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Postoperative Management of Lung Transplant Recipients in the Intensive Care Unit.
Di Nardo, M, Tikkanen, J, Husain, S, Singer, LG, Cypel, M, Ferguson, ND, Keshavjee, S, Del Sorbo, L
Anesthesiology. 2022;(3):482-499
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Abstract
The number of lung transplantations is progressively increasing worldwide, providing new challenges to interprofessional teams and the intensive care units. The outcome of lung transplantation recipients is critically affected by a complex interplay of particular pathophysiologic conditions and risk factors, knowledge of which is fundamental to appropriately manage these patients during the early postoperative course. As high-grade evidence-based guidelines are not available, the authors aimed to provide an updated review of the postoperative management of lung transplantation recipients in the intensive care unit, which addresses six main areas: (1) management of mechanical ventilation, (2) fluid and hemodynamic management, (3) immunosuppressive therapies, (4) prevention and management of neurologic complications, (5) antimicrobial therapy, and (6) management of nutritional support and abdominal complications. The integrated care provided by a dedicated multidisciplinary team is key to optimize the complex postoperative management of lung transplantation recipients in the intensive care unit.
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2.
[Not Available].
Laurenius, A, Näslund, I, Sandvik, J, Videhult, P, Wirén, M
Lakartidningen. 2018
Abstract
Each year 6,800 bariatric operations are performed in Sweden. Bariatric surgery involves both a reduced intake and a reduced absorption of vitamins and minerals. There has been debate about whose responsibility long-term follow-up is, particularly regarding monitoring vitamin and mineral status. The Swedish Society for Bariatric Surgery and the Norwegian Association for Bariatric Surgery, who oversee their respective national quality registers, have appointed an expert group to develop guidelines for postoperative supplementation and nutritional monitoring of vitamins and minerals, along with a schedule for routine follow-up. Several existing international guidelines have served as the basis for the development of this guidance. The Finnish Association for Metabolic Surgery and The Danish Association for the Study of Obesity have also decided to adopt the recommendations. The care of the patient group with severe obesity is a common responsibility of primary care and hospitals, as patients are heavily affected by obesity-related morbidity, which, even without surgery, requires major health care efforts, not least from primary care. After surgery, a large proportion of these efforts can be reduced, but focus changes.
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Perioperative management of adult diabetic patients. Postoperative period.
Cheisson, G, Jacqueminet, S, Cosson, E, Ichai, C, Leguerrier, AM, Nicolescu-Catargi, B, Ouattara, A, Tauveron, I, Valensi, P, Benhamou, D, et al
Anaesthesia, critical care & pain medicine. 2018;:S27-S30
Abstract
Follow on from continuous intravenous administration of insulin with an electronic syringe (IVES) is an important element in the postoperative management of a diabetic patient. The basal-bolus scheme is the most suitable taking into account the nutritional supply and variable needs for insulin, reproducing the physiology of a normal pancreas: (i) slow (long-acting) insulin (=basal) which should immediately take over from IVES insulin simulating basal secretion; (ii) ultra-rapid insulin to simulate prandial secretion (=bolus for the meal); and (iii) correction of possible hyperglycaemia with an additional ultra-rapid insulin bolus dose. A number of schemes are proposed to help calculate the dosages for the change from IV insulin to subcutaneous insulin and for the basal-bolus scheme. Postoperative resumption of an insulin pump requires the patient to be autonomous. If this is not the case, then it is mandatory to establish a basal-bolus scheme immediately after stopping IV insulin. Monitoring of blood sugar levels should be continued postoperatively. Hypoglycaemia and severe hyperglycaemia should be investigated. Faced with hypoglycaemia <3.3mmol/L (0.6g/L), glucose should be administered immediately. Faced with hyperglycaemia >16.5mmol/L (3g/L) in a T1D or T2D patient treated with insulin, investigations for ketosis should be undertaken systematically. In T2D patients, unequivocal hyperglycaemia should also call to mind the possibility of diabetic hyperosmolarity (hyperosmolar coma). Finally, the modalities of recommencing previous treatments are described according to the type of hyperglycaemia, renal function and diabetic control preoperatively and during hospitalisation.
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Nasoenteric tube versus jejunostomy for enteral nutrition feeding following major upper gastrointestinal operations: a meta-analysis.
Wang, L, Tian, Z, Liu, Y
Asia Pacific journal of clinical nutrition. 2017;(1):20-26
Abstract
BACKGROUND AND OBJECTIVES Following major upper gastrointestinal surgical procedures, early enteral nutrition to the jejunum is strongly recommended, either through a nasoenteric tube or a percutaneous transperitoneal jejunal feeding tube (jejunostomy). However, to date there has been no consensus as to the best enteral feeding strategy. Our aim was to determine the safest and most efficacious early enteral nutrition supplement strategy following major upper gastrointestinal operations. METHODS AND STUDY DESIGN PubMed, Embase and Cochrane Library databases were systematically searched for comparison of trials. The primary outcome analyzed was length of postoperative hospital stay, and secondary outcomes were: duration of enteral nutrition, time to resumption of normal oral intake, and tube dislodgement, tube leakage and tube obstruction complications. Weighted mean differences (WMDs) and risk ratios (RRs) were calculated with 95% confidence intervals (CI). RESULTS A total of 5 studies were included with 420 patients in all. The length of hospital stay, duration of enteral nutrition and the time to resumption of normal oral intake were all significantly shorter in the nasoenteric group (p<0.05). There was no increase or reduction in the RR of tube obstruction between the nasoenteric and jejunostomy groups (p=0.5). The RR of tube dislodgement was increased in the nasoenteric group (p<0.05) while the RR of tube leakage was increased in the jejunostomy group (p<0.05). CONCLUSIONS A nasoenteric tube is more likely to be effective in early postoperative enteral feeding following major upper gastrointestinal operations.
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The effects of enteral immunonutrition in upper gastrointestinal surgery: A systematic review and meta-analysis.
Wong, CS, Aly, EH
International journal of surgery (London, England). 2016;:137-50
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Abstract
AIM: The beneficial of immunonutrition on overall morbidity and mortality remains uncertain. We undertook a systematic review to evaluate the effects of immune-enhancing enteral nutrition (IEN) in upper gastrointestinal (GI) surgery. METHODS Main electronic databases [MEDLINE via Pubmed, EMBASE, Scopus, Web of Knowledge, Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Library, and clinical trial registry (ClinicalTrial.gov)] were searched for studies reported clinical outcomes comparing standard enteral nutrition (SEN) and immunonutrition (IEN). The systematic review was conducted in accordance with the PRISMA guidelines and meta-analysis was analysed using fixed and random-effects models. RESULTS Nineteen RCTs with a total of 2016 patients (1017 IEN and 999 SEN) were included in the final pooled analysis. The ratio of patients underwent oesophagectomy:gastrectomy:pancreatectomy was 2.2:1.2:1.0. IEN, when administered post-operatively, was associated with a significantly lower risk of wound infection (risk ratio (RR) 0.59, 95% confidence interval (CI) 0.40 to 0.88; p = 0.009) and shorter length of hospital stay (MD -2.92 days, 95% CI -3.89 to -1.95; p < 0.00001). No significant differences in other post-operative morbidities of interest (e.g. anastomotic leak and pulmonary infection) and mortality between the two groups were identified. CONCLUSIONS Overall, our analysis found that IEN decreases wound infection rates and reduces length of stay. It should be recommended as routine nutritional support as part of the Enhanced Recovery after Surgery (ERAS) programmes for upper GI Surgery.
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Systematic Nutritional Support in Allogeneic Hematopoietic Stem Cell Transplant Recipients.
Fuji, S, Einsele, H, Savani, BN, Kapp, M
Biology of blood and marrow transplantation : journal of the American Society for Blood and Marrow Transplantation. 2015;(10):1707-13
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) has become an established treatment modality for various hematological diseases. However, in allogeneic HSCT, patients often suffer from severe gastrointestinal complications caused by the conditioning regimen and acute/chronic graft-versus-host disease, which requires support by multidisciplinary nutritional support teams (NST). In addition, pretransplantation nutritional status can affect the clinical outcome after allogeneic HSCT. Therefore, it is important to refer the patient to a NST when becoming aware of nutritional problems before allogeneic HSCT. It is also important to follow nutritional status over the long term, as patients often suffer from various nutritional problems, such as malnutrition and metabolic syndrome, even late after allogeneic HSCT. In summary, NST can contribute to the improvement of nutritional status and possibly prognosis at every stage before and after allogeneic HSCT. Here, we aim to give a comprehensive overview of current understanding about nutritional support in allogeneic HSCT and try to provoke a constructive discussion to stimulate further investigation.
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Post-surgical management of non-functioning pituitary adenoma.
Cortet-Rudelli, C, Bonneville, JF, Borson-Chazot, F, Clavier, L, Coche Dequéant, B, Desailloud, R, Maiter, D, Rohmer, V, Sadoul, JL, Sonnet, E, et al
Annales d'endocrinologie. 2015;(3):228-38
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Abstract
Post-surgical surveillance of non-functioning pituitary adenoma (NFPA) is based on magnetic resonance imaging (MRI) at 3 or 6 months then 1 year. When there is no adenomatous residue, annual surveillance is recommended for 5 years and then at 7, 10 and 15 years. In case of residue or doubtful MRI, prolonged annual surveillance monitors any progression. Reintervention is indicated if complete residue resection is feasible, or for symptomatic optic pathway compression, to create a safety margin between the tumor and the optic pathways ahead of complementary radiation therapy (RT), or in case of post-RT progression. In case of residue, unless the tumor displays elevated growth potential, it is usually recommended to postpone RT until progression is manifest, as efficacy is comparable whether treatment is immediate or postponed. The efficacy of the various RT techniques in terms of tumor volume control is likewise comparable. RT-induced hypopituitarism is frequent, whatever the technique. The choice thus depends basically on residue characteristics: size, delineation, and proximity to neighboring radiation-sensitive structures. Reduced rates of vascular complications and secondary brain tumor can be hoped for with one-dose or hypofractionated stereotactic RT, but there has been insufficient follow-up to provide evidence. Somatostatin analogs and dopaminergic agonists have yet to demonstrate sufficient efficacy. Temozolomide is an option in aggressive NFPA resistant to surgery and RT.
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Current management issues of immediate postoperative care in pediatric kidney transplantation.
Torricelli, FC, Watanabe, A, David-Neto, E, Nahas, WC
Clinics (Sao Paulo, Brazil). 2014;(Suppl 1):39-41
Abstract
The number of pediatric kidney transplants has been increasing in many centers worldwide, as the procedure provides long-lasting and favorable outcomes; however, few papers have addressed the immediate postoperative care of this unique population. Herein, we describe the management of these patients in the early postoperative phase. After the surgical procedure, children should ideally be managed in a pediatric intensive care unit, and special attention should be given to fluid balance, electrolyte disturbances and blood pressure control. Antibiotic and antiviral prophylaxes are usually performed and are based on the recipient and donor characteristics. Thrombotic prophylaxis is recommended for children at high risk for thrombosis, although consensus on the optimum therapy is lacking. Image exams are essential for good graft control, and Doppler ultrasound must be routinely performed on the first operative day and promptly repeated if there is any suspicion of kidney dysfunction. Abdominal drains can be helpful for surveillance in patients with increased risk of surgical complications, such as urinary fistula or bleeding, but are not routinely required. The immunosuppressive regimen starts before or at the time of kidney transplantation and is usually based on induction with monoclonal or polyclonal antibodies, depending on the immunological risk, and maintenance with a calcineurin inhibitor (tacrolimus or ciclosporin), an anti-proliferative agent (mycophenolate or azathioprine) and steroids.
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Postoperative ICU management of patients after subarachnoid hemorrhage.
Gruenbaum, SE, Bilotta, F
Current opinion in anaesthesiology. 2014;(5):489-93
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Abstract
PURPOSE OF REVIEW This article reviews recent advances in the postoperative ICU management of patients after subarachnoid hemorrhage (SAH), especially with regards to hemodynamic management, methods of improving neurological outcomes, and management of cardiac and pulmonary complications. RECENT FINDINGS Several hemodynamic monitors and parameters may be useful for guiding volume therapy, including cardiac output, stroke volume variation monitoring, and global end-diastolic volume index. Early goal-directed hemodynamic therapy after SAH has recently been shown to improve clinical outcomes in patients with a poor clinical grade or coexisting cardiopulmonary complications. Recent laboratory and imaging modalities are being developed to identify patients at risk for developing vasospasm after SAH. Evidence for the use of various prophylactic adjuvant therapies to prevent vasospasm, including magnesium, phosphodiesterase 3 inhibitors, and therapeutic hypothermia, is emerging. Intrathecal administration of vasodilators or fibrinolytics may have offered advantages over systemic drug administration in the treatment of vasospasm. Pulmonary and cardiac complications are common after SAH, and are associated with an increased risk of mortality. SUMMARY The postoperative ICU period after SAH is associated with a significant morbidity and mortality risk, and recent studies have greatly contributed to our understanding of how to optimally manage these patients.
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Enhanced recovery in gastrointestinal surgery: upper gastrointestinal surgery.
Dorcaratto, D, Grande, L, Pera, M
Digestive surgery. 2013;(1):70-8
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Abstract
Over the last 20 years, a new concept of perioperative patient care based on a construct of evidence-based interventions referred to as 'enhanced recovery after surgery' (ERAS) has been developed. The main pillars of ERAS programs include optimal postoperative pain management and early enteral feeding and mobilization after surgery. Several studies, mostly based on experiences with patients undergoing colonic resection, suggest that ERAS implementation is feasible and safe. However, there are very few well-designed studies that have evaluated the usefulness of ERAS programs after major upper abdominal surgery. The present review focuses on the discussion of the most relevant and recently published data on the application of ERAS programs in pancreatic, hepatic, esophageal and gastric surgery. A total of 23 articles have been reviewed by the authors. The high frequency and the potentially hazardous nature of some postoperative complications associated with major upper abdominal surgery and the lack of well-designed randomized controlled trials are limiting factors for the application of ERAS. However, the present results indicate that the implementation of ERAS programs in pancreatic, hepatic, esophageal and gastric surgery patients contributes to a reduction in complications, length of hospital stay and costs without an increase in mortality or readmission rates.