Intravenous fluid-associated morbidity in postoperative patients

INTRODUCTION

There is marked variation in postoperative fluid prescribing which may contribute to postoperative morbidity. However, there are few data regarding the overall incidence of fluid associated morbidity in postoperative patients.

PATIENTS AND METHODS

Data regarding fluid and electrolyte prescription, fluid balance and intravenous fluid associated morbidity were prospectively collected from 71 patients representing 173 patient days of intravenous fluid therapy.

RESULTS

There was no correlation between fluid and electrolytes prescription and pre-operative weight, serum electrolyte levels or ongoing fluid losses. 17% of patients developed significant fluid associated morbidity. 7 patients developed a tachyarrhythmia, which was associated with the prescription of inadequate maintenance potassium. 5 patients developed fluid overload, associated with excessive fluid volume and sodium administration.

CONCLUSIONS

Surgical house-staff do not appear to use the available fluid balance information when prescribing. The introduction of fluid prescribing protocols may improve practice. This study provides an accurate measure of fluid-associated morbidity in order to measure the efficacy of such protocols.

The effects of ketorolac injected via patient controlled analgesia postoperatively on spinal fusion

Lumbar spinal fusions have been performed for spinal stability, pain relief and improved function in spinal stenosis, scoliosis, spinal fractures, infectious conditions and other lumbar spinal problems. The success of lumbar spinal fusion depends on multifactors, such as types of bone graft materials, levels and numbers of fusion, spinal instrumentation, electrical stimulation, smoking and some drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs). From January 2000 to December 2001, 88 consecutive patients, who were diagnosed with spinal stenosis or spondylolisthesis, were retrospectively enrolled in this study. One surgeon performed all 88 posterolateral spinal fusions with instrumentation and autoiliac bone graft. The patients were divided into two groups. The first group (n=30) was infused with ketorolac and fentanyl intravenously via patient controlled analgesia (PCA) postoperatively and the second group (n=58) was infused only with fentanyl. The spinal fusion rates and clinical outcomes of the two groups were compared. The incidence of incomplete union or nonunion was much higher in the ketorolac group, and the relative risk was approximately 6 times higher than control group (odds ratio: 5.64). The clinical outcomes, which were checked at least 1 year after surgery, showed strong correlations with the spinal fusion status. The control group (93.1%) showed significantly better clinical results than the ketorolac group (77.6%). Smoking had no effect on the spinal fusion outcome in this study. Even though the use of ketorolac after spinal fusion can reduce the need for morphine, thereby decreasing morphine related complications, ketorolac used via PCA at the immediate postoperative state inhibits spinal fusion resulting in a poorer clinical outcome. Therefore, NSAIDs such as ketorolac, should be avoided after posterolateral spinal fusion.

Withdrawal following sufentanil/propofol and sufentanil/midazolam

PURPOSE

Patients in the ICU after long-term administration of an opioid/hypnotic often develop delirium. To assess the nature of this phenomenon, patients in a surgical ICU following ventilatory support and sedation with an opioid/hypnotic/sedative were studied.

METHODOLOGY

Following sufentanil/midazolam (group 1; n =14) or sufentanil/propofol (group 2; n =15) sedation, patients were evaluated for changes in mean arterial blood pressure and heart rate, the activity of the central nervous system (sensory evoked potentials, spectral edge frequency of EEG), and the endogenous opioids plasma concentrations (beta-endorphin, met-enkephalin). Data obtained were correlated with the individual intensities of withdrawal symptoms 6-, 12-, and 24 h following sedation.

RESULTS

Following a mean duration of ventilation of 7.7 days (+/-3.6 SD) in groups 1 and 3.5 (+/-1.7 SD) in group 2, withdrawal intensities peaked within the 6th hour after cessation. Plasma beta-endorphin and met-enkephalin levels were low during sedation, and only the sufentanil/midazolam group demonstrated a postinhibitory overshoot. Withdrawal symptom intensities demonstrated an inverse correlation with beta-endorphin and met-enkephalin levels, a direct linear correlation with amplitude height of the evoked potential, and blood pressure and heart rate changes. Withdrawal intensities did not correlate with EEG power spectral edge frequency.

CONCLUSION

The endorphinergic system is suppressed when a potent exogenous opioid like sufentanil is given over a long period of time. Following sedation, abstinence symptoms seem to be related to postinhibitory increased endorphin synthesis. This is mostly seen in the combination of sufentanil/midazolam. In addition, an increase in the amplitude of the sensory-evoked potential suggests a postinhibitory excitatory state within the nociceptive system.

Choice of dressing has a major impact on blistering and healing outcomes in orthopaedic patients

OBJECTIVE

To investigate the effect of three postoperative dressings on orthopaedic wound healing.

METHOD

Three hundred orthopaedic patients were divided into three treatment groups and allocated to management with one of three dressings: Primapore, Tegaderm with pad, and OpSite Post-Op. Staff completed a questionnaire to evaluate the wound progression. Outcome measures were the presence of infection, blistering and the number of dressing changes required.

RESULTS

There was a significantly lower incidence of blistering with OpSite Post-Op (6%) than Tegaderm with pad (16%) and Primapore (24%) (p<0.001). Patients in the OpSite Post-Op group had the lowest exudate levels.

CONCLUSION

Dressings that employ a clear film and have a high moisture vapour transmission rate have been shown to reduce both the rate of blistering and wound discharge. The additional expense inherent in using such dressings may, in reality, prove cost-effective because of the reduced need for dressings changes and the subsequent earlier discharge of these patients from hospital with an uncomplicated wound.

Removal of Short-term Indwelling Urethral Catheters

OBJECTIVE

The objective of this systematic review was to determine the effect of the timing of removal of indwelling urethral catheters (IUCs) on the duration to and volume of first void, length of hospitalization, number of patients developing urinary retention and requiring recatheterization, patient satisfaction, and the percentage of IUCs removed according to the scheduled time for removal.

MATERIALS AND METHODS

Published and unpublished literature in English and other languages between January 1966 and June 2002, which compared the effects of the timing of removal of short-term indwelling urethral catheters on patient outcomes, was systematically reviewed using multiple electronic databases. To determine eligibility of the trials for inclusion in the review, assessment of methodologic quality and data extraction was undertaken independently by 2 reviewers and verified by a third reviewer. Odds ratio (OR) for dichotomous data and a weighted mean difference for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, a narrative overview has been undertaken.

RESULTS

Eight randomized controlled trials were eligible for this review. When IUCs were removed at midnight, the time to first void was significantly shorter (P = .012) after gynecologic surgery and significantly longer in patients after urologic surgery and procedures. Seven trials reported that the volume of the first void was greater in patients whose IUCs were removed late at night, and this was statistically significant in 4 trials. Patients who had their IUC removed at midnight were discharged from the hospital significantly (P < .00001) earlier than those who had their IUC removed in the morning, a finding that could result in potential cost savings for hospitals.

CONCLUSION

Based on the limited available evidence, this article suggests benefits in terms of patient outcomes and reduction in the length of hospitalization after midnight removal of the IUCs. Further trials should be undertaken in wider settings and on specific groups of patients to enhance generalizability.

Neurosurgery in the law court

AIM

The evident rise in the number of neurosurgical malpractice and the apparent lack of adequate training in neurosurgery patient management are discussed. However, alongside neurosurgeons, neurosurgical malpractice claims involve also physicians from primary to specialist care, particularly those attending neurosurgical patients in emergency rooms. Some pathologies and disputed treatments are described.

METHODS

The case series includes 138 medical malpractice lawsuits examined over a 10-year period (1992-2002). The pathologies for which disputed treatment led to malpractice lawsuit as well as their frequency are presented.

RESULTS

Of the total 138 lawsuits examined, 38 did not involve professional health care workers, whereas the remaining 100 cases involved: neurosurgeons (48 cases); other specialist or primary physicians (51 cases); nursing staff (1 case). These malpractice lawsuits and the relevant pathologies are examined in detail.

CONCLUSION

On the basis of personal experience, some considerations and recommendations are suggested for the clinical practice.

Children in hospitals often have adverse events

A new study found a total of 51,615 patient safety events involving children in hospitals during 2000. The study quantifies impact of patient safety events in terms of excess hospital stays and charges. Postoperative respiratory failure increased death rate as much as 76%.

Severe hypernatremia after cesarean delivery secondary to transient diabetes insipidus of pregnancy

BACKGROUND

Transient diabetes insipidus is an uncommon complication of pregnancy, usually manifesting with polydipsia and polyuria. This condition is considered to result from excess placental vasopressinase activity and is managed with deamino D arginine vasopressin.

CASE

While on restricted oral intake after cesarean delivery, the patient gradually became disoriented and agitated in conjunction with markedly increased urine output disproportional to her intravenous crystalloid fluid intake. Marked hypernatremia of 178 mEq/dL was noted. Urine osmolality was low at 248 mOsm/L. The clinical presentation and electrolyte abnormalities were considered consistent with transient diabetes insipidus of pregnancy. The patient responded well to nasal-spray-administered deamino D arginine vasopressin and increased intravenous fluid intake, with resolution of symptoms and gradual normalization of serum sodium levels.

CONCLUSION

Transient diabetes insipidus of pregnancy should be considered in the differential diagnosis of severe hypernatremia in obstetric patients with restricted oral intake after operative delivery.

Vacuum-Assisted Wound Closure Achieves Early Fascial Closure of Open Abdomens after Severe Trauma

BACKGROUND

This study reviews the efficacy of vacuum-assisted wound closure (VAWC) to obtain primary fascial closure of open abdomens after severe trauma.

METHODS

The study population included shock resuscitation patients who had open abdomens treated with VAWC. The VAWC dressing was changed at 2- to 3-day intervals and downsized as fascial closure was completed with interrupted suture. The Trauma Research Database and the medical records were reviewed for pertinent data.

RESULTS

Over 26 months, 35 patients with open abdomens were managed by VAWC. Six died early, leaving 29 patients who were discharged. Of these, 25 (86%) were successfully closed using VAWC at a mean of 7 +/- 1 days (range, 3-18 days). Of the four patients that failed VAWC, two developed fistulas. No patients developed evisceration, intra-abdominal abscess, or wound infection.

CONCLUSION

VAWC achieved early fascial closure in a high percentage of open abdomens, with an acceptable rate of complications.

Early enteral feeding after closure of colostomy in pediatric patients

BACKGROUND/PURPOSE

The aim of this study was to determine the benefits and adverse effects of protocolized early postoperative enteral feeding in pediatric patients undergoing a closure of colostomy.

METHODS

Pediatric patients, completely treated for anorectal malformation, who underwent a closure of colostomy during September 2000 and May 2002 received early postoperative feeding according to the authors' protocol (EF group). Retrospective data of consecutive patients operated on from March 1998 to August 2000 who received traditional feeding practice were used as a control (TF group). The protocol began with a small volume of formula or breast feeding within the first postoperative day. Volume allowance was advanced every 4 hours up to the daily maintenance volume. Full feeding was defined as when the patient was able to tolerate at least 80% of daily maintenance volume. TF group received nothing by mouth until documentation of bowel function. The groups were compared with regard to postoperative stay, postoperative hour of full feeding, first bowel movement, and adverse effects. Statistical analyses were performed with chi2 test, Student's t test, and Mann-Whitney U test.

RESULTS

There were 34 and 30 patients in EF and TF groups, respectively. Median age of the patients was 13 months, and median weight was 8.39 kg. Except for the associated anomalies, which were found more in the EF group, there were no differences in the demographic characteristics of the 2 groups. On average, feeding was initiated at 19.7 (16 to 24) hours in the EF group and 51.7 (18 to 92) hours in the TF group (P <.01). Median full feeding hours were 45.5 and 70.5 hours in the EF and TF group, respectively (P <.01). First bowel movement in the EF group was recorded at the average of 4.14 postoperative nurse shifts, compared with 5.96 shifts in the TF group (P <.01). Postoperative stay was significantly reduced from the average of 6.1 days to 4.5 days (P <.01). The overall hospital expenses were not significantly different between the 2 groups. (203.95 dollars US in TF group and 198.50 dollars US in EF group; P =.75) There was 1 vomiting case in the EF group that was temporary and resolved spontaneously. Septic complications were noted in 8 patients in the EF group and 6 patients in the TF group (P =.27). The majority were uncomplicated urinary tract infections.

CONCLUSIONS

Early feeding after a closure of colostomy in pediatric patients stimulated early bowel movement and reduced hospital stay with no increased adverse effects.

Emetic effects of morphine and piritramide

BACKGROUND

Successful management of postoperative pain requires that adequate analgesia is achieved without excessive adverse effects. Opioid-induced nausea and vomiting is known to impair patients' satisfaction, but there are no studies providing sufficient power to test the hypothesis that the incidence of opioid-induced nausea and vomiting differs between micro -opioid receptor agonists. Thus, we tested the hypothesis that the incidence of vomiting and nausea differs between morphine and piritramide.

METHODS

In a prospective, randomized, double-blind fashion, we administered either morphine (n=250) or piritramide (n=250) by patient-controlled analgesia (PCA) for postoperative pain relief. We used a bolus dose of 1.5 mg with a lockout time of 10 min. Incidence and intensity (numerical rating scale) of postoperative nausea, vomiting, pain, patient satisfaction (score 0-10), side-effects (score 0-3) and drug consumption were measured.

RESULTS

Mean drug consumption did not differ between the piritramide and morphine groups (30.8 (SD 22.4) mg day(-1) vs 28.4 (21.8) mg day(-1)) during the first postoperative day and there were no significant differences in the overall incidence of nausea (30% vs 27%) and vomiting (19% vs 15%). Intensity of nausea correlated inversely (P=0.01) with morphine consumption but not with piritramide consumption. Pain scores both at rest (2.2 (1.9) vs 2.6 (2)) and during movement (4.4 (2.2) vs 4.9 (2.3)) were slightly but significantly less with morphine.

CONCLUSIONS

Opioid-induced emesis was observed in about one-third of the patients using morphine and piritramide for PCA and the incidence of vomiting was one-half of that. Potential differences in the incidence of vomiting during PCA therapy between these micro-opioid receptor agonists can be excluded.

Tamsulosin reduces the incidence of acute urinary retention following early removal of the urinary catheter after radical retropubic prostatectomy

OBJECTIVES

To determine the efficacy of tamsulosin in preventing acute urinary retention following early catheter removal after radical retropubic prostatectomy.

METHODS

Between February 2000 and October 2000, cystography was performed on postoperative day 7 after radical retropubic prostatectomy by a single surgeon (group 1). Between September 2001 and August 2002, cystography was performed on postoperative day 8 after radical retropubic prostatectomy by the same surgeon (group 2). The protocol for performing cystography and assessment of extravasation was similar for both groups. Tamsulosin 0.4 mg was administered 3 days before and 4 days after cystography for all men in group 2.

RESULTS

Of 179 cystograms in group 1, 135 (75%) revealed no extravasation, and the catheters were removed in 130 of these cases. Of 246 cystograms in group 2, 230 (93.5%) revealed no extravasation, and the catheters were removed in 229 of these cases. A significantly greater proportion of men in group 2 had no extravasation (P = 0.0007). The incidence of acute urinary retention in groups 1 and 2 was 10% and 2.6%, respectively (P = 0.0018). The incidence of anastomotic stricture was not significantly different between the two groups.

CONCLUSIONS

Our data strongly suggest that tamsulosin significantly reduces the risk of acute urinary retention after attempts at early catheter removal following radical retropubic prostatectomy. Therefore, we recommend administering a 7-day course of tamsulosin therapy when attempting to remove the urinary catheter before postoperative day 8.

Are in-dwelling catheters necessary for 24 hours after hysterectomy?

OBJECTIVE

In-dwelling catheters for 24 hours after operation are used routinely in gynecologic surgery. This study assesses whether the immediate removal of an in-dwelling catheter after the operation affects the rate of recatheterization, febrile morbidity, symptomatic urinary tract infections, or subjective pain assessments.

STUDY DESIGN

This study was a prospective randomized controlled trial comprised of 250 women who underwent hysterectomy and who did not require bladder suspension or strict fluid treatment. The in-dwelling catheter was removed either immediately after the operation or on the first day after the operation. The association between clinical variables and the length of catheterization were assessed by chi-squared analysis.

RESULTS

Patients were assigned randomly into 2 groups, with no significant differences in the outcomes, only in the perception of pain. Clinical events included fever (>/=38.5 degrees C) that occurred in 6 patients in the in-dwelling catheter group compared with 5 patients in the early removal group (P=.01), symptomatic urinary tract infections in 3 patients in both groups (P=.99), and recatheterization in 3 patients in the in-dwelling catheter group compared with 5 patients in the early removal group (P=.17). Subjectively, patients in the early removal group reported significantly less pain than did the in-dwelling group (P<.001).

CONCLUSION

The early removal of in-dwelling catheters after operation was not associated with an increased rate of febrile events, urinary tract infections, or need for recatheterization. In addition, subjective pain assessment was significantly less in the early removal group. Early removal of an in-dwelling catheter immediately after operation is not associated with adverse events.

[Small bowel necrosis associated with postoperative percutaneous jejunal tube feeding]

Small bowel necrosis is a rare but highly lethal complication associated with postoperative jejunal tube feeding. The causative mechanism remains unclear but is most likely the result of several factors. The ischemic necrosis was preceded by progressive abdominal pain, distension, hypotension and hypovolemia. Timely recognition and surgical intervention may save the patient's life. Percutaneous enteral tube feeding may be used with utmost caution.

Mediastinal chest sump tubes following cardiac surgery: an unconventional method

The practice of using conventional mediastinal chest tubes (MCTs) connected to a closed collection device is commonplace in cardiovascular surgery care settings. The MCT collection device requires a closed system to maintain a negative intrathoracic pressure with the goal of preventing inadvertent trapping of air and blood within the mediastinal space. Despite the proposed integrity of the closed system, there is no guarantee that the suction's negative pressure will prevent cardiac tamponade. In addition, it has been postulated that the required negative intrathoracic suction may potentiate mediastinal tissue damage. This clinical paper will describe the use of multi-lumen MCTs open to atmosphere following surgical repair for congenital heart defects. It is postulated that open MCTs may potentially reduce the risks of cardiac tamponade and mediastinal tissue damage. Through case presentation, the mechanics of open MCTs, nursing care, and possible complications will be delineated.

Complications related to postoperative casting after surgical treatment of subluxed/dislocated hips in patients with cerebral palsy

Three hundred sixteen subluxed/dislocated hips (222 patients) underwent upper femoral osteotomy. Of these, 286 (90.5%) hips were casted (average patient age: 8.9 years) and 30 (9.5%) were not (average patient age: 13.6 years). Average follow-up was 4.7 years. Complications in the casted/noncasted groups (per hip) were: 43/0 (15%/0%) skin sores; 11/1 (3.8%/3.3%) wound infections; 6/0 (2.1%/0%) instrumentation failures; 22/1 (7.7%/3.3%) reoperations; and 13/1 (4.5%/3.3%) rehospitalizations. Differences between the groups were not statistically significant. Casted patients were younger and more neurologically involved. Casting is useful to ensure healing of osteotomies, prevent instrumentation failure and injury to the operated legs, and allow for ease of handling. Complications that occurred were managed and had no long-term sequelae.

The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study

We prospectively randomised 100 patients undergoing cemented total knee replacement to receive either a single deep closed-suction drain or no drain. The total blood loss was significantly greater in those with a drain (568 ml versus 119 ml, p < 0.01; 95% CI 360 to 520) although those without lost more blood into the dressings (55 ml versus 119 ml, p < 0.01; 95% CI -70 to 10). There was no statistical difference in the postoperative swelling or pain score, or in the incidence of pyrexia, ecchymosis, time at which flexion was regained or the need for manipulation, or in the incidence of infection at a minimum of five years after surgery in the two groups. We have been unable to provide evidence to support the use of a closed-suction drain in cemented knee arthroplasty. It merely interferes with mobilisation and complicates nursing. Reinfusion drains may, however, prove to be beneficial.

Long-term amiodarone therapy and the risk of complications after cardiac surgery: results from the Canadian Amiodarone Myocardial Infarction Arrhythmia Trial (CAMIAT)

OBJECTIVE

This study was undertaken to determine the association between amiodarone therapy and risk of complications of cardiac surgery in patients in the randomized placebo-controlled, double-blind Canadian Amiodarone Myocardial Infarction Arrhythmia Trial.

METHODS

Prospectively collected data regarding postoperative complications in 82 patients who underwent cardiac surgery during Canadian Amiodarone Myocardial Infarction Arrhythmia Trial participation were analyzed; 36 patients were randomly assigned to receive amiodarone and 46 were assigned to receive placebo. Of the patients randomly assigned to receive amiodarone, 24 patients continued amiodarone treatment to within 7 days of the operation (active amiodarone group) and 12 patients had the amiodarone discontinued at least 7 days before the operation (discontinued amiodarone group).

RESULTS

The baseline characteristics of the three groups were similar. The risks of ventricular fibrillation, atrial fibrillation, and respiratory complications were similar. The risk of requiring an intra-aortic balloon pump was significantly increased by amiodarone (34.8% vs 16.7% vs 8.7% for active amiodarone, discontinued amiodarone, and placebo groups, respectively, P =.024). There was no significant difference in the use of temporary pacing. Neither the mean duration of stay in the intensive care unit nor the 7- and 30-days mortalities were affected by amiodarone.

CONCLUSIONS

Patients receiving long-term amiodarone treatment after myocardial infarction had a higher rate of intra-aortic balloon use after cardiac surgery. There was no increased risk of pulmonary complications, need for pacing, or death.

Effects of 3 days of "postoperative" low caloric feeding with or without bed rest on insulin sensitivity in healthy subjects

BACKGROUND AND AIMS

Insulin resistance after surgery is caused by the surgical trauma and presumably also by other factors, such as starvation and immobilization. The purpose of this study was to evaluate the effect of traditional postsurgical low caloric feeding and bed rest on insulin sensitivity and substrate utilization, in younger and older healthy subjects.

METHODS

Twelve healthy subjects underwent hyperinsulinaemic, normoglucaemic clamps and indirect calorimetry before and after 3 days of bed rest and low caloric feeding. Six of the subjects underwent a second study with 3 days of low caloric feeding without bed rest.

RESULTS

Insulin sensitivity decreased by 57+/-16 % after low caloric feeding combined with bed rest, with no difference between age groups, and by 56+/-9% after low caloric feeding only. Glucose oxidation decreased, while fat oxidation increased. No significant differences were seen between age groups or between the protocols.

CONCLUSIONS

Low caloric feeding, a commonly used nutritional routine in clinical practice, induce marked alterations in insulin sensitivity and substrate utilization. Increasing age or bed rest did not seem to influence this development. These findings suggest that the routine low caloric feeding is capable of contributing to postoperative insulin resistance.