surgery protocols (ERAS) setting. AIMS: We predicted different fluid and vasoactive drug consumption during the procedure and less complications in the group of patients, where invasive hemodynamic monitoring was used. METHODS: Two groups of patients undergoing elective laparoscopic colorectal surgery were compared: A control group (CG), with standard hemodynamic monitoring, and a study group, (SG) with invasive hemodynamic monitoring and appropriate intraoperative interventions. We compared differences in intraoperative fluid consumption, length of hospital stay (LOS) and post-operative morbidity. RESULTS: A group of 29 patients in SG had similar average intraoperative fluid balance (+438 mL) as 27 patients in CG (+345 mL) p = 0.432. Average LOS was 8 days (±4) in SG and 6 days (±1) in CG (p = 0.124). Acute renal failure, anastomotic dehiscence, and indication for antibiotic treatment were predictors of statistically significant prolongation of hospital stay 3rd day after surgery, but independent of SG. CONCLUSION: Since no differences between the groups were shown in overall fluid and vasoactive drug consumption, we conclude that GDFT is not needed in laparoscopic colorectal surgery, when ERAS is followed.
To compare the 2-stage and 4-stage basic life support teaching technique. The second aim was to test if students' self-evaluated knowledge was in accordance with their actual knowledge.
A total of ...126 first-year students of the Faculty of Medicine in Ljubljana were involved in this parallel study conducted in the academic year 2009/2010. They were divided into ten groups. Five groups were taught the 2-stage model and five the 4-stage model. The students were tested in a scenario immediately after the course. Questionnaires were filled in before and after the course. We assessed the absolute values of the chest compression variables and the proportions of students whose performance was evaluated as correct according to our criteria. The results were analyzed with independent samples t test or Mann-Whitney-U test. Proportions were compared with χ(2) test. The correlation was calculated with the Pearson coefficient.
There was no difference between the 2-stage (2S) and the 4-stage approach (4S) in the compression rate (126±13 min-1 vs 124±16 min -1, P=0.180, independent samples t test), compression depth (43±7 mm vs 44±8 mm, P=0.368, independent samples t test), and the number of compressions with correct hand placement (79±32% vs 78±12, P=0.765, Mann-Whitney U-test). However, students from the 4-stage group had a significantly higher average number of compressions per minute (70±13 min -1 2S, 78±12 min-1 4S, P=0.02, independent samples t test). The percentage of students with all the variables correct was the same (13% 2S, 15% 4S, P=0.741, χ2 test). There was no correlation between the students' actual and self-evaluated knowledge (P=0.158, Pearson coefficient=0.127).
The 4-stage teaching technique does not significantly improve the quality of chest compressions. The students' self-evaluation of their performance after the course was too high.
Introduction. Cardiopulmonary resuscitation is influenced by the quality of basic life support (BLS). The primary objective of our study was to compare efficiency in the acquisition of BLS skills ...using conventional training and the 4-stage approach as a teaching method for BLS training.
Methods. In a prospective, randomised, 2-parallel group study, 266 first year medical students were randomised to either conventional training or the 4-stage approach using 2000 and 2005 ERC (European Resuscitation Council) guidelines. The students were tested immediately after receiving training. Three ERC-certified instructors assessed BLS skills using video recordings.
Results. The students who were taught according to the 4-stage approach using 2000 guidelines preformed significantly better in the following steps: calls for help (p<0.01), opens the airway (p<0.01), places hands for chest compression correctly (p<0.01) and performs chest compressions correctly (p<0.01), while using 2005 guidelines, only chest compression hand position improved significantly in the 4-stage teaching group (p<0.01).
Conclusions. The 4-stage approach improved the efficiency of several steps of the BLS algorithm and the ability to follow the algorithm in the correct sequence using 2000 ERC guidelines, while in students using the 2005 ERC guidelines only chest compression hand position improved significantly. Students who were taught according to 2000 ERC guidelines had significantly better hand position than students who were taught according to 2005 guidelines, independent of teaching method used.
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