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Hughes MJ, McNally S, Wigmore SJ. Enhanced recovery following liver surgery: a systematic review and meta-analysis. HPB (Oxford) 2014; 16:699-706. [PMID: 24661306 PMCID: PMC4113251 DOI: 10.1111/hpb.12245] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 01/17/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) programmes aim to improve postoperative outcomes. They are being utilized increasingly in hepatic surgery. This review aims to evaluate the impact of ERAS programmes on outcomes following liver surgery. METHODS EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for trials comparing outcomes in patients undergoing liver surgery utilizing ERAS principles with those in patients receiving conventional care. The primary outcome was occurrence of postoperative complications within 30 days. Secondary outcomes included length of stay (LoS), functional recovery and adherence to ERAS protocols. RESULTS Nine articles were included in the review, of which two were randomized controlled trials (RCTs). Overall complication rates were 25.0% (range: 11.5-46.4%) in ERAS patients, and 31.0% (range: 11.8-46.2%) in conventional care patients. Significantly reduced overall complication rates following ERAS care were demonstrated by a meta-analysis of the data reported in the two RCTs (odds ratio: 0.49, 95% confidence interval 0.28-0.84; P = 0.01) The median LoS reported by the studies was 5.0 days (range: 2.5-7.0 days) in ERAS patients, and 7.5 days (range: 3.0-11.0 days) in non-ERAS patients. Recovery milestones, when reported, were improved following ERAS care. CONCLUSIONS The adoption of ERAS protocols improves morbidity and LoS following liver surgery. Future ERAS programmes should accommodate the unique requirements of liver surgery in order to optimize postoperative outcomes.
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Sasser WC, Robert SM, Askenazi DJ, O’Meara LC, Borasino S, Alten JA. Peritoneal dialysis: an alternative modality of fluid removal in neonates requiring extracorporeal membrane oxygenation after cardiac surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2014; 46:157-161. [PMID: 25208433 PMCID: PMC4566426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/01/2014] [Accepted: 05/30/2014] [Indexed: 06/03/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for patients with cardiopulmonary failure after cardiac surgery. Fluid overload (FO) is associated with increased morbidity and mortality in this population. We present our experience using peritoneal dialysis (PD) as an adjunct for fluid removal in eight consecutive neonates requiring ECMO after cardiac surgery between 2010 and 2012. PD was added to FO management when fluid removal goals were not being met by hemofiltration (HF) or hemodialysis (HD). Percent FO was 36% at ECMO initiation; 88% (seven of eight) achieved negative fluid balance before discontinuation of ECMO. PD removed median 119 mL/kg/day (interquartile range [IQR], 70-166) compared with median 132 mL/kg/day (IQR, 47-231) removed by HF/HD. PD and HF/HD fluid removal were performed concurrently 38% of the time. Unlike HF/HD, PD was never stopped secondary to hemodynamic compromise. Median duration of ECMO was 155 hours (IQR, 118-215). Six of eight patients were successfully decannulated. These results suggest PD safely and effectively removes fluid in neonates on ECMO after cardiac surgery. PD may increase total fluid removal potential when combined with other modalities.
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Abdel‐Aleem H, Aboelnasr MF, Jayousi TM, Habib FA. Indwelling bladder catheterisation as part of intraoperative and postoperative care for caesarean section. Cochrane Database Syst Rev 2014; 2014:CD010322. [PMID: 24729285 PMCID: PMC10780245 DOI: 10.1002/14651858.cd010322.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Caesarean section (CS) is the most common obstetric surgical procedure, with more than one-third of pregnant women having lower-segment CS. Bladder evacuation is carried out as a preoperative procedure prior to CS. Emerging evidence suggests that omitting the use of urinary catheters during and after CS could reduce the associated increased risk of urinary tract infections (UTIs), catheter-associated pain/discomfort to the woman, and could lead to earlier ambulation and a shorter stay in hospital. OBJECTIVES To assess the effectiveness and safety of indwelling bladder catheterisation for intraoperative and postoperative care in women undergoing CS. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 December 2013) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing indwelling bladder catheter versus no catheter or bladder drainage in women undergoing CS (planned or emergency), regardless of the type of anaesthesia used. Quasi-randomised trials, cluster-randomised trials were not eligible for inclusion. Studies presented as abstracts were eligible for inclusion providing there was sufficient information to assess the study design and outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for eligibility and trial quality, and extracted data. Data were checked for accuracy. MAIN RESULTS The search retrieved 16 studies (from 17 reports). Ten studies were excluded and one study is awaiting assessment. We included five studies involving 1065 women (1090 recruited). The five included studies were at moderate risk of bias.Data relating to one of our primary outcomes (UTI) was reported in four studies but did not meet our definition of UTI (as prespecified in our protocol). The included studies did not report on our other primary outcome - intraoperative bladder injury (this outcome was not prespecified in our protocol). Two secondary outcomes were not reported in the included studies: need for postoperative analgesia and women's satisfaction. The included studies did provide limited data relating to this review's secondary outcomes. Indwelling bladder catheter versus no catheter - three studies (840 women) Indwelling bladder catheterisation was associated with a reduced incidence of bladder distension (non-prespecified outcome) at the end of the operation (risk ratio (RR) 0.02, 95% confidence interval (CI) 0.00 to 0.35; one study, 420 women) and fewer cases of retention of urine (RR 0.06, 95% CI 0.01 to 0.47; two studies, 420 women) or need for catheterisation (RR 0.03, 95% CI 0.01 to 0.16; three studies 840 participants). In contrast, indwelling bladder catheterisation was associated with a longer time to first voiding (mean difference (MD) 16.81 hours, 95% CI 16.32 to 17.30; one study, 420 women) and more pain or discomfort due to catheterisation (and/or at first voiding) (average RR 10.47, 95% CI 4.71 to 23.25, two studies, 420 women) although high levels of heterogeneity were observed. Similarly, compared to women in the 'no catheter' group, indwelling bladder catheterisation was associated with a longer time to ambulation (MD 4.34 hours, 95% CI 1.37 to 7.31, three studies, 840 women) and a longer stay in hospital (MD 0.62 days, 95% CI 0.15 to 1.10, three studies, 840 women). However, high levels of heterogeneity were observed for these two outcomes and the results should be interpreted with caution.There was no difference in postpartum haemorrhage (PPH) due to uterine atony. There was also no difference in the incidence of UTI (as defined by trialists) between the indwelling bladder catheterisation and no catheterisation groups (two studies, 570 women). However, high levels of heterogeneity were observed for this non-prespecified outcome and results should be considered in this context. Indwelling bladder catheter versus bladder drainage - two studies (225 women)Two studies (225 women) compared the use of an indwelling bladder catheter versus bladder drainage. There was no difference between groups in terms of retention of urine following CS, length of hospital stay or the non-prespecified outcome of UTI (as defined by the trialist).There is some evidence (from one small study involving 50 women), that the need for catheterisation was reduced in the group of women with an indwelling bladder catheter (RR 0.04, 95% CI 0.00 to 0.70) compared to women in the bladder drainage group. Evidence from another small study (involving 175 women) suggests that women who had an indwelling bladder catheter had a longer time to ambulation (MD 0.90, 95% CI 0.25 to 1.55) compared to women who received bladder drainage. AUTHORS' CONCLUSIONS This review includes limited evidence from five RCTs of moderate quality. The review's primary outcomes (bladder injury during operation and UTI), were either not reported or reported in a way not suitable for our analysis. The evidence in this review is based on some secondary outcomes, with heterogeneity present in some of the analyses. There is insufficient evidence to assess the routine use of indwelling bladder catheters in women undergoing CS. There is a need for more rigorous RCTs, with adequate sample sizes, standardised criteria for the diagnosis of UTI and other common outcomes.
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Van Buren G, Bloomston M, Hughes SJ, Winter J, Behrman SW, Zyromski NJ, Vollmer C, Velanovich V, Riall T, Muscarella P, Trevino J, Nakeeb A, Schmidt CM, Behrns K, Ellison EC, Barakat O, Perry KA, Drebin J, House M, Abdel-Misih S, Silberfein EJ, Goldin S, Brown K, Mohammed S, Hodges SE, McElhany A, Issazadeh M, Jo E, Mo Q, Fisher WE. A randomized prospective multicenter trial of pancreaticoduodenectomy with and without routine intraperitoneal drainage. Ann Surg 2014; 259:605-12. [PMID: 24374513 DOI: 10.1097/sla.0000000000000460] [Citation(s) in RCA: 259] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To test by randomized prospective multicenter trial the hypothesis that pancreaticoduodenectomy (PD) without the use of intraperitoneal drainage does not increase the frequency or severity of complications. BACKGROUND Some surgeons have abandoned the use of drains placed during pancreas resection. METHODS We randomized 137 patients to PD with (n = 68, drain group) and without (n = 69, no-drain group) the use of intraperitoneal drainage and compared the safety of this approach and spectrum of complications between the 2 groups. RESULTS There were no differences between drain and no-drain cohorts in demographics, comorbidities, pathology, pancreatic duct size, pancreas texture, baseline quality of life, or operative technique. PD without intraperitoneal drainage was associated with an increase in the number of complications per patient [1 (0-2) vs 2 (1-4), P = 0.029]; an increase in the number of patients who had at least 1 ≥grade 2 complication [35 (52%) vs 47 (68%), P = 0.047]; and a higher average complication severity [2 (0-2) vs 2 (1-3), P = 0.027]. PD without intraperitoneal drainage was associated with a higher incidence of gastroparesis, intra-abdominal fluid collection, intra-abdominal abscess (10% vs 25%, P = 0.027), severe (≥grade 2) diarrhea, need for a postoperative percutaneous drain, and a prolonged length of stay. The Data Safety Monitoring Board stopped the study early because of an increase in mortality from 3% to 12% in the patients undergoing PD without intraperitoneal drainage. CONCLUSIONS This study provides level 1 data, suggesting that elimination of intraperitoneal drainage in all cases of PD increases the frequency and severity of complications.
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Kappel RM, Cohen Tervaert JW, Pruijn GJM. Autoimmune/inflammatory syndrome induced by adjuvants (ASIA) due to silicone implant incompatibility syndrome in three sisters. Clin Exp Rheumatol 2014; 32:256-258. [PMID: 24739521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 11/26/2013] [Indexed: 06/03/2023]
Abstract
Three sisters who carried the BRCA-1 gene mutation had a preventive mastectomy and were reconstructed with silicone breast implants. After the reconstruction all three patients developed fatigue, arthralgia, myalgia and sleep disturbances within a period of four years. Because the complaints were thought to be related to the silicone breast implants, they were advised to have the implants replaced by non-silicone gel containing Monobloc Hydrogel breast implants. After this replacement operation, all complaints improved as evaluated 2.5 years later. Since the complaints developed during the presence of silicone implants and since the reversal was observed after replacement by hydrogel implants we postulate that our patients suffered from ASIA due to silicone implants, i.e. Silicone Implant Incompatibility Syndrome (SIIS). The generation of this syndrome in three sisters suggests that the susceptibility to the development of SIIS may be genetically determined.
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Tschudin-Sutter S, Meinke R, Schuhmacher H, Dangel M, Eckstein F, Reuthebuch O, Widmer AF. Drainage days-an independent risk factor for serious sternal wound infections after cardiac surgery: a case control study. Am J Infect Control 2013; 41:1264-7. [PMID: 23870294 DOI: 10.1016/j.ajic.2013.03.311] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/28/2013] [Accepted: 03/28/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative sternal wound infections are a potentially devastating complication following cardiac surgery. The aim of our study was to determine risk factors associated with patients' baseline characteristics and peri- and postoperative management for the development of surgical site infections (SSIs) after cardiac surgery involving sternotomy. METHODS Since 2009 the University Hospital of Basel, a tertiary care center in Switzerland, has participated in the national SSI-surveillance program by conducting postdischarge surveillance. We conducted a nested case-control study involving 30 consecutive patients with an organ/space SSI after cardiac surgery and 60 control patients. RESULTS Receipt of antibiotics before operation (odds ratio [OR], 1.20; 95% confidence interval [CI], 1.02-1.41; P = .032), decreased albumin levels (OR, 0.87; 95% CI, 0.76-0.99; P = .040, respectively), time on extracorporal circulation (OR, 1.02; 95% CI, 1.00-1.03; P = .012), number of drainages (OR, 9.15; 95% CI, 2.01-41.76; P = .004), length of drain retention (OR, 1.44; 95% CI, 1.10-1.90; P = .009), and resuscitation (OR, 7.30; 95% CI, 1.53-34.71; P = .012) were associated with SSIs. Incidence density drainage days-accounting for both number of drains and length of retention-were the only independent risk factor (OR, 1.12; 95% CI, 1.02-1.11; P = .018). CONCLUSIONS Retention of drainages in the operative site longer than 48 hours was the only independent risk factor for the development of organ/space sternal wound infections after cardiac surgery.
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Ohayon R, Rose R, Ebert K, Lewis C, Vater M, Overby V. Incidence of incorrectly sized graduated compression stockings and lower leg skin irregularities in postoperative orthopedic patients. MEDSURG NURSING : OFFICIAL JOURNAL OF THE ACADEMY OF MEDICAL-SURGICAL NURSES 2013; 22:370-374. [PMID: 24600933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The purpose of this study was to determine the incidence of incorrectly sized knee-high graduated compression stockings (GCS) and skin irregularities in the lower legs of postoperative orthopedic patients. METHODS Using a descriptive study design, researchers evaluated a convenience sample of postoperative orthopedic surgical patients on each postoperative day. Surgical and non-surgical legs were measured to determine the appropriate size for knee-high GCS, and lower legs were assessed for the presence of skin irregularities (edema, erythema, ecchymosis, blistering, excessive coolness or warmth, breaks in the skin integrity) using standardized criteria. The size of GCS in use was recorded, as well as confounding variables of sex, age, and body mass index. Data were summarized with descriptive statistics, with incidence of incorrect GCS size or skin irregularities calculated as a percentage of total subjects studied. FINDINGS Fifty-two postoperative orthopedic patients were evaluated on their operative day and on postoperative days 1 to 3. Contrary to anecdotal observations before beginning this descriptive study, the incidence of incorrectly fitting GCS was low (< or = 10%), and only 2 of 52 (< 4%) subjects had any skin irregularities in the lower leg during the study period. CONCLUSIONS The incidence of incorrectly sized GCS and skin irregularities under GCS for postoperative orthopedic patients was small.
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Simpson JR, Katz SG, Laan TV. Oversedation in postoperative patients requiring ventilator support greater than 48 hours: a 4-year National Surgical Quality Improvement Program-driven project. Am Surg 2013; 79:1106-1110. [PMID: 24160809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Prolonged mechanical ventilation of postoperative patients can contribute to an increase in morbidity. Every effort should be made to wean patients from the ventilator after surgery. Oversedation may prevent successful extubation. Cases identified by the National Surgical Quality Improvement Program (NSQIP) for Huntington Hospital were reviewed. Oversedation, days on the ventilator, type and duration of sedation, and cost were studied. Data were collected from the NSQIP database and patient charts. Oversedation was determined by the Richmond Agitation Sedation Score (RASS) of each patient. The hospital pharmacy provided data on propofol. Forty-three (35%) patients were oversedated. Propofol was used in 111 (90%) cases with an average use of 4.8 days. Propofol was used greater than 48 hours in 77 (62%) cases. After identifying inconsistent nurse documentation of sedation, corrective actions helped decrease oversedation, average number of days on the ventilator, number of days on propofol, hospital expenditure on propofol, and number of patients on the ventilator greater than 48 hours. Oversedation contributed to prolonged mechanical ventilation. Standardization of RASS and physician sedation order sheets contributed to improving our NSQIP rating. Sedation use decreased and fewer patients spent less time on the ventilator. NSQIP is an effective tool to identify issues with quality in surgical patients.
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Reidunsdatter RJ, Albrektsen G, Hjermstad MJ, Rannestad T, Oldervoll LM, Lundgren S. One-year course of fatigue after post-operative radiotherapy in Norwegian breast cancer patients--comparison to general population. Acta Oncol 2013; 52:239-48. [PMID: 23210971 DOI: 10.3109/0284186x.2012.742563] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Fatigue after treatment for breast cancer (BC) is common, but poorly understood. We examined the fatigue levels during first year after radiotherapy (RT) according to the extent of RT (local or locoregional), hormonal therapy (HT) and chemotherapy (CT). The impact of comorbidity was also explored. Moreover, we compared fatigue levels in patients with the general population (GenPop) data. MATERIAL AND METHODS BC patients (n = 250) referred for post-operative RT at St. Olavs Hospital, Trondheim, Norway, were enrolled. Fatigue was measured by the EORTC QLQ-C30-fatigue subscale, ranging from 0 to 100, before RT (baseline), after RT, and at three, six, and 12 months. Clinical and treatment-related factors were recorded at baseline. GenPop data was available from a previous survey (n = 652). Linear mixed models and analysis of covariance were applied. RESULTS Compliance ranged from 87% to 98%. At baseline, mean value (SD) of fatigue in BC patients was 26.8 (23.4). The level increased during RT (mean change 8.3, 95% CI 5.5-11.1), but declined thereafter and did not differ significantly from pre-treatment levels at subsequent time points. In age-adjusted analyses, locoregional RT accounted for more overall fatigue than local RT (mean difference 6.6, 95% CI 1.2-12.0), but the association was weakened and not statistical significant when adjusting for CT and HT. Similar pattern was seen for CT and HT. The course of fatigue differed significantly by CT (p < 0.001, interaction test). At baseline, fatigue levels were higher in patients with than without CT, but at subsequent time points similar levels were evident, indicating a temporary adverse effect of CT. Comorbidity was significantly associated with increased level of fatigue, independent of other factors (mean difference 8.1, 95% CI 2.2-14.1). BC-patients were not significantly more fatigued than GenPop, except for immediately after ending RT, and then only among those without comorbidity (mean 35.9 vs. 25.8, p < 0.001). CONCLUSION Comorbidity seems to be a more important determinant for fatigue levels than the cancer treatment.
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Cannon RM, Brown RE, St Hill CR, Dunki-Jacobs E, Martin RCG, McMasters KM, Scoggins CR. Negative effects of transfused blood components after hepatectomy for metastatic colorectal cancer. Am Surg 2013; 79:35-39. [PMID: 23317602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
There has been conflicting evidence regarding negative effects of blood transfusion in oncology patients. This study was undertaken to determine any negative effects of specific blood product transfusion after resection of hepatic colorectal metastases (CRM). Retrospective review of patients undergoing hepatectomy for CRM from 1995 to 2009 at a single institution was performed. Specific attention was paid to the effect of blood transfusion within 30 days of operation on overall survival, disease-free survival (DFS), and complications. To mitigate the bias introduced by complications that require blood transfusion to treat, only nonbleeding complications were considered. Complications were analyzed with univariate and multivariate logistic regression. Survival was analyzed according to Kaplan-Meier and Cox proportional hazards. There were 239 patients included in the study. There were 64 (26.8%) receiving a transfusion of any kind with 25.5 per cent getting red cells (PRBCs), 7.11 per cent getting fresh-frozen plasma, and 3.77 per cent getting platelets. Multivariate analysis revealed only PRBC transfusion to be independently associated with nonbleeding complications (odds ratio, 1.980; 95% confidence interval, 1.094 to 3.582; P = 0.0239). There was no significant adverse effect of transfusion with any product on overall or DFS. PRBC transfusion appears to increase the risk of postoperative complications; thus, strategies to minimize blood use may be warranted.
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Samad L, Zaidi Z. Tubed vs tubeless PCNL in children. J PAK MED ASSOC 2012; 62:892-896. [PMID: 23139970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To compare post-operative outcomes between tubeless and conventional large-bore nephrostomy tube drainage following percutaneous nephrolithotomy in children. METHODS The study comprised 54 patients under 14 years of age who were undergoing percutaneous nephrolithotomy at 60 renal units and met the inclusion criteria. They were randomised to placement of a 16F nephrostomy tube (Group A, 30 renal units) or tubeless drainage (Group B, 30 renal units) at the end of the procedure. Patient age, number and position of stones, operating time, change in haemoglobin, post-operative analgesia requirement, length of hospital stay and post-operative complications were compared between the two groups, using SPSS version 17 and t test. RESULTS Group A had 28 patients, while Group B had 26. The mean age in Group A was 7.2 +/- 3.2 years, and in Group B it was 6.3 +/- 3.6 years (age range 3-13 years and 1-13 years respectively). The mean size of stone was 28.6 +/- 16.7mm and 20.4 +/- 9.3mm; mean change in Hb was 0.78 +/- 0.69mg/dl and 0.63 +/- 0.54mg/dl; and the mean operating time was 54 +/- 20.7 minutes versus 66.9 +/- 22.9 minutes in the two groups respectively. There was significantly less requirement for post-operative pethidine in Group B versus Group A (p=0.01). The postoperative clearance and complications were comparable between the two groups, while the duration of hospital stay was significantly shorter in Group B compared to Group A (p=0.007). CONCLUSION Tubeless percutaneous nephrolithotomy in children is safe and effective. Post-operative analgesia requirement is less and hospital stay is shortened compared to the conventional nephrostomy placement after percutaneous nephrolithotomy.
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Plante J, Turgeon AF, Zarychanski R, Lauzier F, Vigneault L, Moore L, Boutin A, Fergusson DA. Effect of systemic steroids on post-tonsillectomy bleeding and reinterventions: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 345:e5389. [PMID: 22930703 PMCID: PMC3429364 DOI: 10.1136/bmj.e5389] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the risk of postoperative bleeding and reintervention with the use of systemic steroids in patients undergoing tonsillectomy. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, Cochrane Library, Scopus, Web of Science, Intute, Biosis, OpenSIGLE, National Technical Information Service, and Google Scholar were searched. References from reviews identified in the search and from included studies were scanned. REVIEW METHODS Randomised controlled trials comparing the administration of systemic steroids during tonsillectomy with any other comparator were eligible. Primary outcome was postoperative bleeding. Secondary outcomes were the rate of admission for a bleeding episode, reintervention for a bleeding episode, blood transfusion, and mortality. RESULTS Of 1387 citations identified, 29 randomised controlled trials (n=2674) met all eligibility criteria. Seven studies presented a low risk of bias, but none was specifically designed to systematically identify postoperative bleeding. Administration of systemic steroids did not significantly increase the incidence of post-tonsillectomy bleeding (29 studies, n=2674 patients, odds ratio 0.96 (95% confidence interval 0.66 to 1.40), I²=0%). We observed a significant increase in the incidence of operative reinterventions for bleeding episodes in patients who received systemic steroids (12, n=1178, 2.27 (1.03 to 4.99), I²=0%). No deaths were reported. Sensitivity analyses were consistent with the findings. CONCLUSIONS Although systemic steroids do not appear to increase bleeding events after tonsillectomy, their use is associated with a raised incidence of operative reinterventions for bleeding episodes, which may be related to increased severity of bleeding events. Systemic steroids should be used with caution, and the risks and benefits weighed, for the prevention of postoperative nausea and vomiting after tonsillectomy before further research is performed to clarify their condition of use.
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Abantanga FA. Nasogastric tube use in children after abdominal surgery- how long should it be kept in Situ? West Afr J Med 2012; 31:19-23. [PMID: 23115091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Traditionally, the use of a nasogastric tube (NGT) after a laparotomy is said to prevent vomiting, aspiration, abdominal distension and paralytic ileus, which are likely to complicate the postoperative course. OBJECTIVE To determine if discontinuation of NGT within 24 hours of abdominal surgical procedures in children has any effect on postoperative recovery. MATERIALS AND METHODS We prospectively studied children who needed NGT passed for abdominal surgical procedures. NGTs were removed within 24 hours in all but 46 children who had the tube in situ for 3 to 5 days. Time to first and full oral feeds, length of hospital stay and complications were compared between the groups. RESULTS Children who had their NGTs removed within 24 hours (N = 120, Group 1) were compared with those who had NGT in place for 3 to 5 days (N = 46, Group 2). The mean time to first oral sips was 1.02 ± 0.13 days for Group 1 and 3.09 ± 0.29 days for Group 2 (p = 0.001). The mean time to full feeding was 2.22 ± 0.54 days for Group 1 and 4.54 ± 0.55 days for Group 2 (p = 0.001). Mean length of hospital stay (LOHS) was 8.32 ± 5.49 days for Group 1 and 12.78 ± 8.79 days for Group 2 (p = 0.001). Mean LOHS was 9.55 ± 6.85 days for both groups combined. Ten complications associated with the removal of the NGT occurred in both groups- 6 in Group 1 and 4 in Group 2 (p = 0.37). These were mainly vomiting and abdominal distension. CONCLUSION Our findings suggest that routine use of NGTs for decompression after laparotomy may be safely dispensed with after the child has recovered from anaesthesia.
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Brennan JM, Alexander KP, Hodges AB, Laschinger JC, Jones KW, O’Brien S, Webb LE, Dokholyan RS, Peterson ED. Patterns of anticoagulation following bioprosthetic valve implantation: observations from ANSWER. THE JOURNAL OF HEART VALVE DISEASE 2012; 21:78-87. [PMID: 22474747 PMCID: PMC3925668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend a three-month administration of warfarin following bioprosthetic valve replacement (BVR). However, strong evidence supporting this recommendation is lacking, making process variation likely. METHODS In the ANSWER Registry, a total of 386 patients who had received either Epic or Biocor BVRs between May 2007 and August 2008 at 40 centers was enrolled. Patterns of discharge anticoagulation and outpatient International Normalized Ratio (INR) values were collected. Mortality, embolic, and bleeding events were assessed up to six months after BVR. RESULTS The median patient age was 74 years (interquartile range (IQR): 67-80 years), 39% of patients were female, and 65% were classified as a high thromboembolic risk. Warfarin was prescribed in 38% of all BVR patients, and in 49% of those at high risk of thromboembolism. The median time to therapeutic INR was nine days (IQR: 1 to 18 days), and 20% of patients failed to reach therapeutic levels. Among those patients achieving a therapeutic INR, 78% and 57% respectively had at least one subtherapeutic or supratherapeutic INR during the subsequent follow up to three months. During the follow up, patients treated with warfarin had similar rates of embolic events (2.8% versus 3.1%, p = 0.884), but a substantially higher incidence of bleeding than those not treated with warfarin (12% versus 3%, p = 0.0012). Among patients who were anticoagulated, those with supratherapeutic INR-values had a seven-fold higher risk for overt bleeding events (26% versus 3%). CONCLUSION Anticoagulation strategies after BVR are highly variable. In this population, challenges in achieving and maintaining therapeutic warfarin anticoagulation are common, and are associated with an increased risk of bleeding. Further studies are required to clarify the optimal post-BVR anticoagulation strategy.
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Eldzarov PE, Zelianin AS, Iamkovoĭ AD. [Complications and mistakes of the intramedullary blocking ostheosynthesis]. Khirurgiia (Mosk) 2012:73-77. [PMID: 23258364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The aim of the study was to reveal the reasons of complications and mistakes of the blocking intramedullary core ostheosynthesis of the long limb bones. 89 operations were performed in 86 patients, aged 18-78 years. The follow-up results were obtained in 79 patients. Satisfactory and excellent results were registered in 72 (94.7%) patients. 4 (5.3%) patients showed the inconsistency of the ostheosynthesis. They received the additional reconstructive operation. The early performance of the revisional intervention permits avoiding severe complications of the blocking intramedullary core ostheosynthesis.
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Tannuri ACA, Silva LM, Leal AJG, Moraes ACFD, Tannuri U. Does administering albumin to postoperative gastroschisis patients improve outcome? Clinics (Sao Paulo) 2012; 67:107-11. [PMID: 22358234 PMCID: PMC3275118 DOI: 10.6061/clinics/2012(02)04] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 09/21/2011] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES Newborns who undergo surgery for gastroschisis correction may present with oliguria, anasarca, prolonged postoperative ileus, and infection. New postoperative therapeutic procedures were tested with the objective of improving postoperative outcome. PATIENTS AND METHODS One hundred thirty-six newborns participated in one of two phases. Newborns in the first phase received infusions of large volumes of crystalloid solution and integral enteral formula, and newborns in the second phase received crystalloid solutions in smaller volumes, with albumin solution infusion when necessary and the late introduction of a semi-elemental diet. The studied variables were serum sodium and albumin levels, the need for albumin solution expansion, the occurrence of anasarca, the length of time on parenteral nutrition, the length of time before initiating an enteral diet and reaching a full enteral diet, orotracheal intubation time, length of hospitalization, and survival rates. RESULTS Serum sodium levels were higher in newborns in the second phase. There was a correlation between low serum sodium levels and orotracheal intubation time; additionally, low serum albumin levels correlated with the length of time before the initiation of an oral diet and the time until a full enteral diet was reached. However, the discharge weights of newborns in the second phase were higher than in the first phase. The other studied variables, including survival rates (83.4% and 92.0%, respectively), were similar for both phases. CONCLUSIONS The administration of an albumin solution to newborns in the early postoperative period following gastroschisis repair increased their low serum sodium levels but did not improve the final outcome. The introduction of a semi-elemental diet promoted an increase in body weight at the time of discharge.
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Kühn AL, Huch B, Wendt G, Dooms G, Droste DW. First description of posterior reversible encephalopathy syndrome as a complication of glycerolnitrate patch following open cardiac surgery. Acta Neurol Scand 2011; 124:218-20. [PMID: 21595634 DOI: 10.1111/j.1600-0404.2010.01445.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) affects predominantly the parietal and occipital lobes. Frequent clinical features are epileptic seizure, altered mental status and visual disturbances. CLINICAL PRESENTATION We present the first case of a patient with pericarditis and mitral valve insufficiency, who developed PRES after application of a glycerolnitrate patch day three post-operatively and whose neurological deficits improved within 2 days after withdrawal of patch therapy. CONCLUSION The precise pathomechanism of PRES is unknown. The lower sympathetic innervation of the posterior circulation may be one explanation for its particular vulnerability to vasodilatation caused by glycerolnitrate.
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Dardashti A, Ederoth P, Algotsson L, Brondén B, Lührs C, Bjursten H. Blood transfusion after cardiac surgery: is it the patient or the transfusion that carries the risk? Acta Anaesthesiol Scand 2011; 55:952-61. [PMID: 21574966 DOI: 10.1111/j.1399-6576.2011.02445.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The transfusion of red blood cells (RBCs) after cardiac surgery has been associated with increased long-term mortality. This study reexamines this hypothesis by including pre-operative hemoglobin (Hb) levels and renal function in the analysis. METHODS A retrospective single-center study was performed including 5261 coronary artery bypass grafting (CABG) patients in a Cox proportional hazard survival analysis. Patients with more than eight RBC transfusions, early death (7 days), and emergent cases were excluded. Patients were followed for 7.5 years. Previously known risk factors were entered into the analysis together with pre-operative Hb and estimated glomerular filtration rate (eGFR). In addition, subgroups were formed based on the patients' pre-operative renal function and Hb levels. RESULTS When classical risk factors were entered into the analysis, transfusion of RBCs was associated with reduced long-term survival. When pre-operative eGFR and Hb was entered into the analysis, however, transfusion of RBCs did not affect survival significantly. In the subgroups, transfusion of RBCs did not have any effect on long-term survival. CONCLUSIONS When pre-operative Hb levels and renal function are taken into account, moderate transfusions of RBC after CABG surgery do not seem to be associated with reduced long-term survival.
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Grzelak P, Sapieha M, Kurnatowska I, Nowicki M, Strzelczyk J, Stefańczyk L. Contrast-enhanced sonography of postbiopsy arteriovenous fistulas in kidney grafts. JOURNAL OF CLINICAL ULTRASOUND : JCU 2011; 39:378-382. [PMID: 21688270 DOI: 10.1002/jcu.20812] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 01/18/2011] [Indexed: 05/30/2023]
Abstract
PURPOSE To assess the usefulness of contrast-enhanced ultrasonography (CE-US) in the visualization of a kidney graft following a biopsy that was complicated by an arteriovenous fistula (AVF). METHODS Four postrenal transplant patients who had developed AVFs following graft biopsy were examined using standard US and CE-US. Additionally, follow-up examinations were conducted using CE-US, at 4-6 weeks and 10-12 weeks following fistula closure. RESULTS The fistulas were detected using color Doppler US, Power Doppler US, and B-flow technique. Reduced parenchymal flow was only detected in one case using standard flow visualization techniques. CE-US allowed for the visualization of regions of disturbed parenchymal perfusion that were not visible in the standard examinations. At follow-up, B-mode ultrasound and standard flow examinations appeared normal. However, all contrast-enhanced images showed clearly demarcated residual regions of reduced parenchymal perfusion, in areas where the fistulas had been previously present. CONCLUSIONS A posttraumatic AVF reduces parenchymal perfusion in the affected region. CE-US examination may help in monitoring fistulas during the active phase and following spontaneous closure.
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Zhang H, Xiong EQ, Liu LM, Yan SX, Zhou ZS, Lu GS. Penile necrosis after circumcision owing to inappropriate postoperative treatment. J Pediatr Surg 2011; 46:1469-70. [PMID: 21763857 DOI: 10.1016/j.jpedsurg.2011.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 03/09/2011] [Accepted: 03/09/2011] [Indexed: 11/29/2022]
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Husted H, Troelsen A, Kehlet H. [Undocumented regimes after total hip and knee arthroplasty can deteriorate the results]. Ugeskr Laeger 2011; 173:1802-1805. [PMID: 21689509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Undocumented traditions in perioperative care after total hip and knee arthroplasty are passed on as gold standard. However, evidence-based medicine may interfere with traditions. It is therefore essential to revisit traditions or routines once in a while and re-evaluate current practice according to existing evidence. Fast track surgery is an example of replacing traditions with evidence-based clinical features in order to optimise perioperative outcome. This article reviews some traditions that may influence outcome regarding pain, infection, blood loss, mobilisation, length of stay in hospital, thromboembolic prophylaxis, and costs.
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MESH Headings
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/rehabilitation
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/rehabilitation
- Early Ambulation
- Evidence-Based Medicine
- Humans
- Intraoperative Care/adverse effects
- Intraoperative Care/methods
- Perioperative Care/adverse effects
- Perioperative Care/methods
- Perioperative Care/standards
- Postoperative Care/adverse effects
- Postoperative Care/methods
- Treatment Outcome
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Golbus JR, Wojcik BM, Charpie JR, Hirsch JC. Feeding complications in hypoplastic left heart syndrome after the Norwood procedure: a systematic review of the literature. Pediatr Cardiol 2011; 32:539-52. [PMID: 21336978 DOI: 10.1007/s00246-011-9907-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/31/2011] [Indexed: 11/25/2022]
Abstract
Gastrointestinal and feeding complications after the Norwood procedure in infants with hypoplastic left heart syndrome increases morbidity and mortality. These problems are the result of intraoperative challenges, shunt-dependent physiology, and the absence of best-practice guidelines. In response, a systematic review of feeding-related complications and management strategies was performed. A literature search from 1950 to March 2010 identified 21 primary research articles and 4 reviews. Dysphagia, necrotizing enterocolitis (NEC), and poor nutritional status are significant feeding-related complications. Three studies directly compared the modified Blalock-Taussig shunt with the right ventricle-to-pulmonary artery conduit (RV-PA). Patients palliated with either shunt had impaired mesenteric blood flow. Mortality did not differ between shunt types. Three studies demonstrated improved outcomes, e.g., increased survival, decreased incidence of NEC, and decreased median time to recommended daily allowance of calories, with a postoperative feeding algorithm. Two studies showed increased survival between stage I and II surgical palliation after implementation of a home-monitoring system consisting of daily weight and systemic oxygen saturation measurements. The RV-PA shunt does not significantly alter mortality or increase mesenteric blood flow. A postoperative feeding algorithm and a home-monitoring system may improve outcomes and decrease average hospital length of stay (LOS). Additional studies are needed to determine which interventions, as part of a standardized protocol, improve survival and decrease complications.
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Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev 2011:CD007635. [PMID: 21328298 DOI: 10.1002/14651858.cd007635.pub2] [Citation(s) in RCA: 296] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In recent years the Enhanced Recovery after Surgery (ERAS) postoperative pathway in (ileo-)colorectal surgery, aiming at improving perioperative care and decreasing postoperative complications, has become more common. OBJECTIVES We investigated the effectiveness and safety of the ERAS multimodal strategy, compared to conventional care after (ileo-)colorectal surgery. The primary research question was whether ERAS protocols lead to less morbidity and secondary whether length of stay was reduced. SEARCH STRATEGY To answer the research question we entered search strings containing keywords like "fast track", "colorectal and surgery" and "enhanced recovery" into major databases. We also hand searched references in identified reviews concerning ERAS. SELECTION CRITERIA We included published randomised clinical trials, in any language, comparing ERAS to conventional treatment in patients with (ileo-) colorectal disease requiring a resection. RCT's including at least 7 ERAS items in the ERAS group and no more than 2 in the conventional arm were included. DATA COLLECTION AND ANALYSIS Data of included trials were independently extracted by the reviewers. Analyses were performed using "REVMAN 5.0.22". Data were pooled and rate differences as well as weighted mean differences with their 95% confidence intervals were calculated using either fixed or random effects models, depending on heterogeneity (I(2)). MAIN RESULTS 4 RCTs were included and analysed. Methodological quality of included studies was considered low, when scored according to GRADE methodology. Total numbers of inclusion were limited. The trials included in primary analysis reported 237 patients, (119 ERAS vs 118 conventional). Baseline characteristics were comparable. The primary outcome measure, complications, showed a significant risk reduction for all complications (RR 0.50; 95% CI 0.35 to 0.72). This difference was not due to reduction in major complications. Length of hospital stay was significantly reduced in the ERAS group (MD -2.94 days; 95% CI -3.69 to -2.19), and readmission rates were equal in both groups. Other outcome parameters were unsuitable for meta-analysis, but seemed to favour ERAS. AUTHORS' CONCLUSIONS The quantity and especially quality of data are low. Analysis shows a reduction in overall complications, but major complications were not reduced. Length of stay was reduced significantly. We state that ERAS seems safe, but the quality of trials and lack of sufficient other outcome parameters do not justify implementation of ERAS as the standard of care. Within ERAS protocols included, no answer regarding the role for minimally invasive surgery (i.e. laparoscopy) was found. Furthermore, protocol compliance within ERAS programs has not been investigated, while this seems a known problem in the field. Therefore, more specific and large RCT's are needed.
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