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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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Preoperative frailty assessment combined with prehabilitation and nutrition strategies: Emerging concepts and clinical outcomes.
Gritsenko, K, Helander, E, Webb, MPK, Okeagu, CN, Hyatali, F, Renschler, JS, Anzalone, F, Cornett, EM, Urman, RD, Kaye, AD
Best practice & research. Clinical anaesthesiology. 2020;(2):199-212
Abstract
Important elements of the preoperative assessment that should be addressed for the older adult population include frailty, comorbidities, nutritional status, cognition, and medications. Frailty has emerged as a plausible predictor of adverse outcomes after surgery. It is present in older patients and is characterized by multisystem physiologic decline, increased vulnerability to stressors, and adverse clinical outcomes. Preoperative preparation may include a prehabilitation program, which aims to address nutritional insufficiencies, modify chronic polypharmacy, and enhance physical and respiratory conditions prior to hospital admission. Special considerations are taken for particularly high-risk patients, where the approach to prehabilitation can address specific, individual risk factors. Identifying patients who are nutritionally deficient allows practitioners to intervene preoperatively to optimize their nutritional status, and different strategies are available, such as immunonutrition. Previous studies have shown an association between increased frailty and the risk of postoperative complications, morbidity, hospital length of stay, and 30-day and long-term mortality following general surgical procedures. Evidence from numerous studies suggests a potential benefit of including a standard assessment of frailty as part of the preoperative workup of older adult patients. Studies addressing validated frailty assessments and the quantification of their predictive capabilities in various surgeries are warranted.
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Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review.
Schneider, S, Armbrust, R, Spies, C, du Bois, A, Sehouli, J
Archives of gynecology and obstetrics. 2020;(2):315-326
Abstract
PURPOSE The "Enhanced recovery after surgery" (ERAS) concept has been continuously developed for many surgical disciplines. Shorter length of stay (LOS) and associated cost savings have been achieved without an increase in the complication or readmission rate. Current guidelines helped to support an increasing standardisation of care. One innovation of the recently published update is the proposal to integrate prehabilitation (PREHAB) into the ERAS concept. On this basis, the authors provide an overview of the current data on ERAS concepts in gynecological oncology and review the evidence of prehabilitation concepts. METHODS Systematic literature review of all comparative studies on ERAS concepts in gynecological oncology and prehabilitation undergoing abdominal cancer surgery was performed using the standard databases. Outcomes of interest included prehabilitation program composition (exercise, nutritional, and psychological interventions), duration and outcome measures used to determine impact of prehabilitation vs. standard care. RESULTS Five studies reported on PREHAB programs in gynecology (three RCTs, one study protocol, one pilot study). There is no trial evaluating a pathway for patients with extensive ovarian or cervical cancer. Study protocols were heterogenous, but showed improvements in both physical and psychological parameters. ERAS protocols in ovarian cancer patients were investigated in 12 observational studies, mostly single center and only 1 RCT, in 4 studies patients with ovarian cancer or patients. Most studies showed improvement in complication rate and shorter LOS. DISCUSSION PREHAB programs seem feasible in abdominal cancer surgery and may improve surgical outcome. However, there is no prospective trial in gynecological oncology so far. Furthermore, there is no concept combining ERAS and PREHAB interventions. Therefore, the authors encourage the further development of both by describing in a novel treatment algorithm.
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4.
Effects of intensive lipid-lowering therapy on mortality after coronary bypass surgery: A meta-analysis of 7 randomised trials.
Alkhalil, M
Atherosclerosis. 2020;:75-78
Abstract
BACKGROUND AND AIMS The recent reported analysis from the ODYSSEY OUTCOMES trial showed that patients with previous coronary bypass graft surgery (CABG) had enhanced clinical benefits in response to intensive low-density lipoprotein-cholesterol (LDL-c). Nonetheless, the impact on cardiovascular and all-cause mortality was difficult to ascertain given the relatively small number. METHODS We conducted a meta-analysis investigating the role of more versus less intensive lipid-lowering treatment, taking into consideration the difference in studies duration when reporting treatment effect. RESULTS A significant 14% reduction in deaths from any cause [RR 0.86 (95% CI, 0.74 to 0.99)] and 25% reduction in cardiovascular mortality [RR 0.75, (95% CI, 0.65 to 0.86)] were associated with intensive LDL-c reduction in patients post CABG. Importantly, this reduction was apparent in patients who were stable or developed an acute coronary syndrome following CABG. CONCLUSIONS Patients with previous CABG incurred reduction in all-cause mortality and particularly cardiovascular mortality in response to intensive LDL-c reduction. Patient's clinical presentation following CABG did not modulate the associated benefits with intensive LDL-c reduction. Characterising atherosclerotic disease may help identify other high-risk groups who may benefit maximally from additional lipid-lowering therapies.
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ERAS protocol in gynecologic oncology.
Bajsová, S, Klát, J
Ceska gynekologie. 2019;(5):376-385
Abstract
OBJECTIVE To summarize current knowledge of the ERAS protocol in gynecologic oncology surgery. DESIGN Review article. SETTINGS Department of Obstetrics and Gynecology, University Hospital Ostrava, Ostrava, Department of Obstetrics and Gynecology, University of Ostrava, Ostrava. METHODS Literature review, PubMed and Medline databases were used to search relevant literature from 1995 to 2019. CONCLUSION ERAS (Enhanced Recovery after Surgery) is a perioperative treatment program based on evidence-based medicine. Guidelines consist of pre-operative, perioperative and post-operative care items. Implementation of the ERAS protocol leads to a decrease in complications up to 40% and a reduction in hospitalization by up to 30%, thereby reducing overall costs without increasing the number of rehospitalizations. Multidisciplinary cooperation not only with anesthesiologists and consultant surgeons, but also with nutritional specialists and nurses is crucial.
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Critical Care Management of Living Donor Liver Transplants.
Lemon, K, Al-Khafaji, A, Humar, A
Critical care clinics. 2019;(1):107-116
Abstract
This article represents a review of the postoperative management of donors and recipients after living donor liver transplant, including monitoring, liberation from mechanical ventilation, nutritional support, and pain control. Vascular complications, such as biliary and sepsis, and bleeding are also discussed. Finally, commonly used immunosuppression and antimicrobial prophylaxes are reviewed.
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External suction versus simple water-seal on chest drainage following pulmonary surgery: an updated meta-analysis.
Zhou, J, Chen, N, Hai, Y, Lyu, M, Wang, Z, Gao, Y, Pang, L, Liao, H, Liu, L
Interactive cardiovascular and thoracic surgery. 2019;(1):29-36
Abstract
OBJECTIVES The decision to apply simple water-seal drainage or the addition of an external suction to the simple water-seal drainage following pulmonary surgery is made based on the surgeon's experience or preference and has remained controversial. This meta-analysis aimed to assess the effects of the addition of suction to simple water-seal on the postoperative outcomes. METHODS PubMed, EMBASE and Web of Science were searched from their inception to 30 August 2017. The risk ratio and the weight mean difference were calculated for dichotomous and continuous outcomes, respectively, each with 95% confidence intervals (CIs). The heterogeneity and risk of bias were also assessed. RESULTS A total of 10 randomized controlled trials enrolling 1601 patients were included. Overall, compared with simple water-seal, the addition of external suction reduced the occurrence of postoperative pneumothorax (risk ratio 0.35, 95% CI 0.13-0.93; P = 0.04) and other cardiopulmonary complications (risk ratio 0.65, 95% CI 0.48-0.89; P = 0.008), and increased the duration of chest tube drainage (weight mean difference 0.92 days, 95% CI 0.04-1.81, P = 0.04). However, the effect difference between the 2 groups was not significant regarding air leak duration, length of hospital stay and the occurrence of prolonged air leak. The stability of these studies was strong. No evidence of publication bias was detected. CONCLUSIONS The addition of suction to simple water-seal made no difference to air leak duration, hospital stay or the occurrence of prolonged air leak following pulmonary surgery. In patients where there is concern about a residual or increasing pneumothorax, the addition of suction may be applied selectively.
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Fluid Management With Peritoneal Dialysis After Pediatric Cardiac Surgery.
Barhight, MF, Soranno, D, Faubel, S, Gist, KM
World journal for pediatric & congenital heart surgery. 2018;(6):696-704
Abstract
Children who undergo cardiac surgery with cardiopulmonary bypass are a unique population at high risk for postoperative acute kidney injury (AKI) and fluid overload. Fluid management is important in the postoperative care of these children as fluid overload is associated with increased morbidity and mortality. Peritoneal dialysis catheters are an important tool in the armamentarium of a cardiac intensivist and are used for passive drainage for fluid removal or dialysis for electrolyte and uremia control in AKI. Prophylactic placement of a peritoneal catheter is a safe method of fluid removal that is associated with few major complications. Early initiation of peritoneal dialysis has been associated with improved clinical markers and outcomes such as early achievement of a negative fluid balance, lower vasoactive medication needs, shorter duration of mechanical ventilation, and decreased mortality. In this review, we discuss the safety and potential benefits of peritoneal catheters for dialysis or passive drainage in children following cardiopulmonary bypass.
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9.
[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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10.
Diabetes management before, during, and after bariatric and metabolic surgery.
Kheniser, KG, Kashyap, SR
Journal of diabetes and its complications. 2018;(9):870-875
Abstract
Metabolic surgery is unrivaled by other therapeutic modalities due to its ability to foster diabetes remission. Metabolic surgery is an integral therapeutic modality in obese and morbidly obese populations because pharmacological and behavioral therapy often fail to effectively manage type II diabetes. However, given the invasiveness of the metabolic surgery relative to behavioral therapy and the need to conform to preparatory and discharge guidelines, patients must adhere to strict nutritional and diabetes management protocols. Also, the pharmacological regimen that is instituted upon discharge is distinct from the preoperative regimen. Oftentimes, the dose for insulin and oral medications are significantly decreased or withdrawn. As time elapses and depending on several factors (e.g., exercise adherence), diabetes control becomes tenuous in a small portion of the patients because there is weight regain and on-going beta cell failure. At this time interval, intensification of diabetes therapy becomes prudent. Indeed, pharmacotherapy from the preoperative to the postoperative phase is labile and may be complex. Therefore, by discussing pharmacology options during the preoperative, perioperative, and postoperative period, the goal is to guide clinician-driven care.