Disparate opinions regarding indications for coronary artery revascularization before elective vascular surgery

Despite consensus guidelines, the optimal strategy for preoperative cardiac risk management among patients scheduled for major noncardiac surgery remains controversial. This study assesses current opinion about the role of preoperative coronary revascularization for patients with coronary artery disease scheduled for elective vascular surgery. Thirty-one practicing cardiologists recruited from 4 different regions reviewed case records, imaging tests, and coronary angiograms of 12 patients with coronary artery disease participating in the Coronary Artery Revascularization Prophylaxis (CARP) trial. The need for preoperative coronary revascularization was determined and results summarized using 3 categories: favoring conservative management, neutral, or recommending revascularization (either by percutaneous intervention or bypass surgery). We found recommendations were frequently disparate and often deviated from published guidelines (40% of the time). The likelihood of discordance between 2 cardiologists was 54%, with a 26% chance that recommendations for revascularization would be directly contradictory. Opinions were more often conservative (43%) or aggressive (40%) than neutral (17%). Similar inconsistency was found as to the preferred method of revascularization, with only 1 patient having complete agreement. Thus, this study reveals substantial differences of opinion among cardiologists across the country about the role of preoperative coronary artery revascularization for patients scheduled for elective vascular operations. Deviations from published guidelines are common, suggesting that current consensus statements need additional data to support their recommendations.

Prilocaine or mepivacaine for combined sciatic-femoral nerve block in patients receiving elective knee arthroscopy

AIM

The aim of this study was to evaluate the onset time of surgical block, recovery of motor function and duration of post-operative analgesia of combined sciatic-femoral nerve block performed with either mepivacaine or prilocaine.

METHODS

With Ethical Committee approval and written informed consent, 30 ASA physical status I-II patients, undergoing elective arthroscopic knee surgery, received a combined sciatic-femoral nerve block with 30 ml of either 2% mepivacaine (n=15) or 1% prilocaine (n=15). An independent observer recorded the onset time of sensory and motor blocks, the need for intraoperative analgesia supplementation, recovery of motor function, and first request of post-operative pain medication.

RESULTS

Onset time of nerve block required 15+/-5 min with prilocaine and 12+/-7 min with mepivacaine (p=0.33). No patient required general anesthesia to complete surgery; 3 patients receiving prilocaine (20%) and 2 patients receiving mepivacaine (13%) required 0.1 mg fentanyl intravenously to complete surgery (p=0.99). Recovery of motor function and first request of post-operative pain medication occurred after 238+/-36 min and 259+/-31 min with prilocaine, and 220+/-48 min and 248+/-47 min with mepivacaine (p=0.257 and p=0.43, respectively). Patient satisfaction was good in all studied patients.

CONCLUSION

Prilocaine 1% provides adequate sensory and motor block for arthroscopic knee surgery, with a clinical profile similar to that produced by 2% mepivacaine, and may be a good option for surgical procedures of intermediate duration and not associated with severe postoperative pain.

Propofol and remifentanil total intravenous anesthesia for a patient with Huntington disease

Huntington disease presents many challenges for the anesthetist. Of primary importance is that these patients are at increased risk of pulmonary aspiration. The use of short-acting anesthetic drugs should, therefore, be advantageous in promoting the rapid return of protective airway reflexes. We report the first documented use, to date, of propofol and remifentanil total intravenous anesthesia in a patient with Huntington disease and demonstrate its efficacy and safety.

Planned elective repeat caesarean section versus planned vaginal birth for women with a previous caesarean birth

BACKGROUND

When a woman has had a previous caesarean birth, there are two options for her care in a subsequent pregnancy: planned elective repeat caesarean or planned vaginal birth. While there are risks and benefits for both planned elective repeat caesarean birth and planned vaginal birth after caesarean, current sources of information are limited to non-randomised cohort studies. Studies designed in this way have significant potential for bias and consequently conclusions based on these results are limited in their reliability and should be interpreted with caution.

OBJECTIVES

To assess, using the best available evidence, the benefits and harms of a policy of planned elective repeat caesarean section with a policy of planned vaginal birth after caesarean section for women with a previous caesarean birth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register (24 June 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), and PubMed (1966 to 24 June 2004).

SELECTION CRITERIA

Randomised controlled trials with reported data that compared outcomes in mothers and babies who planned a repeat elective caesarean section with outcomes in women who planned a vaginal birth, where a previous birth had been by caesarean.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

There were no randomised controlled trials identified.

REVIEWERS' CONCLUSIONS

Planned elective repeat caesarean section and planned vaginal birth after caesarean section for women with a prior caesarean birth are both associated with benefits and harms. Evidence for these care practices is drawn from non-randomised studies, associated with potential bias. Any results and conclusions must therefore be interpreted with caution. Randomised controlled trials are required to provide the most reliable evidence regarding the benefits and harms of both planned elective repeat caesarean section and planned vaginal birth for women with a previous caesarean birth.

A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms

BACKGROUND

Although the initial results of endovascular repair of abdominal aortic aneurysms were promising, current evidence from controlled studies does not convincingly show a reduction in 30-day mortality relative to that achieved with open repair.

METHODS

We conducted a multicenter, randomized trial comparing open repair with endovascular repair in 345 patients who had received a diagnosis of abdominal aortic aneurysm of at least 5 cm in diameter and who were considered suitable candidates for both techniques. The outcome events analyzed were operative (30-day) mortality and two composite end points of operative mortality and severe complications and operative mortality and moderate or severe complications.

RESULTS

The operative mortality rate was 4.6 percent in the open-repair group (8 of 174 patients; 95 percent confidence interval, 2.0 to 8.9 percent) and 1.2 percent in the endovascular-repair group (2 of 171 patients; 95 percent confidence interval, 0.1 to 4.2 percent), resulting in a risk ratio of 3.9 (95 percent confidence interval, 0.9 to 32.9). The combined rate of operative mortality and severe complications was 9.8 percent in the open-repair group (17 of 174 patients; 95 percent confidence interval, 5.8 to 15.2 percent) and 4.7 percent in the endovascular-repair group (8 of 171 patients; 95 percent confidence interval, 2.0 to 9.0 percent), resulting in a risk ratio of 2.1 (95 percent confidence interval, 0.9 to 5.4).

CONCLUSIONS

On the basis of the overall results of this trial, endovascular repair is preferable to open repair in patients who have an abdominal aortic aneurysm that is at least 5 cm in diameter. Long-term follow-up is needed to determine whether this advantage is sustained.

[New chapter of vascular surgery; stent-graft placement in the treatment of aortic aneurysm]

INTRODUCTION AND AIM

This paper deals with a novel chapter of aneurysm surgery, the stent-graft implantation. The interdisciplinary cooperation between angio-radiology and surgery made available a much less invasive therapeutic option. The new technique was first applied in 1991.The authors present the technique, conditions and results of the procedure and also give a survey on the domestic situation.

METHOD

In general anaesthesia using inguinal approach a self-expanding stent-graft (diameter: 8 mm) equipped with barbs was inserted in the aorta and deployed into the aneurysm under X-ray guidance. Vanguard (Boston-Scientific Co.), Talent (Medtronic Co.) and Exluder (Gore-Tex Co.) instruments were used.

RESULTS

In 40 patients (29 men and 11 women, mean age: 59.7 years) 55 stent-grafts were implanted. Thirty-one thoracic and 9 infrarenal aneurysms were treated. In 3 patients ruptured aneurysm, in 3 other instances covered ruptured aneurysm, and in 3 persons symptomatic aortic aneurysm were treated. Thirty-one patients underwent elective procedures. Two deaths occurred in the early, and 4 in the late postoperative period (at months 3, 6, 7 and 36 postoperatively). In 9 patients adjunctive vascular surgery interventions were performed in 13 instances. Primary endoleak occurred in 3, whereas secondary endoleak was observed in 4 instances. All of these healed spontaneously. The authors compared the domestic results with internationally published data. This included 1120 traditional aneurysm resections and 110 stent-graft implantations performed in Hungary and 2283 surgical and 3843 endovascular procedures published in international scientific journals.

CONCLUSIONS

The indications for this new procedure are still being formed. Despite the higher incidence of complications, this less traumatic intervention can be applied with benefit for patients. Nevertheless, at the time being, financial considerations may prevent the more widespread use in the practice. In Hungary the conditions are already available for this endovascular treatment and the authors support its employment.

Intramuscular tramadol increases gastric pH during anesthesia

PURPOSE

Tramadol, [(1RS, 2RS)-2-dimethylamino) methyl-1-(3-methoxyphenyl)-cyclohexanol hydrochloride], is an analgesic in clinical use. It has been reported that tramadol inhibits muscarinic type 3 receptor function, which primarily mediates smooth muscle contraction and glandular secretion. We investigated the effects of tramadol on the pH of gastric juices during anesthesia to determine whether tramadol inhibits secretion from the gastric glands.

METHODS

ASA physical status I or II adult patients (n = 30) presenting for major elective orthopedic surgery of the upper extremities or mastectomy were enrolled. Patients were randomly assigned to receive treatment with tramadol (n = 10), famotidine (n = 10), or saline (n = 10). General anesthesia was then induced using propofol, vecuronium bromide, and fentanyl. After inducing anesthesia, the gastric pH was measured using pH test paper and, then, 100 mg tramadol, 20 mg famotidine, or saline were injected into the deltoid muscle. Three hours after starting the operation, gastric juice was again aspirated and its gastric pH measured.

RESULTS

There were no differences in the pH before anesthesia between the three groups. By contrast, gastric pH was increased in the tramadol group by the same amount as it was in the famotidine group three hours after administering the drugs. Gastric pH of the saline, famotidine, and tramadol groups was 2.6 +/- 2.5, 6.3 +/- 2.0, and 6.4 +/- 0.8, respectively.

CONCLUSION

These results suggest that tramadol inhibits the secretion of gastric acid.

Eritropoyetina preoperatoria como estrategia de ahorro de sangre en cirugía ortopédica mayor en pacientes de edad avanzada

BACKGROUND AND OBJECTIVE

Preoperative anemia is a major risk factor for perioperative transfusion in orthopedic surgery and aging is associated with an increased risk for developing anemia. The aim of this study was to compare the efficacy and safety of preoperative epoetin alfa in patients older and younger than 65 years in orthopedic surgery. PATIENTS AHD METHOD: This study involved 75 patients scheduled for total joint arthroplasty who had an hemoglobin level between 100 and 130 g/l. Patients were assigned to receive weekly doses of subcutaneous epoetin alfa (40000 IU) on days -21, -14, -7, -1 before surgery. We tabulated age, weight, gender, baseline analytic parameters, perioperative evolution of the mean hemoglobin level, transfusion, side effects and complications.

RESULTS

Fifty-four patients were included in group A (> or = 65 years) and 21 in group B (< 65 years). The two study groups did not differ in terms of demographic characteristics and baseline analysis but differed in age and associated diseases. The preoperative increase in mean hemoglobin level (20 and 18 g/l) and transfusion rate (15% and 14.3%) were similar in both groups. There were no complications associated with the use of epoetin alfa.

CONCLUSIONS

Preoperative epoetin alfa administration seems to be as effective and safe in patients younger as in those older than 65 years.

Comparison of maternal mortality and morbidity between trial of labor and elective cesarean section among women with previous cesarean delivery

OBJECTIVE

This study was undertaken to assess the safety of trial of labor after previous cesarean delivery.

STUDY DESIGN

Retrospective cohort study of 308,755 Canadian women with previous cesarean delivery between 1988 and 2000. Occurrences of in-hospital maternal death, uterine rupture, and other severe maternal morbidity were compared between women with a trial of labor and those with an elective cesarean section.

RESULTS

Rates of uterine rupture (0.65%), transfusion (0.19%), and hysterectomy (0.10%) were significantly higher in the trial-of-labor group. Maternal in-hospital death rate, however, was lower in the trial-of-labor group (1.6 per 100,000) than in the elective cesarean section group (5.6 per 100,000). The association between trial of labor and uterine rupture was stronger in low volume (<500) than in high volume (> or =500 births per year) obstetric units.

CONCLUSION

Trial of labor is associated with increased risk of uterine rupture, but elective cesarean section may increase the risk of maternal death.

[Patient dissatisfaction with anesthetic care]

BACKGROUND

The evaluation of services by patients is an essential component of quality improvement in anesthesiology. Therefore, it is important to identify the factors for patient dissatisfaction.

METHODS

We retrospectively studied 9974 consecutive patients who had received spinal or general anesthesia for elective surgery between 1999 and 2002. Pre-anesthetic, intra-anesthetic and post-anesthetic variables were recorded and patient satisfaction was assessed using direct interviews at the post-anesthetic clinic. Qualitative data on dissatisfaction were obtained by asking patients' reasons for dissatisfaction.

RESULTS

348 of the 8843 respondents (3.9%) had dissatisfaction with anesthesia. The rates of dissatisfaction were higher in women than in men and in spinal anesthesia than in general anesthesia, and were observed mostly in the patients aged from 20 to 39 years. Qualitative data show that the common reasons for dissatisfaction with anesthesia were spinal anesthesia as the most dissatisfactory factor, followed by epidural anesthesia, postoperative pain, vomiting/nausea and memory of tracheal extubation. However, other various factors were associated with dissatisfaction.

CONCLUSIONS

It is difficult for anesthesiologists to satisfy all patients, because patients' senses of values were varied. However, we conclude that anesthesiologists can improve the quality of anesthesia by enlightenment of the patient about anesthesia, and moreover, by better peri-anesthetic management for dissatisfactory factors with anesthesia.

Informed consent for elective and emergency surgery: questionnaire study

OBJECTIVES

To evaluate women's experience of giving consent to obstetric and gynaecological surgery and to examine differences between those undergoing elective and emergency procedures.

DESIGN

A prospective questionnaire study.

SETTING

A large teaching hospital.

POPULATION

1006 consecutive patients undergoing elective or emergency surgery in obstetrics and gynaecology.

METHODS

Questionnaires were administered to women who had given consent to surgery following the introduction of national guidelines and consent form. Differences in responses between elective and emergency patients were assessed using frequencies, single and multivariable analyses.

MAIN OUTCOME MEASURES

Patients' experience and recall of the consent process, their overall satisfaction and their views on what is important for adequate consent.

RESULTS

There were significant differences between patients undergoing elective or emergency surgery. Patients undergoing emergency surgery were less likely to have read (OR 0.22) or understood (OR 0.40) the consent form, and were more likely to report feeling frightened by signing it (OR 2.52). They were more likely to report they felt they had no choice about signing the consent form (OR 2.11), and that they would have signed regardless of its content (OR 3.14). Overall, significantly more patients undergoing elective (80%) or emergency (63%) surgery reported satisfaction with the consent process. Patients were more likely to report satisfaction if they read (OR 1.80) and agreed with (OR 3.49) the consent form, and if someone checked that they understood (OR 3.09).

CONCLUSION

Patients' needs may not be adequately addressed by current guidelines for consent to treatment, particularly in emergency circumstances. The introduction of more complex forms and procedures appears to conflict with patients' need for personal communication and advocacy. The implications on the ethical and legal standing of consent are considerable.

Endovascular Versus Open Surgical Repair of Abdominal Aortic Aneurysm: A Comparison of Early and Intermediate Results in Patients Suitable for Both Techniques

PURPOSE

To assess early and intermediate results of endovascular repair of abdominal aortic aneurysms (EVAR), and to compare them with open surgery (OS) in concurrent patients suitable for both types of treatment.

METHODS

During 3 years, 180 patients with AAA underwent repair. We excluded patients with ruptured aneurysms (33), juxtarenal aneurysms (11), iliac aneurysms (8), with peripheral embolization (2) and those treated with a cryopreserved homograft (2). From the remaining patients (n=124), we selected those suitable for both techniques (n=83), of which 53 were treated by EVAR and 30 by OS. Analysis was performed using Kaplan-Meier curves and Log Rank tests.

RESULTS

Hospital mortality was not significantly higher in the OS group (6.6% OS vs. 3.7% EVAR), p=0.55. The EVAR group had significantly shorter operative time, length of hospital stay and less blood loss. The median follow up time was 2.18 years for OR and 1.58 years for EVAR. There were no conversions from EVAR to OS and no differences in late survival (p=0.255, Cox regression analysis) with a cumulative survival rate at 3 years of 89% for EVAR and 73% for OS. By 3 years 24% (95% CI, 11-47%) of EVAR patients had presented endoleaks with an endovascular re-intervention rate of 27% (95% CI, 13-50%). One patient in the OS group needed a late open intervention.

CONCLUSIONS

EVAR compares favourably with OS in terms of reduction of operative time, hospital length of stay and blood loss. This study did not show a difference in early or late mortality. EVAR durability remains the most critical issue to be addressed.

Socioeconomic Status and Outcome From Intensive Care in England and Wales

OBJECTIVE

The objective of this study was to estimate the association between socioeconomic status (SES) and outcome for admissions to intensive care.

RESEARCH DESIGN

Retrospective cohort study.

SUBJECTS

We studied 51,572 admissions to 99 intensive-care units in England and Wales between 1995 and 2000.

MEASURES

The SES of admissions was measured using Carstairs deprivation scores. Outcome was hospital mortality after adjustment for case mix using the APACHE II method.

RESULTS

Admissions of lower SES were, on average, younger and less likely to be following surgery. There was evidence of a SES gradient for hospital mortality in admissions after elective surgery after adjusting for case mix (test for trend P <0.001), with higher SES associated with lower mortality. In the least-deprived quintile of SES, the odds ratio for hospital mortality was 0.70 (95% confidence interval, 0.58-0.84) compared with the most deprived quintile. There was no evidence of a SES gradient for hospital mortality in nonsurgical or emergency surgical admissions, and the decision to withdraw active treatment did not differ by SES.

CONCLUSIONS

There is a SES gradient for hospital mortality in elective surgical admissions that is not explained by differences in case mix or the withdrawal of active treatment. Further research is required to establish if this finding can be explained by unmeasured differences in health status at admission to an intensive-care unit or differences in care and to establish the potential impact these results may have on interpreting comparative surgical performance data.

Predeposit autologous donation in spinal surgery: a multicentre study

BACKGROUND

Allogeneic blood transfusions (ABT) are often necessary in elective spine surgery because of perioperative blood loss. Preoperative autologous blood donation (PABD) has emerged as the principal means to avoid or reduce the need for ABT. Consequently, a multicentre study was conducted to determine the yield and efficacy of PABD in spine surgery and the possible role of recombinant human erythropoietin (EPO) in facilitating PABD.

METHODS

We retrospectively reviewed the hospital charts and blood bank records from all consecutive spine surgery patients who were referred for PABD. Data were obtained from two A-category hospital blood banks and one general hospital. Although we collected data from 1994, the analytic study period was from the last quarter of 1995 to December 2003. Fifty-four (7%) out of 763 patients referred for PABD were rejected, and medical records were available for 680 patients who were grouped into spinal fusion (556; 82%) and scoliosis surgery (124;18%). EPO was administered to 120 patients (17.6%). From 1999 to 2003, PABD steadily increased from 60 to 209 patients per year.

RESULTS

Overall, 92% of the patients were able to complete PABD, 71% were transfused, and almost 80% avoided ABT. PABD was more effective in fusions (86%) than in scoliosis (47%). Blood wastage was 38%, ranging from 18% for scoliosis to 42% for fusions. EPO allowed the results in the anaemic patients to be improved.

CONCLUSIONS

Therefore, despite the limitations of this retrospective study, we feel that PABD is an excellent alternative to ABT in spine surgery. However, the effectiveness of PABD may be enhanced if associated with other blood-saving techniques.

The accuracy of trained nurses in pre-operative health assessment: results of the OPEN study

We quantified the accuracy of trained nurses to correctly assess the pre-operative health status of surgical patients as compared to anaesthetists. The study included 4540 adult surgical patients. Patients' health status was first assessed by the nurse and subsequently by the anaesthetist. Both needed to answer the question: 'is this patient ready for surgery without additional work-up, Yes/No?' (primary outcome). The secondary outcome was the time required to complete the assessment. Anaesthetists and nurses were blinded for each other's results. The anaesthetists' result was the reference standard. In 87% of the patients, the classifications by nurses and anaesthetists were similar. The sensitivity of the nurses' assessment was 83% (95% CI: 79-87%) and the specificity 87% (95% CI: 86-88%). In 1.3% (95% CI: 1.0-1.6%) of patients, nurses classified patients as 'ready' whereas anaesthetists did not. Nurses required 1.85 (95% CI: 1.80-1.90) times longer than anaesthetists. By allowing nurses to serve as a diagnostic filter to identify the subgroup of patients who may safely undergo surgery without further diagnostic workup or optimisation, anaesthetists can focus on patients who require additional attention before surgery.

Safety and efficacy of unmodified whole blood vs. buffy coat-depleted red cell concentrates in autologous transfusion of elective orthopaedic surgery patients

Storing autologous blood as whole blood (WB) has been proposed for increasing the cost-effectiveness of preoperative autologous blood donation programmes. However, experimental data suggest that autologous leucocytes might lead to immunomodulation similar to the effect attributed to allogeneic leucocytes. In a retrospective analysis, the postoperative outcome of 120 patients undergoing elective orthopaedic surgery and having donated up to two units of autologous WB (AWB) was compared with that of a control group of 52 patients, whose autologous donation had been processed into buffy coat-depleted red cell concentrates (RCC). At least one autologous unit, but no allogeneic units, had been transfused in all analysed patients. Donation schemes were equally efficacious in both groups. There was no significant difference in postoperative infection rates between the two groups. Overall rates were 7.7% in the RCC group and 8.3% in the WB group. Surgical, thromboembolic and other recorded complications, length of postoperative hospital stay and days of the use of antibiotics were also not significantly different between the two groups. The results of this study suggest that transfusion of up to two units of unmodified AWB is as efficacious as the transfusion of autologous RCC and does not negatively influence the postoperative outcome in elective orthopaedic surgery.

[The relationship between the respiratory parameters under spontaneous breathing and effect site propofol concentrations]

BACKGROUND

The prediction of the hypnotic states is useful to maintain the adequate anesthesia. During propofol anesthesia, the respiratory depression has been documented in a dose-dependent manner. Therefore, we investigated whether the respiratory depression under the spontaneous breathing reflected the estimated effect site propofol concentrations (Cp) in a dose-dependent fashion.

METHODS

We enrolled 12 patients for elective lower limb surgery under combined subarachnoid anesthesia and propofol sedation. The respiratory parameters and BIS were measured at the Cp of 5 microg x ml(-1) followed by the 0.5 microg x ml(-1) decrements until the patients' movement. Effective indices to predict patients' movement were determined by receiver-operator characteristics.

RESULTS

The significant correlations within a particular patient between the respiratory parameters and Cp were observed, although those were not between the patients. An EtCO2 of 53 mmHg or greater represents a clinically determinant condition for non-movement of the patients.

CONCLUSIONS

We concluded that the respiratory parameters during spontaneous breathing were useful indices to predict the changes in the effect site propofol concentrations and to maintain the adequate anesthetic levels.

Umfrage zur aktuellen Situation der Regionalan�sthesie im deutschsprachigen Raum

The practice of regional anaesthesia in German speaking countries was investigated by a survey. The last part of the trilogy contains the presentation and evaluation of the data about the methods in obstetric anaesthesia. In 2002 questionnaires were mailed to 750 randomly selected departments of anaesthesia, 384 hospitals (51.2%) responded of which 278 had an obstetric unit. Caesarean section rate was 22.5+/-8.2% and for elective caesarean section spinal anaesthesia was mostly used. General anaesthesia was never used in 58.3% of Swiss, 10.2% of German, and 21.1% of Austrian hospitals. For non-elective caesarean section 42.1% of the hospitals often used a spinal anaesthesia, and 44.8% sometimes, in Switzerland these were 92.9% and 7.1%, respectively. Pain relief for labour was usually achieved with epidural anaesthesia or drugs. The trend from general to regional anaesthesia for caesarean section is continued, as is the trend from local infiltrative techniques to epidural anaesthesia for vaginal delivery. Switzerland was in the forefront for these developments.