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.

Possible adverse effects of drugs used in refractive surgery

Adverse drug reaction reports were compiled from the National Registry of Drug-Induced Ocular Side Effects, Casey Eye Institute, Portland, Oregon, USA; the United States Food and Drug Administration, Rockville, Maryland; the World Health Organization, Uppsala, Sweden; and a Medline literature review of the past 50 years. The reported side effects of mydriatics, cycloplegics, benzodiazepines, tetracyclines, iodine, topical anesthetics, medications used for hemostasis, nonsteroidal antiinflammatory drugs, steroids, antibiotics, and artificial tears are described. Physicians should be aware of the side-effect profile and current industry standards for medications used in corneal refractive surgery, including off-label uses. Guidelines are provided for some classes of medications.

Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS)

Four hundred and nineteen incidents that occurred in the recovery room were extracted from the Anaesthetic Incident Monitoring Study database, representing 5% of the total database of 8372 reports. Incidents were reported mainly in daylight hours, with over 50% occurring in ASA 1-2 patients. The most common presenting problems related to respiratory/airway issues (183; 43%), cardiovascular problems (99; 24%) and drug errors (44; 11%). One hundred and twenty-two events (29%) led to a major physiological disturbance and required management in the High Dependency Unit or Intensive Care Unit. Contributing factors cited included error of judgement (77; 18%), communication failure (57; 14%) and inadequate pre-operative preparation (29; 7%), whilst factors minimising the incident included previous experience (97; 23%), detection by monitoring (72; 17%) and skilled assistance (54; 13%). Staffing and infrastructure of the recovery room needs to be supported, with ongoing education and quality assurance programmes developed to ensure that such events can be reduced in the future.

The impact of the duration of mechanical ventilation on the respiratory outcome in smokers undergoing cardiac surgery

STUDY OBJECTIVE

To determine the impact of the duration of mechanical ventilation on the rate of pulmonary complications in smokers undergoing cardiac surgery.

METHODS

Retrospective analysis of 2163 patients who underwent elective cardiac surgery between September 1993 and August 1999. Based on a 3-month preoperative smoking cessation, patients were classified as smokers, ex-smokers and non-smokers. Their postoperative pulmonary complications were compared and related to the duration of mechanical ventilation.

RESULTS

Postoperative pulmonary complications were twice as common in smokers (29.5%) as non-smokers (13.6%) and ex-smokers (14.7%). Although smokers required a longer duration of mechanical ventilation, this was not statistically significant. Smokers had a higher rate of increase in postoperative pulmonary complications beyond 6 h of mechanical ventilation (P<0.002).

CONCLUSION

Prolonged mechanical ventilation in active smokers undergoing cardiac surgery is associated with a significant increase in the respiratory morbidity. Surgical strategies that allow early extubation may improve the respiratory outcome in smokers.

Evaluation of toxicity and quality of life using a diary card during postoperative radiotherapy for rectal cancer

PURPOSE

Adjuvant pelvic radiotherapy after radical surgery for rectal cancer may produce several side-effects (mainly gastrointestinal) capable of affecting patient lifestyle. This prospective study evaluated by means of a diary card the toxicity and daily changes in the quality of life of patients with rectal cancer treated with postoperative pelvic radiotherapy.

METHODS

We used a diary card listing ten items about lifestyle changes and side-effects compiled by patients themselves. The patients were stratified by age (< or = 65 vs. > 65 years), the presence or not of a stoma, and the administration or not of concurrent chemotherapy.

RESULTS

Twenty-seven patients were evaluable. The mean number of bowel movements increased across time, without statistically significant differences. Nausea and appetite did not significantly change during the treatment period. There was a statistically significant, progressive increase in the perception of pain (P < 0.03). Although not significantly, the anxiety scores were lower during radiotherapy than at baseline. Daily activities and compliance with therapy did not significantly change during the treatment. There was a significant worsening in overall well-being (P < 0.04) and quality of life evaluation (P < 0.03). The patients who received chemoradiotherapy experienced a worsened lifestyle and greater side-effects. Older patients experienced less pain but had statistically significant higher levels of anxiety. Patients with a stoma reported a better quality of life score than those without.

CONCLUSIONS

The use of a diary card may be an adequate means of detecting the extent of treatment-related changes in the lifestyle of patients with rectal cancer treated by postoperative radiotherapy.

Dollars and sense: the economics and outcomes of patients undergoing carotid endarterectomy at Royal Adelaide Hospital

This study examined the costs and outcomes of patients undergoing carotid endarterectomy who returned directly to the vascular unit after surgery rather than to the intensive care unit (ICU)/high dependency unit (HDU). The ICU/HDU is for critically ill patients. HDU is the step-down area from the ICU. The nurse-to-patient ratio for these patients is 1:2 and senior medical staff are available 24 hours a day. To prepare staff for the change in practice, an intense educational program was provided and protocols for patient management were developed and implemented. Outcomes were then monitored for the group of patients who returned directly to the vascular unit. Case notes audits, informal patient interviews, daily monitoring of patient outcomes, and an analysis of costing data from Australian Diagnostic Related Groups demonstrated that 50% of patients required transfer to the ICU/HDU after surgery for respiratory, hemodynamic, or neurologic management. The remaining 50% of patients returned directly to the vascular unit with no major complications and had better outcomes with less intensive nursing care overall. The length of hospital stay and the management costs were reduced significantly.

A review of "chest tubes" during donor care and after transplantation

Thoracostomy tubes, also called chest tubes, are commonly present after transplantation or during donor care. The function of the thoracostomy tube is to provide a conduit for transporting fluid, gas, or blood from the pleural cavity to an attached drainage unit. Malfunction of the tube or parts of the unit assembly may lead to serious consequences and jeopardize transplant recipient recovery or donor organs. This review discusses the components of the thoracostomy tube and drainage unit assembly, normal operation, routine evaluation, and common problems that the organ procurement or transplantation coordinator may need to anticipate or treat.

Postoperative epidural analgesia following elective major abdominal surgery in high risk patients: a retrospective cohort study

AIM

To describe the effect of post-operative epidural analgesia on morbidity and mortality rates in a group of high-risk patients undergoing elective major abdominal surgery.

METHODS

Retrospective chart review of patients in American Society of Anaesthetists Physical Status (ASA) category III or IV, who underwent elective major I or II general surgical procedures between 01/01/1996 and 01/09/1998. Patients were identified from a prospective audit database. Patients who had epidural analgesia or conventional parenteral opioids were compared for outcome measures.

RESULTS

There were 167 patients identified (72 epidural, 95 non-epidural group). There was no significant difference in demographic data, inpatient stay, intensive care unit stay, or mortality rates (11% epidural v 17% non-epidural, p>0.05). There was no significant difference in morbidity rates, however there was a non-significant trend towards a lower morbidity in the epidural group.

CONCLUSIONS

This study does not show any benefit from post-operative epidural analgesia on morbidity and mortality rates in high risk patients undergoing major abdominal surgery. It does illustrate that ASA 3 and 4 patients undergoing major abdominal surgery have a high morbidity and mortality.

Postoperative pelvic radiotherapy with or without elective irradiation of para-aortic nodes and liver in rectal cancer patients. A controlled clinical trial of the EORTC Radiotherapy Group

OBJECTIVE

The purpose of this randomized multicenter study was to assess the impact on disease free and overall survival of low dose irradiation to para-aortic nodes and liver in patients with a locally advanced resected rectal cancer receiving a 50 Gy postoperative pelvic radiotherapy.

PATIENTS AND METHODS

Main inclusion criteria were: a curative resection for a histologically proved carcinoma of the rectum, Gunderson-Sosin stages B2-B3, C1-C3, age <70 years. The patients were randomized between pelvic irradiation (Lim-XRT): 50 Gy in 25 fractions over 5 weeks and extended irradiation (Ext-XRT): same scheme/doses in the pelvis and extended fields on para-aortic nodes and liver, delivering 25 Gy in 19 fractions over 25 days. From 1983 to 1992, 484 patients were enrolled by 18 EORTC institutions and 29 patients were ineligible. The end-points were local and distant relapses, toxicity and survival.

RESULTS

Compliance to treatment: 87.2% in Lim-XRT arm and 71.8% in Ext-XRT arm. Moderate acute hematological and hepatic toxicities were significantly increased in Ext-XRT arm. Among 325 patients at risk, 44 suffered a severe intestinal complication requiring surgery in 29. The 5- and 10-year estimates of disease free survival were respectively 42 and 31% in Lim-XRT arm and 47 and 31% in Ext-XRT arm (ns). The corresponding figures for overall survival were respectively 45 and 40% in Lim-XRT arm and 48 and 37% in Ext-arm (ns). The 10 years estimate of intra-pelvic failures was approximately 30% in both arms. Patients in Ext-arm appeared to have a slight shorter interval free of liver metastases (P=0.047).

CONCLUSION

Low dose irradiation to the para-aortic nodes and liver did not improve survival for patients with resected adenocarcinoma of the rectum.

Total parenteral nutrition: potion or poison?

The role of nutritional support in clinical care has burgeoned over the past 40 y. Initially, total parenteral nutri-tion (TPN) was considered to be the standard of care. Later, the concept that enteral nutrition (EN) promoted gut function and prevented the translocation of intestinal bacteria resulted in EN becoming the standard of care. Furthermore, TPN was consid-ered to be a dangerous form of therapy. Critical review of the data suggests that, in humans, TPN does not cause mucosal atrophy or increase bacterial translocation. Increased sepsis with TPN can be ascribed to overfeeding; the dangers of TPN-induced complications have been exaggerated. TPN is an equally effective alternative to EN when a risk of malnutrition is present and EN is not tolerated or when gut failure is present.

Postoperative anticoagulation in vascular surgery: part 1. A retrospective comparison of clinical outcomes for unfractionated heparin versus low-molecular-weight heparin

The use of postoperative anticoagulation is not uncommon for patients undergoing vascular procedures, whether for adjunctive therapy to the surgical procedure or for resumption of preoperative anticoagulation. Longer postoperative length of stay is necessary to achieve an adequate therapeutic international normalized ratio with traditional protocols that call for the use of unfractionated heparin. We retrospectively examined 195 cases to determine whether low-molecular-weight heparin, specifically enoxaparin, was an effective postoperative replacement for intravenous unfractionated heparin, with the impact on postoperative length of stay. There was no difference in the frequency of complications except for increased incidence of return to surgery for graft thrombosis (n = 11) in patients who received traditional intravenous unfractionated heparin with adjusted-dose warfarin daily (n = 139, P <.02). For all 195 vascular procedures combined, the average postoperative length of stay with use of enoxoparin was shortened with use of enoxaparin (P <.0008). There was a 2-day reduction in the average postoperative length of stay for the femoral-distal procedure group (n = 18, P <.004). In the first part of the article, we summarize our findings and offer new applications and ideas for vascular nurses to consider when postoperative anticoagulation is indicated after vascular procedures. Factors contributing to safe and efficacious postoperative anticoagulation with use of low-molecular-weight heparin, specifically enoxaparin, are presented to the vascular nurse. In the second part, we discuss the roles of members of the vascular team, as well as our experience with use of enoxaparin as implemented in the clinical setting.

Repair of the flexor pollicis longus tendon in children

This is a retrospective study of primary repairs of flexor pollicis longus in 16 children under 15 years of age. Patients with injuries to the median or ulnar nerve at the wrist, crush injuries, skin loss or fracture were excluded. Repairs were carried out within 24 hours using a modified Kessler technique. The mean follow-up was for two years. The final results were evaluated using the criteria of Buck-Gramko and Tubiana. They were good or excellent in all except one patient who had a secondary tendon rupture. When compared with the non-injured thumb, however, there was a significant decrease in active interphalangeal flexion (> 30 degrees) in one-third of cases. A new method of assessment is proposed for the recovery of function of the flexor pollicis tendon which is more suitable for children. Postoperative immobilisation using a short splint had a negative effect on outcome. The zone of injury, an early mobilisation programme or concurrent injury to the digital nerve had no significant effect on the final result.

Respiratory failure due to the combined effects of transdermal fentanyl and epidural bupivacaine/diamorphine following radical nephrectomy

The transdermal therapeutic system (TTS) fentanyl has been designed for rate-controlled drug delivery. When the system is applied, a fentanyl depot concentrates in the upper skin layers. Plasma concentrations are not measurable until 2 hours after application, and it takes an 8-16 hr latency period until full clinical fentany effects are observed. Following removal, serum fentanyl concentrations decline gradually and fall to about 50% in approximately 16 hours. We report the case of a 77-year-old man with a history of severe arthritis, who was receiving transdermal fentanyl and developed respiratory failure after starting epidural diamorphine/bupivacaine for postoperative pain relief following radical nephrectomy.

Evaluation of 3-hour ambulation post cardiac catheterization

There is much variation in the length of immobilization for patients post cardiac catheterization. While it is generally agreed that a period of time on bedrest is necessary to prevent post procedural complications, the optimal duration remains unknown. The purpose of this study was to evaluate the effects of 3-hour ambulation post cardiac catheterization with a 7 french (F) arterial catheter on bleeding, hematoma formation, and vascular complications. Retrospective chart data were gathered for a period of 8 months for patients who were on the traditional 5-hour ambulation protocol, and prospective data were gathered for a period of 7 months for patients who received the 3-hour protocol. A total of 880 patients were included in the study, with 472 in the 5-hour ambulation group and 408 in the 3-hour ambulation group. The overall incidence of delayed bleeding and hematoma formation for the 15 month study period was 19.1%, with no occurrence of vascular complications in either group. Patients who received the 3-hour ambulation protocol experienced a significantly lower rate of bleeding and hematoma formation (13%) than patients who received the 5-hour ambulation protocol (24.4%) (p < 0.001). Ambulating patients 3 hours post cardiac catheterization with a 7F catheter was found to be safe, and thus has the potential to decrease hospital length of stay, as well as increase patient comfort.

Impact of multiple organ system dysfunction and nosocomial infections on survival of children treated with extracorporeal membrane oxygenation after heart surgery

OBJECTIVES

To evaluate whether cardiac and noncardiac variables may be used to predict survival in children treated with extracorporeal membrane oxygenation (ECMO) after cardiopulmonary bypass and to determine when to discontinue ECMO support.

DESIGN

Retrospective review.

SETTING

Neonatal and pediatric intensive care units of Kosair Children's Hospital.

PATIENTS

Fifty-nine children treated with ECMO after cardiopulmonary bypass from 1987 through 1996.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical, nursing, operative, and perfusion records for each patient were reviewed. The primary outcome measure was survival to hospital discharge. Cardiac and noncardiac variables were recorded at serial times. Nineteen of 59 patients (32%) survived. No cardiac variable was a clinically useful predictor of survival or marker for when to discontinue ECMO. Among the noncardiac variables, progressive multiple organ system dysfunction and development of a nosocomial infection were significantly associated with nonsurvival. No patient with a positive blood culture (n = 3) within the first 24 hrs of ECMO survived, and 21 of 24 children with a positive culture from any site during ECMO died (p = .007). Despite their higher mortality, children with positive cultures were supported with ECMO significantly longer than those with negative cultures (275+/-168 vs. 135+/-108 hrs, respectively; p = .0004). For all patients, the longest duration of ECMO that resulted in survival was 256 hrs. For children with a positive culture, the longest duration of support that resulted in survival was 200 hrs.

CONCLUSIONS

Support with ECMO beyond 256 hrs was not associated with survival. Progressive multiple organ system dysfunction and nosocomial infections have a negative impact on survival. Serious consideration should be given to discontinuing ECMO support whenever there is a progressive increase in the number of abnormally functioning organ systems, a nosocomial infection occurs, or native cardiac function has not improved significantly by 250 hrs of ECMO support.

Confusion and aggression in restrained elderly persons undergoing hip repair surgery

The purpose of this pilot study was to observe and describe the behaviors of confusion and aggression in physically restrained elderly hospitalized persons following hip repair surgery. Five elderly persons who were 75-95 years of age and physically restrained following hip repair surgery comprised the sample of this descriptive study. Descriptive data including age, sex, medical diagnosis, current medications, serum electrolyte and arterial blood gas results, date/time of hip fracture, subsequent surgical repair, and restraint application were obtained from the medical record. Observations of behaviors associated with confusion and aggression were conducted at six separate observation times lasting approximately 20 to 30 minutes each. The observation periods were divided into two mornings, two afternoons, and two evening sessions. These behaviors were assessed by utilizing a combined observational tool developed by the researcher, and was created from the Clinical Assessment of Confusion--A, by Vermeersch, and Ryden Aggression Scale. After data analysis, three patterns of confusion emerged. These were the major pattern of confusion, the minor pattern of confusion, and pattern of confusion relative to time. All patients experienced low serum sodium levels immediately prior to the application of physical restraints. Based on the results of the pilot study, further investigation is needed.

[Drainage of pyelo-ureteral junction surgery: personal technique and review of the literature]

OBJECTIVES

To compare the various Stenting techniques used in ureteropelvic junction (UPJ) surgery and to present a personal series of 54 cases in which the Multipurpose Blue Stent (BARD, ANGIOMED) was used.

PATIENTS AND METHOD

Between 1994 and 1998, 54 patients were treated for UPJ obstruction (52 underwent a Anderson-Hynes pyeloplasty and 2 a ureterocalicostomy). The Multipurpose Blue Stent insertion technique is described. The stent is removed on postoperative day 10 in the ward without cystoscopy.

RESULTS

Clinical, isotopic and ultrasound improvement was obtained in 98% cases. Seven complications were reported: 4 urinary tract infections and 2 stent displacements without noticeable detrimental consequences on the outcome; 1 anastomotic leakage following a ureterocalicostomy requiring a redo operation (which was successful). The average hospital stay was 3 days.

DISCUSSION

This stenting method is compared to those reported in the literature and proves to be more satisfactory in terms of hospital stay and removal.

CONCLUSION

Postoperative leakage in non-stented operated UPJs is an under-reported but significant complication. Trans-anastomotic stenting has proven to be much safer than non-stenting. The Multipurpose Blue Stent reduces hospital stay and does not require a second hospitalisation to be removed.

[Miliary pneumonia after the intravesical BCG therapy of a superficial urothelial carcinoma of the bladder]

HISTORY AND ADMISSION FINDINGS

A multilocular superficial epithelial carcinoma (T1G3) and carcinoma in situ (Cis G3) of the bladder were resected transurethrally followed by intravesical instillation of BCG. The initial cycle of BCG administration had been free of complication, but then high fever, fatigue, cough and dyspnoea had developed with subsequent BCG maintenance treatment. Physical examination on admission revealed fever, clearly reduced general condition, and increased breath sounds with fine rales in the upper and middle lobes.

INVESTIGATIONS

A clearly raised erythrocyte sedimentation rate (86 mm/h) and a CRP level at the upper limit of normal (13.6 mg/dl) indicated marked inflammatory reaction. The chest radiogram showed diffuse miliary opacities. Mycobacteria were not demonstrated in either gastric juice or bronchial secretion.

TREATMENT AND COURSE

As BCG-induced miliary pneumonia was diagnosed, triple tuberculostatic treatment was commenced (ethambutol, 1200 mg/d; rifampicin, 600 mg/d; isoniazid, 300 mg/d). Nonetheless his condition deteriorated further. When prednisolone, 40 mg/d was added the symptoms improved rapidly. The tuberculostatic drugs were continued for 6 months. All symptoms had disappeared after 4 months.

CONCLUSION

Miliary pneumonia is a rare complication of intravesical BCG installation of a superficial bladder cancer. As living bacteria cannot be excluded as the cause, triple tuberculostatic treatment must be started at once. If this fails to bring about improvement, additional steroid medication is recommended.

Relation between long-term steroid treatment after heart transplantation, hypofibrinolysis and myocardial microthrombi generation

BACKGROUND

Thrombotic complications and transplant coronary artery disease are among the main causes of morbidity and mortality after heart transplantation. A thrombophilic state has been described in transplant recipients, and correlated to immunosuppressive therapy with cyclosporine A or azathioprine, whereas the prothrombotic effects of steroids, even though always given, have never been duly considered. A reduced fibrinolytic capacity due to high levels of PAI-1, the most important inhibitor of plasminogen activators, was suggested to play a role in the development of cardiovascular diseases and transplant coronary artery disease. A severe hypofibrinolytic state secondary to PAI-1 increase has been found in patients with Cushing's disease, and in hypercorticism secondary to long-term steroid treatment after renal transplantation.

METHODS

We evaluated plasma clotting and fibrinolytic behaviors in 2 groups of heart transplant patients treated with (26 cases) or without (23 cases) steroids together with cyclosporine A and azathioprine. Twenty-five healthy subjects were studied as normal controls. The following tests were assayed at least 1 year after transplantation: fibrinogen, factor VIII coagulant activity, von Willebrand factor antigen, euglobulin lysis time, tissue plasminogen activator antigen and activity, PAI-1 antigen and activity. In addition, the presence of cardiac microthrombi was evaluated on 2 endomyocardial biopsy specimens obtained in each patient both on day 7 after heart transplantation (first control) and usually 1 year or more later (last control).

RESULTS

Plasma levels of fibrinogen, factor VIII and von Willebrand factor were significantly higher in both groups of patients than in normal controls. Fibrinolytic activity was significantly reduced in transplant patients treated with steroids, compared with steroid-free patients and normal controls. In steroid-treated heart transplant recipients, the hypofibrinolytic state was due to a significant and pathological increase in PAI-1 antigen and activity levels. The fibrinolytic impairment was more evident in patients transplanted for ischemic heart disease and treated with steroids than in patients with previous dilated cardiomyopathy and treated either with or without steroids. Myocardial microthrombi were found in 2/49 cases at the first biopsy control, and in 12/49 cases at the last biopsy control after transplantation. This different prevalence was statistically significant (chi2 = 8.33, p = .003). Plasma PAI-1 activity was significantly higher and, as a consequence, euglobulin lysis time was more prolonged in microthrombi-positive patients than in microthrombi-negative ones. Among the 12 transplant recipients who developed cardiac microthrombi, 7 patients were treated with steroids and showed higher PAI-1 levels and more reduced fibrinolytic activity than the 5 steroid-free patients.

CONCLUSIONS

Our data confirm the prothrombotic state induced by long-term steroid treatment, characterized by an increase in PAI-1 levels and secondary impairment of fibrinolytic capacity. In heart transplant patients, steroid-related hypofibrinolysis might constitute a further risk factor for transplant coronary artery disease.

[Early catheter removal after transurethral resection of the prostate]

BACKGROUND

Thanks to the introduction of new optical systems and advances in technology, transurethral resection is now the most widely used method in the management of prostatic adenoma.

METHODS

A study has been carried out on 25 patients aged from 50 to 80 years submitted to an uncomplicated transurethral resection of the prostate for benign hyperplasia. Patients with intense retention of urine, capsular perforation, bladder neck undermining, considerable haemorrhage in the recovery room and postoperative fever have been excluded from the study. The urethral catheter which is normally removed 3 to 5 days post operatively, was removed within 24 hours of surgery.

RESULTS

80% of patients were discharged within 48 hours and the follow-up carried out by means of bacterial urinary culture, urinary pressure monitor and echography, showed that there were no significant complications.

CONCLUSIONS

In conclusions, this study made it possible to select patients on which an early catheter removal is possible and to evaluate the real advantages of such a method.