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BACKGROUND: Video-assisted thoracoscopic surgery (VATS) often induces significant postoperative pain, potentially leading to chronic pain and decreased quality of life. This study aimed to evaluate the acetaminophen/ibuprofen combination effectiveness in reducing analgesic requirements and pain intensity in patients undergoing VATS. STUDY DESIGN: This is a double-blinded randomized controlled trial. METHODS: Adult patients scheduled for elective VATS for lung resection were randomized to receive either intravenous acetaminophen and ibuprofen (intervention group) or 100 mL normal saline (control group). Treatments were administered post-anesthesia induction and every 6 h for three cycles. The primary outcome was total analgesic consumption at 24 h postoperatively. Secondary outcomes were cumulative analgesic consumption at 2 and 48 h; analgesic-related side effects at 2, 24, and 48 h; quality of recovery at 24 h and 48 h postoperatively; pain intensity at rest and during coughing; and rescue analgesics use. Chronic postsurgical pain (CPSP) was assessed through telephone interviews 3 months postoperatively. RESULTS: The study included 96 participants. The intervention group showed significantly lower analgesic consumption at 24 h and 48 h postoperatively (24 h: median difference: - 100 µg equivalent intravenous fentanyl [95% confidence interval (CI) - 200 to - 5 µg], P = 0.037; 48 h: median difference: - 140 µg [95% CI - 320 to - 20 µg], P = 0.035). Compared to the controls, the intervention group exhibited a significantly lower quality of recovery 24 h post-surgery, with no significant difference at 48 h. All pain scores except for coughing at 48 h post-surgery were significantly lower in the intervention group compared to the controls. No significant differences were observed between the groups in postoperative nausea and vomiting occurrence, hospital stay length, and CPSP. CONCLUSION: Perioperative administration of acetaminophen/ibuprofen significantly decreased analgesic needs in patients undergoing VATS, providing an effective postoperative pain management strategy, and potentially minimizing the need for stronger analgesics.
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Acetaminofén , Analgésicos no Narcóticos , Analgésicos Opioides , Ibuprofeno , Dolor Postoperatorio , Cirugía Torácica Asistida por Video , Humanos , Método Doble Ciego , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/prevención & control , Acetaminofén/administración & dosificación , Acetaminofén/uso terapéutico , Masculino , Femenino , Cirugía Torácica Asistida por Video/efectos adversos , Ibuprofeno/administración & dosificación , Ibuprofeno/uso terapéutico , Persona de Mediana Edad , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Analgésicos no Narcóticos/administración & dosificación , Analgésicos no Narcóticos/uso terapéutico , Anciano , Combinación de Medicamentos , Dimensión del Dolor , AdultoRESUMEN
BACKGROUND: There is little evidence regarding the benefits of lung-protective ventilation in patients undergoing one-lung ventilation for thoracic surgery. This study aimed to determine the optimal level of positive end-expiratory pressure (PEEP) during one-lung ventilation for minimizing postoperative atelectasis through lung ultrasonography. METHODS: A total of 142 adult patients scheduled for video-assisted thoracoscopic surgery at Seoul National University Hospital between May 2019 and February 2020 were enrolled in this study. Patients were randomly assigned to different groups: 1) PEEP 3 cmH
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Ventilación Unipulmonar , Atelectasia Pulmonar , Adulto , Humanos , Cirugía Torácica Asistida por Video , Respiración con Presión Positiva , Pulmón/diagnóstico por imagen , Atelectasia Pulmonar/prevención & controlRESUMEN
BACKGROUND: An orientation strategy providing repeated verbal reminders of time, place, and person has been widely used for the non-pharmacological management of delirium. We hypothesised that using this strategy could reduce emergence agitation and improve recovery profiles. METHODS: This prospective observer-blinded RCT included male and female patients aged 18-70 yr undergoing minimally invasive abdominal surgery. During emergence from general anaesthesia, subjects in the orientation group (n=57) were provided a repeated reminder, including orientation: '(Patient's name), you are now recovering from general anaesthesia after surgery at Seoul National University Hospital, open your eyes!' via noise-cancelling headphones, whereas those in the control group (n=57) only heard their name: '(Patient's name), open your eyes!'. The primary outcome was the incidence of emergence agitation (Riker sedation agitation scale [SAS] ≥5). The incidence of dangerous agitation (SAS=7), maximal SAS score in the operating room, and recovery profile until 24 h postoperatively were evaluated as secondary outcomes. RESULTS: The incidence of emergence agitation in the operating room was significantly lower in the orientation group than in the control group (16/57 [28.1%] vs 38/57 [66.7%]; relative risk [95% confidence interval], 0.5 [0.3-0.7]; P<0.001). The incidence of dangerous agitation (0 [0.0%] vs 10 [17.5%], P=0.001) and the median maximal SAS score (4 [4-5] vs 5 [4-6], P<0.001) were also lower in the orientation group. Secondary outcomes, other than agitation-related variables, were comparable between the two groups. CONCLUSIONS: Repeated verbal stimulation of orientation may serve as a simple and easily applicable strategy to reduce emergence agitation after general anaesthesia. CLINICAL TRIAL REGISTRATION: NCT05105178.
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Delirio del Despertar , Humanos , Masculino , Femenino , Delirio del Despertar/epidemiología , Delirio del Despertar/prevención & control , Estudios Prospectivos , Periodo de Recuperación de la Anestesia , Anestesia General/efectos adversos , Abdomen/cirugía , Agitación Psicomotora/etiología , Agitación Psicomotora/prevención & control , Agitación Psicomotora/epidemiologíaRESUMEN
BACKGROUND: Airway driving pressure, easily measured as plateau pressure minus PEEP, is a surrogate for alveolar stress and strain. However, the effect of its targeted reduction remains unclear. METHODS: In this multicentre trial, patients undergoing lung resection surgery were randomised to either a driving pressure group (n=650) receiving an alveolar recruitment/individualised PEEP to deliver the lowest driving pressure or to a conventional protective ventilation group (n=650) with fixed PEEP of 5 cm H2O. The primary outcome was a composite of pulmonary complications within 7 days postoperatively. RESULTS: The modified intention-to-treat analysis included 1170 patients (mean [standard deviation, sd]; age, 63 [10] yr; 47% female). The mean driving pressure was 7.1 cm H2O in the driving pressure group vs 9.2 cm H2O in the protective ventilation group (mean difference [95% confidence interval, CI]; -2.1 [-2.4 to -1.9] cm H2O; P<0.001). The incidence of pulmonary complications was not different between the two groups: driving pressure group (233/576, 40.5%) vs protective ventilation group (254/594, 42.8%) (risk difference -2.3%; 95% CI, -8.0% to 3.3%; P=0.42). Intraoperatively, lung compliance (mean [sd], 42.7 [12.4] vs 33.5 [11.1] ml cm H2O-1; P<0.001) and Pao2 (median [inter-quartile range], 21.5 [14.5 to 30.4] vs 19.5 [13.5 to 29.1] kPa; P=0.03) were higher and the need for rescue ventilation was less frequent (6.8% vs 10.8%; P=0.02) in the driving pressure group. CONCLUSIONS: In lung resection surgery, a driving pressure-guided ventilation improved pulmonary mechanics intraoperatively, but did not reduce the incidence of postoperative pulmonary complications compared with a conventional protective ventilation. CLINICAL TRIAL REGISTRATION: NCT04260451.
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Cirugía Torácica , Procedimientos Quirúrgicos Torácicos , Humanos , Femenino , Persona de Mediana Edad , Masculino , Respiración con Presión Positiva/efectos adversos , Pulmón , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Procedimientos Quirúrgicos Torácicos/efectos adversos , Volumen de Ventilación PulmonarRESUMEN
Owing to concerns about delayed gastric emptying or hyperglycemia, evidence is lacking regarding whether pre-operative carbohydrate loading can be routinely administered to patients with type 2 diabetes. The objective of this study was to determine the aspiration risk and gastric volume after pre-operative carbohydrate loading in patients with type 2 diabetes. A prospective, single-center, observational cohort study. The study was conducted at a tertiary teaching hospital in Seoul, Korea, from May 2020 to May 2021. Patients (n = 49) with type 2 diabetes underwent elective noncardiac surgery. All patients were administered carbohydrate loading two hours before surgery. Once in the operating room, they underwent gastric ultrasonography to determine gastric volume. The anesthesiologists monitored the patients' glucose concentrations during and after surgery. The primary outcome was the predicted risk of aspiration. The secondary outcomes were gastric volume, antral grade, satisfaction score, and perioperative glucose profile. Forty-nine patients were analyzed. All patients had a low risk of aspiration after carbohydrate loading, as follows: 33 (67.3%) patients classified as antral grade 0 and 16 (32.7%) patients classified as antral grade 1. The median time from carbohydrate drink ingestion to ultrasound examination was 120 min (IQR 115-139). After carbohydrate loading, the median gastric volume in the right-lateral position after carbohydrate loading was 2.64 ml (IQR 0.00-32.05). The mean glucose concentrations (SD) were 134 (24) mg/dl, 159 (37) mg/dl, 150 (32) mg/dl, and 165 (36) mg/dl at baseline, after induction, 30 min after surgery, and in the post anesthesia care unit, respectively. The median satisfaction score of the patients was 5 (IQR 4-5). Pre-operative carbohydrate loading may be feasible for patients with type 2 diabetes and without complications.Trial registration: ClinicalTrials.gov (NCT04456166). Registered on 2 July 2020.
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Anestésicos , Diabetes Mellitus Tipo 2 , Humanos , Estudios Prospectivos , Dieta de Carga de Carbohidratos , Diabetes Mellitus Tipo 2/complicaciones , Proyectos Piloto , Ultrasonografía , Carbohidratos , Glucosa , Cuidados Preoperatorios , Vaciamiento GástricoRESUMEN
BACKGROUND: Although nefopam has been reported to have opioid-sparing and analgesic effects in postsurgical patients, its effectiveness in video-assisted thoracoscopic surgery (VATS) is unknown. OBJECTIVES: This study aimed to investigate the opioid-sparing and analgesic effects of perioperative nefopam infusion for lung resection. STUDY DESIGN: Double-blinded randomized controlled trial. SETTING: Operating room, postoperative recovery room, and ward at a single tertiary university hospital. METHODS: Ninety patients scheduled for elective VATS for lung resection were randomized to either the nefopam (group N) or control group (group C). Group N received 20 mg nefopam over 30 minutes immediately after the induction of anesthesia. Nefopam was administered continuously for 24 hours postoperative, using a dual-channel elastomeric infusion pump combined with fentanyl-based intravenous patient-controlled analgesia. Group C received the same volume of normal saline as nefopam solution administered in the same manner. The primary outcome measure was fentanyl consumption for the first postoperative 24 hours. The secondary outcome measures were the cumulative fentanyl consumption during the first postoperative 48 hours, pain intensity at rest and during coughing evaluated using an 11-point numeric rating scale, quality of recovery at postoperative time points 24 hours and 48 hours, and the occurrence of analgesic-related side effects during the first postoperative 24 hours and postoperative 24 to 48 hour period. Variables related to chronic postsurgical pain (CPSP) were also investigated by telephone interviews with patients at 3 months postoperative. This prospective randomized trial was approved by the appropriate institutional review board and was registered in the ClinicalTrials.gov registry. RESULTS: A total of 83 patients were enrolled. Group N showed significantly lower fentanyl consumption during the first postoperative 24 hours and 48 hours (24 hours: median difference: -270 µg [95%CI, -400 to -150 µg], P < 0.001); 48 hours: median difference: -365 µg [95% CI: -610 to -140 µg], P < 0.001). Group N also showed a significantly lower pain score during coughing at 24 hours postoperative (median difference, -1 [corrected 95% CI: -2.5 to 0], adjusted P = 0.040). However, there were no significant between-group differences in the postoperative quality of recovery, occurrence of analgesic-related side effects, length of hospital stay, and occurrence of CPSP. LIMITATIONS: Despite the significant opioid-sparing effect of perioperative nefopam infusion, it would have been difficult to observe significant improvements in other postoperative outcomes owing to the modest sample size. CONCLUSION: Perioperative nefopam infusion using a dual-channel elastomeric infusion pump has a significant opioid-sparing effect in patients undergoing VATS for lung resection. Therefore, it could be a feasible option for multimodal analgesia in these patients.
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Analgésicos no Narcóticos , Nefopam , Analgésicos/uso terapéutico , Analgésicos no Narcóticos/uso terapéutico , Analgésicos Opioides/uso terapéutico , Fentanilo/uso terapéutico , Humanos , Nefopam/efectos adversos , Nefopam/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Estudios Prospectivos , Solución Salina/uso terapéutico , Cirugía Torácica Asistida por VideoRESUMEN
BACKGROUND: An intervention to potentiate hypoxic pulmonary vasoconstriction may reduce intrapulmonary shunt and hypoxemia during one-lung ventilation. Previous animal studies reported that repeated intermittent hypoxic stimuli potentiated hypoxic pulmonary vasoconstriction, but no clinical study has examined the effects of this intervention on hypoxemia during one-lung ventilation. We thus performed a single-center, parallel-group, double-blind, randomized controlled trial to investigate whether repeated intermittent hypoxic stimuli to the operative lung reduce hypoxemia during the subsequent one-lung ventilation for thoracoscopic surgery. METHODS: Patients undergoing one-lung ventilation were randomized into two groups (n = 68 each). Before one-lung ventilation, in the intermittent hypoxia group, the nondependent lung was not ventilated for 2 min and then ventilated for 2 min while the dependent lung was continuously ventilated. This was repeated five times. In the continuous normoxia group, both lungs were ventilated for 20 min. We measured SpO2, PaO2, FiO2, PaCO2, SaO2, and central venous oxygen saturation during one-lung ventilation. The primary outcome was the number of patients with hypoxemia defined as a SpO2 <95% during one-lung ventilation, which was analyzed with a chi-squared test. RESULTS: Hypoxemia was less frequent in the intermittent hypoxia group than in the continuous normoxia group during OLV [6/68 (8.8%) vs 17/68 (25.0%), risk ratio (95% CI) 0.35 (0.15-0.84), p = 0.012]. The PaO2 (p = 0.008 for 30 min and 0.007 for 60 min) and PaO2/FiO2 (p = 0.008 for both) were higher 30 and 60 min after starting one-lung ventilation, and the alveolar-arterial pressure gradient (p = 0.010) and shunt index (p = 0.008) were lower 30 min after starting one-lung ventilation in the intermittent hypoxia group than in the continuous normoxia group. Postoperative adverse events did not differ significantly between groups. CONCLUSIONS: Repeated intermittent hypoxic stimuli to the operative lung seemed to potentiate hypoxic pulmonary vasoconstriction, and thus reduced hypoxemia during the subsequent one-lung ventilation.
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Hipoxia/epidemiología , Ventilación con Presión Positiva Intermitente/métodos , Complicaciones Posoperatorias/epidemiología , Toracoscopía/métodos , Femenino , Humanos , Hipoxia/etiología , Ventilación con Presión Positiva Intermitente/efectos adversos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Toracoscopía/efectos adversosRESUMEN
PURPOSE: The effect of anesthetic types on postoperative acute kidney injury (AKI) remains unclear particularly in patients undergoing non-cardiac surgery. The purpose of this retrospective study was to compare total intravenous anesthesia (TIVA) and inhalation anesthesia in terms of the risk of AKI after open major abdominal surgery (MAS). METHODS: Adult patients who underwent open MAS (gastrectomy, hepatectomy, colectomy, or pancreatectomy) at our institute from 2016 to 2018 were included. Using the multivariable logistic regression, the risk of postoperative AKI was compared among patients who underwent TIVA (TIVA group) and inhalation anesthesia (inhalation group) both in the total cohort and in the propensity score-matched cohort. Additional multivariable logistic regression analysis was performed with inverse probability of treatment weighting (IPTW) using the propensity score. RESULTS: In total, 3616 patients were analyzed. The incidence of postoperative AKI was 5.0% (77/1546) and 7.8% (161/2070) in the TIVA and inhalation groups, respectively. The risk of AKI was significantly higher in the inhalation group [adjusted odds ratio (aOR) 1.72; 95% confidence interval (CI) 1.27-2.35; P = 0.002] than the TIVA group. In the matched cohort (n = 1518 in each group), the inhalation group also had a higher risk of AKI (aOR 1.66; 95% CI 1.20-2.31; P = 0.002). The multivariable logistic regression with IPTW showed similar results (aOR 1.59; 95% CI 1.30-1.95; P < 0.001). CONCLUSIONS: The risk of AKI after open MAS differed significantly according to the anesthetic used. Patients receiving inhalation anesthesia may have a greater risk of postoperative AKI than those undergoing TIVA.
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Lesión Renal Aguda , Anestésicos por Inhalación , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/epidemiología , Adulto , Anestesia por Inhalación/efectos adversos , Anestesia Intravenosa/efectos adversos , Anestésicos por Inhalación/efectos adversos , Anestésicos Intravenosos , Humanos , Puntaje de Propensión , Estudios RetrospectivosRESUMEN
BACKGROUND: Pneumoperitoneum and steep Trendelenburg position promote the formation of pulmonary atelectasis during laparoscopic gynaecological surgery. OBJECTIVE: To determine whether lung ultrasound-guided alveolar recruitment manoeuvres could reduce peri-operative atelectasis compared with conventional recruitment manoeuvres during laparoscopic gynaecological surgery. DESIGN: Randomised controlled trial. SETTING: Tertiary hospital, Republic of Korea, from August 2018 to January 2019. PATIENTS: Adult patients scheduled for laparoscopic gynaecological surgery under general anaesthesia. INTERVENTION: Forty patients were randomised to receive either ultrasound-guided recruitment manoeuvres (manual inflation until no visibly collapsed area was seen with lung ultrasonography; intervention group) or conventional recruitment manoeuvres (single manual inflation with 30âcmH2O pressure; control group). Recruitment manoeuvres were performed 5âmin after induction and at the end of surgery in both groups. All patients received volume-controlled ventilation with a tidal volume of 8âmlâkg-1 and a positive end-expiratory pressure of 5âcmH2O. MAIN OUTCOME MEASURES: The primary outcome was the lung ultrasound score at the end of surgery; a higher score indicates worse lung aeration. RESULTS: Lung ultrasound scores at the end of surgery were significantly lower in the intervention group compared with control group (median [IQR], 7.5 [6.5 to 8.5] versus 9.5 [8.5 to 13.5]; difference, -2 [95% CI, -4.5 to -1]; Pâ=â0.008). The intergroup difference persisted in the postanaesthesia care unit (7 [5 to 8.8] versus 10 [7.3 to 12.8]; difference, -3 [95% CI, -5.5 to -1.5]; Pâ=â0.005). The incidence of atelectasis was lower in the intervention group compared with control group at the end of surgery (35 versus 80%; Pâ=â0.010) but was comparable in the postanaesthesia care unit (40 versus 55%; Pâ=â0.527). CONCLUSIONS: The use of ultrasound-guided recruitment manoeuvres improves peri-operative lung aeration; these effects may persist in the postanaesthesia care unit. However, the long-term effects of ultrasound-guided recruitment manoeuvres on clinical outcomes should be the subject of future trials. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03607240).
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Laparoscopía , Pulmón , Adulto , Femenino , Procedimientos Quirúrgicos Ginecológicos/efectos adversos , Humanos , Pulmón/diagnóstico por imagen , República de Corea , Ultrasonografía , Ultrasonografía IntervencionalRESUMEN
Performance measurement variables can be applied in clinical practice to evaluate hemodynamic instability. This study aimed to evaluate the relationship between the performance measurement of mean arterial pressure during cardiac surgery using cardiopulmonary bypass and postoperative mortality. A retrospective cohort study of patients who underwent cardiac surgery requiring cardiopulmonary bypass between 2013 and 2016 was conducted. The median performance error (MDPE) and median absolute performance error (MDAPE) were calculated using the preoperative mean arterial pressure as a reference, and intraoperative mean arterial pressures as measured values. Multivariable logistic regression analyses were performed using performance measurement variables to predict 30-day mortality. Overall survival according to performance measurement variables was evaluated using Cox proportional hazard models and Kaplan-Meier survival curves were generated to compare survival probability. Among 1203 patients, 110 (9.1%) died after surgery, and the 30-day mortality rate was 2.3% (28/1203). After adjusting for confounders, MDPE and MDAPE were significant mean arterial pressure derived predictors of 30-day mortality and overall survival. Intraoperative hypotension measured by performance measurement variables was independently associated with 30-day and overall mortality after cardiac surgery requiring cardiopulmonary bypass. Kaplan-Meier survival curves showed lower survival probability in patients with higher MDAPE during the pre- and post- cardiopulmonary bypass periods (P < 0.001 by log-rank test). Intraoperative hypotension measured by performance measurement variables was independently associated with 30-day and overall mortality after cardiac surgery requiring CPB. We propose that performance measurement variables are useful for quantifying the degree of intraoperative hypotension and predicting survival following cardiac surgery.Trial registration: ClinicalTrials.gov, identifier: NCT03785132.
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Procedimientos Quirúrgicos Cardíacos , Hipotensión , Presión Sanguínea , Puente Cardiopulmonar , Humanos , Estudios RetrospectivosRESUMEN
BACKGROUND: Although the Kidney Disease: Improving Global Outcomes (KDIGO) criteria are used to define acute kidney injury, the criteria have limitations for including 2 different serum creatinine criteria in stage 1. We hypothesized that there would be differences in clinical outcomes between the 2 subgroups of stage 1 acute kidney injury in patients undergoing cardiac or thoracic aortic surgery. METHODS: We reviewed 2510 cases. Patients with KDIGO stage 1 were divided into 2 subgroups (stage 1a: 0.3 mg/dL or greater of absolute increase in serum creatinine, n = 376; and stage 1b: 50% or greater relative increase, n = 365). Propensity score analysis was performed between stage 1a and 1b groups, yielding 240 pairs. We compared the length of hospital stay, the incidence of cardiovascular complications, 5-year all-cause mortality between these subgroups. Overall survival was compared between the subgroups after propensity score matching. We performed sensitivity analysis for Acute Kidney Injury Network (AKIN) criteria. RESULTS: Length of hospital stay and 5-year all-cause mortality were worse in patients with KDIGO stage 1b compared with stage 1a. Five-year patient survival was significantly worse in patients with stage 1b compared with stage 1a after matching (log rank test, P = .002). We found similar results regarding AKIN criteria. Subgroup analysis showed that the significant difference in survival existed only when baseline serum creatinine was 0.8 mg/dL or greater. CONCLUSIONS: The KDIGO or AKIN criteria for stage 1 acute kidney injury could be further divided into 2 substages with different severity of clinical outcomes. These modified criteria could give additional prognostic information in patients undergoing cardiac or thoracic aortic surgery.
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Lesión Renal Aguda/clasificación , Lesión Renal Aguda/diagnóstico , Aorta Torácica/cirugía , Procedimientos Quirúrgicos Cardíacos , Complicaciones Posoperatorias/clasificación , Complicaciones Posoperatorias/diagnóstico , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Postoperative anaemia is common after total knee arthroplasty (TKA). Emerging evidence shows the beneficial effects of peri-operative iron supplementation in patients at risk of postoperative anaemia. OBJECTIVE: To evaluate the efficacy of intra-operative administration of iron isomaltoside for the prevention of postoperative anaemia in patients undergoing TKA. DESIGN: Randomised, controlled, double-blind, parallel-group study. SETTING: A tertiary care teaching hospital; between 29 March 2018 and 16 April 2019. PATIENTS: Eighty-nine patients scheduled for unilateral TKA were included. INTERVENTION: Iron isomaltoside or placebo were administered intravenously over 30âmin during surgical wound closure. MAIN OUTCOME MEASURES: The primary outcome measure was the incidence of anaemia at 30 days after TKA: anaemia was defined as haemoglobin less than 12âgâdl-1 for female and less than 13âgâdl-1 for male. RESULTS: In total, 89 patients were included in the final analysis (44 in the treatment group; 45 in the control group). The administered dose of iron isomaltoside in the treatment group was 1136â±â225âmg. The incidence of anaemia at 30 days after TKA was significantly lower in the treatment group (34.1%, 15/44) than that in the control group (62.2%, 28/45): relative risk 0.55 (95% confidence interval, 0.34 to 0.88), Pâ=â0.008. Haemoglobin concentration, serum ferritin concentrations, and transferrin saturation were also significantly higher in the treatment group at 30 days after TKA. CONCLUSION: The intra-operative administration of iron isomaltoside effectively prevents postoperative anaemia in patients undergoing TKA, and thus it can be included in patient blood management protocols for reducing postoperative anaemia in these population. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03470649.
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Anemia , Artroplastia de Reemplazo de Rodilla , Artroplastia de Reemplazo de Rodilla/efectos adversos , Disacáridos , Femenino , Compuestos Férricos/efectos adversos , Humanos , MasculinoRESUMEN
BACKGROUND AND OBJECTIVES: Epidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural analgesia before thoracotomy incision reduces acute and chronic post-thoracotomy pain in adults compared with epidural analgesia after incision. METHODS: We searched databases including MEDLINE, Embase, and CENTRAL for randomized controlled trials comparing epidural analgesia initiated before (pre-emptive group) and after (control group) thoracotomy incision in adults. The primary outcomes were the pain intensity during rest and coughing within 72 hours after surgery and the incidence of pain 1 to 6 months after surgery. Data were combined with random-effects meta-analyses. We rated the quality of evidence as high, moderate, low, and very low using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. RESULTS: We included 19 trials with 1062 participants involving 529 in the pre-emptive group and 533 in the control group. The pain intensity was significantly lower at rest within 72 hours after surgery (19 studies, n=1062) and during coughing within 48 hours after surgery (11 studies, n=638), and the incidence of pain was significantly lower 1 to 6 months after surgery (6 studies, n=276) in the pre-emptive group than in the control group. The quality of evidence was moderate or low in the primary outcomes. CONCLUSIONS: Our review provides low-quality evidence that pre-emptive epidural analgesia reduces the intensity of acute pain and the incidence of chronic pain after thoracotomy in adults. PROTOCOL REGISTRATION NUMBER: CRD42019131620.
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Dolor Agudo , Analgesia Epidural , Dolor Crónico , Dolor Agudo/diagnóstico , Dolor Agudo/epidemiología , Dolor Agudo/prevención & control , Adulto , Analgesia Epidural/efectos adversos , Humanos , Dolor Postoperatorio/diagnóstico , Dolor Postoperatorio/epidemiología , Dolor Postoperatorio/etiología , Toracotomía/efectos adversosRESUMEN
BACKGROUND: Although previous studies have reported nephrotoxicity associated with hydroxyethyl starch (HES), the long-term effect of HES on renal function after nephrectomy has rarely been reported. We evaluated the association between intraoperative HES administration and short- and long-term renal function after nephrectomy. METHODS: We retrospectively reviewed 1106 patients who underwent partial or radical nephrectomy. The patients were divided into 2 groups: patients who received (HES group) or did not receive 6% HES 130/0.4 intraoperatively (non-HES group). The primary outcome was new-onset chronic kidney disease (CKD) stage 3a (estimated glomerular filtration rate [eGFR] <60 mL/min/1.73 m) or higher or all-cause mortality during 60 months after surgery. Propensity score matching was performed to address baseline differences between the 2 groups. Renal survival determined by stage 3a and stage 5 CKD (eGFR <15 mL/min/1.73 m) or all-cause mortality were compared up to 60 months before and after matching. We compared postoperative acute kidney injury (AKI) and CKD upstaging in the matched cohort as secondary outcomes. Ordinal logistic regression and Cox proportional hazards regression analyses using inverse probability of treatment weighting were performed for postoperative AKI and our primary outcome, respectively. A subgroup analysis of partial nephrectomy was performed. RESULTS: Thirty percent of patients received HES intraoperatively. Balanced solution and 0.9% normal saline was administered during surgery in both groups. Renal survival was not significantly different between groups after matching (log-rank test P = .377 for our primary outcome, and P = .981 for stage 5 or all-cause mortality, respectively). In the matched cohort (HES group: n = 280, non-HES group: n = 280), the incidence of AKI or CKD upstaging at 1 year was not significantly different (AKI: n = 94, 33.6% in HES group versus n = 90, 32.1% in non-HES group; CKD upstaging: n = 132, 47.1% in HES group versus n = 122, 43.6% in non-HES group; odds ratio [OR], 1.16; 95% confidence interval [CI], 0.83-1.61; P = .396). Intraoperative HES administration was not associated with postoperative renal outcomes (AKI: OR, 0.97; 95% CI, 0.81-1.16; P = .723; CKD stage 3a or higher or all-cause mortality: hazard ratio, 1.01; 95% CI, 0.89-1.14; P = .920). Subgroup analysis yielded similar results. CONCLUSIONS: Intraoperative 6% HES 130/0.4 administration was not significantly associated with short- and long-term renal function or renal survival up to 5 years in patients undergoing partial or radical nephrectomy. However, wide CI including large harm effect precludes firm conclusion and inadequate assessment of safety cannot be ruled out by our results.
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Derivados de Hidroxietil Almidón/efectos adversos , Enfermedades Renales/epidemiología , Pruebas de Función Renal , Nefrectomía , Soluciones Farmacéuticas/efectos adversos , Sustitutos del Plasma/efectos adversos , Lesión Renal Aguda/tratamiento farmacológico , Lesión Renal Aguda/epidemiología , Anciano , Estudios de Cohortes , Femenino , Fluidoterapia , Tasa de Filtración Glomerular , Humanos , Incidencia , Enfermedades Renales/inducido químicamente , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Puntaje de Propensión , Resultado del TratamientoRESUMEN
BACKGROUND: The relationship between intraoperative low bispectral index (BIS) values and poor clinical outcomes has been controversial. Intraoperative hypotension is associated with postoperative complication. The purpose of this study was to investigate the influence of intraoperative low BIS values and hypotension on postoperative mortality in patients undergoing major abdominal surgery. METHODS: This retrospective study analyzed 1862 cases of general anesthesia. We collected the cumulative time of BIS values below 20 and 40 as well as electroencephalographic suppression and documented the incidences in which these states were maintained for at least 5 min. Durations of intraoperative mean arterial pressures (MAP) less than 50 mmHg were also recorded. Multivariable logistic regression was used to evaluate the association between suspected risk factors and postoperative mortality. RESULTS: Ninety-day mortality and 180-day mortality were 1.5 and 3.2% respectively. The cumulative time in minutes for BIS values falling below 40 coupled with MAP falling below 50 mmHg was associated with 90-day mortality (odds ratio, 1.26; 95% confidence interval, 1.04-1.53; P = .019). We found no association between BIS related values and 180-day mortality. CONCLUSIONS: The cumulative duration of BIS values less than 40 concurrent with MAP less than 50 mmHg was associated with 90-day postoperative mortality, not 180-day postoperative mortality.
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Electroencefalografía/mortalidad , Hipotensión/mortalidad , Hipotensión/fisiopatología , Monitoreo Intraoperatorio/mortalidad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Monitores de Conciencia/tendencias , Electroencefalografía/métodos , Electroencefalografía/tendencias , Femenino , Humanos , Hipotensión/diagnóstico , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/tendencias , Mortalidad/tendencias , Complicaciones Posoperatorias/diagnóstico , Estudios Retrospectivos , Factores de Riesgo , Factores de TiempoRESUMEN
BACKGROUND: Although the intraoperative alveolar recruitment maneuver (RM) efficiently treats atelectasis, the effect of FIO2 on atelectasis during RM is uncertain. We hypothesized that a high FIO2 (1.0) during RM would lead to a higher degree of postoperative atelectasis without benefiting oxygenation when compared to low FIO2 (0.4). METHODS: In this randomized controlled trial, patients undergoing elective laparoscopic surgery in the Trendelenburg position were allocated to low- (FIO2 0.4, n = 44) and high-FIO2 (FIO2 1.0, n = 46) groups. RM was performed 1-min post tracheal intubation and post changes in supine and Trendelenburg positions during surgery. We set the intraoperative FIO2 at 0.4 for both groups and calculated the modified lung ultrasound score (LUSS) to assess lung aeration after anesthesia induction and at surgery completion. The primary outcome was modified LUSS at the end of the surgery. The secondary outcomes were the intra- and postoperative PaO2 to FIO2 ratio and postoperative pulmonary complications. RESULTS: The modified LUSS before capnoperitoneum and RM (P = 0.747) were similar in both groups. However, the postoperative modified LUSS was significantly lower in the low FIO2 group (median difference 5.0, 95% CI 3.0-7.0, P < 0.001). Postoperatively, substantial atelectasis was more common in the high-FIO2 group (relative risk 1.77, 95% CI 1.27-2.47, P < 0.001). Intra- and postoperative PaO2 to FIO2 were similar with no postoperative pulmonary complications. Atelectasis occurred more frequently when RM was performed with high than with low FIO2; oxygenation was not benefitted by a high-FIO2. CONCLUSIONS: In patients undergoing laparoscopic surgery in the Trendelenburg position, absorption atelectasis occurred more frequently with high rather than low FIO2. No oxygenation benefit was observed in the high-FIO2 group. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03943433 . Registered 7 May 2019.
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Pulmón/diagnóstico por imagen , Oxígeno/metabolismo , Complicaciones Posoperatorias/fisiopatología , Atelectasia Pulmonar/diagnóstico por imagen , Adulto , Femenino , Inclinación de Cabeza , Humanos , Intubación Intratraqueal/métodos , Laparoscopía/métodos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Alveolos Pulmonares/metabolismo , UltrasonografíaRESUMEN
BACKGROUND: The 15-item Quality of Recovery (QoR-15) scale is a validated patient-reported outcome questionnaire that measures the quality of postoperative recovery. This study aimed to validate a translated Korean version of QoR-15 (QoR-15K) in a broad range of surgical patients. METHODS: After Korean translation of the original English version of the QoR-15, we performed psychometric validation of the QoR-15K to evaluate the quality of recovery after surgery. The validity, reliability, responsiveness, and clinical feasibility of the QoR-15K were evaluated. A subgroup analysis in patients with video-assisted lung resection was performed. RESULTS: Among 193 patients, 188 (97.4%) completed the QoR-15K after surgery. We found good convergent validity between the postoperative QoR-15K and the global QoR visual analogue scale (ρ=0.61, P<0.001). The negative correlation between the QoR-15K score and the extent of surgery (ρ=-0.33, P<0.001), the duration of surgery (ρ=-0.33, P<0.001), and the severity of postoperative pain (ρ=-0.40, P<0.001) supported construct validity. The postoperative QoR-15K showed good internal consistency (Cronbach α=0.90), split-half reliability (0.81), and test-retest reliability (0.95; 95% confidence interval [CI], 0.94-0.96). The QoR-15K score decreased from 140 (preoperative, inter-quartile range [IQR] 128-146) to 100 (postoperative day 1, IQR 75-122), median difference -36.5 (95% CI, -41 to -32.5; P<0.0001). The QoR-15K indicated excellent responsiveness with Cliff's effect size -0.78 (95% CI, -0.84 to -0.71). Subgroup analysis yielded similar results. CONCLUSIONS: The QoR-15K is valid and has excellent reliability, a high degree of responsiveness, and clinical feasibility as a metric of quality of recovery in Korean surgical population. CLINICAL TRIAL REGISTRATION: NCT04169087.
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Recuperación Mejorada Después de la Cirugía , Medición de Resultados Informados por el Paciente , Encuestas y Cuestionarios , Anciano , Periodo de Recuperación de la Anestesia , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , República de Corea , Estudios de Validación como AsuntoRESUMEN
BACKGROUND: The long-term incidence of chronic postsurgical pain (CPSP) after thoracic surgery has not yet been reported. METHODS: We retrospectively reviewed the electronic medical records of 4218 consecutive patients who underwent thoracic surgery for lung cancer between 2007 and 2016. We evaluated the long-term incidence of CPSP after thoracic surgery at intervals of 3 months for 36 months. A Cox proportional hazard regression analysis was performed to investigate the predictors of CPSP after thoracic surgery. RESULTS: A total of 3200 patients were included in the analysis. Of these, 459 (14.3%) and 558 (17.4%) patients were diagnosed with CPSP within 3 and 36 months after surgery, respectively. Furthermore, the incidence of CPSP decreased over time. Additionally, 99 (3.1%) patients were newly diagnosed with CPSP at least 6 months after surgery. Female sex (HR 1.20, 95% CI 1.00 to 1.43; p=0.04), longer duration of surgery (HR 1.11, 95% CI 1.03 to 1.20; p<0.01), higher 11-point Numeric Rating Scale score at first outpatient visit after surgery (HR 1.29, 95% CI 1.24 to 1.34; p<0.001), postoperative chemotherapy (HR 1.55, 95% CI 1.26 to 1.90; p<0.001), and postoperative radiation therapy (HR 1.35, 95% CI 1.05 to 1.74; p=0.02) were significant predictors of CPSP for 36 months after surgery. CONCLUSION: Our study showed a decreasing trend in the incidence of CPSP as well as delayed-onset or recurrent CPSP after thoracic surgery. A better understanding of the progression of CPSP after thoracic surgery may provide important information on its prediction and treatment.
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Dolor Crónico/epidemiología , Neoplasias Pulmonares/cirugía , Dolor Postoperatorio/epidemiología , Procedimientos Quirúrgicos Torácicos/efectos adversos , Dolor Crónico/diagnóstico , Dolor Crónico/etiología , Femenino , Humanos , Incidencia , Neoplasias Pulmonares/epidemiología , Masculino , Dolor Postoperatorio/diagnóstico , Estudios Prospectivos , Estudios RetrospectivosRESUMEN
Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.
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Respiración con Presión Positiva/métodos , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Torácicos/efectos adversos , Volumen de Ventilación Pulmonar/fisiología , Humanos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/fisiopatología , Estudios RetrospectivosRESUMEN
BACKGROUND: Spinal anesthesia using a surface landmark-guided technique can be challenging in patients with anatomical alterations of the lumbar spine; however, it is unclear whether using ultrasonography can decrease the technical difficulties in these populations. We assessed whether an ultrasound-assisted technique could reduce the number of needle passes required for block success compared with the landmark-guided technique in patients with abnormal spinal anatomy. METHODS: Forty-four patients with abnormal spinal anatomy including documented lumbar scoliosis and previous spinal surgery were randomized to receive either surface landmark-guided or preprocedural ultrasound-assisted spinal anesthesia. All spinal procedures were performed by 1 of 3 experienced anesthesiologists. The primary outcome was the number of needle passes required for successful dural puncture. Secondary outcomes included the success rate on the first pass, total procedure time, periprocedural pain scores, and the incidences of radicular pain, paresthesia, and bloody tap during the neuraxial procedure. Intergroup difference in the primary outcome was assessed for significance using Mann-Whitney U test. RESULTS: The median (interquartile range [IQR; range]) number of needle passes was significantly lower in the ultrasound group than in the landmark group (ultrasound 1.5 [1-3 {1-5}]; landmark 6 [2-9.3 {1-15}]; P < .001). First-pass success was achieved in 11 (50.0%) and 2 (9.1%) patients in the ultrasound and landmark groups, respectively (P = .007). The total procedure time, defined as the sum of the time for identifying landmarks and performing spinal anesthesia, did not differ significantly between the 2 groups (ultrasound 141 seconds [115-181 seconds {101-336 seconds}]; landmark 146 seconds [90-295 seconds {53-404 seconds}]; P = .888). The ultrasound group showed lower periprocedural pain scores compared with the landmark group (ultrasound 3.5 [1-5 {0-7}]; landmark 5.5 [3-8 {0-9}]; P = .012). The incidences of complications during the procedure showed no significant differences between the 2 groups. CONCLUSIONS: For anesthesiologists with experience in neuraxial ultrasonography, the use of ultrasound significantly reduces the technical difficulties of spinal anesthesia in patients with abnormal spinal anatomy compared with the landmark-guided technique. Our results can lead to practical suggestions that encourage the use of neuraxial ultrasonography for spinal anesthesia in such patients.