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1.
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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Perioperative Goal-Directed Fluid Therapy: A Prime Component of Enhanced Recovery After Surgery.
McLain, N, Parks, S, Collins, MJ
AANA journal. 2021;(4):351-357
Abstract
Perioperative goal-directed fluid therapy (GDFT) is a prime component of the Enhanced Recovery After Surgery (ERAS) protocol. Multiple studies have demonstrated a relationship between GDFT and positive patient outcomes, including shorter hospital stays, decreased ileus formation, reduced gastrointestinal-related issues, decreased nausea, and hemodynamic stability. Electrolyte disturbances following a positive fluid balance may occur, and GDFT is aimed at euvolemia to avoid a hypervolemic state. Carbohydrate loading, early discontinuation of postoperative intravenous fluids, and use of isoosmotic solutions all are components of GDFT. Lactated Ringer's solution is the fluid recommended for nonrenal patients and patients with hepatic compromise. The negative consequences associated with hypervolemia deem it pertinent to devise an individualized GDFT plan in the ERAS protocol.
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The Effect of Perioperative Administration of Probiotics on Colorectal Cancer Surgery Outcomes.
Pitsillides, L, Pellino, G, Tekkis, P, Kontovounisios, C
Nutrients. 2021;(5)
Abstract
The perioperative care of colorectal cancer (CRC) patients includes antibiotics. Although antibiotics do provide a certain protection against infections, they do not eliminate them completely, and they do carry risks of microbial resistance and disruption of the microbiome. Probiotics can maintain the microbiome's balance postoperatively by maintaining intestinal mucosal integrity and reducing bacterial translocation (BT). This review aims to assess the role of probiotics in the perioperative management of CRC patients. The outcomes were categorised into: postoperative infectious and non-infectious complications, BT rate analysis, and intestinal permeability assessment. Fifteen randomised controlled trials (RCTs) were included. There was a trend towards lower rates of postoperative infectious and non-infectious complications with probiotics versus placebo. Probiotics reduced BT, maintained intestinal mucosal permeability, and provided a better balance of beneficial to pathogenic microorganisms. Heterogeneity among RCTs was high. Factors that influence the effect of probiotics include the species used, using a combination vs. single species, the duration of administration, and the location of the bowel resection. Although this review provided evidence for how probiotics possibly operate and reported notable evidence that probiotics can lower rates of infections, heterogeneity was observed. In order to corroborate the findings, future RCTs should keep the aforementioned factors constant.
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Exercise prehabilitation in lung cancer: Getting stronger to recover faster.
Avancini, A, Cavallo, A, Trestini, I, Tregnago, D, Belluomini, L, Crisafulli, E, Micheletto, C, Milella, M, Pilotto, S, Lanza, M, et al
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology. 2021;(8):1847-1855
Abstract
Despite several recent advances, lung cancer surgery is still associated with potentially severe postoperative complications. It has been suggested that preoperative exercise training could render patients with borderline functional parameters eligible for surgery, improve perioperative outcomes and that these benefits might reduce healthcare costs. Nevertheless, given the substantial heterogeneity of the available studies, no specific guidelines for preoperative exercise training have been released so far. This narrative review aims to provide an overview of the potential benefits of exercise training in the preoperative period as a central intervention for lung cancer patients. In detail, the effects of exercise (with different regimens) were evaluated in terms of physical functions, patients' eligibility for curative surgery, postoperative complications and length of stay, with an exploratory focus on healthcare costs and long-term outcomes. Furthermore, a feasible approach for every-day clinical practice is proposed in order to increase the expected benefit deriving from a more extensive and methodical application of prehabilitation exercise, ideally in the context of a comprehensive approach to lung cancer patients, including nutritional and psychological support.
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Postoperative management considerations of the elderly patient undergoing orthopaedic surgery.
Gjorgjievski, M, Ristevski, B
Injury. 2020;:S23-S27
Abstract
INTRODUCTION The elderly population is rapidly increasing, corresponding to an increase in orthopaedic surgical procedures for this group of patients. Current guidelines mostly concentrate on the patient's age when considering surgical fitness in the elderly. However, patient frailty may be a more significant factor when assessing postoperative risk in surgical management. In this article, we will analyse some of the factors associated with the postoperative care of the geriatric population after orthopaedic surgery. METHODS This manuscript summarizes a presentation from the 2019 Osteosynthesis and Trauma Care (OTC) meeting in Toronto, ON, given by an invited presenter on the topic of Postoperative medical management of the geriatric patient undergoing orthopaedic surgery. The information in the presentation is based on current literature and available guidelines. RESULTS Highlighted were factors that can have a significant impact on the management and outcomes of elderly patients undergoing orthopaedic surgery. These included: cognitive impairment, postoperative analgesic control, pulmonary complications, falls, nutrition optimization, urinary tract infections, pressure ulcers, and functional decline. CONCLUSION There is a higher rate of postoperative complications in the surgical management of the elderly, and thus, special considerations following orthopaedic surgery in this patient group are necessary. Determining patient frailty based on clinical judgment using specific postoperative considerations could be a more reliable method in determining the surgical risk in the elderly patient. Additionally, more attention needs to be diverted towards early mobilization and patient education, as these factors can significantly help to avoid some of the postoperative complications that seem to affect the geriatric population.
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Anesthetic management of geriatric patients.
Lim, BG, Lee, IO
Korean journal of anesthesiology. 2020;(1):8-29
Abstract
The number of elderly patients who frequently access health care services is increasing worldwide. While anesthesiologists are developing the expertise to care for these elderly patients, areas of concern remain. We conducted a comprehensive search of major international databases (PubMed, Embase, and Cochrane) and a Korean database (KoreaMed) to review preoperative considerations, intraoperative management, and postoperative problems when anesthetizing elderly patients. Preoperative preparation of elderly patients included functional assessment to identify preexisting cognitive impairment or cardiopulmonary reserve, depression, frailty, nutrition, polypharmacy, and anticoagulation issues. Intraoperative management included anesthetic mode and pharmacology, monitoring, intravenous fluid or transfusion management, lung-protective ventilation, and prevention of hypothermia. Postoperative checklists included perioperative analgesia, postoperative delirium and cognitive dysfunction, and other complications. A higher level of perioperative care was required for older surgical patients, as multiple chronic diseases often makes them prone to developing postoperative complications, including functional decline and loss of independence. Although the guiding evidence remains poor so far, elderly patients have to be provided optimal perioperative care through close interdisciplinary, interprofessional, and cross-sectional collaboration to minimize unwanted postoperative outcomes. Furthermore, along with adequate anesthetic care, well-planned postoperative care should begin immediately after surgery and extend until discharge.
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Impact of sarcopenia in trauma and surgical patient population: A literature review.
Wahlen, BM, Mekkodathil, A, Al-Thani, H, El-Menyar, A
Asian journal of surgery. 2020;(6):647-653
Abstract
Sarcopenia refers to the progressive and generalised loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and mortality. The present review explored the impact, diagnosis, prevention and management of sarcopenia in surgical and trauma patients. Recent evidence suggests that there are many factors contributing to its development other than age. Pathophysiology of sarcopenia is complex which makes its diagnosis difficult and there is no universal approach. It is a predictor of poor outcomes including post-operative complications, length of hospital stay and mortality in trauma and surgery patients. Sedentary lifestyle, age-dependent hormone and cytokine imbalance, decreased protein synthesis and regeneration, and motor unit remodelling are some of the main risk factors for sarcopenia. Dual energy X-ray absorptiometry, bio-electrical impedance analysis and computed tomography are frequently utilized for its diagnosis. Management of sarcopenia involves appropriate management of comorbidities, interventions to facilitate physical activities, nutrition interventions and pharmacotherapy.
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Getting patient blood management Pillar 1 right in the Asia-Pacific: a call for action.
Abdullah, HR, Ang, AL, Froessler, B, Hofmann, A, Jang, JH, Kim, YW, Lasocki, S, Lee, JJ, Lee, SY, Lim, KKC, et al
Singapore medical journal. 2020;(6):287-296
Abstract
Preoperative anaemia is common in the Asia-Pacific. Iron deficiency anaemia (IDA) is a risk factor that can be addressed under patient blood management (PBM) Pillar 1, leading to reduced morbidity and mortality. We examined PBM implementation under four different healthcare systems, identified challenges and proposed several measures: (a) Test for anaemia once patients are scheduled for surgery. (b) Inform patients about risks of preoperative anaemia and benefits of treatment. (c) Treat IDA and replenish iron stores before surgery, using intravenous iron when oral treatment is ineffective, not tolerated or when rapid iron replenishment is needed; transfusion should not be the default management. (d) Harness support from multiple medical disciplines and relevant bodies to promote PBM implementation. (e) Demonstrate better outcomes and cost savings from reduced mortality and morbidity. Although PBM implementation may seem complex and daunting, it is feasible to start small. Implementing PBM Pillar 1, particularly in preoperative patients, is a sensible first step regardless of the healthcare setting.
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Prehabilitation: metabolic considerations.
Chabot, K, Gillis, C, Carli, F
Current opinion in clinical nutrition and metabolic care. 2020;(4):271-276
Abstract
PURPOSE OF REVIEW The major components of ERAS attenuate the inflammatory response and modulate metabolism in direction of sparing body protein and preserving function. However, these perioperative interventions might have limited effectiveness on postoperative outcomes if preoperative risk factors are not addressed and optimized. RECENT FINDINGS The preoperative metabolic perturbations characterized by insulin resistance and sarcopenia might predispose patients to a higher degree of postoperative catabolism. High-risk populations for such metabolic disturbances include elderly and frail patients, and patients with metabolic syndrome. Research on the effect of prehabilitation on perioperative metabolism is limited, but recent findings suggest that interventions designed to improve insulin sensitivity prior to surgery might represent a promising therapeutic target to minimize surgical complications. SUMMARY The present paper will discuss the metabolic implications of modulating preoperative risk factors with elements of multimodal prehabilitation, such as exercise training and nutrition.
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10.
Preoperative carbohydrates: what is new?
Gianotti, L, Sandini, M, Hackert, T
Current opinion in clinical nutrition and metabolic care. 2020;(4):262-270
Abstract
PURPOSE OF REVIEW The aim of this review is to give an overview of recently published articles covering preoperative carbohydrate loading in surgical patients. RECENT FINDINGS Between January 1, 2017, and December 31, 2019, 26 publications addressing the effect of carbohydrate load were retrieved through a systematic search. Seventeen were randomized clinical trials, three prospective observational studies and six retrospective series with case-control comparison. Most of the studies were underpowered, addressed surrogate endpoints, and variability among dose and timing of carbohydrate (CHO) treatment was high. The most recent literature endorses preoperative carbohydrate loading up to 2 h before operations as a safe treatment. The new evidence confirm that this strategy is effective in reducing perioperative insulin resistance and the proportion of hyperglycemia episodes, and improving patient well-being and comfort but without affecting surgery-related morbidity. SUMMARY Further properly designed randomized clinical trials, addressing more clinically relevant endpoints such as length of hospitalization and morbidity rate, are warrant.