-
1.
Hyperoxia and Antioxidants for Myocardial Injury in Noncardiac Surgery: A 2 × 2 Factorial, Blinded, Randomized Clinical Trial.
Holse, C, Aasvang, EK, Vester-Andersen, M, Rasmussen, LS, Wetterslev, J, Christensen, R, Jorgensen, LN, Pedersen, SS, Loft, FC, Troensegaard, H, et al
Anesthesiology. 2022;(3):408-419
-
-
Free full text
-
Abstract
BACKGROUND Hyperoxia and oxidative stress may be associated with increased risk of myocardial injury. The authors hypothesized that a perioperative inspiratory oxygen fraction of 0.80 versus 0.30 would increase the degree of myocardial injury within the first 3 days of surgery, and that an antioxidant intervention would reduce degree of myocardial injury versus placebo. METHODS A 2 × 2 factorial, randomized, blinded, multicenter trial enrolled patients older than 45 yr who had cardiovascular risk factors undergoing major noncardiac surgery. Factorial randomization allocated patients to one of two oxygen interventions from intubation and at 2 h after surgery, as well as antioxidant intervention or matching placebo. Antioxidants were 3 g IV vitamin C and 100 mg/kg N-acetylcysteine. The primary outcome was the degree of myocardial injury assessed by the area under the curve for high-sensitive troponin within the first 3 postoperative days. RESULTS The authors randomized 600 participants from April 2018 to January 2020 and analyzed 576 patients for the primary outcome. Baseline and intraoperative characteristics did not differ between groups. The primary outcome was 35 ng · day/l (19 to 58) in the 80% oxygen group; 35 ng · day/l (17 to 56) in the 30% oxygen group; 35 ng · day/l (19 to 54) in the antioxidants group; and 33 ng · day/l (18 to 57) in the placebo group. The median difference between oxygen groups was 1.5 ng · day/l (95% CI, -2.5 to 5.3; P = 0.202) and -0.5 ng · day/l (95% CI, -4.5 to 3.0; P = 0.228) between antioxidant groups. Mortality at 30 days occurred in 9 of 576 patients (1.6%; odds ratio, 2.01 [95% CI, 0.50 to 8.1]; P = 0.329 for the 80% vs. 30% oxygen groups; and odds ratio, 0.79 [95% CI, 0.214 to 2.99]; P = 0.732 for the antioxidants vs. placebo groups). CONCLUSIONS Perioperative interventions with high inspiratory oxygen fraction and antioxidants did not change the degree of myocardial injury within the first 3 days of surgery. This implies safety with 80% oxygen and no cardiovascular benefits of vitamin C and N-acetylcysteine in major noncardiac surgery.
-
2.
The effect of glucose control in liver surgery on glucose kinetics and insulin resistance.
Blixt, C, Larsson, M, Isaksson, B, Ljungqvist, O, Rooyackers, O
Clinical nutrition (Edinburgh, Scotland). 2021;(7):4526-4534
Abstract
BACKGROUND & AIMS Clinical outcome is negatively correlated to postoperative insulin resistance and hyperglycemia. The magnitude of insulin resistance can be modulated by glucose control, preoperative nutrition, adequate pain management and minimal invasive surgery. Effects of glucose control on perioperative glucose kinetics in liver surgery is less studied. METHODS 18 patients scheduled for open hepatectomy were studied per protocol in this prospective, randomized study. In the treatment group (n = 9), insulin was administered intravenously to keep arterial blood glucose between 6 and 8 mmol/l during surgery. The control group (n = 9) received insulin if blood glucose >11.5 mmol/l. Insulin sensitivity was measured by an insulin clamp on the day before surgery and immediately postoperatively. Glucose kinetics were assessed during the clamp and surgery. RESULTS Mean intraoperative glucose was 7.0 mM (SD 0.7) vs 9.1 mM (SD 1.9) in the insulin and control group respectively (p < 0.001; ANOVA). Insulin sensitivity decreased in both groups but significantly (p = 0.03, ANOVA) more in the control group (M value: 4.6 (4.4-6.8) to 2.1 (1.2-2.6) and 4.6 (4.1-5.0) to 0.6 (0.1-1.8) mg/kg/min in the treatment and control group respectively). Endogenous glucose production (EGP) increased and glucose disposal (WGD) decreased significantly between the pre- and post-operative clamps in both groups, with no significant difference between the groups. Intraoperative kinetics demonstrated that glucose control decreased EGP (p = 0.02) while WGD remained unchanged (p = 0.67). CONCLUSION Glucose control reduces postoperative insulin resistance in liver surgery. EGP increases and WGD is diminished immediately postoperatively. Insulin seems to modulate both reactions, but mostly the WGD is affected. Intraoperative EGP decreased while WGD remained unaltered. REGISTRATION NUMBER OF CLINICAL TRIAL ANZCTR 12614000278639.
-
3.
Pain Management in Children: NSAID Use in the Perioperative and Emergency Department Settings.
Cooney, MF
Paediatric drugs. 2021;(4):361-372
-
-
Free full text
-
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are often used for pediatric pain management in the emergency setting and postoperatively. This narrative literature review evaluates pain relief, opioid requirements, and adverse effects associated with NSAID use. A PubMed search was conducted to identify randomized controlled trials evaluating the use of conventional systemic NSAIDs as pain management for children in the perioperative or emergency department (traumatic injury) setting. Trials of cyclooxygenase-2 inhibitors ("coxibs") were excluded. Search results included studies of ibuprofen (n = 12), ketoprofen (n = 5), ketorolac (n = 6), and diclofenac (n = 4). NSAIDs reduced the opioid requirement in 10 of 13 studies in which this outcome was measured. NSAID use did not compromise pain relief; NSAIDs provided improved or similar pain scores compared with opioids (or other control) in 24 of 27 studies. Adverse event frequencies were reported in 26 studies; adverse event frequencies with NSAIDs were lower than with opioids (or other control) in three of 26 studies, similar in 21 of 26 studies, and more frequent in two of 26 studies. Perioperative and emergency department use of NSAIDs may reduce opioid requirements while maintaining pain control, with similar or reduced frequencies of opioid-associated adverse events.
-
4.
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.
-
5.
Protective and therapeutic experience of perioperative safety in extremely elderly patients with biliary diseases.
Zhang, Z, Zhao, Y, Lin, F, Liu, L, Zhang, C, Liu, Z, Zhu, M, Wan, B, Deng, H, Yang, H, et al
Medicine. 2021;(21):e26159
-
-
Free full text
-
Abstract
To explore the protective and therapeutic measures of improving perioperative safety in extremely elderly patients with biliary diseases, so as to improve the therapeutic efficacy of surgery. A retrospective case–control study of 412 elderly patients with biliary diseases was carried out from July 2013 to July 2019. Seventy eight cases were divided into the high age (HA) group (≥80 years) and 334 into the middle–low age (MLA) group (60–79 years). In the HA compared with MLA group, 1. Preoperative coexisting diseases: the occurrence of coexisting coronary heart disease (CHD), hypertension, chronic bronchitis with emphysema, hypoproteinemia, and anemia were significantly increased; 2. Laboratory examinations: function of liver, kidneys, heart, lungs, and blood coagulation significantly declined; 3. Surgical procedures: open cholecystectomy with transcystic common bile duct (CBD) exploration significantly higher, while laparoscopic cholecystectomy significantly lower; 4. Operative effects: intraoperative blood loss, operation time, postoperative hospital stay, and length of hospitalization significantly increased or prolonged; 5. Postoperative complications: postoperative respiratory failure, pulmonary infection, anemia and electrolyte disorder significantly increased; 6. Therapeutic outcomes: no significant difference in the therapeutic effects. Although the surgical risk was significantly increased, there was no significant difference in the therapeutic efficacy in the HA compared with MLA group, suggesting that surgical treatment in extremely elderly patients with biliary diseases is safe and feasible. The key is to actively treat preoperative coexisting diseases, strictly adhere to surgical indications, reasonably select surgical procedures, precisely perform the operation, closely monitor and control intraoperative emergencies, timely prevent and treat postoperative complications, so as to improve the perioperative safety of extremely elderly patients with biliary diseases.
-
6.
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.
-
7.
The case for statin use to reduce perioperative adverse cardiovascular and cerebrovascular events.
Ratcliffe, F, Rothwell, PM
British journal of anaesthesia. 2020;(5):525-534
-
-
Free full text
-
Abstract
Ischaemic heart disease and stroke are the leading causes of death worldwide at 119 per 100,000 and 85 per 100,000 population. For the USA, heart disease is leading cause of death at 165 per 100,000 population. In developed countries, strokes and acute myocardial infarction in the general population have fallen from smoking reduction, lifestyle modifications and therapeutic interventions including statins. In a population-based stroke study in the UK involving primary care practices, of in-hospital strokes 90% were ischaemic, and 37% occurred within 1 week of an operation. Approximately 50% of the patients were not on a statin. In the UK, there is a national screening initiative for the prevention of atherosclerotic cardiovascular disease (ASCVD) offered to people aged 40-74 yr old. The QRISK3 tool calculates the risk of developing heart disease or stroke over 10 yr, from which recommendations are made on interventions for the prevention of ASCVD up to age 84 yr, with similar screening and assessment tools in Europe and the US. If the QRISK3 score tool for calculating cardiovascular risk is considered sufficiently robust for population screening in primary care, should anaesthetists not use the same screening for secondary care? We present a case for statin use over the perioperative period, to reduce early vascular adverse events based on statins' early pleiotropic actions, using the primary care QRISK tool for screening of ASCVD risk.
-
8.
Participation of pulmonary embolism response teams during the perioperative period.
Porres-Aguilar, M, Anaya-Ayala, JE, Grimaldo-Gómez, FA, Santos-Martínez, LE, Jiménez, D, Porres-Muñoz, M, Izaguirre-Ávila, R, Carrillo-Esper, R
Archivos de cardiologia de Mexico. 2020;(3):321-327
Abstract
La tromboembolia pulmonar aguda representa una causa frecuente de morbimortalidad cardiovascular, sólo rebasada por los síndromes coronarios agudos y la enfermedad cerebrovascular. El inicio y la intervención de un equipo multidisciplinario de respuesta rápida en la tromboembolia pulmonar son imperantes para mejorar el pronóstico y reducir al mínimo las posibles secuelas en el subgrupo de pacientes más graves. En este artículo de revisión se describe y revisa de manera general el papel actual y potencial que tienen dichos equipos de respuesta rápida, con un enfoque particular en el perioperatorio. Acute pulmonary embolism represents a frequent cause of cardiovascular morbidity and mortality, only exceeded by acute coronary syndromes and cerebrovascular disease. The start-up and implementation of a designated pulmonary embolism response team is necessary to improve prognosis and minimize long-term sequelae in the subgroup of patients with significant pulmonary embolism. Herein, we describe and discuss an overview of the current and potential role of pulmonary embolism response teams, with a focus on the perioperative period.
-
9.
Perioperative nonhormonal pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy: a systematic review and network meta-analysis.
Samy, A, Raslan, AN, Talaat, B, El Lithy, A, El Sharkawy, M, Sharaf, MF, Hussein, AH, Amin, AH, Ibrahim, AM, Elsherbiny, WS, et al
Fertility and sterility. 2020;(1):224-233.e6
Abstract
OBJECTIVE To synthesize evidence on the most effective pharmacological interventions for bleeding reduction during open and minimally invasive myomectomy. DESIGN Systematic review and network meta-analysis of randomized controlled trials (RCTs). SETTING Not applicable. PATIENTS Trials assessing efficacy of pharmacological interventions during different types of myomectomy. INTERVENTIONS Misoprostol, oxytocin, vasopressin, tranexamic acid (TXA), epinephrine, or ascorbic acid. MAIN OUTCOME MEASURES Intraoperative blood loss and need for blood transfusion. RESULTS The present review included 26 randomized control trials (RCTs) (N = 1627). For minimally invasive procedures (9 RCTs; 474 patients), network meta-analysis showed that oxytocin (mean difference [MD] -175.5 mL, 95% confidence interval [CI] -30.1.07, -49.93), ornipressin (MD -149.6 mL, 95% CI - 178.22, -120.98), misoprostol, bupivacaine plus epinephrine, and vasopressin were effective in reducing myomectomy blood loss, but the evidence is of low quality. Ranking score of treatments included in subgroup analysis of minimally invasive myomectomy showed that oxytocin ranked first in reducing blood loss, followed by ornipressin. For open myomectomy (17 RCTs; 1,153 patients), network meta-analysis showed that vasopressin plus misoprostol (MD -652.97 mL, 95% CI - 1113.69, -174.26), oxytocin, TXA, and misoprostol were effective; however, the evidence is of low quality. Vasopressin plus misoprostol ranked first in reducing blood loss during open myomectomy (P = .97). CONCLUSION There is low-quality evidence to support uterotonics, especially oxytocin, and peripheral vasoconstrictors as effective options in reducing blood loss and need for blood transfusion during minimally invasive myomectomy. Oxytocin is the most effective intervention in minimally invasive myomectomy. For open myomectomy, a combination of uterotonics and peripheral vasoconstrictors is needed to effectively reduce blood loss.
-
10.
Update on Pheochromocytoma and Paraganglioma from the SSO Endocrine and Head and Neck Disease Site Working Group, Part 2 of 2: Perioperative Management and Outcomes of Pheochromocytoma and Paraganglioma.
Patel, D, Phay, JE, Yen, TWF, Dickson, PV, Wang, TS, Garcia, R, Yang, AD, Kim, LT, Solórzano, CC
Annals of surgical oncology. 2020;(5):1338-1347
-
-
Free full text
-
Abstract
This is the second part of a two-part review on pheochromocytoma and paragangliomas (PPGLs). In this part, perioperative management, including preoperative preparation, intraoperative, and postoperative interventions are reviewed. Current data on outcomes following resection are presented, including outcomes after cortical-sparing adrenalectomy for bilateral adrenal disease. In addition, pathological features of malignancy, surveillance considerations, and the management of advanced disease are also discussed.