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Vaglio S, Prisco D, Biancofiore G, Rafanelli D, Antonioli P, Lisanti M, Andreani L, Basso L, Velati C, Grazzini G, Liumbruno GM. Recommendations for the implementation of a Patient Blood Management programme. Application to elective major orthopaedic surgery in adults. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:23-65. [PMID: 26710356 PMCID: PMC4731340 DOI: 10.2450/2015.0172-15] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Stefania Vaglio
- Italian National Blood Centre, National Institute of Health, Rome, Italy
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Gianni Biancofiore
- Liver Transplant Anaesthesia and Critical Care, University Hospital Pisana, Pisa, Italy
| | - Daniela Rafanelli
- Immunohaematology and Transfusion Unit, Pistoia 3 Local Health Authority, Pistoia, Italy
| | - Paola Antonioli
- Department of Infection Prevention Control and Risk Management, Ferrara University Hospital, Ferrara, Italy
| | - Michele Lisanti
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Lorenzo Andreani
- 1 Orthopaedics and Trauma Section, University Hospital Pisana, Pisa, Italy
| | - Leonardo Basso
- Orthopaedics and Trauma Ward, Cottolengo Hospital, Turin, Italy
| | - Claudio Velati
- Transfusion Medicine and Immunohaematology Department of Bologna Metropolitan Area, Bologna, Italy, on behalf of Italian Society of Transfusion Medicine and Immunohaematology (SIMTI); Italian Society of Italian Society of Orthopaedics and Traumatology (SIOT); Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Therapy (S.I.A.A.R.T.I.); Italian Society for the Study of Haemostasis and Thrombosis (SISET), and the National Association of Hospital Medical Directors (ANMDO) working group
| | - Giuliano Grazzini
- Italian National Blood Centre, National Institute of Health, Rome, Italy
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Baron R, Binder A, Biniek R, Braune S, Buerkle H, Dall P, Demirakca S, Eckardt R, Eggers V, Eichler I, Fietze I, Freys S, Fründ A, Garten L, Gohrbandt B, Harth I, Hartl W, Heppner HJ, Horter J, Huth R, Janssens U, Jungk C, Kaeuper KM, Kessler P, Kleinschmidt S, Kochanek M, Kumpf M, Meiser A, Mueller A, Orth M, Putensen C, Roth B, Schaefer M, Schaefers R, Schellongowski P, Schindler M, Schmitt R, Scholz J, Schroeder S, Schwarzmann G, Spies C, Stingele R, Tonner P, Trieschmann U, Tryba M, Wappler F, Waydhas C, Weiss B, Weisshaar G. Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc19. [PMID: 26609286 PMCID: PMC4645746 DOI: 10.3205/000223] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Indexed: 02/08/2023]
Abstract
In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.
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Affiliation(s)
| | | | | | | | - Stephan Braune
- German Society of Internal Medicine Intensive Care (DGIIN)
| | - Hartmut Buerkle
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Peter Dall
- German Society of Gynecology & Obstetrics (DGGG)
| | - Sueha Demirakca
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Verena Eggers
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ingolf Eichler
- German Society for Thoracic and Cardiovascular Surgery (DGTHG)
| | | | | | | | - Lars Garten
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | - Irene Harth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | - Johannes Horter
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Ralf Huth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Uwe Janssens
- German Society of Internal Medicine Intensive Care (DGIIN)
| | | | | | - Paul Kessler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Matthias Kumpf
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Andreas Meiser
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Anika Mueller
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | | | - Bernd Roth
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | | | | | | | - Monika Schindler
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
| | - Reinhard Schmitt
- German Society for Specialised Nursing and Allied Health Professions (DGF)
| | - Jens Scholz
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Stefan Schroeder
- German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN)
| | | | - Claudia Spies
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | | | - Peter Tonner
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Uwe Trieschmann
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Michael Tryba
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Frank Wappler
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Christian Waydhas
- German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
| | - Bjoern Weiss
- German Society of Anaesthesiology and Intensive Care Medicine (DGAI)
| | - Guido Weisshaar
- German Society of Neonatology and Pediatric Intensive Care (GNPI)
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Tzortzis V, Dimitropoulos K, Karatzas A, Zachos I, Stamoulis K, Melekos M, Gravas S. Feasibility and safety of radical cystectomy under combined spinal and epidural anesthesia in octogenarian patients with ASA score ≥3: A case series. Can Urol Assoc J 2015; 9:E500-4. [PMID: 26279724 DOI: 10.5489/cuaj.2063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION This study evaluated the feasibility and safety of open radical cystectomy (RC) under combined regional anesthesia (CRA) in high-risk octogenarian patients. METHODS We retrospectively evaluated the medical records of high-risk, octogenarian bladder cancer patients submitted to open RC with CRA. Demographic and clinical data, intraoperative parameters and perioperative and postoperative complications were recorded using the Clavien-Dindo classification. RESULTS In total, 14 male and 4 female patients, with a median age of 82.5 years were enrolled. Ureterocutaneostomy was performed in 15 patients and Bricker ileal conduit in the remaining 3. Operative time ranged from 97 to 184 minutes. Five patients were transfused and no major intraoperative complications occurred. Postoperative complications 30 days later included ileus (Grade II) in 3 patients, surgical trauma infection in 1 patient (Grade II), respiratory infection in 2 patients (Grade III), and hydronephrosis with concurrent urinary tract infection in 3 patients (Grade III). No deaths occurred. CONCLUSIONS Our study showed that octogenarian, high-risk bladder cancer patients with indications for RC can safely undergo the surgical procedure under CRA, without apparent increase in major complications.
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Affiliation(s)
- Vassilios Tzortzis
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Konstantinos Dimitropoulos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Anastasios Karatzas
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Ioannis Zachos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Konstantinos Stamoulis
- Department of Anesthesiology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Michael Melekos
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
| | - Stavros Gravas
- Department of Urology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Thessaly, Greece
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Galvez C, Bolufer S, Navarro-Martinez J, Lirio F, Corcoles JM, Rodriguez-Paniagua JM. Non-intubated video-assisted thoracic surgery management of secondary spontaneous pneumothorax. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:104. [PMID: 26046045 DOI: 10.3978/j.issn.2305-5839.2015.04.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 04/23/2015] [Indexed: 11/14/2022]
Abstract
Secondary spontaneous pneumothorax (SSP) is serious entity, usually due to underlying disease, mainly chronic obstructive pulmonary disease (COPD). Its morbidity and mortality is high due to the pulmonary compromised status of these patients, and the recurrence rate is almost 50%, increasing mortality with each episode. For persistent or recurrent SSP, surgery under general anesthesia (GA) and mechanical ventilation (MV) with lung isolation is the gold standard, but ventilator-induced damages and dependency, and postoperative pulmonary complications are frequent. In the last two decades, several groups have reported successful results with non-intubated video-assisted thoracic surgery (NI-VATS) with thoracic epidural anesthesia (TEA) and/or local anesthesia under spontaneous breathing. Main benefits reported are operative time, operation room time and hospital stay reduction, and postoperative respiratory complications decrease when comparing to GA, thus encouraging for further research in these moderate to high risk patients many times rejected for the standard regimen. There are also reports of special situations with satisfactory results, as in contralateral pneumonectomy and lung transplantation. The aim of this review is to collect, analyze and discuss all the available evidence, and seek for future lines of investigation.
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Affiliation(s)
- Carlos Galvez
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
| | - Sergio Bolufer
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
| | - Jose Navarro-Martinez
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
| | - Francisco Lirio
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
| | - Juan Manuel Corcoles
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
| | - Jose Manuel Rodriguez-Paniagua
- 1 Thoracic Surgery Service, 2 Anethesiologist and Surgical Critical Care Service, University General Hospital of Alicante, C/Pintor Baeza 12, 03010, Alicante, Spain ; 3 Thoracic Surgery Service, Vinalopo Hospital, C/Tonico Sansano Mora 14, 03293 Elche, Alicante, Spain ; 4 Thoracic Surgery, Alicante, Spain
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Basaran B, Basaran A, Kozanhan B, Kasdogan E, Eryilmaz MA, Ozmen S. Analgesia and respiratory function after laparoscopic cholecystectomy in patients receiving ultrasound-guided bilateral oblique subcostal transversus abdominis plane block: a randomized double-blind study. Med Sci Monit 2015; 21:1304-12. [PMID: 25948166 PMCID: PMC4434982 DOI: 10.12659/msm.893593] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Transversus abdominis plane (TAP) block has been shown to ameliorate postoperative pain after abdominal surgery. Postoperative pain-associated respiratory compromise has been the subject of several studies. Herein, we evaluate the effect of oblique subcostal TAP (OSTAP) block on postoperative pain and respiratory functions during the first 24 postoperative hours. Material/Methods In this double-blind, randomized study, 76 patients undergoing laparoscopic cholecystectomy were assigned to either the OSTAP group (n=38) or control group (n=38). Bilateral ultrasound-guided OSTAP blocks were performed with 20 ml 0.25% bupivacaine after induction of general anesthesia. Both the OSTAP and control groups were treated with paracetamol, tenoxicam, and tramadol as required for postoperative analgesia. Visual Analog Scale (VAS) pain scores (while moving and at rest), forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), peak expiratory flow rate (PEFR), arterial blood gas variables, and opioid consumption were assessed during first 24 h. Results VAS pain scores at rest and while moving were significantly lower in the OSTAP group on arrival to PACU and at 2 h postoperatively. The total postoperative tramadol requirement was significantly reduced at 0–2 h and 2–24 h in the OSTAP group. Postoperative deterioration in FEV1 and FVC was significantly less in the OSTAP group when compared to the control group (P<0.01 and P<0.05, respectively). There were no between-group differences in arterial blood gas variables. Conclusions After laparoscopic cholecystectomy, OSTAP block can provide significant improvement in respiratory function and better pain relief with lower opioid requirement.
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Affiliation(s)
- Betul Basaran
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
| | - Ahmet Basaran
- Department of Obstetrics and Gynecology, Konya Training and Research Hospital, Konya, Turkey
| | - Betul Kozanhan
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
| | - Ela Kasdogan
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
| | - Mehmet Ali Eryilmaz
- Department of General Surgery, Konya Training and Research Hospital, Konya, Turkey
| | - Sadik Ozmen
- Department of Anesthesiology, Konya Training and Research Hospital, Konya, Turkey
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Tzeng CY, Chang SL, Wu CC, Chang CL, Chen WG, Tong KM, Huang KC, Hsieh CL. Single-blinded, randomised preliminary study evaluating the effects of 2 Hz electroacupuncture for postoperative pain in patients with total knee arthroplasty. Acupunct Med 2015; 33:284-8. [PMID: 25910930 PMCID: PMC4552907 DOI: 10.1136/acupmed-2014-010722] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To explore the point-specific clinical effect of 2 Hz electroacupuncture (EA) in treating postoperative pain in patients undergoing total knee arthroplasty (TKA), METHODS: In a randomised, partially single-blinded preliminary study, 47patients with TKA were randomly divided into three groups: control group (CG, n=17) using only patient-controlled analgesia (PCA); EA group (EAG, n=16) with 2 Hz EA applied at ST36 (Zusanli) and GB34 (Yanglingquan) contralateral to the operated leg for 30 min on the first two postoperative days, also receiving PCA; and non-point group (NPG, n=14), with EA identical to the EAG except given 1 cm lateral to both ST36 and GB34. The Mann-Whitney test was used to show the difference between two groups and the Kruskal-Wallis test to show the difference between the three groups. RESULTS The time until patients first required PCA in the CG was 34.1±22.0 min, which was significantly shorter than the 92.0±82.7 min in the EAG (p<0.001) and 90.7±94.8 min in the NPG (p<0.001); there was no difference between the EAG and NPG groups (p>0.05). The total dosage of PCA solution given was 4.6±0.9 mL/kg body weight in the CG, 4.2±1.0 mL/kg in the EAG and 4.5±1.0 mL/kg in the NPG; there were no significant differences (p>0.05) among the three groups. CONCLUSIONS In this small preliminary study, EA retarded the first demand for PCA in comparison with no EA. No effect was seen on the total dosage of PCA required and no point-specific effect was seen.
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Affiliation(s)
- Chung-Yuh Tzeng
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan Department of Nursing, Hung Kuang University, Taiwan
| | - Shih-Liang Chang
- Department of Medicinal Botanicals and Health Care, Da-Yeh University, Chunghwa, Taiwan
| | - Chih-Cheng Wu
- Department of Anesthesia, Taichung Veterans General Hospital, Taichung, Taiwan Department of Financial and Computational Mathematics, Providence University, Taichung, Taiwan
| | | | - Wen-Gii Chen
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
| | - Kwok-Man Tong
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Kui-Chou Huang
- Department of Orthopedic Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Ching-Liang Hsieh
- Graduate Institute of Integrated Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan Department of Chinese Medicine, China Medical University Hospital, Taichung, Taiwan Research Center for Chinese Medicine and Acupuncture, China Medical University, Taichung, Taiwan
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Divakar SR, Singh C, Verma CM, Kulkarni CD. Cesarean section under epidural anesthesia in a documented case of ruptured aneurysm of the sinus of valsalva. J Anaesthesiol Clin Pharmacol 2015; 31:119-22. [PMID: 25788785 PMCID: PMC4353136 DOI: 10.4103/0970-9185.150565] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Ruptured aneurysm of sinus of Valsalva (RSOV) occurring in pregnancy is a rare cardiac anomaly and it may be either congenital or acquired. Congenital sinus of Valsalva aneurysms are commonly associated with other structural defects such as ventricular septal defect (50-55%), aortic regurgitation (AR) (25-35%), bicuspid aortic valve (10-15%) and Marfan's syndrome (10%). RSOV in pregnancy accentuates the hemodynamic stress on maternal cardiovascular system and pose a significant challenge from obstetric anesthesia point of view. We report a case of 35-year-old documented patient of RSOV with mild AR presenting completely asymptomatic at 37 weeks 4 days of gestation. A successful elective lower segment cesarean section was conducted under epidural anesthesia.
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Affiliation(s)
- S R Divakar
- Department of Anesthesiology and Critical Care, GSVM Medical College and LLR Hospitals, Kanpur, Uttar Pradesh, India
| | - Chandrashekhar Singh
- Department of Anesthesiology and Critical Care, GSVM Medical College and LLR Hospitals, Kanpur, Uttar Pradesh, India
| | - Chandra Mohan Verma
- Department of Cardiology, LPS Institute of Cardiology, GSVM Medical College and LLR Hospitals, Kanpur, Uttar Pradesh, India
| | - Chaitanya D Kulkarni
- Department of Radiology, GSVM Medical College and LLR Hospitals, Kanpur, Uttar Pradesh, India
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Zhang S, Wu X, Guo H, Ma L. Thoracic epidural anesthesia improves outcomes in patients undergoing cardiac surgery: meta-analysis of randomized controlled trials. Eur J Med Res 2015; 20:25. [PMID: 25888937 PMCID: PMC4375848 DOI: 10.1186/s40001-015-0091-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 01/22/2015] [Indexed: 02/08/2023] Open
Abstract
To assess the efficacy of thoracic epidural anesthesia (TEA) with or without general anesthesia (GA) versus GA in patients who underwent cardiac surgery, PubMed, Embase, the Cochrane online database, and Web of Science were searched with the limit of randomized controlled trials (RCTs) relevant to ‘thoracic epidural anesthesia’ and ‘cardiac surgery’. Studies were identified and data were extracted by two reviewers independently. The quality of included studies was also assessed according to the Cochrane handbook. Outcomes of mortality, cardiac and respiratory functions, and treatment-associated complications were pooled and analyzed. The comprehensive search yielded 2,230 citations, and 25 of them enrolling 3,062 participants were included according to the inclusion criteria. Compared with GA alone, patients received TEA and GA showed reduced risks of death, myocardial infarction, and stroke, though there were no significant differences (P > 0.05). With regard to treatment-related complications, the pooled results for respiratory complications (risk ratio (RR), 0.69; 95% CI: 0.51, 0.91, P < 0.05), supraventricular arrhythmias (RR, 0.61; 95% CI: 0.42, 0.87, P < 0.05), and pain (mean difference (MD), −1.27; 95% CI: −2.20, −0.35, P < 0.05) were 0.69, 0.61, and −1.27, respectively. TEA was also associated with significant reduction of stays in intensive care unit (MD, −2.36; 95% CI: −4.20, −0.52, P < 0.05) and hospital (MD, −1.51; 95% CI: −3.03, 0.02, P > 0.05) and time to tracheal extubation (MD, −2.06; 95% CI:−2.68, −1.45, P < 0.05). TEA could reduce the risk of complications such as supraventricular arrhythmias, stays in hospital or intensive care unit, and time to tracheal extubation in patients who experienced cardiac surgery.
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Affiliation(s)
- Shengsuo Zhang
- Department of anesthesiology, General Hospital of Beijing military region PLA, Beijing, 100010, China.
| | - Xinmin Wu
- Department of anesthesiology, The First Hospital, Peking University, Beijing, 100034, China.
| | - Hang Guo
- Department of anesthesiology, General Hospital of Beijing military region PLA, Beijing, 100010, China.
| | - Li Ma
- Department of anesthesiology, General Hospital of Beijing military region PLA, Beijing, 100010, China.
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Kendigelen P, Tütüncü AÇ, Erbabacan ŞE, Kaya G, Altındaş F. Anaesthetic Management of a Patient with Synchronous Kartagener Syndrome and Biliary Atresia. Turk J Anaesthesiol Reanim 2015; 43:205-8. [PMID: 27366497 DOI: 10.5152/tjar.2015.94546] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2014] [Accepted: 09/24/2014] [Indexed: 11/22/2022] Open
Abstract
Kartagener syndrome is an autosomal recessive disorder characterized by primary ciliary dyskinesia accompanied by sinusitis, bronchiectasis, and situs inversus. Synchronous extrahepatic biliary atresia and Kartagener syndrome are very rare. During the preoperative preparation of patients with Kartagener syndrome, special attention is required for the respiratory and cardiovascular system. It is important to provide suitable anaesthetic management to avoid problems because of ciliary dysfunction in the perioperative period. Further, maintaining an effective pain control with regional anaesthetic methods reduces the risk of pulmonary complications. Infants with biliary atresia operated earlier have a higher chance of survival. Hepatic dysfunction and decrease in plasma proteins are important for the kinetics of drugs. In this presentation, the anaesthetic management of patients with synchronous Kartagener syndrome and biliary atresia, both of which are rare diseases, is evaluated.
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Affiliation(s)
- Pınar Kendigelen
- Department of Anaesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Ayşe Çiğdem Tütüncü
- Department of Anaesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Şafak Emre Erbabacan
- Department of Anaesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Güner Kaya
- Department of Anaesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
| | - Fatiş Altındaş
- Department of Anaesthesiology and Reanimation, İstanbul University Cerrahpaşa Faculty of Medicine, İstanbul, Turkey
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Page AJ, Ejaz A, Spolverato G, Zavadsky T, Grant MC, Galante DJ, Wick EC, Weiss M, Makary MA, Wu CL, Pawlik TM. Enhanced recovery after surgery protocols for open hepatectomy--physiology, immunomodulation, and implementation. J Gastrointest Surg 2015; 19:387-99. [PMID: 25472030 DOI: 10.1007/s11605-014-2712-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 11/19/2014] [Indexed: 01/31/2023]
Abstract
There has been recent interest in enhanced-recovery after surgery (ERAS®) or "fast-track" perioperative protocols in the surgical community. The subspecialty field of colorectal surgery has been the leading adopter of ERAS protocols, with less data available regarding its adoption in hepato-pancreato-biliary surgery. This review focuses on available data pertaining to the application of ERAS to open hepatectomy. We focus on four fundamental variables that impact normal physiology and exacerbate perioperative inflammation: (1) the stress of laparotomy, (2) the use of opioids, (3) blood loss and blood product transfusions, and (4) perioperative fasting. The attenuation of these inflammatory stressors is largely responsible for the improvements in perioperative outcomes due to the implementation of ERAS-based pathways. Collectively, the data suggest that the implementation of ERAS principles should be strongly considered in all patients undergoing hepatectomy.
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Affiliation(s)
- Andrew J Page
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Kim HJ, Park JH, Kim JW, Kang KT, Chang BS, Lee CK, Yeom JS. Prediction of Postoperative Pain Intensity after Lumbar Spinal Surgery Using Pain Sensitivity and Preoperative Back Pain Severity. PAIN MEDICINE 2014; 15:2037-45. [DOI: 10.1111/pme.12578] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kampe S, Weinreich G, Darr C, Eicker K, Stamatis G, Hachenberg T. The impact of epidural analgesia compared to systemic opioid-based analgesia with regard to length of hospital stay and recovery of bowel function: retrospective evaluation of 1555 patients undergoing thoracotomy. J Cardiothorac Surg 2014; 9:175. [PMID: 25417134 PMCID: PMC4246432 DOI: 10.1186/s13019-014-0175-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 10/28/2014] [Indexed: 11/25/2022] Open
Abstract
Background To assess the protocols of epidural analgesia versus systemic opioid-based analgesia retrospectively in 1555 thoracotomies in our thoracic centre during 2011–2013. Methods Pain therapy is aggressive and standardized in our thoracic centre thoughout the complete postoperative stay. Patients receive either standardized epidural analgesia with ropivacaine + sufentanil 4–8 mls/h (500 mls bag) and are bridged when the epidural bag is finished to a standardized controlled-release oxycodone protocol with non opioid every 6 hours (EDA Group), or patients receive immediately postoperative standardized oral analgesic protocol with controlled-released oxycodone and non opioid every 6 h (Opioid Group). All patients are visited daily by a pain specialist throughout the whole stay. Results Data of 1555 thoracotomies from 2011-2013 were analysed, 838 patients in the EDA Group and 717 patients in the Opioid Group. There was no difference with regard to sex or age between groups. 7.5% of patients in the EDA Group and 13% in the Oxy Group had a preexisting pain therapy (p = 0.001). In the EDA Group epidural analgesia was performed for 4.6 ± 1.5 days. Length of hospital stay was the same in both groups (EDA: 9.9.6 ± 4.9 vs Opioid: 9.6 ± 5.8 days). 84.7% of patients in the EDA Group and 79.1% of patients of the Oxy Group were dismissed with oral opioid (p < 0.004). When patients were dismissed with opioid medication patients in the EDA Group were dismissed with higher oxycodone opioid doses than patients in the Opioid Group (29.5 ± 15.2 mg vs 26.9 ± 15.2 mg, p = 0.01). There was no difference with regard to dejection time between the two groups (EDA: 3.8 ± 2.2 days vs Opioid: 3.7 ± 1.6 days, n.s.). Conclusion We first present data monitoring postoperative analgesic protocols after thoracotomies throughout the whole stay in hospital until dismission. Our retrospective data indicate that patients with epidural analgesia stay as long in hospital as patients with systemic opioid based therapy. Patients with initial epidural analgesia are dismissed with higher oxycodone opioid doses than patients with initial opioid based postoperative analgesia. We found no difference in recovery of bowel function. Study limitations The study design is retrospectively and results might be biased.
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Affiliation(s)
- Sandra Kampe
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Gerhard Weinreich
- Department of Pneumology, Ruhrlandklinik, West German Lung Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Christopher Darr
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Kolja Eicker
- Department of Anesthesiology and Pain Medicine, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Tüschener Weg 40, 45239, Essen, Germany.
| | - Georgios Stamatis
- Department of Thoracic Surgery and Thoracic Endoscopy, Ruhrlandklinik, West German Lung Center - University Hospital Essen, University Duisburg-Essen, Essen, Germany.
| | - Thomas Hachenberg
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Magdeburg, Otto von Guericke University Magdeburg, Magdeburg, Germany.
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Analgesic techniques in hip and knee arthroplasty: from the daily practice to evidence-based medicine. Anesthesiol Res Pract 2014; 2014:569319. [PMID: 25484894 PMCID: PMC4251423 DOI: 10.1155/2014/569319] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/14/2014] [Accepted: 10/21/2014] [Indexed: 11/17/2022] Open
Abstract
Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are major orthopedic surgery models, addressing mainly ageing populations with multiple comorbidities and treatments, ASA II–IV, which may complicate the perioperative period. Therefore effective management of postoperative pain should allow rapid mobilization of the patient with shortening of hospitalization and social reintegration. In our review we propose an evaluation of the main analgesics models used today in the postoperative period. Their comparative analysis shows the benefits and side effects of each of these methods and guides us to how to use evidence-based medicine in our daily practice.
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Meisenzahl D, Souquet J, Kessler P. [Perioperative pain management: what is evidence based?]. DER ORTHOPADE 2014; 43:1079-81, 1084-8. [PMID: 25380683 DOI: 10.1007/s00132-014-3039-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adequate post-operative acute pain therapy after spinal surgical procedures is essential for many patients. However, patients already receiving chronic opioid therapy pre-operatively present a special challenge for the treating physician during the post-operative period when managing their acute pain. The team must consider multiple approaches of acute pain management and it is important to proceed according to current evidence-based methods. THERAPY A wide spectrum of options for pain management after spinal surgery is currently available. This includes various therapeutic methods as well as regional anesthesia. Considering the various options, the method of choice for post-operative analgesia depends on the expected pain, therapy effectiveness, and the applicability with regard to potential side-effects. METHOD In addition to the basic analgesic therapy consisting of opioid and non-opioid drugs, chronic pain patients may require co-analgesics or combination analgesics from this class. CONCLUSION Regional anesthesia is currently the predominant method of choice for post-operative acute pain management. Neuraxial blockage is especially important when considering all spinal procedures.
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Affiliation(s)
- D Meisenzahl
- Abteilung für Anästhesiologie, Intensiv- und Schmerzmedizin, Orthopädische Universitätsklinik Friedrichsheim gGmbH (Stiftung Friedrichsheim), Leiter: Professor P. Kessler, Marienburgstr. 2, 60528, Frankfurt, Deutschland,
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Managing post-thoracotomy pain: Epidural or systemic analgesia and extended care – A randomized study with an “as usual” control group. Scand J Pain 2014; 5:240-247. [DOI: 10.1016/j.sjpain.2014.07.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Accepted: 07/07/2014] [Indexed: 11/19/2022]
Abstract
Abstract
Background and aims
Thoracotomies can cause severe pain, which persists in 21–67% of patients. We investigated whether NSAID + intravenous patient-controlled analgesia (IV-PCA) with morphine is an efficacious alternative to thoracic epidural analgesia (TEA). We also wanted to find out whether an extended controlled pain management protocol within a clinical study can decrease the incidence of persistent post-thoracotomy pain.
Methods
Thirty thoracotomy patients were randomized into 3 intervention groups with 10 patients in each. G1: preoperative diclofenac 75mg orally+150 mg/24h IV for 44h, then PO; G2: valdecoxib 40mg orally+parecoxib 80mg/24h IV for 44h, then PO. IV-PCA morphine was available in groups 1 and 2 during pleural drainage, and an intercostal nerve block at the end of surgery was performed; G3: parac-etamol+patient controlled epidural analgesia (PCEA) with a background infusion of bupivacaine with fentanyl. After PCA/PCEA oxycodone PO was provided when needed. These patients were contacted one week, 3 and 6 months after discharge. Patients (N = 111) not involved in the study were treated according to hospital practice and served as a control group. The control patients’ data from the perioperative period were extracted, and a prospective follow-up questionnaire at 6 months after surgery similar to the intervention group was mailed.
Results
The intended sample size was not reached in the intervention group because of the global withdrawal of valdecoxib, and the study was terminated prematurely. At 6 months 3% of the intervention patients and 24%ofthe control patients reported persistent pain (p<0.01). Diclofenac and valdecoxib provided similar analgesia, and in the combined NSAID group (diclofenac+valdecoxib) movement-related pain was milder in the PCEA group compared with the NSAID group. The duration of pain after coughing was shorter in the PCEA group compared with the NSAID+IV-PCA group. The only patient with persistent painat6 months postoperatively had a considerably longer duration ofpain after coughing than the other Study patients. The patients with mechanical hyperalgesia had more pain on movement.
Conclusions
Both PCEA and NSAID+IV-PCA morphine provided sufficient analgesia with little persistent pain compared with the incidence of persistent pain in the control group. High quality acute pain management and follow-up continuing after discharge could be more important than the analgesic method per se in preventing persistent post-thoracotomy pain. In the acute phase the measurement of pain when coughing and the duration of pain after coughing could be easy measures to recognize patients having a higher risk for persistent post-thoracotomy pain.
Implications
To prevent persistent post-thoracotomy pain, the extended protocol for high quality pain management in hospital covering also the sub-acute phase at home, is important. This study also provides some evidence that safe and effective alternatives to thoracic epidural analgesia do exist. The idea to include the standard “as usual” care patients as a control group and to compare them with the intervention patients provides valuable information of the added value of being a study patient, and deserves further consideration in future studies.
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Estimating the incidence of suspected epidural hematoma and the hidden imaging cost of epidural catheterization: a retrospective review of 43,200 cases. Reg Anesth Pain Med 2014; 38:409-414. [PMID: 23924685 DOI: 10.1097/aap.0b013e31829ecfa6] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND OBJECTIVES Hematoma associated with epidural catheterization is rare, but the diagnosis might be suspected relatively frequently. We sought to estimate the incidence of suspected epidural hematoma after epidural catheterization and to determine the associated cost of excluding or diagnosing an epidural hematoma through radiologic imaging. METHODS We conducted an electronic retrospective chart review of 43,200 patient charts using 4 distinct search strategies and cost analysis, all from a single academic institution from 2001 through 2009. The charts were reviewed for use of radiologic imaging studies to identify patients with suspected and confirmed epidural hematomas. Costs for imaging to exclude or confirm the diagnosis were related to the entire cohort. RESULTS In our analysis, during a 9-year period that included 43,200 epidural catheterizations, 102 patients (1/430) underwent further imaging studies to exclude or confirm the presence of an epidural hematoma-revealing 6 confirmed cases and an overall incidence (per 10,000 epidural blocks) of epidural hematoma of 1.38 (95% confidence interval, 0-0.002). Among our patients, 207 imaging studies, primarily lumbar spine magnetic resonance imaging, were performed. Integrating Medicare cost expenditure data, the estimated additional cost during a 9-year period for imaging and hospital charges related to identifying epidural hematomas nets to approximately $232,000 or an additional $5.37 per epidural. CONCLUSIONS Approximately 1 in 430 patients undergoing epidural catheterization will be suspected to have an epidural hematoma. The cost of excluding the diagnosis, when suspected, is relatively low when allocated across all patients undergoing epidural catheterization.
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Perioperative multimodal anesthesia using regional techniques in the aging surgical patient. PAIN RESEARCH AND TREATMENT 2014; 2014:902174. [PMID: 24579048 PMCID: PMC3918371 DOI: 10.1155/2014/902174] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 10/31/2013] [Accepted: 11/01/2013] [Indexed: 11/17/2022]
Abstract
Background. Elderly patients have unique age-related comorbidities that may lead to an increase in postoperative complications involving neurological, pulmonary, cardiac, and endocrine systems. There has been an increase in the number of elderly patients undergoing surgery as this portion of the population is increasing in numbers. Despite advances in perioperative anesthesia and analgesia along with improved delivery systems, monotherapy with opioids continues to be the mainstay for treatment of postop pain. Reliance on only opioids can oftentimes lead to inadequate pain control or increase in the incidence of adverse events. Multimodal analgesia incorporating regional anesthesia is a promising alternative that may reduce needs for high doses and dependence on opioids along with any potential associated adverse effects. Methods. The following databases were searched for relevant published trials: Cochrane Central Register of Controlled Trials and PubMed. Textbooks and meeting supplements were also utilized. The authors assessed trial quality and extracted data. Conclusions. Multimodal drug therapy and perioperative regional techniques can be very effective to perioperative pain management in the elderly. Regional anesthesia as part of multimodal perioperative treatment can often reduce postoperative neurological, pulmonary, cardiac, and endocrine complications. Regional anesthesia/analgesia has not been proven to improve long-term morbidity but does benefit immediate postoperative pain control. In addition, multimodal drug therapy utilizes a variety of nonopioid analgesic medications in order to minimize dosages and adverse effects from opioids while maximizing analgesic effect and benefit.
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Tighe PJ, Harle CA, Boezaart AP, Aytug H, Fillingim R. Of rough starts and smooth finishes: correlations between post-anesthesia care unit and postoperative days 1-5 pain scores. PAIN MEDICINE 2013; 15:306-15. [PMID: 24308744 DOI: 10.1111/pme.12287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The goal of this project was to explore the association between post-anesthesia care unit (PACU) pain scores recorded within the first and second hour of the end of surgery with maximum and median pain scores recorded on postoperative days (PODs) 1 through 5. DESIGN This study was a retrospective cohort study of clinically documented pain scores in a mixed surgical population. SETTING This study was set in a single tertiary-care teaching hospital over a 1-year time period. PATIENTS All patients were adult patients undergoing a single, non-ambulatory, non-obstetric surgical procedure. MEASURES Pain scores, measured using the numerical rating scale, from PODs 0 through 5 were obtained from an integrated data repository. Kendall's Tau-b correlations were then calculated between maximum pain scores occurring within each of the two PACU time periods and maximum and median pain scores in each of the five ensuing PODs. RESULTS A total of 349,797 pain scores from 8,332 patients were reviewed. Correlations between maximum pain score by time period demonstrated a significant and high correlation at Tau-b = 0.86, between 1-hour PACU pain scores and 2-hour PACU pain scores. However, the correlation of maximum pain scores recorded in the PACU with those recorded on PODs 1 through 5 was significantly lower, ranging from 0.19 to 0.27. The correlation of maximum PACU pain score with median pain scores recorded on PODs 1 through 5 ranged from 0.22 to 0.29. The correlation structures of the PODs 1 through 5 median pain scores may be consistent with an autoregressive pattern. CONCLUSIONS Maximum scores measured within the PACU likely reflect a set of circumstances distinct from those experienced on PODs 1 through 5.
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Affiliation(s)
- Patrick James Tighe
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
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Friedrich-Freksa M, Schulz E, Nitzke T, Wenzel O, Popken G. Performing radical cystectomy and urinary diversion in regional anesthesia: potential risk reduction in the treatment of bladder cancer. Urol Int 2013; 91:103-8. [PMID: 23752480 DOI: 10.1159/000348542] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/18/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To assess the feasibility and performance of radical cystectomy with urinary diversion using exclusively regional anesthesia (i.e. combined spinal thoracic epidural anesthesia, CSTEA), avoiding the adverse effects of general anesthesia. MATERIALS AND METHODS In our hospital, radical cystectomy with extended pelvic and iliac lymphadenectomy and urinary diversion was performed on 28 patients using CSTEA without applying general anesthesia, in 2011 and 2012. Under maintained spontaneous breathing, the patients were awake and responsive during the entire procedure. Outcome measurements included operative time, blood loss, start of oral nutrition, start of mobilization, postoperative pain levels using numerical and visual analog scales (NAS/VAS), postoperative complications according to the Clavien-Dindo classification and length of hospital stay. RESULTS All surgical procedures were performed without any complications and caused no anesthesiologically or surgically untoward effects. We observed no more severe complications than grade 1 according to the Clavien-Dindo classification. CONCLUSIONS Our data show that CSTEA is an effective and safe technique for radical cystectomy, whereby spontaneous breathing and reduced interference with the cardiopulmonary system potentially lower the perioperative risks, especially for high-risk patients. We recommend practice of CSTEA for radical cystectomy to further evaluate and monitor the safety, efficacy, outcomes and complications of CSTEA.
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Moawad HE, Mousa SA, El-Hefnawy AS. Single-dose paravertebral blockade versus epidural blockade for pain relief after open renal surgery: A prospective randomized study. Saudi J Anaesth 2013; 7:61-7. [PMID: 23717235 PMCID: PMC3657929 DOI: 10.4103/1658-354x.109814] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Paravertebral block (PVB) has been an established technique for providing analgesia to the chest and abdomen. We conducted the current study to compare single-dose PVB versus single-dose epidural blockade (EP) for pain relief after renal surgery. METHODS Eighty patients scheduled for renal surgery were randomly assigned into two groups according to the analgesic technique, PVB group or EP group. General anesthesia was induced for all patients. Postoperative pain was assessed over 24 h using 10-cm visual analog scale (VAS). Postoperative total pethidine consumption was recorded. Any postoperative events, such as nausea, vomiting, shivering, or respiratory complications, were recorded. Hemodynamics and blood gasometry were also recorded. RESULTS EP group showed significant decrease of both heart rate and mean blood pressure at most of the operative periods when compared with PVB group. There was no difference in total rescue analgesic consumption. Postoperative VAS showed no significant difference between the studied groups. Postoperative events were comparable in both the groups. CONCLUSION Single injection PVB resulted in similar analgesia but greater hemodynamic stability than epidural analgesia in patients undergoing renal surgery, therefore this technique may be recommended for patients with coexisting circulatory disease.
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Affiliation(s)
- Hazem Ebrahem Moawad
- Department of Anaesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Egypt
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71
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Paravertebral block via the surgical field versus epidural block for patients undergoing thoracotomy: a randomized clinical trial. Surg Today 2013; 43:963-9. [PMID: 23702705 DOI: 10.1007/s00595-012-0485-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 07/02/2012] [Indexed: 10/26/2022]
Abstract
PURPOSE A paravertebral block (PVB) given via the surgical field can be safer and technically simpler than an epidural block (EP) for postoperative pain control. We conducted this clinical trial to confirm the effectiveness of PVB after thoracotomy. METHODS In this non-inferiority trial, patients were randomly assigned to receive PVB (n = 35) or EP (n = 35). The primary endpoint was the pain assessed using the visual analog scale (VAS) at rest, 2, 24, and 48 h after thoracotomy, with the non-inferiority margin set at 15 mm. The secondary end points were the pain assessed using the VAS on exercising and on coughing, 2, 24, and 48 h after surgery, respectively, and the complications and need for additional analgesic agents. RESULTS This trial revealed that PVB was not inferior to EP with respect to the primary end point: The mean VAS scores at rest, 2, 24, and 48 h after thoracotomy were 26.3, 10.8, and 8.3 mm in the PVB group and 23.6, 12.4, and 12.6 mm in the EP group, respectively (P < 0.01 for non-inferiority at all points). There were no significant differences between the groups in the incidence of complications or the need for additional analgesic agents. CONCLUSION PVB may replace EP for postoperative pain control because of its technical simplicity and safety.
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Park DJ, Jeong JH, Lee HO. The Effects of a Self-Training Physiotherapy Program on Pulmonary Functions, Postoperative Pulmonary Complications and Post-thoracotomy Pain after Lobectomy of Patients with Lung Cancer. J Phys Ther Sci 2013. [DOI: 10.1589/jpts.25.253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Du-Jin Park
- Department of Physical Therapy, Graduate School of Catholic University of Pusan
| | - Jong-Hwa Jeong
- Department of Rehabilitation, Pusan National University Hospital
| | - Hyun-Ok Lee
- Department of Physical Therapy, College of Health Sciences, Catholic University of Pusan: 9 Bugok 3-dong, Geumjung-gu, Busan 609-757, Republic of Korea
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Yang M, Ahn HJ, Kim JA, Yu JM. Risk score for postoperative complications in thoracic surgery. Korean J Anesthesiol 2012; 63:527-32. [PMID: 23277814 PMCID: PMC3531532 DOI: 10.4097/kjae.2012.63.6.527] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 06/16/2012] [Accepted: 07/09/2012] [Indexed: 11/10/2022] Open
Abstract
Background Risk scoring system for thoracic surgery patients have not been widely used, as of recently. We tried to forge a risk scoring system that predicts the risk of postoperative complications in patients undergoing major thoracic surgery. We used a prolonged ICU stay as a representative of postoperative complications and tested various possible risk factors for its relation. Methods Data from all patients who underwent major lung and esophageal cancer surgeries, between 2005 and 2007 in our hospital, were collected retrospectively (n = 858). Multiple logistic regression analysis was performed with various possible risk factors to build the risk scoring system for prolonged ICU stay (> 3 days). Results A total of 9% of patients exhibited more than 3 days of ICU stay. Age, operation name, preoperative lung injury, no epidural analgesia, and predicted post operative forced expiratory volume in 1 second (ppoFEV1) were the risk factors for prolonged ICU stay, by multivariable analysis (P < 0.05). Risk score, p was derived from the formula: logit(p/[1-p]) = -5.39 + 0.06 × age + 1.12 × operation name(2) + 1.52 × operation name(3) + 1.32 × operation name(4) + 1.56 × operation name(5) + 1.30 × preoperative lung injury + 0.72 × no epidural analgesia - 0.02 × ppoFEV1 [Age in years, operation name(2): pneumonectomy, operation name(3): esophageal cancer operation, operation name(4): completion pneumonectomy, operation name(5): extended operation, preoperative lung injury(+), epidural analgesia(-), ppoFEV1 in %]. Conclusions Age, operation name, preoperative lung injury, epidural analgesia, and ppoFEV1 can predict postoperative morbidity in thoracic surgery patients.
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Affiliation(s)
- Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Wrighton LJ, O'Bosky KR, Namm JP, Senthil M. Postoperative management after hepatic resection. J Gastrointest Oncol 2012; 3:41-7. [PMID: 22811868 DOI: 10.3978/j.issn.2078-6891.2012.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Accepted: 01/12/2012] [Indexed: 12/18/2022] Open
Abstract
Hepatic resection has become the mainstay of treatment for both primary and certain secondary malignancies. Outcomes after hepatic resection have significantly improved with advances in surgical and anesthetic techniques and perioperative care. Metabolic and functional changes after hepatic resection are unique and cause significant challenges in management. In-depth understanding of hepatic physiology is essential to properly address the postoperative issues. Strategies implemented in the postoperative period to improve outcomes include adequate nutritional support, proper glycemic control, and interventions to reduce postoperative infectious complications among several others. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.
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Affiliation(s)
- Lindsay J Wrighton
- Department of Surgery, Loma Linda University, Loma Linda, California, USA
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Khan RS, Skapinakis P, Ahmed K, Stefanou DC, Ashrafian H, Darzi A, Athanasiou T. The Association Between Preoperative Pain Catastrophizing and Postoperative Pain Intensity in Cardiac Surgery Patients. PAIN MEDICINE 2012; 13:820-7. [DOI: 10.1111/j.1526-4637.2012.01386.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Esme H, Apiliogullari B, Duran FM, Yoldas B, Bekci TT. Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy. Eur J Cardiothorac Surg 2012; 41:10-3. [PMID: 21596578 DOI: 10.1016/j.ejcts.2011.03.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE In the present prospective double-blind randomized trial, the effects of intermittent paravertebral subpleural bupivacaine and morphine on pain management in patients undergoing thoracotomy were evaluated and compared with intermittent systemic analgesia. METHODS Forty-five patients undergoing elective lobectomy were included in the present study. Three randomized groups consisting of 15 patients each were compared. Those in the control group were administered intravenously with tramadol 100 mg plus metamizol 1000 mg every 4 h for 3 days. We placed the catheter just below the parietal pleura along the paravertebral sulcus at the level of T5-T7. At the end of the operation and every 4 h thereafter, the patients received either 1.5 mg kg(-1) bupivacaine (bupivacaine group) or 0.2 mg kg(-1) morphine sulfate (morphine group) with paravertebral subpleural catheter for 3 days. Data regarding demographics, visual analog pain scores, need for supplementary intravenous analgesia, pulmonary function tests, and postoperative pulmonary complications were recorded for each patient. RESULTS Visual analog pain scores (visual analog scale (VAS)) were lower in the morphine and bupivacaine groups compared with control group at all postoperative time points. The mean postoperative VAS was significantly different between the control and bupivacaine groups at postoperative hour 12, the control and morphine groups at postoperative hours 6, 12, 48, and 72, and the bupivacaine and morphine groups at postoperative hours 6 and 24 (p<0.05). In the control group, additional analgesic requirement was significantly higher than in the bupivacaine and morphine groups (p<0.05). Postoperative pulmonary complications occurred in three patients (20%) in the control group, in two patients (13%) in the bupivacaine group, and in one (6%) in the morphine group. CONCLUSIONS The patients undergoing lung resection through a thoracotomy were observed with reduced postoperative pain and better surgical outcomes with respect to the length of hospital stay, postoperative forced expiratory volume in the first second, pulmonary complications, and need for bronchoscopic management, when paravertebral subpleural analgesia was induced by morphine.
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Affiliation(s)
- Hidir Esme
- Department of Thoracic Surgery, Konya Education and Research Hospital, Konya, Turkey.
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Postoperative pain trajectories in cardiac surgery patients. PAIN RESEARCH AND TREATMENT 2012; 2012:608359. [PMID: 22448322 PMCID: PMC3289864 DOI: 10.1155/2012/608359] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 09/20/2011] [Accepted: 10/04/2011] [Indexed: 11/17/2022]
Abstract
Poorly controlled postoperative pain is a longstanding and costly problem in medicine. The purposes of this study were to characterize the acute pain trajectories over the first four postoperative days in 83 cardiac surgery patients with a mixed effects model of linear growth to determine whether statistically significant individual differences exist in these pain trajectories, and to compare the quality of measurement by trajectory with conventional pain measurement practices. The data conformed to a linear model that provided slope (rate of change) as a basis for comparing patients. Slopes varied significantly across patients, indicating that the direction and rate of change in pain during the first four days of recovery from surgery differed systematically across individuals. Of the 83 patients, 24 had decreasing pain after surgery, 24 had increasing pain, and the remaining 35 had approximately constant levels of pain over the four postoperative days.
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Bang J, Kim JU, Lee YM, Joh J, An EH, Lee JY, Kim JY, Choi IC. Spinal epidural hematoma related to an epidural catheter in a cardiac surgery patient -A case report-. Korean J Anesthesiol 2011; 61:524-7. [PMID: 22220233 PMCID: PMC3249578 DOI: 10.4097/kjae.2011.61.6.524] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 09/15/2011] [Accepted: 09/15/2011] [Indexed: 12/04/2022] Open
Abstract
The addition of thoracic epidural anesthesia to general anesthesia during cardiac surgery may have a beneficial effect on clinical outcome. However, epidural catheter insertion in a patient anticoagulated with heparin may increase the risk of epidural hematoma. We report a case of epidural hematoma in a 55-year-old male patient who had a thoracic epidural placed under general anesthesia preceding uneventful mitral valve replacement and tricuspid valve annular plasty. During the immediate postoperative period and first postoperative day, prothrombin time (PT) and activate partial thromboplastin time (aPTT) were mildly prolonged. On the first postoperative day, he complained of motor weakness of the lower limbs and back pain. An immediate MRI of the spine was performed and it revealed an epidural hematoma at the T5-6 level. Rapid surgical decompression resulted in a recovery of his neurological abnormalities to near normal levels. Management and preventing strategies of epidural hematoma are discussed.
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Affiliation(s)
- Jiyoun Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Bösenberg AT, Jöhr M, Wolf AR. Pro con debate: the use of regional vs systemic analgesia for neonatal surgery. Paediatr Anaesth 2011; 21:1247-58. [PMID: 21722227 DOI: 10.1111/j.1460-9592.2011.03638.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro-con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view.
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Affiliation(s)
- Adrian T Bösenberg
- Department Anesthesiology and Pain Management, Faculty Health Sciences, University Washington, Seattle, WA, USA
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80
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Abstract
Scientific studies have proven without doubt that an optimized perioperative pain therapy will improve patient comfort, reduce postoperative complications, enhance postoperative recovery and shorten the length of postoperative hospital stay. It is necessary to incorporate the acute pain therapy into a perioperative multimodal and interdisciplinary therapeutic concept. Local or regional anesthesia will provide the best analgesic effect after surgery and should be considered in all patients. Optimal treatment of patients with peripheral nerve blocks, spinal or epidural analgesia should be treated by a specialized acute pain service. However, only 15-20% of all surgical cases will be taken care of by such a pain service. Therefore, most surgical patients will only receive adequate analgesia if surgeons are familiar with the principles of postoperative pain therapy. Regular assessment of pain perception is the cornerstone of optimized pain therapy. Furthermore, pain assessment will allow the administration and to some extent dosage of analgesic therapy to be delegated to nursing personnel.
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Affiliation(s)
- W Schwenk
- Allgemein- und Viszeralchirurgie, Asklepios Klinik Altona, Hamburg, Deutschland.
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81
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Rao DP, Rao VA. Morbidly obese parturient: Challenges for the anaesthesiologist, including managing the difficult airway in obstetrics. What is new? Indian J Anaesth 2011; 54:508-21. [PMID: 21224967 PMCID: PMC3016570 DOI: 10.4103/0019-5049.72639] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The purpose of this article is to review the fundamental aspects of obesity, pregnancy and a combination of both. The scientific aim is to understand the physiological changes, pathological clinical presentations and application of technical skills and pharmacological knowledge on this unique clinical condition. The goal of this presentation is to define the difficult airway, highlight the main reasons for difficult or failed intubation and propose a practical approach to management Throughout the review, an important component is the necessity for team work between the anaesthesiologist and the obstetrician. Certain protocols are recommended to meet the anaesthetic challenges and finally concluding with “what is new?” in obstetric anaesthesia.
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Affiliation(s)
- Durga Prasada Rao
- Department of Anaesthesiology, Siddhartha Medical College, Government General Hospital, Government of Andhra Pradesh, Vijayawada, India
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82
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Wadhwa R, Sharma S, Poddar D, Sharma S. Pleural puncture with thoracic epidural: A rare complication? Indian J Anaesth 2011; 55:163-6. [PMID: 21712874 PMCID: PMC3106390 DOI: 10.4103/0019-5049.79898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Freedom from pain has almost developed to be a fundamental human right. Providing pain relief via epidural catheters in thoracic and upper abdominal surgeries is widely accepted. Pain relief through this technique not only provides continuous analgesia but also reduces post-operative pulmonary complications and also hastens recovery. But being a blind procedure it is accompanied by certain complications. Hypotension, dura puncture, high epidural, total spinal, epidural haematoma, spinal cord injury and infection are some of the documented side effects of epidural block. There are case reports eliciting neurological complications, catheter site infections, paresthesias, radicular symptoms and worsening of previous neurological conditions. Few technical problems related to breakage of epidural catheter are also mentioned in the literature. The patient had no sequelae on long term follow up even when a portion of catheter was retained. We present a case report where epidural catheter punctured pleura in a patient undergoing thoracotomy for carcinoma oesophagus.
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Affiliation(s)
- Rachna Wadhwa
- PGIMER and Associated Dr. R M L Hospital, New, Delhi, India
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83
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Haller G, Agoritsas T, Luthy C, Piguet V, Griesser AC, Perneger T. Collaborative quality improvement to manage pain in acute care hospitals. PAIN MEDICINE 2010; 12:138-47. [PMID: 21143760 DOI: 10.1111/j.1526-4637.2010.01020.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Collaborative quality improvement programs have been successfully used to manage chronic diseases in adults and acute lung complications in premature infants. Their effectiveness to improve pain management in acute care hospitals is currently unknown. The purpose of this study was to determine whether a collaborative quality improvement program implemented at hospital level could improve pain management and overall pain relief. DESIGN To assess the effectiveness of the program, we performed a before-after trial comparing patient's self-reported pain management and experience before and after program implementation. We included all adult patients hospitalized for more than 24 hours and discharged either to their home or to a nursing facility, between March 1, 2001 and March 31, 2001 (before program implementation) and between September 15, 2005 and October 15, 2005 (after program implementation). SETTING A teaching hospital of 2,096 beds in Geneva, Switzerland. PATIENTS All adult patients hospitalized for more than 24 hours and discharged between 1 to 31 March 2001 (before program) and 15 September to 15 October 2005 (after program implementation). INTERVENTIONS Implementation of a collaborative quality improvement program using multifaceted interventions (staff education, opinion leaders, patient education, audit, and feedback) to improve pain management at hospital level. OUTCOME MEASURES Patient-reported pain experience, pain management, and overall hospital experience based on the Picker Patient Experience questionnaire, perceived health (SF-36 Health survey). RESULTS After implementation of the program only 2.3% of the patients reported having no pain relief during their hospital stay (vs 4.5% in 2001, P=0.05). Among nonsurgical patients, improvements were observed for pain assessment (42.3% vs 27.9% of the patients had pain intensity measured with a visual analog scale, P=0.012), pain management (staff did everything they could to help in 78.9% vs 67.9% of cases P=0.003), and pain relief (70.4% vs 57.3% of patients reported full pain relief P=0.008). In surgical patients, pain assessment also improved (53.7.3% vs 37.6%) as well as pain treatment. More patients received treatments to relieve pain regularly or intermittently after program implementation (95.1% vs 91.9% P=0.046). CONCLUSION Implementation of a collaborative quality improvement program at hospital level improved both pain management and pain relief in patients. Further studies are needed to determine the overall cost-effectiveness of such programs.
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Affiliation(s)
- Guy Haller
- Department of Anesthesiology, Pharmacology and Intensive Care-Division of Anaesthesiology, Geneva University Hospital, 4 rue Perret-Gentil, Geneva, Switzerland.
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84
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Audit of a ward-based patient-controlled epidural analgesia service in Ireland. Ir J Med Sci 2010; 180:417-21. [PMID: 21104335 DOI: 10.1007/s11845-010-0645-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ward-based patient-controlled epidural analgesia (PCEA) for postoperative pain control was introduced at our institution in 2006. We audited the efficacy and safety of ward-based PCEA from January 2006 to December 2008. METHOD Data were collected from 928 patients who received PCEA in general surgical wards for postoperative analgesia using bupivacaine 0.125% with fentanyl 2 μg/mL. RESULTS On the first postoperative day, the median visual analogue pain score was 2 at rest and 4 on activity. Hypotension occurred in 21 (2.2%) patients, excessive motor blockade in 16 (1.7%), high block in 5 (0.5%), nausea in 5 (0.5%) and pruritus in only 1 patient. Excessive sedation occurred in two (0.2%) patients but no intervention was required. There were no serious complications such as epidural abscess, infection or haematoma. CONCLUSION Effective and safe postoperative analgesia can be provided with PCEA in a general surgical ward without recourse to high-dependency supervision.
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85
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Systemic postoperative pain management following minimally invasive pectus excavatum repair in children and adolescents: a retrospective comparison of intravenous patient-controlled analgesia and continuous infusion with morphine. Pediatr Surg Int 2010; 26:665-9. [PMID: 20490811 DOI: 10.1007/s00383-010-2619-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE Optimal postoperative pain management following minimally invasive surgical repair of pectus excavatum is not established. We compared efficacy and adverse effects in patients treated with patient-controlled analgesia (PCA) with those treated with continuous infusion (CI) with morphine in addition to nonsteroidal anti-inflammatory drugs. METHODS 33 patient records were examined retrospectively: 21 given PCA and 12 CI with morphine. Main outcome variables were used doses of morphine, pain scores every 3 h and adverse effects. RESULTS Median (range) used morphine dose was 0.58 (0.21-1.12) and 0.52 (0.34-0.84) mg/kg on the day 1 and 0.3 (0.02-0.6) and 0.33 (0.09-0.53) mg/kg on the day 2 in PCA and CI groups, respectively (p > 0.05). Pain scores were within moderate and low levels during 42 h after surgery and did not differ between the groups. Median (range) oxygen saturation was 96.5 (93-100) and 97 (94-100) in PCA and CI groups, respectively (p > 0.05). Additional oxygen therapy was required in 14.3% in PCA group and 25% in CI group (p > 0.05). The incidence of pulmonary adverse effects was rare and did not differ between the groups. CONCLUSION Both methods of systemic analgesia in addition to non-opioid analgesics were equally effective and resulted in a low incidence of pulmonary adverse effects.
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86
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Wahlen BM, Roewer N, Kranke P. Use of local anaesthetics and adjuncts for spinal and epidural anaesthesia and analgesia at German and Austrian University Hospitals: an online survey to assess current standard practice. BMC Anesthesiol 2010; 10:4. [PMID: 20398410 PMCID: PMC2864275 DOI: 10.1186/1471-2253-10-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2009] [Accepted: 04/17/2010] [Indexed: 12/02/2022] Open
Abstract
Background The present anonymous multicenter online survey was conducted to evaluate the application of regional anaesthesia techniques as well as the used local anaesthetics and adjuncts at German and Austrian university hospitals. Methods 39 university hospitals were requested to fill in an online questionnaire, to determine the kind of regional anaesthesia and preferred drugs in urology, obstetrics and gynaecology. Results 33 hospitals responded. No regional anaesthesia is conducted in 47% of the minor gynaecological and 44% of the urological operations; plain bupivacaine 0.5% is used in 38% and 47% respectively. In transurethral resections of the prostate and bladder no regional anaesthesia is used in 3% of the responding hospitals, whereas plain bupivacaine 0.5% is used in more than 90%. Regional anaesthesia is only used in selected major gynaecological and urological operations. On the contrary to the smaller operations, the survey revealed a large variety of used drugs and mixtures. Almost 80% prefer plain bupivacaine or ropivacaine 0.5% in spinal anaesthesia in caesarean section. Similarly to the use of drugs in major urological and gynaecological operations a wide range of drugs and adjuncts is used in epidural anaesthesia in caesarean section and spontaneous delivery. Conclusions Our results indicate a certain agreement in short operations in spinal anaesthesia. By contrast, a large variety concerning the anaesthesiological approach in larger operations as well as in epidural analgesia in obstetrics could be revealed, the causes of which are assumed to be primarily rooted in particular departmental structures.
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Affiliation(s)
- Bianca M Wahlen
- Staff Anaesthesiologist, University of Wuerzburg, Department of Anaesthesia and Critical Care, Wuerzburg, Germany.
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87
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Martin J, Heymann A, Bäsell K, Baron R, Biniek R, Bürkle H, Dall P, Dictus C, Eggers V, Eichler I, Engelmann L, Garten L, Hartl W, Haase U, Huth R, Kessler P, Kleinschmidt S, Koppert W, Kretz FJ, Laubenthal H, Marggraf G, Meiser A, Neugebauer E, Neuhaus U, Putensen C, Quintel M, Reske A, Roth B, Scholz J, Schröder S, Schreiter D, Schüttler J, Schwarzmann G, Stingele R, Tonner P, Tränkle P, Treede RD, Trupkovic T, Tryba M, Wappler F, Waydhas C, Spies C. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care--short version. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2010; 8:Doc02. [PMID: 20200655 PMCID: PMC2830566 DOI: 10.3205/000091] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Indexed: 12/28/2022]
Abstract
Targeted monitoring of analgesia, sedation and delirium, as well as their appropriate management in critically ill patients is a standard of care in intensive care medicine. With the undisputed advantages of goal-oriented therapy established, there was a need to develop our own guidelines on analgesia and sedation in intensive care in Germany and these were published as 2(nd) Generation Guidelines in 2005. Through the dissemination of these guidelines in 2006, use of monitoring was shown to have improved from 8 to 51% and the use of protocol-based approaches increased to 46% (from 21%). Between 2006-2009, the existing guidelines from the DGAI (Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) and DIVI (Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin) were developed into 3(rd) Generation Guidelines for the securing and optimization of quality of analgesia, sedation and delirium management in the intensive care unit (ICU). In collaboration with another 10 professional societies, the literature has been reviewed using the criteria of the Oxford Center of Evidence Based Medicine. Using data from 671 reference works, text, diagrams and recommendations were drawn up. In the recommendations, Grade "A" (very strong recommendation), Grade "B" (strong recommendation) and Grade "0" (open recommendation) were agreed. As a result of this process we now have an interdisciplinary and consensus-based set of 3(rd) Generation Guidelines that take into account all critically illness patient populations. The use of protocols for analgesia, sedation and treatment of delirium are repeatedly demonstrated. These guidelines offer treatment recommendations for the ICU team. The implementation of scores and protocols into routine ICU practice is necessary for their success.
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Affiliation(s)
- Jörg Martin
- Department of Anesthesiology and Operative Intensive Care, Klinik am Eichert, Göppingen, Germany
| | - Anja Heymann
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | | | - Ralf Baron
- Department of Neurology, Christian-Albrechts University, Kiel, Germany
| | - Rolf Biniek
- Department of Neurology, LVR-Klinik Bonn, Germany
| | - Hartmut Bürkle
- Clinic for Anaesthesiology and Operative Intensive Care and Pain Clinic of Memmingen, Germany
| | | | | | - Verena Eggers
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
| | - Ingolf Eichler
- Department of Cardiac and Vascular Surgery, Klinikum Dortmund GgmbH, Germany
| | - Lothar Engelmann
- Department of Internal Medicine and Intensive Care Medicine, University of Leipzig, Germany
| | - Lars Garten
- Department of Neonatology, Charité University Medicine Berlin, Germany
| | - Wolfgang Hartl
- Department of Surgery Grosshadern, University of Munich, Germany
| | - Ulrike Haase
- Department of Anesthesiology and Intensive Care Medicine, Charité Campus Mitte, Berlin, Germany
| | - Ralf Huth
- University Children's Hospital of Mainz, Germany
| | - Paul Kessler
- Department of Anesthesiology and Intensive Care Medicine, Orthopedic University Hospital, Frankfurt, Germany
| | - Stefan Kleinschmidt
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Wolfgang Koppert
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Franz-Josef Kretz
- Olgahospital, Department of Anesthesiology and Operative Intensive Care, Stuttgart, Germany
| | | | - Guenter Marggraf
- West German Heart Center Essen, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Germany
| | - Andreas Meiser
- Department of Anesthesiology, Intensive Care and Pain, Saarland University Hospital, Homburg, Germany
| | - Edmund Neugebauer
- IFOM - Institute for Research in Operative Medicine, Institute for Surgical Research, Private University of Witten/ Herdecke GmbH, Köln, Germany
| | - Ulrike Neuhaus
- Department of Anesthesiology and Operative Intensive Care, Charité Campus Virchow, Berlin, Germany
| | - Christian Putensen
- Anesthesiology and Operative Intensive Care, University of Bonn, Germany
| | | | - Alexander Reske
- Department of Anesthesiology and Intensive Care, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - Bernard Roth
- Department of General Pediatrics, Cologne, Germany
| | - Jens Scholz
- Department of Anesthesiology and Surgical Intensive Care, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Stefan Schröder
- Department of Psychiatry and Psychotherapy, CMM Hospital Guestrow, Germany
| | - Dierk Schreiter
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | | | - Robert Stingele
- Department of Neurology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Peter Tonner
- Department of Anesthesiology and Intensive Care Medicine, Emergency Medicine Hospital Links der Weser GmbH, Bremen, Germany
| | - Philip Tränkle
- Department of Internal Medicine, Division III, ICU 3IS, Tübingen, Germany
| | - Rolf Detlef Treede
- Department of Neurophysiology, Center for Biomedicine and Medical Technology Mannheim (CBTM), Germany
| | - Tomislav Trupkovic
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, BG Trauma Clinic Ludwigshafen, Germany
| | - Michael Tryba
- Anesthesiology and Operative Intensive Care, Klinikum Kassel, Germany
| | - Frank Wappler
- Department of Anesthesiology and Operative Intensive Care, Hospital Cologne-Merheim, University of Witten/ Herdecke, Cologne, Germany
| | | | - Claudia Spies
- Department of Anesthesiology and Intensive Care Medicine, Campus Virchow-Klinikum and Campus Charité Mitte, Berlin, Germany
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Muehling B, Schelzig H, Steffen P, Meierhenrich R, Sunder-Plassmann L, Orend KH. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg 2010; 33:577-85. [PMID: 19137363 DOI: 10.1007/s00268-008-9892-2] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Fast-track recovery programs have led to reduced patient morbidity and mortality after major surgery. In terms of elective open infrarenal aneurysm repair, no evidence is available about such programs. To address this issue, we have conducted a randomized prospective pilot study. METHODS The study involved prospective randomization of 101 patients with the indication for elective open aneurysm repair in a traditional and a fast-track treatment arm. The basic fast-track elements were no bowel preparation, reduced preoperative fasting, patient-controlled epidural analgesia (PCEA), enhanced postoperative feeding, and postoperative mobilization. Morbidity and mortality, need for postoperative mechanical ventilation, length of stay (LOS) in the intensive care unit (ICU) and total length of postoperative hospital stay were analyzed in terms of an intention to treat. RESULTS Demographic data for the two groups were similar. In the fast-track group the need for postoperative ventilation was significantly lower (6.1% versus 32%; p = 0.002), the median LOS on ICU did not significantly differ (20 h versus 32 h; p = 0.183), full enteral feeding was achieved significantly earlier (5 versus 7 days; p < 0.0001), and the rate of postoperative medical complications-gastrointestinal, cardiac, pulmonary, renal, and infective-was significantly lower (16% versus 36%; p = 0.039). The postoperative hospital stay was significantly shorter in the fast-track group (10 days versus 11 days; p = 0.016); the mortality rate in both groups was 0%. CONCLUSIONS An optimized patient care program in open infrarenal aortic aneurysm repair shows favorable results concerning need for postoperative assisted mechanical ventilation, time to full enteral feeding, and incidence of medical complications. Further ranomized multicentric trials are necessary to justify broad implementation (clinical trials. gov identifier NCT 00615888).
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Affiliation(s)
- Bernd Muehling
- Department of Thoracic and Vascular Surgery, University of Ulm, Steinhövelstrasse 9, 89075 Ulm, Germany.
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Nawaaz MSM, Salem Y. Right hemicolectomy in a patient with severe pulmonary hypertension anesthesia approach. Anesth Essays Res 2010; 4:38-40. [PMID: 25885086 PMCID: PMC4173327 DOI: 10.4103/0259-1162.69309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A 59-year-old obese female patient was diagnosed to be having severe pulmonary hypertension secondary to mixed connective tissue disease and pulmonary fibrosis. She presented for right hemi-colectomy for a large right-sided colonic polypoid mass and multiple polyps diagnosed by colonoscopy. Her surgery was postponed by 2 months by the anesthesiologist due to dyspnea at rest and high pulmonary artery pressure (70–80 mmHg) for further optimization of medical treatment. After 2 months, she was adequately fit enough to undergo surgery. High lumbar epidural anesthesia was adopted and weaned off. She was discharged after 5 days of surgery from the hospital without any sequel. This report presents the merits and recommendations for such patients.
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Affiliation(s)
| | - Yaser Salem
- King Fahad Medical City, PO Box 59046, Riyadh 11525, Saudi Arabia
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90
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A change in practice from epidural to intrathecal morphine analgesia for hepato-pancreato-biliary surgery. World J Surg 2009; 33:1802-8. [PMID: 19548026 DOI: 10.1007/s00268-009-0131-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study was designed to audit the change of anesthetic practice from thoracic epidural analgesia (TEA) to intrathecal morphine (ITM) combined with patient-controlled analgesia (PCA) for hepato-pancreato-biliary (HPB) surgery. METHODS All patients who underwent major HPB surgery and received TEA or ITM from March 2005 to March 2008 were identified. Patients who received PCA alone were used for comparison. Data were retrospectively collected and analyzed for success of TEA, perioperative intravenous fluid (IVF) volume administered, hypotension, complications, and hospital stay. RESULTS During the study period, 51 (32%) patients received TEA, 79 (49%) received ITM plus PCA opiate, and 31 (19%) received PCA alone. The incidence of postoperative hypotension was significantly higher in those who received TEA compared with those who received ITM (21/51 (41%) vs. 7/79 (9%), P < 0.001). The median (range) perioperative IVF administration was higher in the TEA group compared with the ITM group for both the first 24 h (6 (3-11) liters vs. 5 (3-11) liters, P < 0.05) and in total (15.5 (5-48.5) liters vs. 9 (3-70) liters, P < 0.001). Respiratory complications occurred in five (10%) of the TEA group compared with one (1%) in the ITM group (P < 0.05). The median (range) hospital stay was longer in the TEA group compared with the ITM group (9 (3-36) days vs. 7 (3-55) days, P < 0.01). CONCLUSIONS In a resource-limited setting, ITM, compared with TEA, is associated with a reduced incidence of postoperative hypotension, reduced IVF requirements, shorter hospital stay, and lowers the incidence of respiratory complication.
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91
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Hong JY, Lee SJ, Rha KH, Roh GU, Kwon SY, Kil HK. Effects of Thoracic Epidural Analgesia Combined with General Anesthesia on Intraoperative Ventilation/Oxygenation and Postoperative Pulmonary Complications in Robot-Assisted Laparoscopic Radical Prostatectomy. J Endourol 2009; 23:1843-9. [DOI: 10.1089/end.2009.0059] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jeong-Yeon Hong
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Jin Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Koon Ho Rha
- Department of Urology and Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Go Un Roh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - So Young Kwon
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hae Keum Kil
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Abstract
Pain therapy after surgical procedures of the lower extremity is an important goal, whereas insufficient analgesia leads to an essential reduction of the patient's mobility and convalescence. If possible, regional anaesthetic and intrathecal procedures for pre-, intra- and postoperative analgesia should be used. Systemic analgesics should not be used preoperatively, whereas non-opioids and opioids are recommended postoperatively. Surgical options that adequately reduce pain are intra-articular injection of local anaesthetics alone or in combination with opioids and cooling and physiotherapeutic treatment regimens after joint procedures. There is no scientific rationale as an argument for inserting drains. The surgical approach depends more on the individual patient's anatomical characteristics. Whereas the regional analgesic regimen is more effective than systemic therapy, sufficient tools for pain reduction during surgical procedures of the lower extremity are at the orthopaedic surgeon's disposal, too.
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Affiliation(s)
- C J P Simanski
- Klinik für Unfallchirurgie, Orthopädie und Sporttraumatologie Köln-Merheim, Lehrstuhl für Unfallchirurgie und Orthopädie der Universität Witten-Herdecke, Ostmerheimer Strasse 200, 51109, Köln, Deutschland.
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94
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Choi PT, Beattie WS, Bryson GL, Paul JE, Yang H. Effects of neuraxial blockade may be difficult to study using large randomized controlled trials: the PeriOperative Epidural Trial (POET) Pilot Study. PLoS One 2009; 4:e4644. [PMID: 19247497 PMCID: PMC2645707 DOI: 10.1371/journal.pone.0004644] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 01/16/2009] [Indexed: 11/18/2022] Open
Abstract
Background Early randomized controlled trials have suggested that neuraxial blockade may reduce cardiorespiratory complications after non-cardiothoracic surgery, but recent larger trials have been inconclusive. We conducted a pilot study to assess the feasibility of conducting a large multicentre randomized controlled trial in Canada. Methodology/Principal Findings After Research Ethics Board approvals from the participating institutions, subjects were recruited if they were ≥45 years old, had an expected hospital stay ≥48 hours, were undergoing a noncardiothoracic procedure amenable to epidural analgesia, met one of six risk criteria, and did not have contraindications to neuraxial blockade. After informed consent, subjects were randomly allocated to combined epidural analgesia (epidural group) and neuraxial anesthesia, with or without general anesthesia, or intravenous opioid analgesia (IV group) and general anesthesia. The primary outcomes were the rate of recruitment and the percents of eligible patients recruited, crossed over, and followed completely. Feasibility targets were defined a priori. A blinded, independent committee adjudicated the secondary clinical outcomes. Subjects were followed daily while in hospital and then at 30 days after surgery. Analysis was intention-to-treat. Over a 15-month period, the recruitment rate was 0.5±0.3 (mean±SEM) subjects per week per centre; 112/494 (22.7%) eligible subjects were recruited at four tertiary-care teaching hospitals in Canada. Thirteen (26.5%) of 49 subjects in the epidural group crossed over to the IV group; seven (14.3%) were due to failed or inadequate analgesia or complications from epidural analgesia. Five (9.8%) of 51 subjects in the IV group crossed over to the epidural group but none were due to inadequate analgesia or complications. Ninety-eight (97.0%) of 101 subjects were successfully followed up until 30 days after their surgery. Conclusion/Significance Of the criteria we defined for the feasibility of a full-scale trial, only the follow-up target was met. The other feasibility outcomes did not meet our preset criteria for success. The results suggest that a large multicentre trial may not be a feasible design to study the perioperative effects of neuraxial blockade. Trial Registration ClinicalTrials.gov NCT 0221260 Controlled-Trials.com ISRCTN 35629817
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Affiliation(s)
- Peter T Choi
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.
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95
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Zhang Z, Xu F, Zhang C, Liang X. Activation of opioid micro-receptors in medullary raphe depresses sighs. Am J Physiol Regul Integr Comp Physiol 2009; 296:R1528-37. [PMID: 19244586 DOI: 10.1152/ajpregu.90748.2008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Sighs, a well-known phenomenon in mammals, are substantially augmented by hypoxia and hypercapnia. Because (d-Ala(2),N-Me-Phe(4),Gly-ol)-enkephalin (DAMGO), a mu-receptor agonist, injected intravenously and locally in the caudal medullary raphe region (cMRR) decreased the ventilatory response to hypoxia and hypercapnia, we hypothesized that these treatments could inhibit sigh responses to these chemical stimuli. The number and amplitude of sighs were recorded during three levels of isocapnic hypoxia (15%, 10%, and 5% O(2) for 1.5 min) or hypercapnia (3%, 7%, and 10% CO(2) for 4 min) to test the dependence of sigh responses on the intensity of chemical drive in anesthetized and spontaneously breathing rats. The role of mu-receptors in modulating sigh responses to 10% O(2) or 7% CO(2) was subsequently evaluated by comparing the sighs before and after 1) intravenous administration of DAMGO (100 microg/kg), 2) microinjection of DAMGO (35 ng/100 nl) into the cMRR, and 3) intravenous administration of DAMGO after microinjection of d-Phe-Cys-Tyr-d-Trp-Arg-Thr-Pen-Thr-NH(2) (CTAP, 100 ng/100 nl), a micro-receptor antagonist, into the cMRR. Hypoxia and hypercapnia increased the number, but not amplitude, of sighs in a concentration-dependent manner, and the responses to hypoxia were significantly greater than those to hypercapnia. Systemic and local injection of DAMGO into the cMRR predominantly decreased the number of sighs, while microinjection into the rostral and middle MRR had no or limited effects. Microinjecting CTAP into the cMRR significantly diminished the systemic DAMGO-induced reduction of the number of sighs in response to hypoxia, but not to hypercapnia. Thus we conclude that hypoxia and hypercapnia elevate the number of sighs in a concentration-dependent manner in anesthetized rats, and this response is significantly depressed by activating systemic mu-receptors, especially those within the cMRR.
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Affiliation(s)
- Zhenxiong Zhang
- Pathophysiology Program, Lovelace Respiratory Research Institute, Albuquerque, New Mexico 87108, USA
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96
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dos Santos LM, Santos VCJ, Santos SRCJ, Malbouisson LMS, Carmona MJC. Intrathecal morphine plus general anesthesia in cardiac surgery: effects on pulmonary function, postoperative analgesia, and plasma morphine concentration. Clinics (Sao Paulo) 2009; 64:279-85. [PMID: 19488583 PMCID: PMC2694465 DOI: 10.1590/s1807-59322009000400003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 10/09/2008] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To evaluate the effects of intrathecal morphine on pulmonary function, analgesia, and morphine plasma concentrations after cardiac surgery. INTRODUCTION Lung dysfunction increases morbidity and mortality after cardiac surgery. Regional analgesia may improve pulmonary outcomes by reducing pain, but the occurrence of this benefit remains controversial. METHODS Forty-two patients were randomized for general anesthesia (control group n=22) or 400 microg of intrathecal morphine followed by general anesthesia (morphine group n=20). Postoperative analgesia was accomplished with an intravenous, patient-controlled morphine pump. Blood gas measurements, forced vital capacity (FVC), forced expiratory volume (FEV), and FVC/FEV ratio were obtained preoperatively, as well as on the first and second postoperative days. Pain at rest, profound inspiration, amount of coughing, morphine solicitation, consumption, and plasma morphine concentration were evaluated for 36 hours postoperatively. Statistical analyses were performed using the repeated measures ANOVA or Mann-Whiney tests (*p<0.05). RESULTS Both groups experienced reduced FVC postoperatively (3.24 L to 1.38 L in control group; 2.72 L to 1.18 L in morphine group), with no significant decreases observed between groups. The two groups also exhibited similar results for FEV1 (p=0.085), FEV1/FVC (p=0.68) and PaO2/FiO2 ratio (p=0.08). The morphine group reported less pain intensity (evaluated using a visual numeric scale), especially when coughing (18 hours postoperatively: control group= 4.73 and morphine group= 1.80, p=0.001). Cumulative morphine consumption was reduced after 18 hours in the morphine group (control group= 20.14 and morphine group= 14.20 mg, p=0.037). The plasma morphine concentration was also reduced in the morphine group 24 hours after surgery (control group= 15.87 ng.mL-1 and morphine group= 4.08 ng.mL-1, p=0.029). CONCLUSIONS Intrathecal morphine administration did not significantly alter pulmonary function; however, it improved patient analgesia and reduced morphine consumption and morphine plasma concentration.
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Affiliation(s)
- Luciana Moraes dos Santos
- Department of Anesthesia, Heart Institute, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
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97
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Guideline-oriented perioperative management of patients with bronchial asthma and chronic obstructive pulmonary disease. J Anesth 2008; 22:412-28. [PMID: 19011781 DOI: 10.1007/s00540-008-0650-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 05/26/2008] [Indexed: 10/21/2022]
Abstract
Increased airway hyperresponsiveness is a major concern in the perioperative management of patients with bronchial asthma and chronic obstructive pulmonary disease. Guidelines using evidence-based medicine are continually being updated and published regarding the diagnosis, treatment, and prevention of these respiratory disorders. Perioperative management in these patients involves: (1) adequate control of airway hyperresponsiveness, including detection of purulent sputum and infection before surgery; (2) evidence-based control of anesthesia; and (3) the aggressive use of beta-2 adrenergic stimulants and the systemic administration of steroids for the treatment of acute attacks. Good preoperative control, including the use of leukotriene antagonists, can reduce the incidence of life-threatening perioperative complications. Awareness of recent guidelines is thus important in the management of patients with airway hyperresponsiveness. This review covers the most recent guidelines for the perioperative management of patients with bronchial asthma and chronic obstructive pulmonary disease.
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98
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Ouerghi S, Frikha N, Mestiri T, Smati B, Mebazaa MS, Kilani T, Ben Ammar MS. A prospective, randomised comparison of continuous paravertebral block and continuous intercostal nerve block for post-thoracotomy pain. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2008. [DOI: 10.1080/22201173.2008.10872572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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99
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Abstract
Pain after thoracotomy is very severe, probably the most severe pain experienced after surgery. Thoracic epidural analgesia has greatly improved the pain experience and its consequences and has been considered the standard for pain management after thoracotomy. This view has been challenged recently by the use of paravertebral nerve blocks. Nevertheless, severe ipsilateral shoulder pain and the prevention of the postthoracotomy pain syndrome remain the most important challenges for management of postthoracotomy pain.
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Affiliation(s)
- Peter Gerner
- Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA.
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100
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Pratt WB, Steinbrook RA, Maithel SK, Vanounou T, Callery MP, Vollmer CM. Epidural analgesia for pancreatoduodenectomy: a critical appraisal. J Gastrointest Surg 2008; 12:1207-20. [PMID: 18264686 DOI: 10.1007/s11605-008-0467-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2007] [Accepted: 01/07/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery. However, there is no detailed analysis of its efficacy for pancreatic operations. This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy. MATERIAL AND METHODS Data for 233 consecutive patients, who underwent pancreatoduodenectomy, were prospectively acquired and retrospectively reviewed at a single institution, pancreato-biliary specialty practice. From October 2001 to February 2007, all patients were offered thoracic epidural analgesia, and those who declined received intravenous analgesia. Perioperative pain management was dictated as an element of a standardized clinical pathway for pancreatic resections. Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups. RESULTS One hundred eighty-five patients received epidural analgesia, and 48 received intravenous analgesia, with equivalent baseline patient demographics between the groups. Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications. Pancreatic fistulae and postoperative ileus occurred more frequently, and patients with epidural analgesia more often required discharge to rehabilitation facilities. A trend towards longer hospitalizations was observed among epidural analgesia patients, but total costs were statistically equivalent between the groups. Further analysis demonstrates that 31% of epidural infusions were aborted before anticipated (fourth postoperative day) because of hemodynamic compromise and/or inadequate analgesia. These select patients required more transfusions, aggressive fluid resuscitation, and subsequently suffered even higher rates of gastrointestinal and respiratory complications, all attributing to higher costs. Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36%, elderly age (>75 years), and chronic pancreatitis predict failure of epidural infusions. CONCLUSION Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability, which may compromise enteric anastomoses, gastrointestinal recovery, and respiratory function. These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed.
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Affiliation(s)
- Wande B Pratt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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