High-Frequency Heart Rate Variability Index: A Prospective, Observational Trial Assessing Utility as a Marker for the Balance Between Analgesia and Nociception Under General Anesthesia

BACKGROUND

Maintaining a balance between nociception and analgesia perioperatively reduces morbidity and improves outcomes. Current intraoperative analgesic strategies are based on subjective and nonspecific parameters. The high-frequency heart rate (HR) variability index is purported to assess the balance between nociception and analgesia in patients under general anesthesia. This prospective observational study investigated whether intraoperative changes in the high-frequency HR variability index correlate with clinically relevant nociceptive stimulation and the addition of analgesics.

METHODS

Instantaneous and mean high-frequency HR variability indexes were measured continuously in 79 adult subjects undergoing general anesthesia for laparoscopic cholecystectomy. The indexes were compared just before and 2 minutes after direct laryngoscopy, orogastric tube placement, first skin incision, and abdominal insufflation and just before and 6 minutes after the administration of IV hydromorphone.

RESULTS

Data from 65 subjects were included in the final analysis. The instantaneous index decreased after skin incision ([SEM], 58.7 [2.0] vs 47.5 [2.0]; P < .001) and abdominal insufflation (54.0 [2.0] vs 46.3 [2.0]; P = .002). There was no change in the instantaneous index after laryngoscopy (47.2 [2.2] vs 40.3 [2.3]; P = .026) and orogastric tube placement (49.8 [2.3] vs 45.4 [2.0]; P = .109). The instantaneous index increased after hydromorphone administration (58.2 [1.9] vs 64.8 [1.8]; P = .003).

CONCLUSIONS

In adult subjects under general anesthesia for laparoscopic cholecystectomy, changes in the high-frequency HR variability index reflect alterations in the balance between nociception and analgesia. This index might be used intraoperatively to titrate analgesia for individual patients. Further testing is necessary to determine whether the intraoperative use of the index affects patient outcomes.

Cytokine Removal in Critically Ill Patients Requiring Surgical Therapy for Infective Endocarditis (RECReATE): An Investigator-initiated Prospective Randomized Controlled Clinical Trial Comparing Two Established Clinical Protocols

INTRODUCTION

Infective endocarditis (IE) and other severe infections induce significant changes in the immune response in a considerable number of affected patients. Numerous IE patients develop a persistent functional immunological phenotype that can best be characterized by a profound anti-inflammation and/ or functional "anergy." This is pronounced in patients with unresolved infectious foci and was previously referred to as "injury-associated immunosuppression" (IAI). IAI can be assessed by measurement of the monocytic human leukocyte antigen-DR (mHLA-DR) expression, a global functional marker of immune competence. Persistence of IAI is associated with prolonged intensive care unit length of stay, increased secondary infection rates, and death. Immunomodulation to reverse IAI was shown beneficial in early immunostimulatory (randomized controlled) clinical trials.

METHODS

Prospective 1:1 randomized controlled clinical study to compare the course of mHLA-DR in patients scheduled for cardiac surgery for IE. Patients will receive either best standard of care plus cytokine adsorption during surgery while on cardiopulmonary bypass (protocol A) versus best standard of care alone, that is, surgery without cytokine adsorption (protocol B). A total of 54 patients will be recruited and randomized. The primary endpoint is a change in quantitative expression of mHLA-DR (antibodies per cell on CD14+ monocytes/ macrophages, assessed using a quantitative standardized assay) from baseline (preoperation [pre-OP], visit 1) to day 1 post-OP (visit 4).

DISCUSSION

This randomized controlled clinical trial (RECReATE) will compare 2 clinical treatment protocols and will investigate whether cytokine adsorption restores monocytic immune competence (reflected by increased mHLA-DR expression) in patients with IE undergoing cardiac surgery.

TRIAL REGISTRATION

This protocol was registered in ClinicalTrials.gov, under number NCT03892174, first listed on March 27, 2019.

Effect of intraoperative Hartmann's versus hypotonic solution administration on FLACC pain scale scores in children: A prospective randomized controlled trial

Background

In healthy children, an isotonic solution containing no glucose or a small amount of glucose (1–2%) has been recommended as an intraoperative maintenance fluid due to the potential risk of hyponatremia associated with hypotonic solutions. However, a hypotonic solution with glucose is still widely used as a maintenance fluid for pediatric anesthesia. We speculated that the hypotonic solution may worsen postoperative discomfort and irritability in pediatric patients due to hyponatremia.

Patients and methods

In the current study, we compared the post-operative Face, Legs, Activity, Cry, Consolability(FLACC) scale scores of pediatric patients aged 3–10 years who received either a 1:2 dextrose solution or Hartmann's solution during Nuss Bar removal.

Results

The FLACC scale score in the post-anesthesia care unit was higher in the 1:2 dextrose solution group(HYPO) (n = 20) than in the Hartmann’s solution group(ISO) (n = 20) (6.30 vs 4.70, p = 0.044, mean difference and 95% Confidence Interval(CI) was 1.6 (0.04 to 3.16)). We also compared opioid consumption at the post-anesthesia care unit. Total dose of fentanyl per body weight in the post-anesthesia care unit was also higher in the HYPO (0.59 vs 0.37 mcg/kg, p = 0.042, mean difference and 95% CI was 0.22 mcg/kg (0.030 to 0.402)).

Conclusions

Intraoperative use of the hypotonic solution in children causes increased FLACC scale scores, leading to higher opioid consumption in post-anesthesia care unit.

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

OBJECTIVE

To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017.

ELIGIBILITY CRITERIA

Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded.

DATA EXTRACTION AND SYNTHESIS

Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared.

RESULTS

117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions.

CONCLUSIONS

Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions.

STUDY REGISTRATION

Prospero CRD42016035662.

Using Imageless Optical Navigation to Identify the New Hip Center in Crowe IV Dysplasia

In total hip arthroplasty for patients with acetabular dysplasia, cup placement in the native acetabulum is preferred to placement in the pseudoacetabulum. Identifying the true acetabulum may prove challenging. In a patient with Crowe IV dysplasia, 3-dimensional mini-optical navigation was used to match the new hip center to the preoperative radiographic plan, which was identified to be 34 mm inferior to the pseudoacetabulum. This allowed titration of femoral shortening to 20 mm, to arrive at final limb lengthening of 14 mm. Although the use of other enabling technologies in hip dysplasia has been reported, to the authors' knowledge, this is the first reported case demonstrating the use of imageless optical navigation in this setting. It is a navigational tool with a small spatial footprint, does not mandate preoperative axial studies, and does not require multipoint bone surface registration. Imageless navigation may be a useful option for cup positioning and subsequent titration of femoral shortening in the reconstruction of Crowe IV dysplastic hips with degenerative joint disease. [Orthopedics. 2020; 43(2):e119-e122.].

[Rib fracture following intra-operative radiotherapy for breast cancer. Case Report and local experience]

Intra-operative radiotherapy for breast cancer has been developed throughout the last two decades. It is already well-established regarding local control and toxicity for intra-operative radiotherapy using electrons as we now have the necessary background knowledge. However, very few data on later toxicity are available for intra-operative radiotherapy using low-energy photons. We report here the case of a 36-year-old woman who experienced rib fracture following intra-operative and external radiotherapy. This patient has been included in the Targit-boost trial. The intra-operative irradiation has been operated with an INTRABEAM device delivering low-energy photons of 50-kV.

Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines

BACKGROUND

Surgical site infections (SSI) represent a considerable burden for healthcare systems. They are largely preventable and multiple interventions have been proposed over past years in an attempt to prevent SSI. We aim to provide a position paper on Operative Room (OR) prevention of SSI in patients presenting with intra-abdominal infection to be considered a future addendum to the well-known World Society of Emergency Surgery (WSES) Guidelines on the management of intra-abdominal infections.

METHODS

The literature was searched for focused publications on SSI until March 2019. Critical analysis and grading of the literature has been performed by a working group of experts; the literature review and the statements were evaluated by a Steering Committee of the WSES.

RESULTS

Wound protectors and antibacterial sutures seem to have effective roles to prevent SSI in intra-abdominal infections. The application of negative-pressure wound therapy in preventing SSI can be useful in reducing postoperative wound complications. It is important to pursue normothermia with the available resources in the intraoperative period to decrease SSI rate. The optimal knowledge of the pharmacokinetic/pharmacodynamic characteristics of antibiotics helps to decide when additional intraoperative antibiotic doses should be administered in patients with intra-abdominal infections undergoing emergency surgery to prevent SSI.

CONCLUSIONS

The current position paper offers an extensive overview of the available evidence regarding surgical site infection control and prevention in patients having intra-abdominal infections.

Effect of Hydroxyethyl Starch vs Saline for Volume Replacement Therapy on Death or Postoperative Complications Among High-Risk Patients Undergoing Major Abdominal Surgery: The FLASH Randomized Clinical Trial

IMPORTANCE

It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe.

OBJECTIVE

To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018.

INTERVENTIONS

Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90.

RESULTS

Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17).

CONCLUSIONS AND RELEVANCE

Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02502773.

Anesthesia for meningioma surgery

Patients receiving treatment for a meningioma require anesthesia when undergoing open craniotomy and, in some cases, during preoperative tumor embolization and radiosurgery. Adequate anesthesia management is integral to patients' perioperative care, which consists of the three phases of preoperative assessment and optimization, intraoperative care, and postoperative recovery. The preoperative anesthesia evaluation focusses on the cardiorespiratory and neurologic systems, as well as the airway, but also extends to ensure the optimal treatment of significant comorbidities before surgical intervention. The goals of intraoperative care are maintenance of brain physiology, facilitating surgery, and correcting any adverse effects of surgery and underlying pathology to preserve general patient homeostasis. This requires adequate intraoperative patient monitoring, cardiorespiratory support, management of infusion therapy, and application of knowledge about the effects of anesthetic agents on brain physiology. The anesthesiologist's responsibilities for patient care extend well into the postoperative recovery period, with a focus on pain control, prevention, and treatment of postoperative nausea and vomiting (PONV), and, in some patients, intensive care therapy.

Anaesthetic considerations for patients with antiphospholipid syndrome undergoing non-cardiac surgery

Antiphospholipid syndrome (APS) is an acquired thrombotic autoimmune disorder that is clinically characterized by the development of thrombosis and obstetric morbidities in patients with antiphospholipid antibodies. Due to hypercoagulability, the focus of management is anticoagulation for the prevention of thrombosis and its recurrence. When such patients undergo surgery, however, the underlying risk of thrombosis increases as a result of anticoagulant withdrawal, immobilization, and/or intimal injury. Conversely, there is also an increased risk of bleeding due to thrombocytopaenia, possible disseminated intravascular coagulation, or progression to catastrophic APS, as a result of excessive anticoagulation, surgery, and infection. Measures for appropriate perioperative anticoagulation are discussed in this review, as well as anaesthetic considerations for preventing perioperative complications in patients with APS undergoing non-cardiac surgery.

Malignant Lymphoma of the Ovary: A Diagnostic Pitfall of Intraoperative Consultation

Primary ovarian lymphomas are rare, but can potentially evoke diagnostic problems. We present a case of ovarian lymphoma, in which an ambiguous intraoperative pathologic report led to overtreatment (unnecessary surgery). A 73-yr-old woman with fatigue and low-grade fever was diagnosed as having a left ovarian tumor by imaging modalities. Exploratory laparotomy was carried out to confirm the diagnosis. The frozen tissue sections of the ovarian tumor showed condensed proliferation of atypical round cells accompanied with a few small lymphocytes. The pathologists could not determine whether this tumor was a lymphoma or another malignancy (eg, dysgerminoma). Hence, they reported it to gynecologists who operated as simply a malignant tumor in order to evade misdiagnosis. On the basis of the inconclusive pathologic report, the gynecologists decided to change the planned laparotomy to total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymph node dissection. A postoperative paraffin section-based pathologic diagnosis was diffuse large B-cell lymphoma of the ovary, which basically does not require surgical treatments. Subsequently, chemotherapy for B-cell lymphoma was initiated, and no lymphoma recurrence has been reported to date. A more robust preoperative discussion between the gynecologists and the pathologists might have avoided the overtreatment.

Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007-2015) or TNCs (2015-2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty

PURPOSE

Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent^® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling.

METHODS

During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test.

RESULT

All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™.

CONCLUSION

The novel APrevent^® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Glycemic Management in the Operating Room: Screening, Monitoring, Oral Hypoglycemics, and Insulin Therapy

PURPOSE OF REVIEW

This review provides a literature update and practical outline for the management of diabetes and stress hyperglycemia for adult surgical patients in the pre- and intraoperative settings.

RECENT FINDINGS

Hyperglycemia in surgical patients has been associated with increased risk of complication in both diabetic and non-diabetic patients in the perioperative setting. While current recommended perioperative blood glucose target is < 180 mg/dL (10 mmol/L), optimal outcomes may require different treatment targets for diabetic versus non-diabetic patients. Hemoglobin A1C level is associated with elevated risk of hyperglycemia and adverse outcomes, but there is insufficient evidence to recommend routine preoperative testing or optimal values in elective surgical patients. Day of surgery blood glucose testing and treatment are recommended in the perioperative period, and anesthetic management includes appropriate patient selection for use of subcutaneous insulin, intravenous insulin infusions, and insulin pumps. Additionally, administration of both intravenous and perineural dexamethasone is associated with increased blood glucose levels and clinicians should consider the risk benefit ratio in surgical patients. For enhanced recovery after surgery protocols, further evidence is needed to support routine use of carbohydrate loading in diabetic patients. Optimal perioperative care includes screening at-risk patients, use of preoperative oral hypoglycemics and home insulin, anesthetic type and medication selection, blood glucose testing, and treatment for hyperglycemia in the operating room. Partnerships with surgery and endocrinology teams aid optimal postoperative management and discharge planning.

The intraoperative use of aortic balloon occlusion technique for sacral and pelvic tumor resections: A case-control study

INTRODUCTION

Pelvic and sacral tumor surgery is traditionally characterized by several major complications. Bleeding is probably the most feared and dreadful complication. The aim of the study was to evaluate whether the intraoperative use of the intra-aortic balloon occlusion technique could decrease the perioperative blood loss. A secondary aim was to assess aortic balloon-related complications.

MATERIALS AND METHODS

From January 2014 to December 2017 15 patients (Group 1) treated with intra-aortic balloon inflation were prospectively enrolled and compared to a historical control group (Group 2) of 11 patients with similar surgeries. Number of blood units transfused, perioperative hemoglobin values, hours spent in intensive care unit (ICU), length of inpatient stay, and perioperative complications were evaluated.

RESULTS

Intraoperatively, a mean of 6.1 blood units per patient (BUPP) was used in Group 1 and 16.2 BUPP in Group 2. Postoperatively the averages were 2,8 and 5,4 BUPP in Group 1 and 2, respectively. Patients in Group 1 had a faster recovery in hemoglobin values, as well as a shorter length of overall inpatient stay (28,9 vs 59 days) and of ICU stay (33.9 vs 74.6 h). The most relevant complications observed in Group 1 were two thrombosis at the incannulation site that required a surgical arterial thrombectomy.

CONCLUSION

The intra-aortic balloon occlusion is an effective technique to control bleeding during the resections of huge pelvic and sacral tumors. A proper training of a multidisciplinary team and an accurate patient selection are required to prevent major complications.

[Intraoperative fluorescence angiography and cholangiography with indocyanine green in hepatobiliary surgery]

Intraoperative fluorescence angiography and cholangiography with indocyanine green (ICG) are increasingly used in routine hepatobiliary surgery. Its usage is manifold. It improves and facilitates navigation especially in minimal invasive and robotic surgery and therefore increases the safety of the surgical intervention. In laparoscopic cholecystectomy for example, the bileduct anatomy can be easily visualized, even in complicated cholecystitis or anatomical variants without being too time consuming. ICG fluorescence also enables the visualization of vascular structures and perfusion. Anatomical liver resections, for example in hepatocellular carcinoma (HCC), can be performed easily as liver segments and territories can be identified. Anatomical resection is becoming more important, e.g. in the treatment of HCC. Another useful application is the intraoperative detection of bile leakages after liver resection. In particular, the intraoperative control of a biliodigestive anastomosis is possible with ICG fluorescence cholangiography and therefore reduces morbidity. Even primary and secondary liver tumors can be detected with ICG fluorescence. Whereas well-differentiated HCCs homogeneously take up ICG, poorly differentiated HCCs and metastases do not: however, in these cases the adjacent liver parenchyma stores ICG more intensively than healthy liver tissue, which creates a ring-like fluorescence pattern. To conclude, the use of ICG fluorescence in hepatobiliary surgery is diverse but in Germany it is still at the beginning compared to other countries.

APSIC guidelines for the prevention of surgical site infections

Background

The Asia Pacific Society of Infection Control (APSIC) launched the APSIC Guidelines for the Prevention of Surgical Site Infections in 2018. This document describes the guidelines and recommendations for the setting prevention of surgical site infections (SSIs). It aims to highlight practical recommendations in a concise format designed to assist healthcare facilities at Asia Pacific region in achieving high standards in preoperative, perioperative and postoperative practices.

Method

The guidelines were developed by an appointed workgroup comprising experts in the Asia Pacific region, following reviews of previously published guidelines and recommendations relevant to each section.

Results

It recommends that healthcare facilities review specific risk factors and develop effective prevention strategies, which would be cost effective at local levels. Gaps identified are best closed using a quality improvement process. Surveillance of SSIs is recommended using accepted international methodology. The timely feedback of the data analysed would help in the monitoring of effective implementation of interventions.

Conclusions

Healthcare facilities should aim for excellence in safe surgery practices. The implementation of evidence-based practices using a quality improvement process helps towards achieving effective and sustainable results.

Does intravenous acetaminophen reduce perioperative opioid use in pediatric tonsillectomy?

OBJECTIVE

Postoperative pain control is of significant interest in pediatric otolaryngology given the safety concerns with opioid use. We sought to determine if addition of intraoperative intravenous acetaminophen decreases perioperative morphine use in pediatric tonsillectomy.

METHODS

This study is a retrospective cohort study performed at a tertiary care academic children's hospital. 166 pediatric patients (aged 1-16 years) who underwent tonsillectomy with or without adenoidectomy were for review. Seventy-four patients received intraoperative intravenous acetaminophen (intervention cohort), while ninety-two patients served as our control and did not receive any intraoperative intravenous acetaminophen. Perioperative (intraoperative and postoperative) morphine use was our primary outcome measure. Rate of adverse events in the post anesthesia care unit and time for discharge readiness were secondary outcome measures. Wilcoxon two-sample t-test approximation and Fisher's exact test were used for data analyses.

RESULTS

Patients in the intravenous acetaminophen cohort received less morphine (mg/kg) intraoperatively (0.058 versus 0.070, p = 0.089) and in the post anesthesia care unit (0.034 versus 0.051, p = 0.034) than the control cohort. The median time to discharge readiness for the intravenous acetaminophen and control groups was 108.5 versus 105 min (p = 0.018). There was no adverse respiratory event (oxygen desaturation <92% lasting more than a minute, requiring bag mask ventilation or reintubation) in either group in the post anesthesia care unit. There were 5 (7%) episodes of postoperative vomiting in the IV APAP, while 2 (2%) were recorded in the control cohort (p = 0.244).

CONCLUSION

Our findings suggest intraoperative intravenous acetaminophen use in pediatric tonsillectomy can decrease the perioperative use of opioid for optimal pain management.

High Affinity of Chlorin e6 to Immunoglobulin G for Intraoperative Fluorescence Image-Guided Cancer Photodynamic and Checkpoint Blockade Therapy

Cancer photodynamic therapy (PDT) represents an attractive local treatment in combination with immunotherapy. Successful cancer PDT relies on image guidance to ensure the treatment accuracy. However, existing nanotechnology for co-delivery of photosensitizers and image contrast agents slows the clearance of PDT agents from the body and causes a disparity between the release profiles of the imaging and PDT agents. We have found that the photosensitizer Chlorin e6 (Ce6) is inherently bound to immunoglobulin G (IgG) in a nanomolarity range of affinity. Ce6 and IgG self-assemble to form the nanocomplexes termed Chloringlobulin (Chlorin e6 + immunoglobulin G). Chloringlobulin enhances the Ce6 concentration in the tumor without changing its elimination half-life in blood. Utilizing the immune checkpoint inhibitor antiprogrammed death ligand 1 (PD-L1) (αPD-L1) to prepare αPD-L1 Chloringlobulin, we have demonstrated a combination of Ce6-based red-light fluorescence image-guided surgery, stereotactic PDT, and PD-L1 blockade therapy of mice bearing orthotopic glioma. In mice bearing an orthotopic colon cancer model, we have prepared another Chloringlobulin that allows intraoperative fluorescence image-guided PDT in combination with PD-L1 and cytotoxic T lymphocyte antigen 4 (CTLA-4) dual checkpoint blockade therapy. The Chloringlobulin technology shows great potential for clinical translation of combinatorial intraoperative fluorescence image-guided PDT and checkpoint blockade therapy.

Emergency intraoperative vascular surgery consultations at a tertiary academic center

OBJECTIVE

Vascular surgeons are frequently called on to provide emergency assistance to surgical colleagues. Whereas previous studies have included elective preoperative vascular consultations, we sought to characterize the breadth of assistance provided during unplanned intraoperative consultations at a single tertiary academic center.

METHODS

We queried our institutional billing department during a 15-year period and reviewed the records (January 1, 2002-December 31, 2016) and identified unanticipated unplanned vascular surgery intraoperative consultations from all surgical services. Patients' demographics and comorbidities were recorded along with the consulting services, type of index operation, reasons for vascular consultation, regions of anatomic interventions, type of vascular interventions performed, and outcomes achieved.

RESULTS

There were 419 emergency intraoperative consultations identified. Patients were 51% male, with an average age of 57 years and body mass index of 28.3 kg/m². The most frequently consulting subspecialties included surgical oncology (n = 139 [33.2%]), cardiac surgery (n = 82 [19.6%]), and orthopedics (n = 44 [10.5%]). Index cases were elective/nonurgent (n = 324 [77.3%]), urgent (n = 27 [6.4%]), and emergent (n = 68 [16.2%]), with a majority involving tumor resection (n = 240 [57.3%]). The primary reasons for vascular consultation were revascularization (n = 213 [50.8%]), control of bleeding (n = 132 [31.5%]), assistance with dissection or exposure (n = 46 [11%]), embolic protection (n = 24 [5.7%]), and other (n = 4 [1.1%]). The primary blood vessel and anatomic field of intervention were categorized. Most cases (n = 264 [63%]) included preservation of blood flow, including primary arterial repair (n = 181 [43.2%]), patch angioplasty (n = 83 [19.8%]), bypass (n = 63 [15%]), and thrombectomy (n = 38 [9.1%]). Postoperative mean length of stay was 15 days, with 30-day and 1-year mortality of 7.2% and 26.5%.

CONCLUSIONS

Vascular surgeons are called on to provide unplanned open surgical consultations for a wide variety of specialties over wide-ranging anatomic regions, employing a variety of skills and techniques. This study testifies to the essential services supplied to hospitals and our surgical colleagues along with the broad skills and training necessary for modern vascular surgeons.

Structured light imaging for breast-conserving surgery, part I: optical scatter and color analysis

Structured light imaging (SLI) with high spatial frequency (HSF) illumination provides a method to amplify native tissue scatter contrast and better differentiate superficial tissues. This was investigated for margin analysis in breast-conserving surgery (BCS) and imaging gross clinical tissues from 70 BCS patients, and the SLI distinguishability was examined for six malignancy subtypes relative to three benign/normal breast tissue subtypes. Optical scattering images recovered were analyzed with five different color space representations of multispectral demodulated reflectance. Excluding rare combinations of invasive lobular carcinoma and fibrocystic disease, SLI was able to classify all subtypes of breast malignancy from surrounding benign tissues (p-value  <  0.05) based on scatter and color parameters. For color analysis, HSF illumination of the sample generated more statistically significant discrimination than regular uniform illumination. Pathological information about lesion subtype from a presurgical biopsy can inform the search for malignancy on the surfaces of specimens during BCS, motivating the focus on pairwise classification analysis. This SLI modality is of particular interest for its potential to differentiate tissue classes across a wide field-of-view (∼100  cm2) and for its ability to acquire images of macroscopic tissues rapidly but with microscopic-level sensitivity to structural and morphological tissue constituents.

Radiographic and clinical outcomes of huge lumbar disc herniations treated by transforaminal endoscopic discectomy

OBJECTIVES

Large Central disc herniations (occupying more than 50% of canal area) are notorious as they are generally associated with worse outcomes and are technically difficult to manage. Transforaminal endoscopy (TELD) has evolved to become an interesting alternative for lumbar disc herniations. The aim of the paper is to review our technique of transforaminal endoscopy in large central disc herniations and describe the clinical and radiographic results. We also describe an innovative technique of intraoperative epidurography to assess the adequacy of decompression in some cases with severe canal compromise.

PATIENTS AND METHODS

We performed a retrospective analysis of all the patients undergoing TELD from December 2012 to October 2018 for huge central lumbar disc herniations. The procedure was done under local anaesthesia and required a more horizontal approach angle, undercutting of superior articular process and posterior annular release to reach the herniated fragment in the epidural space. In severe cases, a radiopaque dye was introduced via trans-sacral catheter to check the adequacy of decompression. The disc height, lumbar lordosis, segmental lordotic angle on standing radiographs and Canal cross sectional area(CSA) on MRI were evaluated preoperatively and compared with postoperative images at the end of 1 year/final follow-up. The Visual analogue scale(VAS) for Back and Leg pain and Oswestry disability index (ODI), MacNab criteria, return to daily activities, return to work, patient satisfaction rate and recommendation to others were the clinical outcomes evaluated. The percentage of patients achieving the Minimal clinically important difference (MCID) of 3 points for VAS and 12 points for ODI was calculated.

RESULTS

A total of 18 patients, with an average age of 35.1years (range 20-61), were operated. The mean VAS back improved from 5.7(±1.77) to 1(±0.77) and VAS leg improved from 7.3(±1.37) to 1.1(±1.09). The ODI improved from 49.88(±11.42) to 13.88(±7.28) at final follow-up. According to MacNab criteria, 17 patients had excellent and 1 had good outcome at final follow-up. The patient satisfaction rate was 90.5%, with 94% patient recommendation rate. All the patients returned to daily activities and work/modified work within a median of 5 weeks. There was 1 patient who required conversion to open surgery due to incidental dural tear, 1 patient who had a remnant disc required a revision tubular discectomy and 1 patient who had recurrence at 6 weeks and again at 2 years which was treated by repeat TELD. Five patients had impending cauda equina. All the patients achieved the MCID for VAS and ODI within a median period of 6 weeks and 3 months, respectively. The recovery rate was 90.1%. Five patients had grade 4 weakness of great toe/ankle dorsiflexion, one also had ankle flexion weakness preoperatively which improved after surgery. The CSA improved from a preoperative mean of 62.26(±30.3)mm² to 122.16(±56.5)mm² postoperatively. The CSA improved to 141.05(±63.86)mm² at 1 year followup. The average disc height which was 9.71 mm(±2.4) was maintained at follow-up of one year which was 9.21 mm(±2.4). The lumbar lordosis and segmental lordotic angle changed from 27.08°(±15.9) and 2.82°(±5.7) to 35.8°(±8.56) and 4.85°(±4.39) respectively.

CONCLUSION

TELD may be considered as an alternative to microdiscectomy or fusion procedures for huge central disc herniations with favourable outcomes. However, sufficient expertise with the procedure is necessary. Intraoperative decompression may be confirmed with intraoperative epidurography. The patient acceptability of the procedure is good and causes minimal disruption of the normal anatomy.

Approaches to Bloodless Surgery for Oncology Patients

Providing optimal care to surgical oncology patients who cannot be transfused for religious or other reasons can be challenging. However, with careful planning, using a combination of blood-conserving methods, these "bloodless" patients have clinical outcomes that are similar to other patients who can be transfused. Bloodless surgery can be accomplished safely for most patients, including those undergoing technically challenging oncologic surgery. This article reviews best practices used in a bloodless program during the preoperative, intraoperative, and postoperative periods, with the aim of achieving optimal outcomes when transfusion is not an option for surgical oncology patients.

Intraoperative Radiotherapy (Iort) for Breast Cancer Using the Intrabeam™ System

Introduction

Intraoperative radiotherapy (IORT) with low-energy X-rays (30–50 KV) is an innovative technique that can be used both for accelerated partial breast irradiation (APBI) and intraoperative boosting in patients affected by breast cancer. Immediately after tumor resection the tumor bed can be treated with low-distance X-rays by a single high dose. Whereas often a geographic miss in covering the boost target occurs with external beam boost radiotherapy (EBRT), the purpose of IORT is to cover the tumor bed safely. This report will focus on the feasibility and technical aspects of the Intrabeam™ device and will summarize our experience with side effects and local control.

Materials and methods

Between February 2002 and June 2003 57 breast cancer patients, all eligible for breast conserving surgery (BCS), were treated at the Mannheim Medical Center with IORT using the mobile X-ray system Intrabeam™. The patient population in this feasibility study was not homogeneous consisting of 49 patients with primary stage I or II breast cancer, seven with local recurrence after previous EBRT and one with a second primary in a previously irradiated breast. The selection criteria for referral for IORT included tumor size, tumor cavity size, margin status and absence of an extensive intraductal component. The previously irradiated patients with local recurrences and 16 others received IORT as single modality. In all other cases IORT was followed by EBRT with a total dose of 46 Gy in 2-Gy fractions. The intraoperatively delivered dose after tumor resection was 20 Gy prescribed to the applicator surface. EBRT was delivered with a standard two-tangential-field technique using linear accelerators with 6- or 18-MV photons. Patients were assessed every three months by their radiation oncologist or surgeon during the first year after treatment and every six months thereafter. Breast ultrasound for follow-up was done every six months and mammographies once yearly. Acute side effects were scored according to the CTC/EORTC score and late side effects according to the Lent-Soma classification.

Results

Twenty-four patients received IORT only; eight patients because they had received previous radiotherapy, 16 because of a very favorable risk profile or their own preference. Thirty-three patients with tumor sizes between 1 and 30 mm and no risk factors were treated by IORT as a boost followed by EBRT. The Intrabeam™ system was used for IORT. The Intrabeam source produces 30–50 KV X-rays and the prescribed dose is delivered in an isotropic dose distribution around spherical applicators. Treatment time ranged between 20 and 48 minutes. No severe acute side effects or complications were observed during the first postoperative days or after 12 months. One local recurrence occurred 10 months after surgery plus IORT followed by EBRT. In two patients distant metastases were diagnosed shortly after BCS.

Discussion

IORT with the Intrabeam system is a feasible method to deliver a single high radiation dose to breast cancer patients. As a preliminary boost it has the advantage of reducing the EBRT course by 1.5 weeks, and as APBI it might be a promising tool for patients with a low risk of recurrence. The treatment is well tolerated and does not cause greater damage than the expected late reaction in normal tissue.

Parathyroid Autofluorescence-How Does It Affect Parathyroid and Thyroid Surgery? A 5 Year Experience

Injury to parathyroid glands during thyroid and parathyroid surgery is common and postoperative hypoparathyroidism represents a serious complication. Parathyroid glands possess a unique autofluorescence in the near-infrared spectrum which could be used for their identification and protection at an early stage of the operation. In the present study parathyroid autofluorescence was visualized intraoperatively using a standard Storz laparoscopic near-infrared/indocyanine green (NIR/ICG) imaging system with minor modifications to the xenon light source (filtered to emit 690 nm to 790 nm light, less than 1% in the red and green above 470 nm and no blue light). During exposure to NIR light parathyroid tissue was expected to show autofluorescence at 820 nm, captured in the blue channel of the camera. Over a period of 5 years, we investigated 205 parathyroid glands from 117 patients. 179 (87.3%) glands were correctly identified by their autofluorescence. Surrounding structures such as thyroid, lymph nodes, muscle, or adipose tissue did not reveal substantial autofluorescence. We conclude that parathyroid glands can be identified by their unique autofluorescence at an early stage of the operation. This may help to preserve these fragile structures and their vascularization and lower the rate of postoperative hypocalcemia.

A direct immunohistochemistry (IHC) method improves the intraoperative diagnosis of breast papillary lesions including breast cancer

AIMS

The goal of this study is to evaluate a novel direct immunohistochemistry staining method on frozen tissues for the intraoperative diagnosis of breast papillary lesions.

METHODS AND RESULTS

Keratin 5 (CK5) and smooth muscle myosin heavy chain (SMMHC) antibodies were labeled with horseradish peroxidase polymers and used for direct immunohistochemistry (IHC) staining on frozen sections of breast tissues during surgical operations. The results from direct IHC on 102 cases of breast papillary lesions were compared with those obtained by the conventional staining method on formalin-fixed paraffin-embedded tissues (FFPE). Compared to the conventional method, direct IHC staining can significantly improve the accuracy of intraoperative diagnosis of breast papillary lesions from 70% to 97% (p < 0.01). No false negative cases were found with direct IHC in this study. In comparison, 53% of cases with the conventional method were found false negative. Direct IHC also significantly reduced the deferred diagnosis rate from 21% to 3% (p < 0.01). Furthermore, the entire procedure of direct IHC can be finished within 10 minutes, which makes it more feasible for the use of intraoperative frozen section diagnosis.

CONCLUSION

The direct IHC staining method can significantly improve the efficiency and accuracy of intraoperative diagnosis of breast papillary lesions. It also fits better for the quick turnaround time required for intraoperative diagnosis.

Portal Venous Pressure Variation during Hepatectomy: A Prospective Study

INTRODUCTION

Excessive portal venous pressure in the liver remnant is an independent factor in the occurrence of posthepatectomy liver failure and small-for-size syndrome. The baseline portal pressure prior to hepatectomy was not considered previously. The aim of this study is to assess the impact of portal pressure change during hepatectomy on the patient outcome.

MATERIAL AND METHODS

Prospective observational study including 30 patients subjected to intraoperative measurement of portal pressure before and after hepatectomy. This variation was related to the patient outcome. Control group evaluation was assessed. Patient, disease and procedure features were considered. The optimal cut-off of portal pressure variation was determined. Linear regression or logistic regression was applied to identify predictors of the outcome.

RESULTS

The univariate analysis showed that portal pressure increase after hepatectomy was associated with coagulation impairment in the first 30 postoperative days (p < 0.05), and with the occurrence of major complications (p = 0.01), namely hepatic failure (p = 0.041). The multivariate analysis showed that portal venous pressure increase ≥ 2 mmHg is an independent factor for worse outcomes.

DISCUSSION

As in previous studies, this study concludes that, after hepatectomy, in addition to the functional liver remnant, other factors are responsible for deterioration of liver function and patient outcome, such as the portal pressure increase and the exposure to chemotherapy prior to hepatectomy. This work may influence the definition of future indications for portal influx modulation.

CONCLUSION

Patient outcomes are influenced by the portal venous pressure increase: an increment ≥ 2 mmHg after hepatectomy seems to increase the risk of major complications.

Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial

IMPORTANCE

An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain.

OBJECTIVE

To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018.

INTERVENTIONS

Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute).

RESULTS

Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02148692.

Evaluation and Management of Cirrhotic Patients Undergoing Elective Surgery

PURPOSE OF REVIEW

Cirrhotic patients have an increased risk of surgical complications and higher perioperative morbidity and mortality based on the severity of their liver disease. Liver disease predisposes patients to perioperative coagulopathies, volume overload, and encephalopathy. The goal of this paper is to discuss the surgical risk of cirrhotic patients undergoing elective surgeries and to discuss perioperative optimization strategies.

RECENT FINDINGS

Literature thus far varies by surgery type and the magnitude of surgical risk. CTP and MELD classification scores allow for the assessment of surgical risk in cirrhotic patients. Once the decision has been made to undergo elective surgery, cirrhotic patients can be optimized pre-procedure with the help of a checklist and by the involvement of a multidisciplinary team. Elective surgeries should be performed at hospital centers staffed by healthcare providers experienced in caring for cirrhotic patients. Further research is needed to develop ways to prepare this complicated patient population before elective surgery.

A Single Positive Tissue Culture Increases the Risk of Rerevision of Clinically Aseptic THA: A National Register Study

BACKGROUND

The diagnostic and prognostic value of unexpected positive intraoperative cultures remains unclear in diagnosing prosthetic joint infection (PJI) in THA revisions.

QUESTIONS/PURPOSES

Therefore, we asked: (1) What is the clinical importance of bacterial growth in intraoperative tissue cultures taken during first-time revision of a clinically aseptic THA in terms of all-cause rerevision and rerevision for PJI specifically? (2) Is there a difference in outpatient antibiotic treatment patterns that is dependent on the number of positive intraoperative cultures?

METHODS

This register-based study included all procedures reported to the Danish Hip Arthroplasty Register (DHR) as first-time aseptic loosening revisions performed during January 2010 to May 2016. DHR data were merged with that of the Danish Microbiology Database, which contains data from all intraoperatively obtained cultures in Denmark. Both registers have been validated and have a very high degree of completeness and very few patients are missing as a result of emigration. Revisions were grouped based on the number of unexpected positive cultures growing the same bacterial genus: zero, one, or two or more cultures. We defined a positive culture as "unexpected" if it was observed after a revision THA that had been reported to the DHR as aseptic. In Denmark, cultures are routinely obtained even in revisions coded as aseptic, and in this report, 91% (2090 of 2305) of the revision THAs coded as aseptic had cultures taken. The revisions were followed until rerevision, death, or end of the 1-year followup period. The relative risk for rerevision resulting from all causes and PJI was estimated. The Danish National Prescription Registry was reviewed for outpatient antibiotic prescription within 6 weeks of revision. We included 2305 first-time aseptic revisions. Unexpected growth was found in 282 THAs (12%), of which 170 (60%) had growth in only one culture or mixed microbial growth. Coagulase-negative Staphylococcus was the dominating bacteria in 121 revisions (71%). Rerevision was performed on 163 THAs (7%) with PJI being the indication for rerevision in 43 THAs (26%).

RESULTS

The risk of all-cause rerevision was greater among first-time revisions with one positive culture (relative risk [RR], 1.73; 95% confidence interval [CI], 1.07-2.80; p = 0.020), but not in the two or more positive group (RR, 1.52; 95% CI, 0.82-2.80; p = 0.180) when compared with the culture-negative THAs. First-time revisions with one positive culture also had a higher risk of rerevision for PJI specifically (RR, 2.63; 95% CI, 1.16-5.96; p = 0.020), but this was not the case in the two or more positive group (RR, 2.28; 95% CI, 0.81-6.43; p = 0.120). Outpatient antibiotic prescription was more frequent after revisions with two or more positive cultures compared with culture-negative revision (50 of 112 [45%] versus 353 of 2023 [17%]; p < 0.001). This was not the case in revisions with one positive culture (36 of 170 [21%] versus 353 of 2023 [17%]; p = 0.220).

CONCLUSIONS

First-time clinically aseptic THA revisions with unexpected growth in one biopsy culture had an increased risk for rerevision, both in terms of all-cause revision and revision for PJI. The predominant bacteria in revisions with later rerevision was coagulase-negative Staphylococcus. This emphasizes that unexpected bacterial growth with common bacteria may be clinically important, even if only one of five biopsy cultures is positive.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Presurgical and Intraoperative Augmented Reality in Neuro-Oncologic Surgery: Clinical Experiences and Limitations

Virtual reality (VR) and augmented reality (AR) represent novel adjuncts for neurosurgical planning in neuro-oncology. In addition to established use in surgical and medical training, VR/AR are gaining traction for clinical use preoperatively and intraoperatively. To understand the utility of VR/AR in the clinical setting, we conducted a literature search in Ovid MEDLINE and EMBASE with various search terms designed to capture the use of VR/AR in neurosurgical procedures for resection of cranial tumors. The search retrieved 302 articles, of which 35 were subjected to full-text review; 19 full-text articles were included in the review. Key findings highlighted by the individual authors were extracted and summarized into themes to present the value of VR/AR in the clinical setting. These studies included various VR/AR systems applied to surgeries involving heterogeneous pathologies and outcome measures. Overall, VR/AR were found to be qualitatively advantageous due to enhanced visualization of complex anatomy and improved intraoperative lesion localization. When these technologies were compared with existing neuronavigation systems, quantitative clinical benefits were also reported. The capacity to visualize three-dimensional images superimposed on patient anatomy is a potentially valuable tool in complex neurosurgical environments. Surgical limitations may be addressed through future advances in image registration and tracking as well as intraoperatively acquired imaging with the ability to yield real-time virtual models.

Surgeon-led Intraoperative Ultrasound Localization for Nonpalpable Breast Cancers: Results of 5 Years of Practice

BACKGROUND

The uptake of breast screening has led to a rise in the number of nonpalpable breast cancer diagnoses. Breast conserving therapy (BCT) is the treatment of choice for early breast cancer, and this requires localization of the lesion. Commonly detection is achieved by wire-guided localization in the radiology department. This technique has complications and requires utilization of a radiologist. Intraoperative ultrasound (IOUS) has been shown to be a safe alternative, but there is little data on its use. The aim of this study is to report the use of surgeon-led IOUS over the past 5 years, assessing the ability to detect lesions and the re-excision rate for involved margins.

PATIENTS AND METHODS

A retrospective observational study was performed on consecutive patients undergoing IOUS-marked BCT between 2014 and 2018. The technique is described, and patients' records were reviewed to assess the histologic specimen reports and need for subsequent re-excision.

RESULTS

Ninety-five IOUS BCT operations were performed. Every cancer was identified by IOUS and removed. Fourteen margins were positive and required re-excision. Of these, only 2 contained residual tumor.

CONCLUSION

This is the first data from the United Kingdom for IOUS skin marking without wire localization. IOUS is a safe method of localization in BCT. It offers advantages both to the patient and the unit as it reduces pressure on the radiology department.

The Impact of Aversive Advice During Percutaneous Coronary Intervention on Smoking Cessation in Patients With Acute Coronary Syndrome

BACKGROUND

Smoking cessation is important to prevent recurrence of acute coronary syndrome (ACS), but even in patients with ACS, smoking is hard to quit.

OBJECTIVES

This study hypothesized that aversive advice during the percutaneous coronary intervention (PCI) procedure works effectively to promote smoking cessation in patients with ACS.

METHODS

This study was conducted as a prospective, single-blinded, randomized controlled trial. A total of 66 patients were randomly assigned to an aversive advice group or a control group and instructed to visit the outpatient clinic 1, 4, and 24 weeks after discharge. In the aversive advice group, a physician who did not participate in the patient follow-up said the following 3 sentences to the patients during the PCI procedure: "Smoking caused your chest pain"; "If you do not stop smoking right now, this pain will come again"; and "The next time you feel this pain you will probably die." All patients received usual advice on the importance of quitting smoking.

RESULTS

At 24 weeks after discharge, the smoking cessation rate was higher in the aversive advice group than in the control group. In a multivariable logistic regression analysis, after adjustment for age, smoking quantity, alcohol consumption, and disease severity, the result was maintained (odds ratio = 4.47, 95% confidence interval: 1.50 to 13.34).

CONCLUSIONS

Aversive advice during a PCI procedure is effective at smoking cessation in patients with ACS. A physician's attention and involvement during the PCI procedure improves the rate of smoking cessation in patients with ACS.

Is Needlescopic Cholecystectomy a Safe Way to Improve Mininvasiveness and Cosmesis in Young Female Patients?

INTRODUCTION

Needlescopic cholecystectomy (NC) was introduced in the late 1990s. It uses a reduced trocar caliber in an otherwise standard four-port laparoscopic cholecystectomy (LC) and seeks to achieve "scarless" surgery without compromising patient safety.

MATERIALS AND METHODS

Between May 2016 and November 2017, 29 patients underwent elective NC at the Department of General Surgery of Sant'Andrea Hospital (La Spezia, Italy). Inclusion criteria were female sex, age between 18 and 45 years, good performance status (ASA 1-2) and BMI lower than 25. Twenty-one patients underwent a standard 4-port technique: 12mm port in the supraumbilical area, 5mm port in the subxiphoid position, 3mm port in the mid-epigastric area and another 3 mm port in the right mid-clavicular position. In 8 patients, 3mm ports were replaced by 2mm angiocath. A Critical View of Safety (CVS) was achieved in all procedures. Intra-operative cholangiography (IOC) via the cystic duct before any transection of the structures was routinely performed in selected cases, such as those with an unclear biliary anatomy or risk factors for main-duct stones. In our institution, laparoscopic transcystic common bile duct (CBD) exploration is routinely performed in CBD lithiasis.

RESULTS

The mean operative time was 66.79 min (range 25-120 min). IOC was performed in 12 patients (41.4%) with suspected choledocolythiasis. There was no conversion to conventional laparoscopic cholecystectomy or open cholecystectomy. The mean hospital stay was 1.48 days (1-7 days). A Clavien-Dindo IIIB complication occurred in one patient on the third postoperative day. The mean VAS pain score was 3 (0-7). Closure of the skin with primary intention was achieved in all patients. Mean return to work was 6.76 days (3-15 days) and the mean return to previous physical activity was 12.17 days (4-30 days). All of the patients completed the Scar Satisfaction Questionnaire: 26 (89.7% ) and 3 patients (10.3%) were very satisfied and satisfied, respectively.

CONCLUSION

Any effort to reduce invasiveness and improve cosmesis must not jeopardize safety. Our case series demonstrates that needlescopy can be safely associated with intraoperative cholangiography to recognize CBD stones. This technique offers the advantage of minor postoperative pain, better cosmesis results, early return to routine life activities and great satisfaction for the patient. Needlescopy is a valuable and safe alternative that is suitable for elective cholecystectomy in properly selected patients, such as young female patients.

Near-Infrared Indocyanine Green-Enhanced Fluorescence and Evaluation of the Bowel Microperfusion During Robotic Colorectal Surgery: a Retrospective Original Paper

BACKGROUND

Leakage of the anastomosis after colorectal surgery is a severe complication, and one of the most important causes is poor vascular supply. However, a microvascular deficit is often not detectable during surgery under white light. Near-infrared indocyanine green (ICG)-enhanced fluorescence may be useful for assessing microvascular deficits and conceivably preventing anastomotic leakage.

OBJECTIVES

This paper presents a preliminary retrospective case series on robotic colorectal surgery. The aim is to evaluate the feasibility, safety and role of near-infrared ICG-enhanced ?uorescence for the intraoperative assessment of peri-anastomotic tissue vascular perfusion.

MATERIALS AND METHODS

From among more than 164 robotic colorectal cases performed, we retrospectively analyzed 28 that were all performed by the same surgeon (PCG) using near-infrared ICG-enhanced fluorescence technology: 16 left colectomies (57.1%), 8 rectal resections (28.6%), 3 right colectomies (10.8%) and 1 pancolectomy (3.6%).

RESULTS

The rates of conversion, intraoperative complications, dye allergic reaction and mortality were all 0%. In two cases (7.1%)-1 left and 1 right colectomy-the level of the anastomosis was changed intraoperatively after ICG showed ischemic tissues. Despite the application of ICG, one anastomotic leak (after left colectomy for a chronic recurrent sigmoid diverticulitis with pericolic abscess) was observed.

CONCLUSIONS

ICG technology may help to determine when to intraoperatively change the anastomotic level to a safer location. In our case series, ICG results led to a change in the level of the anastomosis in 7.1% of the cases. Despite the use of ICG, we observed one leak. This may have been related to vascularization-independent causes (e.g., infection in this case) or may reflect a need for better standardization of this ICG technology. In particular, we need a way to objectively assess the ICG signal and the related risk of leakage. More randomized, prospective, well-powered trials are needed to unveil the full potential of this innovative surgical technology.

Intraoperative ultrasound-guided reduction of femoral shaft fractures using intramedullary nailing: a technical note

OBJECTIVES

Intramedullary (IM) nailing is the preferred method for treatment of femoral shaft fractures. However, for the surgical staff and the patients, exposure to large dose of X-rays is inevitable during the procedure. In this paper, a new technique based on ultrasound is proposed to guide the reduction of femoral fractures, reducing radiation exposure.

METHODS AND RESULTS

By means of particular continuous transverse and multiplanar longitudinal scanning, the deformity pattern information of the fracture could be efficiently acquired. Adequate reduction could be achieved under the real-time guidance of intraoperative ultrasound.

CONCLUSIONS

Intraoperative ultrasound can guide the reduction of femoral shaft fracture using IM nailing, and reduce the radiation exposure of medical staff and patients.

The Evolving Concept of Damage Control in Neurotrauma: Application of Military Protocols in Civilian Settings with Limited Resources

OBJECTIVE

The aim of the present review was to describe the evolution of the damage control concept in neurotrauma, including the surgical technique and medical postoperative care, from the lessons learned from civilian and military neurosurgeons who have applied the concept regularly in practice at military hospitals and civilian institutions in areas with limited resources.

METHODS

The present narrative review was based on the experience of a group of neurosurgeons who participated in the development of the concept from their practice working in military theaters and low-resources settings with an important burden of blunt and penetrating cranial neurotrauma.

RESULTS

Damage control surgery in neurotrauma has been described as a sequential therapeutic strategy that supports physiological restoration before anatomical repair in patients with critical injuries. The application of the concept has evolved since the early definitions in 1998. Current strategies have been supported by military neurosurgery experience, and the concept has been applied in civilian settings with limited resources.

CONCLUSION

Damage control in neurotrauma is a therapeutic option for severe traumatic brain injury management in austere environments. To apply the concept while using an appropriate approach, lessons must be learned from experienced neurosurgeons who use this technique regularly.

[INTRAOPERATIVE RADIOTHERAPY (IORT) IN EARLY BREAST CANCER - 500 PATIENTS, ONE CENTER'S EXPERIENCE]

AIMS

To present our Institute's experience with intraoperative radiotherapy in this selected population by collecting and analyzing clinical data, including long-term follow-up.

BACKGROUND

Breast-conserving therapy is the standard treatment for early-stage breast cancer. The treatment includes tumor resection and a whole breast irradiation. Intraoperative radiotherapy is a single dose of irradiation given to the tumor bed immediately after it is removed. This treatment is suitable for a selected population of patients with early stage breast cancer, which constitutes about 20% of all breast cancer patients and is supposed to replace the standard whole breast radiation treatment.

METHODS

Between the years 2006-2017, 737 women with early breast cancer were treated in Carmel Medical Center with intraoperative radiotherapy. We herein report the results of the first 500 patients who were treated until 2015.

RESULTS

In 13.8% of the patients, additional breast treatment was recommended due to poor pathological characteristics of the disease in final pathological examination. During a median follow-up period of 74 months (1-136), recurrence was observed in 22 patients (4.4%), and in 7 patients (1.4%) recurrence was observed in regional lymph nodes; 13 patients (2.6%) developed metastatic disease. Risk factors for regional recurrence were identified: tumor size greater than 2 cm, lack of adjuvant therapy and poor genetic profile of the disease.

CONCLUSIONS

Intraoperative radiotherapy is feasible and may offer an alternative to the standard whole breast radiotherapy, in low risk early breast cancer patients. The patients should be selected according to known risk factors.

Intravenous 3-Dimensional Digital Subtraction Angiography During Surgical Treatment of Intracranial Aneurysm

BACKGROUND

Although intraarterial 3-dimensional digital subtraction angiography (ia-3DDSA) using an angiographic C-arm system is still the gold standard for postoperative confirmation of surgical clipping of intracranial aneurysms, ia-3DDSA requires catheterization and intraarterial injection of contrast medium, which adds risks to the surgical procedure and takes time. We propose a less invasive acquisition of 3D digital subtraction angiography with intravenous injection (iv-3DDSA) in the hybrid operating room to confirm the results of surgical clipping immediately after surgery.

CASE DESCRIPTION

A 56-year-old woman was diagnosed with an incidental wide-necked aneurysm located at the distal anterior cerebral artery. We performed surgical clipping. During the surgery, indocyanine green video angiography and Doppler ultrasonography were used for confirmation, and after the surgery iv-3DDSA and ia-3DDSA were performed with the angiography C-arm system in the hybrid operating room while the patient was still under anesthesia. We could confirm that there was no neck remnant left and that the parent vessels were patent on both iv-3DDSA and ia-3DDSA images. The image quality of iv-3DDSA was sufficient for all treatment evaluations and offered the additional benefits of visualizing the whole angioarchitecture including the contralateral side, being less invasive, and requiring only a few minutes until the availability of images.

CONCLUSIONS

Iv-3DDSA can be useful for postsurgical confirmation of clipping of aneurysms in the hybrid operating room.

Effects of tramadol on emergence agitation after general anesthesia for nasal surgery: A retrospective cohort study

Emergence agitation (EA) is common after nasal surgery. Strong opioids and N-methyl-D-aspartate (NMDA) receptor antagonists prevent EA. Tramadol also acts as an opioid receptor agonist and an NMDA receptor antagonist, but few studies have evaluated the effects of tramadol on EA. This retrospective study investigated whether tramadol is effective for reducing EA in adult patients undergoing nasal surgery.Of 210 adult patients undergoing a nasal surgical procedure under general anesthesia, the medical records of 113 were analyzed retrospectively. The patients were divided into 2 groups: patients who received tramadol during the operation (tramadol group, n = 52) and patients who did not (control group, n = 61). The incidence of EA, recovery time, changes in hemodynamic parameters, postoperative pain scores, and adverse events were compared between the 2 groups.The incidence of EA was higher in the control group than in the tramadol group (50.8% [31/61] vs 26.9% [14/52]; odds ratio 2.805; 95% confidence interval, 1.3 to 6.2; P = .010). Changes in systolic blood pressure in the 2 groups were similar, whereas changes in heart rate during emergence differed depending on the group (P = .020), although pairwise comparisons did not reveal any differences between the groups. Recovery time, postoperative pain scores, and adverse events were similar in the 2 groups.In adult patients undergoing nasal surgery, tramadol infusion decreases the incidence of EA after sevoflurane anesthesia without delaying recovery or increasing the number of adverse events.

Preoperative prealbumin and transferring: Relation to 30-day risk of complication in elective spine surgical patients

OF BACKGROUND DATA

There is growing interest in identifying nutritional biomarkers associated with poor outcomes of elective spine surgery. Prealbumin and transferrin are both biomarkers of nutritional status that can be obtained from clinical laboratories. However, associations of preoperative measures of these nutritional biomarkers across their range with risk of complications from spine surgery have not been fully investigated.

OBJECTIVE

Determine associations of preoperative prealbumin and transferrin levels with 30-day risk of complication among elective spine surgery patients.

STUDY DESIGN

Cohort study with preoperative prealbumin and transferrin collected as standard of care.

OUTCOME MEASURES

30-day risk of medical complication.

METHODS

Data were obtained from medical records of 274 consecutive adult patients ages ≥50 years who underwent elective spine surgery from June 2013 to June 2014. Prealbumin (mg/dL), serum transferrin (mg/dL), and preoperative factors were abstracted from medical records. Prealbumin and transferrin levels were categorized into quartiles and as below versus median or higher. The primary outcome measure was 30-day risk of medical complication, such as renal failure or infections. Associations of the biomarkers with outcome risk were assessed with chi-square tests and with risk ratios (RR) and 95% confidence intervals (CI) estimated with multivariable log-binomial regression.

RESULTS

The 274 adults studied had a median prealbumin level of 27.4 mg/dL and a median transferrin level of 265.0 mg/dL. The 30-day risk of complication was 12.8% (95% CI: 8.8%-16.7%). Risk of complication did not vary by quartile for either prealbumin (P = .26) or transferrin (P = .49) and was not associated either with prealbumin (below median, RR = 1.1, 95% CI: 0.8, 1.5) or transferrin (below median, RR = 1.1, 95% CI: 0.8, 1.6).

CONCLUSIONS

Among adults undergoing elective spine surgery, the 30-day risk of complication was not associated with prealbumin or transferrin. Nutrition status, as measured by prealbumin and transferrin, does not appear to be associated with complication risk.

LEVEL OF EVIDENCE

Level III.

Intraoperative rapid aspiration cytological method for parathyroid glands identification and protection

To explore new methods for intraoperative identification of parathyroid glands, 86 thyroid cancer patients, admitted to Xijing hospital from July 2017 to July 2018, were included. During lymph node dissection, parathyroid glands were firstly judged by clinician eyeballing, based on his clinical experience. Then, cytological detection was used for rapid identification via Diff-quik staining. PTH monitoring was performed by PTH detection kit. Finally, frozen pathology was examined and regarded as the golden standard. In this study, 172 suspicious parathyroid glands were observed. According to frozen pathology outcome, the accuracy, sensitivity and specificity of clinician eyeballing were calculated as 63.3%, 100%, and 13.9%. Kappa test showed poor consistency (kappa = 0.156), AUC area was 0.569 ± 0.045, 95%CI = (0.480-0.658), p = 0.123. For cytological and PTH detection, the accuracy, sensitivity and specificity were 91.7% vs. 92.3%, 93.6% vs. 93.8% and 89.0% vs. 90.3%. Kappa value was 0.829 vs. 0.842, indicating good consistency. AUC area was 0.908 ± 0.027 vs. 0.918 ± 0.025, 95%CI = (0.856-0.960) vs. (0.869-0.966), p < 0.001, indicating higher diagnositic value. Besides, compared with frozen pathology, cytological detection was easily and rapid. The time-taking between frozen pathology and cytological detection or PTH detection were 39.0 ± 6.59 min vs. 5.02 ± 0.78 min and 39.0 ± 6.59 min vs. 6.1 ± 1.23 min, p < 0.001. In conclusion, intra-operative cytological detection maybe potential for in-situ preservation of parathyroid glands.

Intraoperative CT Scan Verification of Pedicle Screw Placement in AIS to Prevent Malpositioned Screws: Safety Benefit and Cost

STUDY DESIGN

Prospective database review.

OBJECTIVES

Determine if use of intraoperative 3D imaging of pedicle screw position provides clinical and cost benefit.

SUMMARY OF BACKGROUND

Injury or reoperation from malpositioned pedicle screws in adolescent idiopathic scoliosis (AIS) surgery occurs but is increasingly considered to be a never-event. To avoid complications, intraoperative 3D imaging of screw position may be obtained.

METHODS

A prospective, consecutive AIS database at a high-volume pediatric spine center was examined three years before and after implementation of an intraoperative low-dose computed tomographic (CT) scan protocol. All screws were placed via freehand technique and corrected if found to be outside optimal trajectory on the postplacement CT scan. Demographic and outcome data were compared between cohorts, along with number, location, and reason for screw change. Cost analysis was based on the average cost of revision surgery for screw malposition versus intraoperative CT use.

RESULTS

There were 153 patients in the pre-CT and 153 in the post-CT cohorts with a minimum 2-year follow-up. Two reoperations were needed for revision of improper screw placement in the pre-CT group and none in the post-CT group. Number of patients needed to harm was 76 (absolute risk increase = 1.31% [-0.49%, 3.11%]). Of those who had intraoperative CT scans, 80 (52.3%) needed on average 1.75 screw trajectories/lengths changed. Forty-three percent were medial breaches; of these, 39% were in the concavity. There were no differences between patients who did and did not need screw repositioning with regard to body mass index (BMI), age, curve size, surgeon/trainee side, screw density, or preoperative and one-year postoperative Scoliosis Research Society-22 patient questionnaire (SRS-22) scores. The average cost of reoperation for malposition was $4,900, whereas the cost of a single intraoperative CT was $232.

CONCLUSION

Intraoperative CT is an effective tool to prevent reoperation in AIS surgery for incorrect screw placement. Despite high volume, experience, and specialty training, incorrect trajectories occur and systems should be in place for preventable error.

LEVEL OF EVIDENCE

Level II.

Longer Operative Time and Intraoperative Blood Transfusion Are Associated with Postoperative Anastomotic Leak after Lower Gastrointestinal Surgery

Anastomotic leak after lower gastrointestinal surgery is a complication with potential for high morbidity, mortality, and increased costs. A single-institution retrospective chart review was performed on all patients who underwent lower gastrointestinal surgery between June 2009 and June 2013. Fifty-seven variables were included in our analysis and their association with postoperative anastomotic leak was examined. Nine hundred fifty-two patients underwent 983 lower gastrointestinal anastomoses with an overall leak rate in this series of 6 per cent. Type of intestinal anastomosis created (P < 0.00005), operative indication (P < 0.015), operation performed (P < 0.014), intraoperative blood transfusion (P < 0.017), and intraoperative surgical drain placement (P < 0.022) were all predictive of anastomotic leak. Anastomotic leak rate increased by 1.3 times for every additional hour in the operating room after three hours. Both increasing operation time and intraoperative blood transfusions were associated with an increased rate of anastomotic leak. When operative time extends beyond three hours or in those cases were blood transfusions are given, surgeons should consider taking steps to minimize the risks of a potential anastomotic leak.

Intraoperative Vagus Nerve Stimulation Accelerates Postoperative Recovery in Rats

INTRODUCTION

Postoperative ileus (POI) is a heavy burden for healthcare industries and reduces the postoperative quality of life. The aim of this study was to investigate the effects and mechanisms of the intraoperative vagus nerve stimulation (iVNS) on gastrointestinal motility in a rodent model of POI.

METHODS

For control group (control, n = 8), electrodes were placed on the chest wall for recording the electrocardiogram and on the stomach and small intestine for measuring gastric slow waves (GSWs) and small intestinal slow waves (SSWs). For sham group (sham, n = 8) and iVNS group (VNS, n = 8), after the same surgery as the control, intestinal manipulation (IM) was performed to induce POI. iVNS was performed during the surgery for the iVNS group. Small intestinal transit (SIT), gastric emptying (GE), postoperative pain, and plasma TNF-α were evaluated after operation.

RESULTS

IM delayed GE that was normalized by iVNS (P < 0.05). iVNS reduced plasma TNF-α increased by IM (P = 0.04). iVNS prevents the injury of ileum mucosa induced by IM (P < 0.05). iVNS reduced the postoperative pain (P < 0.05). iVNS prevented the IM-induced decrease in vagal activity (sham 0-30 min vs. 150-180 min, P = 0.03, VNS 0-30 min vs. 150-180 min, P = 0.58) and increase in sympathovagal balance (sham 0-30 min vs. 150-180 min, P = 0.04, VNS 0-30 min vs. 150-180 min, P = 0.72).

CONCLUSIONS

iVNS accelerates postoperative recovery by improving GE, reducing postoperative pain, and preventing the injury of ileum mucosa mediated via the autonomic mechanisms.

Comparison of a Radiant Patient Warming Device with Forced Air Warming during Laparoscopic Cholecystectomy

The importance of maintaining a patient's core body temperature during anaesthesia to reduce the incidence of postoperative complications has been well documented. The standard practice of this institution is the use of a forced air device for intraoperative warming. The purpose of this study was to compare this standard with an alternative warming device using a radiant heat source which only heated the face.

This prospective, randomized controlled trial compared the efficacy of two methods of intraoperative warming: the BairHugger™ (Augustine Medical, U.S.A.) forced air device and the SunTouch™ (Fisher & Paykel Healthcare, N.Z.) radiant warmer during laparoscopic cholecystectomy in 42 female patients. Oesophageal core temperatures were recorded automatically on to computer during operations using standardised anaesthesia, intravenous infusions and draping.

The study failed to show any statistical or clinical difference between the two patient groups in terms of mean core temperature both intraoperatively (P=0.42) and in the recovery period (P=0.54). Mean start to end core temperature differences were marginly lower in the radiant group (0.08°C) but not statistically or clinically significantly different.

Given some of the drawbacks with forced air systems, such as the expense of the single use blanket, this new radiant warming device offers an alternative method of active warming with advantages in terms of cost and possible application to a wide variety of surgical procedures.

NT-Pro BNP Secretion and Clinical Endpoints in Cardiac Surgery Intensive Care Patients

The primary objective of this study was to determine the pattern of N-Terminal pro brain natriuretic peptide (NT-pro BNP) secretion pre and post cardiac surgery and then to investigate the correlation between levels of serum NT-pro BNP and postoperative clinical and biochemical endpoints. This was a prospective observational study performed at a tertiary centre in New Zealand, examining 118 adult patients undergoing cardiac surgery. Interventions included blood samples for NT-Pro BNP and troponin-T taken 48 hours prior to operation and 12, 36 and 72 hours postoperatively. The plasma NT-pro BNP levels increased fourfold postoperatively, to plateau at 36 to 72 hours. Preoperative NT-pro BNP levels correlated with ventilation time (r=0.46), length of stay in intensive care unit (r=0.59), total perioperative noradrenaline dose (r=0.55), but not with postoperative atrial fibrillation or mortality. Using multivariate analysis, serum NT-pro BNP levels at 36 hours were associated with increased noradrenaline dose (P=0.001), decreased preoperative ejection fraction (EF) Group (P=0.013) and elevated preoperative NT-pro BNP (P <0.001). Factors not associated with NT-pro BNP levels at 36 hours include the operation type, bypass and cross-clamp times, use of milrinone and troponin-T. We conclude that NT-pro BNP levels increased markedly after cardiac surgery and that high preoperative NT-pro BNP levels are associated with a slow postoperative recovery, but do not predict the occurrence of postoperative atrial fibrillation or mortality. Myocardial ischaemia is an unlikely cause of the NT-pro BNP elevation, because no correlation existed between troponin-T and NT-pro BNP levels.

Intraoperative Patient Warming using Radiant Warming or Forced-air Warming during Long Operations

Forced-air warming is the most commonly used and effective method of active warming. A new radiant warming device (Suntouch™, Fisher and Paykel) may provide an alternative when the skin surface available for warming is limited. We conducted a randomized controlled trial to compare the efficacy of the Suntouch™ radiant warmer and forced-air warming. With ethics committee approval, 60 surgical patients having procedures anticipated to be more than two hours in duration were recruited. Patients were randomized to either radiant warming or forced-air warming. All intravenous fluids were warmed but prewarming was not used. The final intraoperative core temperatures (°C) for the radiant warming and forced-air warming groups were 36.0±0.5 and 36.4±0.6 (P=0.002) respectively. No other patient variables were significantly different. The Suntouch™ is not as effective as the forced air warming for intraoperative warming during long surgical procedures. The device may be useful when forced-air warming is not possible.