Nonventilatory strategies to prevent postoperative pulmonary complications

PURPOSE OF REVIEW

In this review, we aimed at providing the most recent and relevant clinical evidence regarding the use of nonventilatory strategies to prevent postoperative pulmonary complications (PPCs) after noncardiac surgery.

RECENT FINDINGS

Although nonavoidable, most comorbidities can be modified in order to reduce the incidence of pulmonary events postoperatively. The physical status of patients suffering from chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, and congestive heart failure can be improved preoperatively, and a number of measures can be undertaken to prevent PPCs, including physiotherapy for pulmonary rehabilitation and drug therapies. Also, smokers may benefit from both short and long-term smoke cessation. Furthermore, the risk of PPCs may be reduced upon: choice of an adequate anesthesia strategy (e.g. regional vs. general); appropriate neuromuscular blockade and reversal; use of volatile instead of intravenous anesthetics in lung surgery; judicious intravascular volume expansion (restrictive vs. liberal strategy); regional instead of systemic analgesia after major surgery in high-risk patients; more strict indication for nasogastric decompression in order to avoid silent aspiration; and laparoscopic instead of open bariatric surgery.

SUMMARY

Nonventilatory strategies can play an important role in reducing PPCs and improving clinical outcome after noncardiac surgery, especially in high-risk patients.

The perioperative management of treatment with anticoagulants and platelet aggregation inhibitors

BACKGROUND

When giving anticoagulants and inhibitors of platelet aggregation either prophylactically or therapeutically, physicians face the challenge of protecting patients from thromboembolic events without inducing harmful bleeding. Especially in the perioperative period, the use of these drugs requires a carefully balanced evaluation of their risks and benefits. Moreover, the choice of drug is difficult, because many different substances have been approved for clinical use.

METHOD

We selectively searched for relevant publications that appeared from 2003 to February 2013, with particular consideration of the guidelines of the European Society of Cardiology, the Association of Scientific Medical Societies in Germany (AWMF), the American College of Cardiology, and the American Heart Association.

RESULTS

Vitamin K antagonists (VKA), low molecular weight heparins, and fondaparinux are the established anticoagulants. The past few years have seen the introduction of orally administered selective inhibitors of the clotting factors IIa (dabigatran) and Xa (rivaroxaban, apixaban). The timing of perioperative interruption of anticoagulation is based on pharmacokinetic considerations rather than on evidence from clinical trials. Recent studies have shown that substituting short-acting anticoagulants for VKA before a procedure increases the risk of bleeding without lowering the risk of periprocedural thromboembolic events. The therapeutic spectrum of acetylsalicylic acid and clopidogrel has been broadened by the newer platelet aggregation inhibitors prasugrel and ticagrelor. Patients with drug eluting stents should be treated with dual platelet inhibition for 12 months because of the risk of in-stent thrombosis.

CONCLUSION

Anticoagulants and platelet aggregation inhibitors are commonly used drugs, but the evidence for their perioperative management is limited. The risks of thrombosis and of hemorrhage must be balanced against each other in the individual case. Anticoagulation need not be stopped for minor procedures.

Electrochemotherapy for the treatment of ocular basal cell carcinoma; a novel adjunct in the disease management

Basal Cell Carcinoma (BCC) affecting the ocular region is potentially problematic due to its ability to infiltrate aesthetic and functional structures. Due to the paucity of local tissue, resection frequently requires reconstruction with skin grafts or local flaps. Surgical treatment may not be suitable for patients with multiple co-morbidities. Electrochemotherapy (ECT) is a technique where cells are temporarily permeabilized after exposure to a brief electrical field and when combined with normally impermeant chemotherapy drugs can resolve cutaneous cancers - even those previously recalcitrant to chemotherapy or radiotherapy. Its particular advantage is its speed of application and the minimal damage to the surrounding healthy tissue structures. We present a series of 3 patients with BCCs in the peri-ocular region and significant co-morbidities deemed unsuitable for surgical resection, who underwent ECT. The lesions were all primary BCC ranging in size from 0.5 cm(2) to 1 cm(2). Two lesions were on the upper eyelid and one on the lower eyelid. ECT was performed using an 8-needle electrode and a CE approved electroporation generator with intra-lesional Bleomycin. All lesions responded to treatment. All BCC's completely resolved, with acceptable scarring. No side effects were reported from the Bleomycin or the electric pulses. ECT for peri-ocular BCC is an adjunct to surgical excision in the management of surgically problematic lesions. This technique could provide a useful initial treatment option for patients who are medically unfit or where resection and would be associated with significant morbidity.

A trial of intraoperative low-tidal-volume ventilation in abdominal surgery

BACKGROUND

Lung-protective ventilation with the use of low tidal volumes and positive end-expiratory pressure is considered best practice in the care of many critically ill patients. However, its role in anesthetized patients undergoing major surgery is not known.

METHODS

In this multicenter, double-blind, parallel-group trial, we randomly assigned 400 adults at intermediate to high risk of pulmonary complications after major abdominal surgery to either nonprotective mechanical ventilation or a strategy of lung-protective ventilation. The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within the first 7 days after surgery.

RESULTS

The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P=0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P=0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, -2.45 days; 95% CI, -4.17 to -0.72; P=0.006).

CONCLUSIONS

As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.).

An unusual presentation of giant pilomatrixoma in an adult patient

BACKGROUND

Pilomatrixoma (OMIM ID #132600) is a benign cutaneous tumor originating from the pilosebaceous follicle and characterized by the presence of subcutaneous nodules of up to 3.0 cm in diameter, usually on the head, neck and upper extremities. It is most common in the first two decades of life and after the age of 60.

MAIN OBSERVATIONS

An adult female patient was evaluated, presenting a solid tumoral lesion with erythematous surface and purplish tone, with approximately 7.5 x 5.0 cm in size, in the interscapulovertebral region. It was thought to be an epidermoid cyst, sarcoma, calcified hemangioma, giant dermatofibroma, or nodular basal cell carcinoma. The resection of the lesion was carried out and, at the histological examination, specific details were observed that led to the diagnosis of pilomatrixoma.

CONCLUSION

Pilomatrixoma should be suspected in the differential diagnosis of giant adnexal tumors.

The Revised Cardiac Risk Index in the new millennium: a single-centre prospective cohort re-evaluation of the original variables in 9,519 consecutive elective surgical patients

PURPOSE

Cardiac complications following non-cardiac surgery are major causes of morbidity and mortality. The Revised Cardiac Risk Index (RCRI) has become a standard for predicting post-surgical cardiac complications. This study re-examined the original six risk factors to confirm their validity in a large modern prospective database.

METHODS

Using the definitions in the original risk index, this study included 9,519 patients aged ≥ 50 undergoing elective non-cardiac surgery with an expected length of stay ≥ two days at two major tertiary-care teaching hospitals. The validity of the original predictors was tested in this population using binomial logistic regression modelling, area under the receiver operator curve (ROC) analysis, and the net reclassification index.

RESULTS

Rates of major cardiac complications with 0, 1, 2, ≥ 3 of the predictors were 0.5%, 2.6%, 7.2%, and 14.4%, respectively, in our patient cohort compared with 0.4%, 1.1%, 4.6%, and 9.7%, respectively, in the original cohort. Similar to the original report, binary logistic regression analysis showed that both preoperative treatment with insulin (odds ratio [OR] 1.4; 95% confidence interval [CI] 0.7 to 2.6) and preoperative creatinine > 176.8 mmol·L(-1) (OR 1.7; 95% CI 0.8 to 3.6) did not improve the predictive ability of the index. Analysis of the remaining four factors resulted in an area under the curve (AUC) identical to that seen for the reconstructed six-factor RCRI (AUC = 0.79). We found that a glomerular filtration rate (GFR) < 30 mL·min(-1) was a better predictor of major cardiac complications (OR 2.2; 95% CI 1.2 to 4.3) than creatinine > 176.8 mmol·L(-1). The receiver operating characteristic analysis of this resultant 5-Factor model resulted in an AUC of 0.79, with 0, 1, 2, ≥ 3 of the predictors representing 0.5%, 2.9%, 7.4%, and 17.0% risk, respectively, among our patient cohort.

CONCLUSION

Compared with the RCRI, a simplified 5-Factor model using a high-risk type of surgery, a history of ischemic heart disease, congestive heart failure, cerebrovascular disease, and a preoperative GFR < 30 mL·min(-1) results in superior prediction of major cardiac complications following elective non-cardiac surgery.

Association between age and use of intensive care among surgical Medicare beneficiaries

PURPOSE

The purpose of this study is to determine the role age plays in use of intensive care for patients who have major surgery.

MATERIALS AND METHODS

Retrospective cohort study examining the association between age and admission to an intensive care unit (ICU) for all Medicare beneficiaries 65 years or older who had a hospitalization for 1 of 5 surgical procedures: esophagectomy, cystectomy, pancreaticoduodenectomy, elective open abdominal aortic aneurysm repair (open AAA), and elective endovascular abdominal aortic aneurysm repair (endo AAA) from 2004 to 2008. The primary outcome was admission to an ICU. Secondary outcomes were complications and hospital mortality. We used multilevel mixed-effects logistic regression to adjust for other patient and hospital-level factors associated with each outcome.

RESULTS

The percentage of hospitalized patients admitted to ICU ranged from 41.3% for endo AAA to 81.5% for open AAA. In-hospital mortality also varied, from 1.1% for endo AAA to 6.8% for esophagectomy. After adjusting for other factors, age was associated with admission to ICU for cystectomy (adjusted odds ratio [AOR], 1.56 [95% confidence interval, 1.36-1.78] for age 80-84+ years; 2.25 [1.85-2.75] for age 85+ years compared with age 65-69 years), pancreaticoduodenectomy (AOR, 1.26 [1.06-1.50] for age 80-84 years; 1.49 [1.11-1.99] for age 85+ years), and esophagectomy (AOR, 1.26 [1.02-1.55] for age 80-84 years; 1.28 [0.91-1.80] age 85+ years). Age was not associated with use of intensive care for open AAA or endo AAA. Older age was associated with increases in complication rates and in-hospital mortality for all 5 surgical procedures.

CONCLUSIONS

The association between age and use of intensive care was procedure specific. Complication rates and in-hospital mortality increased with age for all 5 surgical procedures.

[Inappropriate use of health resources and the trivialisation of medicine]

One of the main problems of our health care system is its excessive use. The most evident results of this misuse are the waste of resources and the iatrogenic consequences that are not justified by any expectations in health improvement. Among the possible causes of this inappropriate use, the trivialization of medical practice should be emphasized. This entails not only a loss of respect and consideration, but facilitates and even stimulates reckless use. Although patients and health care workers are both responsible for this recklessness, politicians and health care managers should be held responsible more so. Without a real emancipation allowing health care users and the population to control the factors that determine their health, it is unlikely that the inappropriate use of health resources and its associated iatrogenic consequences will be reduced.

Dopexamine can attenuate the inflammatory response and protect against organ injury in the absence of significant effects on hemodynamics or regional microvascular flow

Introduction

The effects of dopexamine, a β2-agonist, on perioperative and sepsis-related hemodynamic, microvascular, immune, and organ dysfunction are controversial and poorly understood. We investigated these effects in a rodent model of laparotomy and endotoxemia.

Methods

In two experiments, 80 male Wistar rats underwent laparotomy. In 64 rats, this was followed by administration of endotoxin; the remainder (16) underwent sham endotoxemia. Endotoxemic animals received either dopexamine at 0.5, 1, or 2 μg/kg/min or 0.9% saline vehicle (controls) as resuscitation fluid. The effects of dopexamine on global hemodynamics, mesenteric regional microvascular flow, renal and hepatic function and immune activation were evaluated.

Results

Endotoxin administration was associated with a systemic inflammatory response (increased plasma levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, and IL-10, as well as cell-adhesion molecules CD11a and CD11b), and increased pulmonary myeloperoxidase (MPO) activity (indicating pulmonary leukocyte infiltration), whereas biochemical changes demonstrated lactic acidosis with significant renal and hepatic injury. Dopexamine administration was associated with less-severe lactic acidosis (pooled dopexamine versus controls, (lactate, 2.2 mM ± 0.2 mM versus 4.0 mM ± 0.5 mM; P < 0.001) and reductions in the systemic inflammatory response (pooled dopexamine versus control, 4 hour (TNF-α): 324 pg/ml ± 93 pg/ml versus 97 pg/ml ± 14 pg/ml, p < 0.01), pulmonary myeloperoxidase (MPO) activity, and hepatic and renal injury (pooled dopexamine versus control (ALT): 81 IU/L ± 4 IU/L versus 138 IU/L ± 25 IU/L; P < 0.05; (creatinine): 49.4 μM ± 3.9 μM versus 76.2 μM ± 9.8 μM; P < 0.005). However, in this study, clinically relevant doses of dopexamine were not associated with clinically significant changes in MAP, CI, or gut regional microvascular flow.

Conclusions

In this model, dopexamine can attenuate the systemic inflammatory response, reduce tissue leukocyte infiltration, and protect against organ injury at doses that do not alter global hemodynamics or regional microvascular flow. These findings suggest that immunomodulatory effects of catecholamines may be clinically significant when used in critically ill surgical patients and are independent of their hemodynamic actions.

Introduction to the postanaesthetic care unit

High-risk, noncardiac surgery represents only 12.5% of surgical procedures, but 83.3% of deaths. The postanaesthetic care unit (PACU) addresses the need for an improved level of care for these patients by providing postoperative high-dependency or intensive care (Level 2 or 3). The PACU aims to improve the structure of care provision for high-risk surgical patients. By maintaining 24-hour cover at the same staffing level, the risk of poorer ‘out-of- hours’ care is reduced. In a PACU, whose remit is solely postoperative care, evidence-based protocols can be established to standardize the care given. The aim is to provide 24 hours of postoperative optimized care, thus targeting the period when these patients are most vulnerable, to reduce the risk of complications developing and identify complications promptly, should they occur. The PACU is set up to facilitate certain processes to aid optimized care in the postoperative period. These include invasive and noninvasive ventilation, goal-directed haemodynamic management, invasive monitoring and optimal pain management. Identification of high-risk patients who might benefit from PACU care is not always straightforward. However, tools are available to aid the clinician, supplementing clinical assessment and basic investigations. These include clinical prediction rules and cardiopulmonary exercise testing. Both the setting up and the running of a PACU clearly have cost implications. However, the reduction in postoperative morbidity, and thus patients’ length of stay, should, overall, reduce costs. The benefits of a PACU should therefore be seen in terms of improved surgical outcomes, reducing postoperative morbidity and mortality, and cost savings.

The challenge of intra-abdominal sepsis

An overview of intra-abdominal sepsis is necessary at this time with new experimental studies, scoring systems and audits on management outcomes. The understanding of the pathophysiology of the peritoneum in the manifestation of surgical sepsis and the knowledge of the source of pathogenic organisms which reach the peritoneal cavity are crucial in the prevention of intra-abdominal infection. Inter-individual variation in the pattern of mediator release and of end-organ responsiveness may play a significant role in determining the initial physiological response to major sepsis and this in turn may be a key determinant of outcome. The ability to identify the presence of peritoneal inflammation probably has the greatest influence on the final surgical decision. The prevention of the progression of sepsis is by early goal-directed therapy and source control. Recent advances in interventional techniques for peritonitis have significantly reduced the morbidity and mortality of physiologically severe complicated abdominal infection. In the critically ill patients there is some evidence that the prevention of gut mucosal acidosis improves outcome. The aim of this review is to ascertain why intra-abdominal sepsis remains a major clinical challenge and how a better understanding of the pathophysiology may enable its prevention and better management.

METHOD

Electronic searches of the medline (PubMed) database, Cochrane library, and science citation index were performed to identify original published studies on intra-abdominal sepsis and the current management. Relevant articles were searched from relevant chapters in specialized texts and all included.

Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups

Patients with limited cardiac reserve are less likely to survive and develop more complications following major surgery. By augmenting oxygen delivery index (DO₂I) with a combination of intravenous fluids and inotropes (goal directed therapy (GDT)), postoperative mortality and morbidity of high-risk patients may be reduced. However, although most studies suggest that GDT may improve outcome in high-risk surgical patients, it is still not widely practiced. We set out to test the hypothesis that GDT results in greatest benefit in terms of mortality and morbidity in patients with the highest risk of mortality and have undertaken a systematic review of the current literature to see if this is correct. We performed a systematic search of Medline, Embase and CENTRAL databases for randomized controlled trials (RCTs) and reviews of GDT in surgical patients. To minimize heterogeneity we excluded studies involving cardiac, trauma, and paediatric surgery. Extremely high risk, high risk and intermediate risks of mortality were defined as >20%, 5 to 20% and <5% mortality rates in the control arms of the trials, respectively. Meta analyses were performed and Forest plots drawn using RevMan software. Data are presented as odd ratios (OR; 95% confidence intervals (CI), and P-values). A total of 32 RCTs including 2,808 patients were reviewed. All studies reported mortality. Five studies (including 300 patients) were excluded from assessment of complication rates as the number of patients with complications was not reported. The mortality benefit of GDT was confined to the extremely high-risk group (OR = 0.20, 95% CI 0.09 to 0.41; P < 0.0001). Complication rates were reduced in all subgroups (OR = 0.45, 95% CI 0.34 to 0.60; P < 0.00001). The morbidity benefit was greatest amongst patients in the extremely high-risk subgroup (OR = 0.27, 95% CI 0.15 to 0.51; P < 0.0001), followed by the intermediate risk subgroup (OR = 0.43, 95% CI 0.27 to 0.67; P = 0.0002), and the high-risk subgroup (OR 0.56, 95% CI 0.36 to 0.89; P = 0.01). Despite heterogeneity in trial quality and design, we found GDT to be beneficial in all high-risk patients undergoing major surgery. The mortality benefit of GDT was confined to the subgroup of patients at extremely high risk of death. The reduction of complication rates was seen across all subgroups of GDT patients.

Goal-directed therapy in cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Perioperative mortality after cardiac surgery has decreased in recent years although postoperative morbidity is still significant. Although there is evidence that perioperative goal-directed haemodynamic therapy (GDT) may reduce surgical mortality and morbidity in non-cardiac surgical patients, the data are less clear after cardiac surgery. The objective of this review is to perform a meta-analysis on the effects of perioperative GDT on mortality, morbidity, and length of hospital stay in cardiac surgical patients.

METHODS

We conducted a systematic review using Medline, EMBASE, and the Cochrane Controlled Clinical Trials Register. Additional sources were sought from experts. The inclusion criteria were randomized controlled trials, mortality reported as an outcome, pre-emptive haemodynamic intervention, and cardiac surgical population. Included studies were examined in full and subjected to quantifiable analysis, subgroup analysis, and sensitivity analysis where possible. Data synthesis was obtained by using odds ratio (OR) and mean difference (MD) for continuous data with 95% confidence interval (CI) utilizing a random-effects model.

RESULTS

From 4986 potential studies, 5 met all the inclusion criteria (699 patients). The quantitative analysis showed that the use of GDT reduced the postoperative complication rate (OR 0.33, 95% CI 0.15-0.73; P=0,006) and hospital length of stay (MD -2.44, 95% CI -4.03 to -0.84; P=0,003). There was no significant reduction in mortality.

CONCLUSION

The use of pre-emptive GDT in cardiac surgery reduces morbidity and hospital length of stay.

Safety in the operating theatre--a transition to systems-based care

All surgeons want the best, safest care for their patients, but providing this requires the complex coordination of multiple disciplines to ensure that all elements of care are timely, appropriate, and well organized. Quality-improvement initiatives are beginning to lead to improvements in the quality of care and coordination amongst teams in the operating room. As the population ages and patients present with more complex disease pathology, the demands for efficient systematization will increase. Although evidence suggests that postoperative mortality rates are declining, there is substantial room for improvement. Multiple quality metrics are used as surrogates for safe care, but surgical teams--including surgeons, anaesthetists, and nurses--must think beyond these simple interventions if they are to effectively communicate and coordinate in the face of increasing demands.

The impact of age on outcome after major surgical procedures

PURPOSE

The aim of this study was to investigate the effects of age on outcome in a large cohort of surgical intensive care unit (ICU) patients.

METHODS

In this retrospective analysis of prospectively collected data, all 11537 adult patients admitted directly from the operating room to our 50-bed surgical ICU between January 1, 2004, and January 31, 2009, were included. Patients were classified into 5 subgroups according to age (18-50 [reference category], 51-65, 66-75, 76-85, >85 years).

RESULTS

Severity scores and the incidence of comorbid conditions on ICU admission increased steadily with age. Intensive care unit and hospital mortality rates were 4.4% and 8.7%, respectively, and increased with age to reach 12.4% and 28.2%, respectively, in patients older than 85 years. In multivariate logistic regression analysis, age was an independent risk factor for in-hospital death (odds ratio, 1.04; 95% confidence interval, 1.03-1.04, per year; P < .001). Gastrointestinal surgery was independently associated with a higher risk of in-hospital mortality in patients older than 50 years, whereas neurosurgery was associated with a higher risk of in-hospital death only in patients older than 65 years.

CONCLUSIONS

Mortality rates increase with age, with an exponential increase in patients older than 65 years. Age is an independent risk factor for in-hospital death, irrespective of the type of surgical intervention.

Nutrition of the critically ill &#8212; a 21st-century perspective

Health care-induced diseases constitute a fast-increasing problem. Just one type of these health care-associated infections (HCAI) constitutes the fourth leading cause of death in Western countries. About 25 million individuals worldwide are estimated each year to undergo major surgery, of which approximately 3 million will never return home from the hospital. Furthermore, the quality of life is reported to be significantly impaired for the rest of the lives of those who, during their hospital stay, suffered life-threatening infections/sepsis. Severe infections are strongly associated with a high degree of systemic inflammation in the body, and intimately associated with significantly reduced and malfunctioning GI microbiota, a condition called dysbiosis. Deranged composition and function of the gastrointestinal microbiota, occurring from the mouth to the anus, has been found to cause impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins - bacterial endotoxins, as well as whole bacteria or debris of bacteria, the DNA of which are commonly found in most cells of the body, often in adipocytes of obese individuals or in arteriosclerotic plaques. Foods rich in proteotoxins such as gluten, casein and zein, and proteins, have been observed to have endotoxin-like effects that can contribute to dysbiosis. About 75% of the food in the Western diet is of limited or no benefit to the microbiota in the lower gut. Most of it, comprised specifically of refined carbohydrates, is already absorbed in the upper part of the GI tract, and what eventually reaches the large intestine is of limited value, as it contains only small amounts of the minerals, vitamins and other nutrients necessary for maintenance of the microbiota. The consequence is that the microbiota of modern humans is greatly reduced, both in terms of numbers and diversity when compared to the diets of our paleolithic forebears and the individuals living a rural lifestyle today. It is the artificial treatment provided in modern medical care - unfortunately often the only alternative provided - which constitute the main contributors to a poor outcome. These treatments include artificial ventilation, artificial nutrition, hygienic measures, use of skin-penetrating devices, tubes and catheters, frequent use of pharmaceuticals; they are all known to severely impair the microbiomes in various locations of the body, which, to a large extent, are ultimately responsible for a poor outcome. Attempts to reconstitute a normal microbiome by supply of probiotics have often failed as they are almost always undertaken as a complement to - and not as an alternative to - existing treatment schemes, especially those based on antibiotics, but also other pharmaceuticals.

Secondary use of routinely collected patient data in a clinical trial: an evaluation of the effects on patient recruitment and data acquisition

PURPOSE

Clinical trials are time-consuming and require constant focus on data quality. Finding sufficient time for a trial is a challenging task for involved physicians, especially when it is conducted in parallel to patient care. From the point of view of medical informatics, the growing amount of electronically available patient data allows to support two key activities: the recruitment of patients into the study and the documentation of trial data.

METHODS

The project was carried out at one site of a European multicenter study. The study protocol required eligibility assessment for 510 patients in one week and the documentation of 46-186 data elements per patient. A database query based on routine data from patient care was set up to identify eligible patients and its results were compared to those of manual recruitment. Additionally, routine data was used to pre-populate the paper-based case report forms and the time necessary to fill in the remaining data elements was compared to completely manual data collection.

RESULTS

Even though manual recruitment of 327 patients already achieved high sensitivity (88%) and specificity (87%), the subsequent electronic report helped to include 42 (14%) additional patients and identified 21 (7%) patients, who were incorrectly included. Pre-populating the case report forms decreased the time required for documentation from a median of 255 to 30s.

CONCLUSIONS

Reuse of routine data can help to improve the quality of patient recruitment and may reduce the time needed for data acquisition. These benefits can exceed the efforts required for development and implementation of the corresponding electronic support systems.

Nutrition of the critically ill - emphasis on liver and pancreas

About 25 million individuals undergo high risk surgery each year. Of these about 3 million will never return home from hospital, and the quality of life for many of those who return is often significantly impaired. Furthermore, many of those who manage to leave hospital have undergone severe life-threatening complications, mostly infections/sepsis. The development is strongly associated with the level of systemic inflammation in the body, which again is entirely a result of malfunctioning GI microbiota, a condition called dysbiosis, with deranged composition and function of the gastrointestinal microbiota from the mouth to the anus and impaired ability to maintain intact mucosal membrane functions and prevent leakage of toxins-bacterial endotoxins and whole or debris of bacteria, but also foods containing proteotoxins gluten, casein and zein and heat-induced molecules such as advanced glycation end products (AGEs) and advanced lipoxidation end products (ALEs). Markedly lower total anaerobic bacterial counts, particularly of the beneficial Bifidobacterium and Lactobacillus and higher counts of total facultative anaerobes such as Staphylococcus and Pseudomonas are often observed when analyzing the colonic microbiota. In addition Gram-negative facultative anaerobes are commonly identified microbial organisms in mesenteric lymph nodes and at serosal "scrapings" at laparotomy in patients suffering what is called "Systemic inflammation response system" (SIRS). Clearly the outcome is influenced by preexisting conditions in those undergoing surgery, but not to the extent as one could expect. Several studies have for example been unable to find significant influence of pre-existing obesity. The outcome seems much more to be related to the life-style of the individual and her/his "maintenance" of the microbiota e.g., size and diversity of microbiota, normal microbiota, eubiosis, being highly preventive. About 75% of the food Westerners consume does not benefit microbiota in the lower gut. Most of it, refined carbohydrates, is already absorbed in the upper part of the GI tract, and of what reaches the large intestine is of limited value containing less minerals, less vitamins and other nutrients important for maintenance of the microbiota. The consequence is that the microbiota of modern man has a much reduced size and diversity in comparison to what our Palelithic forefathers had, and individuals living a rural life have today. It is the artificial treatment provided by modern care, unfortunately often the only alternative, which belongs to the main contributor to poor outcome, among them; artificial ventilation, artificial nutrition, hygienic measures, use of skin penetrating devices, tubes and catheters, frequent use of pharmaceuticals, all known to significantly impair the total microbiome of the body and dramatically contribute to poor outcome. Attempts to reconstitute a normal microbiome have often failed as they have always been undertaken as a complement to and not an alternative to existing treatment schemes, especially treatments with antibiotics. Modern nutrition formulas are clearly too artificial as they are based on mixture of a variety of chemicals, which alone or together induce inflammation. Alternative formulas, based on regular food ingredients, especially rich in raw fresh greens, vegetables and fruits and with them healthy bacteria are suggested to be developed and tried.

Rational use of oxygen in medical disease and anesthesia

PURPOSE OF REVIEW

Supplemental oxygen is often administered during anesthesia and in critical illness to treat hypoxia, but high oxygen concentrations are also given for a number of other reasons such as prevention of surgical site infection (SSI). The decision to use supplemental oxygen is, however, controversial, because of large heterogeneity in the reported results and emerging reports of side-effects. The aim of this article is to review the recent findings regarding benefits and harms of oxygen therapy in anesthesia and acute medical conditions.

RECENT FINDINGS

Large randomized trials have not found significant reductions in SSI with 80% oxygen during and after abdominal surgery and cesarean section. There is no documented benefit of hyperbaric oxygen treatment for acute ischemic stroke, and there is emerging data to suggest increased mortality with normobaric supplemental oxygen for myocardial infarction without heart failure. Survival and neurologic outcome seem to be adversely affected by hyperoxia in patients with return of spontaneous circulation after cardiac arrest.

SUMMARY

The benefits of supplemental oxygen are not yet confirmed, and new findings suggest that potential side-effects should be considered if the inspired oxygen concentration is increased above what is needed to maintain normal arterial oxygen saturation.

Risk factors for nausea and vomiting after day care general anesthesia in mentally challenged patients undergoing dental treatment

Clinically, the incidence of postoperative nausea and vomiting (PONV) may be higher in mentally challenged patients than in normal healthy patients. The aim of this study was to investigate the risk factors for PONV after day care general anesthesia in mentally challenged patients undergoing dental treatment. We analyzed data on 231 day care general anesthesia cases involving mentally challenged patients undergoing dental treatment. Anesthetic records for the past 5 years were investigated retrospectively. Ten items (age, body weight, sex, duration of general anesthesia, use of propofol, use of sevoflurane, use of nitrous oxide, use of neostigmine, treatment accompanied with bleeding, and transfusion volume) were selected as risk factors for PONV. Postoperative nausea and vomiting was evaluated using the postoperative check sheet and linear discriminant analysis was performed to distinguish PONV incidence using the 10 items as independent variables. The reliability of the linear discriminant function was evaluated using a misjudgment rate and information criteria (AIC). Postoperative nausea and vomiting was observed in 13 cases out of 231 cases. The discriminant function with the smallest AIC (-25.0718) consisted of two independent variables: y=-0.077x(1)-0.001x(2)+0.0716(x(1)=use of propofol, x(2)=age). The misjudgment rate was 31.6%. This result suggests that PONV decreases when propofol is used and that the incidence of PONV decreases with age. To investigate other risk factors, an additional analysis was performed using 83 out of the 231 cases in which sevoflurane was used as an anesthetic agent. The results of the subgroup analysis suggest that the incidence of PONV decreases in male patients and higher weight patients, although the patient's body weight may be related to age, as the study cohort included many children. It is suggested that the major risks for PONV in mentally challenged patients after day care general anesthesia are no use of propofol, lower age, female sex and lower weight.

Fine needle aspiration cytology of pilomatrixoma

AIM

To delineate and characterize the cytomorphologic features of pilomatrixoma (PMX) helpful in correct diagnosis of the lesion on fine needle aspiration cytology (FNAC).

MATERIALS AND METHODS

Archival records of clinical findings, FNAC and histopathological reports of PMX cases were analyzed. Aspirate findings in 14 cases of PMX were correlated with detailed clinical data and subsequent histopathology on excisional biopsy. Different morphological findings were graded semiquantitatively from 0 to 3+.

RESULTS

The series showed female preponderance, with head and neck being the commonest site. Majority patients had a single tumor with mean size of 1.6 cm. Out of 14 biopsy proven cases of PMX, cytology findings revealed PMX in 7 cases on the basis of ghost cells, groups of basaloid cells, squamous cells in combination with multinucleated giant cells and calcium deposits in a background of debris. The main reasons for erroneous diagnosis were predominance of one component over the others and non-representative aspirated material.

CONCLUSIONS

The cytological features of PMX are characteristic and allow a conclusive diagnosis provided the smears are examined keenly bearing in mind the diagnostic traps that can mislead a cytopathologist.

Postoperative nausea and vomiting in a gynecological and obstetrical population in South Eastern Nigeria

BACKGROUND

To determine the incidence of Postoperative nausea and vomiting (PONV) in a high risk surgical group following studies in other predominately black populations that showed a lower rate of postoperative nausea and vomiting than that reported from Caucasian and Oriental populations.

METHODS

A retrospective observational survey was conducted in the University of Nigeria Teaching Hospital (UNTH), Enugu, Nigeria to determine the incidence of PONV within forty-eight hours of anesthesia in an obstetrical (caesarean sections only) and gynecological population that underwent regional and general anesthesia. The study took place from December 2007-April 2009 (16 months) for the gynecological population and from May 2008 to May 2010 (25 months) for the obstetrical population. The folders of 300 patients were randomly reviewed for demographics, anesthetic technique, diagnosis and documented records of PONV within 48 hours of anesthesia.

RESULTS

A total of 300 obstetrical and gynecological patients were used in this study. Twelve women vomited within forty-eight hours of anesthesia (12/300 or 4.0%). Nine patients vomited in the gynecological population (9/112) or 8% of the gynecological population and (3/186) or 1.6% in the obstetric population. All patients were American Society of Anesthesiologists (ASA) 1-4 including surgical emergencies.

CONCLUSION

The incidence of PONV in this surgical population is lower than that from most of the studies reviewed. This might be due to an inherent ethnic/racial variation. The economic implication of spending on expensive anti-emetics means more money can diverted to other needs.

Update on the management of postoperative nausea and vomiting and postdischarge nausea and vomiting in ambulatory surgery

Postoperative nausea and vomiting (PONV) continues to be one of the most common complaints following surgery, occurring in more than 30% of surgeries, or as high as 70% to 80% in certain high-risk populations without prophylaxis. The 5-hydroxytryptamine type 3 (5-HT(3)) receptor antagonists continue to be the mainstay of antiemetic therapy, but newer approaches, such as neurokinin-1 antagonists, a longer-acting serotonin receptor antagonist, multimodal management, and novel techniques for managing high-risk patients are gaining prominence. The related problem of postdischarge nausea and vomiting (PDNV) has received increasing attention from health care providers. The issues of PONV and PDNV are especially significant in the context of ambulatory surgeries, which comprise more than 60% of the combined 56.4 million ambulatory and inpatient surgery visits in the United States. Because of the relatively brief period that ambulatory patients spend in health care facilities, it is particularly important to prevent and treat PONV and PDNV swiftly and effectively.