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Negro M, Crisafulli O, D'Antona G. Effects of essential amino acid (EAA) and glutamine supplementation on skeletal muscle wasting in acute, subacute, and postacute conditions. Clin Nutr ESPEN 2024; 62:224-233. [PMID: 38843393 DOI: 10.1016/j.clnesp.2024.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/24/2024] [Accepted: 05/25/2024] [Indexed: 06/22/2024]
Abstract
Under optimal physiological conditions, muscle mass maintenance is ensured by dietary protein, which balances the amino acid loss during the post-absorption period and preserves the body's protein homeostasis. Conversely, in critical clinical conditions (acute, subacute or postacute), particularly those related to hypomobility or immobility, combined with malnutrition, and local/systemic inflammation, the loss of muscle mass and strength can be quantitatively significant. A decline of more than 1% in muscle mass and of more than 3% in muscle strength has been registered in subjects with aged 20-37 yr after just five days of bed rest, similarly to those observed during one year of age-related decline in individuals over the age of 50. Loss of muscle mass and strength can have a dramatic effect on subjects' functional capacities, on their systemic metabolic control and on the amino acid reserve function, all of which are fundamental for the maintenance of other organs' and tissues' cell processes. References available indicate that the average 1%-2% reduction per day of muscle mass in patients in the intensive care unit (ICU) could represent an independent predictor of hospital mortality and physical disability in the five years following hospitalization. After just a few days or weeks of administration, supplementation with EAAs and glutamine has shown significant effects in maintaining muscle size and strength, which are typically negatively affected by some acute/subacute or postacute critical conditions (muscle recovery after surgery, oncology patients, ICU treatments), especially in the elderly or in those with pre-existing degenerative diseases. In this review, we focused on the theoretical bases and the most relevant clinical studies of EAA and glutamine supplementation as a single compound, with the aim of clarifying whether their combined use in a blend (EAAs-glutamine) could be potentially synergistic to prevent disease-related muscle wasting and its impact on the duration and quality of patients' clinical course.
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Affiliation(s)
- Massimo Negro
- Centro di Ricerca Interdipartimentale nelle Attività Motorie e Sportive (CRIAMS) - Sport Medicine Centre, University of Pavia, Voghera, Italy
| | - Oscar Crisafulli
- Centro di Ricerca Interdipartimentale nelle Attività Motorie e Sportive (CRIAMS) - Sport Medicine Centre, University of Pavia, Voghera, Italy
| | - Giuseppe D'Antona
- Centro di Ricerca Interdipartimentale nelle Attività Motorie e Sportive (CRIAMS) - Sport Medicine Centre, University of Pavia, Voghera, Italy; Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, Italy.
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Griffin SB, Palmer MA, Strodl E, Lai R, Chuah TL, Burstow MJ, Ross LJ. Preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic for adults living with obesity undergoing gynaecology, laparoscopic cholecystectomy and hernia repair procedures: a pilot parallel randomised controlled trial. Br J Nutr 2024; 131:1436-1446. [PMID: 38220220 PMCID: PMC10950445 DOI: 10.1017/s0007114524000114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/05/2023] [Accepted: 01/08/2024] [Indexed: 01/16/2024]
Abstract
Obesity can increase the risk of postoperative complications. Despite increased demand for patients living with obesity to lose weight prior to common surgical procedures, the impact of intentional weight loss on surgical outcomes is largely unknown. We aimed to conduct a pilot study to assess the feasibility of a full-scale randomised controlled trial (RCT) to examine the effect of preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic on surgical outcomes in gynaecology and general surgeries. Between August 2021 and January 2023, a convenience sample of adults living with obesity (BMI ≥ 30 kg/m2) awaiting gynaecology, laparoscopic cholecystectomy and ventral hernia repair procedures were randomised to dietitian-led VLCD (800-1000 kcal using meal replacements and allowed foods), or control (no dietary intervention), 2-12 weeks preoperatively. Primary outcome was feasibility (recruitment, adherence, safety, attendance, acceptability and quality of life (QoL)). Secondary outcomes were anthropometry and 30-d postoperative outcomes. Outcomes were analysed as intention-to-treat. Fifty-one participants were recruited (n 23 VLCD, n 28 control), mean 48 (sd 13) years, 86 % female, and mean BMI 35·8 (sd 4·6) kg/m2. Recruitment was disrupted by COVID-19, but other thresholds for feasibility were met for VLCD group: high adherence without unfavourable body composition change, high acceptability, improved pre/post QoL (22·1 ± 15 points, < 0·001), with greater reductions in weight (-5·5 kg VLCD v. -0·9 kg control, P < 0·05) waist circumference (-6·6 cm VLCD v. +0·6 control, P < 0·05) and fewer 30-d complications (n 4/21) than controls (n 8/22) (P > 0·05). The RCT study design was deemed feasible in a public hospital setting. The dietitian-led VLCD resulted in significant weight loss and waist circumference reduction compared with a control group, without unfavourable body composition change and improved QoL.
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Affiliation(s)
- Sally B. Griffin
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD, Australia
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD, Australia
| | - Michelle A. Palmer
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD, Australia
| | - Esben Strodl
- School of Psychology and Counselling, Queensland University of Technology, Brisbane, QLD, Australia
| | - Rainbow Lai
- Department of Nutrition & Dietetics, Logan Hospital, Meadowbrook, QLD, Australia
| | - Teong L. Chuah
- Surgical and Critical Care Services, Logan Hospital, Meadowbrook, QLD, Australia
- Department of Surgery, Mater Hospital, South Brisbane, QLD, Australia
- Mayne Academy of Surgery, Faculty of Medicine, University of Queensland, St Lucia, QLD, Australia
| | - Matthew J. Burstow
- Surgical and Critical Care Services, Logan Hospital, Meadowbrook, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Lynda J. Ross
- School of Exercise and Nutrition Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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Bologheanu R, Schaubmayr W, Kimberger O, Duma A. Ultrasound evaluation of gastric emptying time of standardized high-calorie liquid meals in healthy adults: A double-blind cross-over randomized study. Clin Nutr ESPEN 2024; 59:264-269. [PMID: 38220385 DOI: 10.1016/j.clnesp.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND AND AIMS Commercially available high-calorie drinks containing fat and protein can be used as dietary supplements in surgical patients. According to preoperative fasting guidelines, high-calorie drinks are non-clear fluids and should not be consumed 6 h before elective procedures. The aim of this study was to evaluate the gastric emptying time of commercially available high-calorie drink formulations in healthy adults using gastric ultrasound. METHODS 25 healthy adult volunteers were included in this double-blind, cross-over prospective study. On three study sessions, fasted volunteers ingested one of the three study products: a solution of 75 g of glucose in 200 ml of water, a fat-free liquid meal, and a nutritionally complete liquid meal with equal volume and energy content. Gastric ultrasound examinations were performed to evaluate the gastric contents qualitatively and the volume of the gastric contents was calculated from the cross-sectional area of the gastric antrum measured in right lateral position by using a validated model. Repeated gastric ultrasounds were performed at baseline and half-hourly after ingesting the products in supine and right lateral position until the criteria for an empty stomach were met. RESULTS The glucose solution and the standard fat-free high-calorie drink with the same caloric content had a median gastric emptying time of 150 min. The nutritionally complete liquid meal had a median gastric emptying time of 180 min. Gastric emptying was complete in all participants before 6 h had elapsed since ingesting the study products. CONCLUSIONS High calorie liquid meals have a gastric emptying time longer than the recommended fasting time for clear fluids, but shorter than the recommended fasting time for solids in healthy adults.
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Affiliation(s)
| | | | - Oliver Kimberger
- Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Andreas Duma
- Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; University Hospital Tulln, Alter Ziegelweg 10, 3430, Tulln an der Donau, Lower Austria, Austria.
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Fyntanidou B, Amaniti A, Soulioti E, Zagalioti SC, Gkarmiri S, Chorti A, Loukipoudi L, Ioannidis A, Dalakakis I, Menni AE, Shrewsbury AD, Kotzampassi K. Probiotics in Postoperative Pain Management. J Pers Med 2023; 13:1645. [PMID: 38138872 PMCID: PMC10745134 DOI: 10.3390/jpm13121645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Postoperative pain is the unpleasant sensory and emotional experience after surgery, its origin being both the inflammatory reaction induced by the surgical trauma on the abdominal wall and the splanchnic pain induced by the activation of nociceptors of the viscera, which are highly sensitive to distension, ischemia, and inflammation. Nowadays, it is well recognized that there is a close relationship between the gut microbiome and pain perception, and that microbiome is highly affected by both anesthesia and surgical manipulation. Thus, efforts to restore the disturbed microbiome via supplementation with beneficial bacteria, namely probiotics, seem to be effective. In this article, the knowledge gained mainly from experimental research on this topic is analyzed, the concluding message being that each probiotic strain works in its own way towards pain relief.
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Affiliation(s)
- Barbara Fyntanidou
- Department of Emergency Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (B.F.); (S.-C.Z.); (S.G.)
| | - Aikaterini Amaniti
- Department of Anesthesia & Intensive Care, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.A.); (L.L.); (I.D.)
| | - Eleftheria Soulioti
- Second Department of Anesthesiology, National and Kapodistrian University of Athens, Attikon University Hospital, 12462 Athens, Greece;
| | - Sofia-Chrysovalantou Zagalioti
- Department of Emergency Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (B.F.); (S.-C.Z.); (S.G.)
| | - Sofia Gkarmiri
- Department of Emergency Medicine, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (B.F.); (S.-C.Z.); (S.G.)
| | - Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.C.); (A.I.); (A.-E.M.); (A.D.S.)
| | - Lamprini Loukipoudi
- Department of Anesthesia & Intensive Care, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.A.); (L.L.); (I.D.)
| | - Aris Ioannidis
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.C.); (A.I.); (A.-E.M.); (A.D.S.)
| | - Ioannis Dalakakis
- Department of Anesthesia & Intensive Care, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.A.); (L.L.); (I.D.)
| | - Alexandra-Eleftheria Menni
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.C.); (A.I.); (A.-E.M.); (A.D.S.)
| | - Anne D. Shrewsbury
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.C.); (A.I.); (A.-E.M.); (A.D.S.)
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece; (A.C.); (A.I.); (A.-E.M.); (A.D.S.)
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Mitaka C, Teranishi K, Wakita M, Misawa S, Nojiri S, Satoh D, Hayashida M. Incidences of and risk factors for clinical and subclinical contrast-associated acute kidney injury in patients who underwent neuroendovascular surgery. Neuroradiol J 2023; 36:601-609. [PMID: 37106524 PMCID: PMC10569205 DOI: 10.1177/19714009231173104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Contrast-associated acute kidney injury (CA-AKI) can develop after intravascular administration of iodinated contrast media. Neutrophil gelatinase-associated lipocalin (NGAL) is an early marker for AKI that helps to detect subclinical CA-AKI. We investigated the incidence of and risk factors for clinical and subclinical CA-AKI in patients who underwent neuroendovascular surgery. METHODS We retrospectively investigated 228 patients who underwent neuroendovascular surgery in 2020. Changes in serum creatinine and urine output were used to detect clinical CA-AKI. Urine NGAL concentration was used to detect subclinical CA-AKI in 67 out of 228 patients. RESULTS In 228 patients, serum creatinine, hemoglobin, hematocrit, total protein, and blood urea nitrogen (BUN) decreased significantly (p < 0.001) after surgery. However, serum creatinine decreased less significantly (p < 0.05) than hemoglobin, hematocrit, total protein, and BUN on postoperative Day 3. Two patients out of 228 developed clinical CA-AKI, and seven patients out of 67 with urine NGAL measurements developed subclinical CA-AKI. Multivariate regression analysis revealed that diabetes mellitus and carotid artery stenosis were significantly (p < 0.05) associated with the development of clinical and/or subclinical CA-AKI. CONCLUSION There was a large difference between the incidences of clinical CA-AKI (0.88%) and subclinical CA-AKI (10.4%). The difference might have primarily resulted from the different sensitivities between serum creatinine and urine NGAL and possibly from underestimation of the incidence of clinical AKI due to a postoperative decrease in serum creatinine caused by hemodilution. In addition to diabetes mellitus, carotid artery stenosis could also be a risk factor for CA-AKI.
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Affiliation(s)
- Chieko Mitaka
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Mitsuru Wakita
- Department of Clinical Laboratory, Juntendo University Hospital, Tokyo, Japan
| | - Shigeki Misawa
- Department of Clinical Laboratory Technology, Faculty Medical Science, Juntendo University, Tokyo, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Daizoh Satoh
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Abstract
Type 1 diabetes (T1D) is an increasingly common condition. Although often more effective, treatment regimens for patients with T1D have become more variable and complex with newer insulin analogues and increasing use of diabetes technology. Both surgery and anesthesia are known to trigger a stress response that causes dramatic metabolic changes in the patient that tend to increase glucose variability. Close monitoring of glucose levels and clear algorithms for insulin administration can ameliorate these characteristic responses. As T1D treatment technology becomes more effective at maintaining glucose in target range, there should be more consideration of using this technology during hospitalization and surgery.
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Affiliation(s)
- Grace B Nelson
- Pediatrics, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38105, USA.
| | - Kathryn M Sumpter
- Pediatrics, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38105, USA
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Hillman DR, Carlucci M, Charchaflieh JG, Cloward TV, Gali B, Gay PC, Lyons MM, McNeill MM, Singh M, Yilmaz M, Auckley DH. Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization. Anesth Analg 2023; 136:814-824. [PMID: 36745563 DOI: 10.1213/ane.0000000000006395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article addresses the issue of patient sleep during hospitalization, which the Society of Anesthesia and Sleep Medicine believes merits wider consideration by health authorities than it has received to date. Adequate sleep is fundamental to health and well-being, and insufficiencies in its duration, quality, or timing have adverse effects that are acutely evident. These include cardiovascular dysfunction, impaired ventilatory function, cognitive impairment, increased pain perception, psychomotor disturbance (including increased fall risk), psychological disturbance (including anxiety and depression), metabolic dysfunction (including increased insulin resistance and catabolic propensity), and immune dysfunction and proinflammatory effects (increasing infection risk and pain generation). All these changes negatively impact health status and are counterproductive to recovery from illness and operation. Hospitalization challenges sleep in a variety of ways. These challenges include environmental factors such as noise, bright light, and overnight awakenings for observations, interventions, and transfers; physiological factors such as pain, dyspnea, bowel or urinary dysfunction, or discomfort from therapeutic devices; psychological factors such as stress and anxiety; care-related factors including medications or medication withdrawal; and preexisting sleep disorders that may not be recognized or adequately managed. Many of these challenges appear readily addressable. The key to doing so is to give sleep greater priority, with attention directed at ensuring that patients' sleep needs are recognized and met, both within the hospital and beyond. Requirements include staff education, creation of protocols to enhance the prospect of sleep needs being addressed, and improvement in hospital design to mitigate environmental disturbances. Hospitals and health care providers have a duty to provide, to the greatest extent possible, appropriate preconditions for healing. Accumulating evidence suggests that these preconditions include adequate patient sleep duration and quality. The Society of Anesthesia and Sleep Medicine calls for systematic changes in the approach of hospital leadership and staff to this issue. Measures required include incorporation of optimization of patient sleep into the objectives of perioperative and general patient care guidelines. These steps should be complemented by further research into the impact of hospitalization on sleep, the effects of poor sleep on health outcomes after hospitalization, and assessment of interventions to improve it.
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Affiliation(s)
- David R Hillman
- From the West Australian Sleep Disorders Research Institute, Centre for Sleep Science, University of Western Australia, Perth, Western Australia, Australia
| | - Melissa Carlucci
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Jean G Charchaflieh
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Tom V Cloward
- Division of Sleep Medicine, Intermountain Health Care and Division of Pulmonary, Critical Care and Sleep Medicine, University of Utah, Salt Lake City, Utah
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Peter C Gay
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mayo Clinic, Rochester, Minnesota
| | - M Melanie Lyons
- Division of Pulmonary, Critical Care, and Sleep Medicine, the Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Mandeep Singh
- Department of Anesthesia, Women's College Hospital, and Toronto Western Hospital, University Health Network; University of Toronto, Toronto, Ontario, Canada
| | - Meltem Yilmaz
- Department of Anesthesiology, Northwestern University, Chicago, Illinois
| | - Dennis H Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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Ueyama H, Kanemoto N, Minoda Y, Taniguchi Y, Nakamura H. Perioperative Essential Amino Acid Supplementation Facilitates Quadriceps Muscle Strength and Volume Recovery After TKA: A Double-Blinded Randomized Controlled Trial. J Bone Joint Surg Am 2023; 105:345-353. [PMID: 36856692 DOI: 10.2106/jbjs.22.00675] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Perioperative essential amino acid (EAA) supplementation suppresses lower-limb muscle atrophy and promotes functional improvement in the first 4 weeks after total knee arthroplasty (TKA). However, its effect on the recovery of muscle volume and strength in the intermediate term is unclear. The aim of this study was to evaluate the effect of perioperative EAA supplementation on the recovery of lower-limb muscle volume and strength in the 2 years after TKA. METHODS Sixty patients who underwent unilateral TKA for primary knee osteoarthritis were included in this double-blinded randomized controlled trial. After excluding dropouts, 26 patients assigned to the EAA group (9 g/day) and 26 assigned to the placebo group (powdered lactose, 9 g/day) were available for analysis. Patients received EAA supplementation or a placebo from 1 week prior to surgery to 2 weeks after it. The rectus femoris muscle area was measured using ultrasonography and quadriceps muscle strength was measured isometrically with a handheld dynamometer, preoperatively and periodically up to 2 years postoperatively. Knee pain, knee range of motion, functional mobility, and Knee Society Score 2011 subjective scores were measured at each time point. Perioperative management, except for supplementation, was identical in the 2 groups. RESULTS Taking the baseline as 100%, the mean values in the EAA and placebo groups were 134% ± 31% and 114% ± 27%, respectively, for the rectus femoris muscle area and 159% ± 54% and 125% ± 40% for the quadriceps muscle strength, respectively, at 2 years after surgery. The differences were significant (p < 0.05). Clinical outcomes were not significantly different between the 2 groups. CONCLUSIONS Perioperative EAA supplementation contributes to the recovery of rectus femoris muscle volume and quadriceps muscle strength in the 2 years after TKA. The EAA supplementation did not impact clinical outcomes. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Hideki Ueyama
- Department of Orthopedic Surgery, Osaka Rosai Hospital, Sakai, Osaka, Japan.,Department of Orthopedic Surgery, Tanabe Central Hospital, Tanabe City, Wakayama, Japan.,Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka City, Japan
| | - Narihiro Kanemoto
- Department of Orthopedic Surgery, Tanabe Central Hospital, Tanabe City, Wakayama, Japan
| | - Yukihide Minoda
- Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka City, Japan
| | - Yoshiki Taniguchi
- Department of Orthopedic Surgery, Tanabe Central Hospital, Tanabe City, Wakayama, Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery, Osaka Metropolitan University Graduate School of Medicine, Osaka City, Japan
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Georges M, Engelhardt T, Ingelmo P, Mentegazzi F, Bertolizio G. Glycemic Stress Index: Does It Correlate with the Intensive Care Length of Stay? CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020328. [PMID: 36832457 PMCID: PMC9954865 DOI: 10.3390/children10020328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/11/2023]
Abstract
Postoperative hyperglycemia is an independent risk factor for postoperative complications. In adults, perioperative hyperglycemia is influenced by prolonged fasting, but data in children are lacking. The Glycemic Stress Index (GSI) has been shown to predict prolonged Pediatric Intensive Care Unit (PICU) stays in neurosurgical patients. This study aimed to confirm the correlation between GSI and duration of intubation, PICU stay, and postoperative complications in infants undergoing elective open heart surgery. The correlation between preoperative fasting and GSI was also investigated. METHODS A retrospective chart review of 85 infants ≤ 6 months undergoing elective open heart surgery was performed. GSI values ≥ 3.9 and 4.5 were tested to determine whether they carried a higher incidence of postoperative complications (metabolic uncoupling, kidney injury, ECMO, and death). The correlation between GSI and the length of intubation, PICU stay, and duration of fasting were also investigated. Perioperative factors such as age, weight, blood gas analysis, use of inotropes, and risk adjustment for congenital heart surgery were also analyzed as possible predictors. RESULTS GSI correlated with the duration of intubation and PICU stay. A GSI ≥ 4.5, but not 3.9, was associated with a higher incidence of metabolic uncoupling. GSI was not influenced by preoperative fasting. None of the preoperative patient factors analyzed was associated with prolonged intubation, PICU stay, or PICU complications. An abnormal creatinine before surgery increased the risk of developing acute kidney injury postoperatively. CONCLUSIONS GSI may be valuable to predict prolonged intubation, PICU stay, and metabolic derangement in infants undergoing cardiac surgery. Fasting does not appear to affect GSI.
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Affiliation(s)
- Mathieu Georges
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
| | - Thomas Engelhardt
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
- Correspondence: ; Tel.: +1-(514)-412-4400 (ext. 24453); Fax: +1-(514)-938-7399
| | - Pablo Ingelmo
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
| | - Federico Mentegazzi
- Intensive Care Medicine, Queens Hospital, BHR University Hospital, Romford RM7 0AG, UK
| | - Gianluca Bertolizio
- Department of Anesthesia, Montreal Children’s Hospital, McGill University, Montreal, QC H4A 3J1, Canada
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Does Exercise Training Improve Physical Fitness and Health in Adult Liver Transplant Recipients? A Systematic Review and Meta-analysis. Transplantation 2023; 107:e11-e26. [PMID: 36192838 DOI: 10.1097/tp.0000000000004313] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The impaired physical fitness of end-stage liver disease patients often persists after liver transplantation (LT) and compromises posttransplant recovery. This systematic review and meta-analysis evaluated evidence supporting the potential of exercise training to improve physical fitness and health-related quality of life (HRQOL) after LT. METHODS Bibliographic searches identified all randomized controlled trials (RCTs) comparing aerobic and strength training versus usual care after LT. Risk of bias was assessed, and study outcomes measuring physical fitness and HRQOL were extracted. Meta-analysis was performed if at least 3 studies reported on an outcome. RESULTS Eight RCTs (n = 334) were identified. Methodological study quality varied and was poorly reported. Meta-analyses showed a trend for favorable effects of exercise on cardiorespiratory fitness (peak oxygen uptake or 6-min walking distance; 6 studies, n = 275; standardized mean difference: 0.23, 95% confidence interval [CI], -0.01 to 0.48) and of strength training either or not combined with aerobic training on muscular fitness (dynamometry-assessed muscle strength or 30-s sit-to-stand test; 3 studies, n = 114; standardized mean difference: 0.34, 95% CI, -0.03 to 0.72). A favorable effect was found for exercise on the Short-Form Health Survey-36 HRQOL physical function subcomponent (3 studies, n = 194; mean difference: 9.1, 95% CI, 0.3-17.8). No exercise-related adverse events were observed. CONCLUSIONS RCTs indicate that exercise training in LT recipients is safe, improves physical function aspects of HRQOL, and may benefit cardiorespiratory and muscular fitness. The strength of evidence is, however, limited by the low number of patients and study quality. More adequately powered, high-quality RCTs are warranted.
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Mihalj M, Karlović Z, Vladić-Spaić D, Matić B, Mikulić I, Mikulić V, Golubović V. Effects of midazolam co-induction to general anesthesia: A randomized clinical trial. Medicine (Baltimore) 2022; 101:e31400. [PMID: 36397390 PMCID: PMC9666170 DOI: 10.1097/md.0000000000031400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND This study aimed to determine the potential advantages of midazolam co-induction with general anesthesia (GA) over the use of propofol alone. METHODS We conducted a randomized, placebo-controlled, single-blinded clinical trial of 102 patients, aged 18 to 65, American Society of Anesthesiologists II and III, who underwent elective laparoscopic gallbladder surgery. Patients were randomly divided into 3 groups: the placebo group (C) received 1 mL of 0.9% saline intravenously and the test groups received intravenous midazolam at doses of 0.03 mg/kg (M1) or 0.06 mg/kg (M2) before induction of GA. We assessed effects of midazolam co-induction on arterial pressure and heart rate (HR) in the early stage of GA prior to surgical incision and effects on perioperative and postoperative glycemia and cortisol levels. Systolic/mean/diastolic (SAP/MAP/DAP) arterial pressure and HR were measured 4 times (preoperative, on the third, sixth and ninth minute after atracurium administration). Cortisol was measured on 3 occasions (preoperatively, 60 minutes after surgical incision, and the following morning) and glucose on 4 occasions (preoperatively, 15 and 60 minutes after incision, and the following morning). We also assessed the incidence of postoperative anxiety, postoperative nausea and vomiting (PONV), and propofol requirement for induction. RESULTS SAP/MAP/DAP were significantly higher in M2 immediately after induction compared to the other study groups (P = .002/.004/.013). Midazolam co-induction led to a significant reduction in postoperative anxiety (P = .03), reduced cortisol concentration 60 minutes after surgical incision (P < .001) and propofol requirements (P < .001). CONCLUSION SUBSECTIONS Midazolam co-induction prevented a marked decline in SAP/MAP/DAP immediately after induction of GA, led to reduced postoperative anxiety and cortisol response to surgery, and reduced propofol requirements for induction.
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Affiliation(s)
- Mirko Mihalj
- Department for Anesthesia and Intensive Care, University Clinical Hospital Mostar, KraljaTvrtka bb, Mostar, Bosnia and Herzegovina
- *Correspondence: Mirko Mihalj, Department for Anesthesia and Intensive Care, University Clinical Hospital Mostar, KraljaTvrtka bb, 88000 Mostar, Bosnia and Herzegovina (e-mail: )
| | - Zoran Karlović
- Department for Anesthesia and Intensive Care, University Clinical Hospital Mostar, KraljaTvrtka bb, Mostar, Bosnia and Herzegovina
| | - Dajana Vladić-Spaić
- Department for Anesthesia and Intensive Care, University Clinical Hospital Mostar, KraljaTvrtka bb, Mostar, Bosnia and Herzegovina
| | - Boris Matić
- Department for Anesthesia and Intensive Care, University Clinical Hospital Mostar, KraljaTvrtka bb, Mostar, Bosnia and Herzegovina
| | - Iva Mikulić
- Clinic for Surgery, University Clinical Hospital Mostar, Kralja Tvrtka bb, Mostar, Bosnia and Herzegovina
| | - Vinka Mikulić
- Department for Laboratory Diagnostics, University Clinical Hospital Mostar, Kralja Tvrtka bb, Mostar, Bosnia and Herzegovina
| | - Vesna Golubović
- The Faculty of Medicine of the University of Rijeka, Rijeka, Croatia
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Stavrou G, Tzikos G, Menni AE, Chatziantoniou G, Vouchara A, Fyntanidou B, Grosomanidis V, Kotzampassi K. Endothelial Damage and Muscle Wasting in Cardiac Surgery Patients. Cureus 2022; 14:e30534. [PMID: 36415406 PMCID: PMC9675898 DOI: 10.7759/cureus.30534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/06/2022] Open
Abstract
This is a post-hoc analysis to assess the effect of anesthesia, surgical trauma, and extracorporeal circuit on endothelial integrity, microvascular permeability, and extracellular fluid balance, as well as on skeletal muscle catabolism, in patients undergoing elective cardiac surgery. We included 127 well-nourished patients undergoing “on-pump” elective cardiac surgery. One day prior to surgery (D0) and again on postoperative day 7 (POD7), body mass index, body composition assessment, hand-grip strength (HGS), and mid-upper arm muscle circumference (MAMC) were measured. Patients were assigned to early recovery (ER) and late recovery (LR) groups, depending on the duration of ICU stay (cut-off 48 hours). The magnitude of change (Δ) in all parameters studied was assessed in ER versus LR groups, regarding (i) epithelial tissue dysfunction (Δ-Extra-Cellular Water percentage (Δ-ECW%), Δ-Phase Angle (Δ-PhA)), (ii) skeletal muscle mass catabolism (Δ-Skeletal muscle mass reduction%, Δ-Hand Grip Strength (Δ-HGS) and Δ-Mid Upper-Arm Muscle Circumference (Δ-MAMC)). Baseline measurements were similar in both groups. A significant difference was observed in all Δ-parameters studied (Δ-ECW%, Δ-PhA and muscle catabolism, Δ-HGS, Δ-MAMC), the worse results being correlated to the LR group. The results raise the issue that patients with early recovery may silently have pathological conditions, continuing even on the day of discharge - further research should be planned.
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Shen ZL, Liu Z, Zhang P, Chen WZ, Dong WX, Chen WH, Lin F, Zang WF, Yan XL, Yu Z. Prognostic significance of postoperative loss of skeletal muscle mass in patients underwent coronary artery bypass grafting. Front Nutr 2022; 9:970729. [PMID: 36118747 PMCID: PMC9478409 DOI: 10.3389/fnut.2022.970729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background Increasing life expectancy of coronary artery bypass grafting (CABG) remains to be the major concern of cardiac surgeons. However, few studies have investigated the effect of postoperative skeletal muscle index (SMI) loss on prognosis. This study aims to evaluate the prognostic role of postoperative SMI loss ≥ 5% after CABG, in order to develop a novel nomogram to predict overall survival (OS). Methods Patients underwent CABG via midline sternotomy from December 2015 to March 2021 were recruited in this study. Preoperative and postoperative 3 months chest computed tomography (CT) images were compared to assess changes in SMI at T12 level. Based on this, patients were classified into the presence or absence of SMI loss ≥ 5%. The association between postoperative SMI loss ≥ 5% and OS was then analyzed by the Kaplan-Meier curves and Cox model. A novel nomogram incorporating independent clinical prognostic variables was also developed. Results The study enrolled 506 patients receiving CABG, of whom 98 patients experienced T12 SMI loss ≥ 5% and had a significantly worse OS (P < 0.0001). Multivariate regression analysis showed that T12 SMI per cent change (%T12 SMI-change) was an independent prognostic factor for OS (HR = 0.809, 95% CI = 0.749–0.874). The nomogram incorporating %T12 SMI-change with other variables was accurate for predicting OS. Besides, we also found that postoperative oral nutritional supplement (ONS) can rescue T12 SMI loss. Conclusion Postoperative SMI loss can predict survival outcome after CABG. The nomogram incorporating changes in SMI provides a superior performance than existing systems.
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Affiliation(s)
- Zi-Le Shen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhang Liu
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Peng Zhang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei-Zhe Chen
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wen-Xi Dong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wen-Hao Chen
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Feng Lin
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wang-Fu Zang
- Department of Cardio-Thoracic Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- *Correspondence: Wang-Fu Zang,
| | - Xia-Lin Yan
- Department of Colorectal Anal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Xia-Lin Yan,
| | - Zhen Yu
- Department of Gastrointestinal Surgery, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Zhen Yu,
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14
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Li X, Tang K, Cui C, Huang P. Nutrition protocol implemented in ERAS of hypopharyngeal cancer: a single center nutrition protocol in China. INTERNATIONAL JOURNAL OF FOOD PROPERTIES 2022. [DOI: 10.1080/10942912.2022.2078837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Xuelong Li
- Department of Clinical Nutrition, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Shandong, China
| | - Kun Tang
- Department of Surgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Shandong, China
| | - Changxing Cui
- Department of Surgery, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Shandong, China
| | - Peng Huang
- Department of Cardiovascular Medicine, the Affiliated Yantai Yuhuangding Hospital of Qingdao University, Shandong, China
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15
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The effects of body mass index on insulin resistance in patients undergoing total hip arthroplasty: a pilot study. INTERNATIONAL ORTHOPAEDICS 2022; 46:1775-1782. [PMID: 35513548 DOI: 10.1007/s00264-022-05423-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/30/2022] [Indexed: 02/05/2023]
Abstract
PURPOSE We aimed to examine the effects of body mass index (BMI) on insulin resistance (IR), glycaemic control and adverse events in patients undergoing total hip arthroplasty (THA). METHODS A total of 118 patients undergoing THA were enrolled in this prospective cohort study and divided into two groups based on their BMI: Group A (n = 50, 18.5 ≤ BMI < 24 kg/m2) and Group B (n = 68, BMI ≥ 24 kg/m2). IR was calculated using Homeostasis Model Assessment 2 (HOMA2). Insulin resistance indicators, fasting plasma glucose (FPG), inflammatory markers, blood loss, length of stay and complications were compared between the two groups. RESULTS Multivariate analysis using generalized estimating equations revealed that BMI and surgery stress were risk factors for IR (P < 0.001). These two factors exhibited significant interactions for HOMA2-IR on post-operative day one (Exp (B) = 1.880, P = 0.003), accompanied by a higher level of FPG (Group B versus Group A, P = 0.004). Furthermore, subgroup analysis based on the IR value demonstrated that patients in Group B with a HOMA2-IR greater than 2.25 after surgery were at increased risk of wound complications (P = 0.045). Similarly, our results showed that the rate of post-operative hyperglycaemia was notably higher in Group B than in Group A (P = 0.013). CONCLUSION Patients with high BMI may experience significantly elevated IR and increased risk of hyperglycaemia and wound complications after THA. Therefore, routine glycaemia monitoring should be suggested for those patients during peri-operative period to optimize surgical stress management.
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Takeuchi K, Hayashida M, Kudoh O, Niimi N, Kataoka K, Kakemizu-Watanabe M, Yamamoto M, Hara A, Kawagoe I, Yamaguchi K. Continuing versus withholding angiotensin receptor blocker (ARB)/calcium channel blocker (CCB) combination tablets during perioperative periods in patients undergoing minor surgery: a single-blinded randomized controlled trial. J Anesth 2022; 36:374-382. [PMID: 35247102 PMCID: PMC9156462 DOI: 10.1007/s00540-022-03053-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
Purpose This trial was conducted to compare effects of continuing versus withholding single-pill combination tablets consisting of angiotensin receptor blockers (ARBs) and calcium channel blockers (CCBs) on perioperative hemodynamics and clinical outcomes. Methods Patients undergoing minor abdominal or urological surgery (n = 106) were randomly assigned to Group C, in which ARB/CCB combination tablets were continued until surgery, or Group W, in which they were withheld within 24 h of surgery. Perioperative hemodynamics and clinical outcomes were compared between the Groups. Results The incidence of hypotension during anesthesia requiring repeated treatment with vasoconstrictors was higher in Group C than Group W (p = 0.0052). Blood pressure during anesthesia was generally lower in Group C than Group W (p < 0.05) despite significantly more doses of ephedrine and phenylephrine administrated in Group C (p = 0.0246 and p = 0.0327, respectively). The incidence of postoperative hypertension did not differ between Groups (p = 0.3793). Estimated glomerular filtration rate (eGFR) on the preoperative day did not differ between Groups (p = 0.7045), while eGFR was slightly lower in Group C than Group W on the first and third postoperative days (p = 0.0400 and p = 0.0088, respectively), although clinically relevant acute kidney injury did not develop. Conclusions Continuing ARB/CCB combination tablets preoperatively in patients undergoing minor surgery increased the incidence of hypotension during anesthesia, increased requirements of vasoconstrictors to treat hypotension, and might deteriorate postoperative renal function, albeit slightly. These results suggest that withholding ARB/CCB tablets preoperatively is preferable to continuing them. Clinical trial registration This trial is registered with the Japan Registry of Clinical Trials (jRCT) at Japanese Ministry of Health, Labour, and Welfare (Trial ID: jRCT1031190027).
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Affiliation(s)
- Kazuyo Takeuchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Naoko Niimi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Kumi Kataoka
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Maho Kakemizu-Watanabe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Makiko Yamamoto
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Atsuko Hara
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Keisuke Yamaguchi
- Department of Anesthesiology and Pain Medicine, Juntendo University Graduate School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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17
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Jaconelli M, Greenhaff PL, Atherton PJ, Lobo DN, Brook MS. The effects of elective abdominal surgery on protein turnover: A meta-analysis of stable isotope techniques to investigate postoperative catabolism. Clin Nutr 2022; 41:709-722. [PMID: 35168004 PMCID: PMC8902515 DOI: 10.1016/j.clnu.2022.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/19/2022] [Accepted: 01/25/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND & AIMS Elective surgery induces skeletal muscle wasting driven by an imbalance between muscle protein synthesis and breakdown. From examination of diverse stable isotope tracer techniques, the dynamic processes driving this imbalance are unclear. This meta-analysis aimed to elucidate the mechanistic driver(s) of postoperative protein catabolism through stable isotope assessment of protein turnover before and after abdominal surgery. METHODS Meta-analysis was performed of randomized controlled trials and cohort studies in patients undergoing elective abdominal surgery that contained measurements of whole-body or skeletal muscle protein turnover using stable isotope tracer methodologies pre- and postoperatively. Postoperative changes in protein synthesis and breakdown were assessed through subgroup analysis of tracer methodology and perioperative care. RESULTS Surgery elicited no overall change in protein synthesis [standardized mean difference (SMD) -0.47, 95% confidence interval (CI): -1.32, 0.39, p = 0.25]. However, subgroup analysis revealed significant suppressions via direct-incorporation methodology [SMD -1.53, 95%CI: -2.89, -0.17, p = 0.03] within skeletal muscle. Changes of this nature were not present among arterio-venous [SMD 0.61, 95%CI: -1.48, 2.70, p = 0.58] or end-product [SMD -0.09, 95%CI: -0.81, 0.64, p = 0.82] whole-body measures. Surgery resulted in no overall change in protein breakdown [SMD 0.63, 95%CI: -0.06, 1.32, p = 0.07]. Yet, separation by tracer methodology illustrated significant increases in urinary end-products (urea/ammonia) [SMD 0.70, 95%CI: 0.38, 1.02, p < 0.001] that were not present among arterio-venous measures [SMD 0.67, 95%CI: -1.05, 2.38, p = 0.45]. CONCLUSIONS Elective abdominal surgery elicits suppressions in skeletal muscle protein synthesis that are not reflected on a whole-body level. Lack of uniform changes across whole-body tracer techniques are likely due to contribution from tissues other than skeletal muscle.
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Affiliation(s)
- Matthew Jaconelli
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Centre, Nottingham, UK; School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Paul L Greenhaff
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Centre, Nottingham, UK; School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Philip J Atherton
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; School of Medicine, University of Nottingham, Royal Derby Hospital, Derby, UK
| | - Dileep N Lobo
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK; Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Matthew S Brook
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, Metabolic and Molecular Physiology, University of Nottingham, Queen's Medical Centre, Nottingham, UK; School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
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Machado P, Pimenta S, Oliveiros B, Ferreira JP, Martins RA, Cruz J. Effect of Exercise Training on Quality of Life after Colorectal and Lung Cancer Surgery: A Meta-Analysis. Cancers (Basel) 2021; 13:4975. [PMID: 34638459 PMCID: PMC8508091 DOI: 10.3390/cancers13194975] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 01/01/2023] Open
Abstract
Surgical treatment affects health-related quality of life (HRQoL) and increases fatigue symptoms in patients with lung cancer (LC) and colorectal cancer (CRC). We aimed to systematically review the effect of exercise training on HRQoL and fatigue after LC and CRC surgery. Randomized controlled trials published before 21 March 2021, were searched in PubMed, Scopus, Web of Science, SPORTDiscus and PEDro. Eligible trials compared the effect of exercise interventions initiated preoperatively or in the first 3 months after surgery versus usual care on postoperative HRQoL and fatigue. Standardized mean differences (SMD) were pooled using random-effects models. Twelve studies with a total of 777 patients were included. In LC patients (10 studies, n = 651), exercise training in general led to a moderate improvement in the physical domain of HRQoL (0.68: 95% CI: [0.47; 0.89]) and a small reduction in fatigue levels after surgery (SMD = 0.28: 95% CI: [0.02; 0.53]), while no effects were found in other HRQoL domains. In CRC (two studies, n = 126), exercise training showed no effects on HRQoL and fatigue after surgery. Exercise training is an effective intervention to improve physical function and fatigue after LC surgery. Further studies are necessary to clarify the effects of exercise on HRQoL and fatigue after CRC surgery.
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Affiliation(s)
- Pedro Machado
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Sara Pimenta
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
| | - Bárbara Oliveiros
- Laboratory of Biostatistics and Medical Informatics (LBIM), Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal;
- Faculty of Medicine, Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3000-548 Coimbra, Portugal
- Institute for Biomedical Imaging and Translational Research (CIBIT), University of Coimbra, 3000-548 Coimbra, Portugal
| | - José Pedro Ferreira
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Raul A. Martins
- University of Coimbra, Research Unit for Sport and Physical Activity (CIDAF, UID/PTD/04213/2019), Faculty of Sport Sciences and Physical Education, 3040-248 Coimbra, Portugal; (J.P.F.); (R.A.M.)
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences of the Polytechnic of Leiria, 2411-901 Leiria, Portugal; (S.P.); (J.C.)
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Papageorgiou V, Ververidis C, Anagnostou T, Savvas I, Kazakos G. Use of propofol to induce food consumption by anorectic dogs following ovariohysterectomy. J Am Vet Med Assoc 2021; 259:56-61. [PMID: 34125612 DOI: 10.2460/javma.259.1.56] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether IV propofol administration at a dose of 2 mg/kg (0.9 mg/lb) could induce food consumption by anorectic female dogs following elective ovariohysterectomy. ANIMALS 51 healthy female dogs that failed to eat voluntarily when food was offered 6 hours after ovariohysterectomy. PROCEDURES In a randomized, blinded, controlled clinical trial, dogs received propofol (2 mg/kg; n = 31) or an equivalent volume of saline (0.9% NaCl) solution (20) IV 6 hours after ovariohysterectomy. Afterward, food was offered to the dogs and food consumption was reassessed. Pain, sedation, and stress were scored before and immediately after treatment. RESULTS 27 of the 31 (87%) dogs in the propofol group consumed food immediately after administration of the assigned treatment, whereas only 1 of 20 (5%) dogs in the placebo group did. No difference in pain, sedation, or stress scores was identified between the 2 groups. Sedation scores for dogs in the propofol group increased immediately after propofol administration. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that food consumption following elective surgical procedures can be effectively induced in anorectic female dogs by IV administration of propofol at a dose of 2 mg/kg.
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Bourazani M, Asimakopoulou E, Magklari C, Fyrfiris N, Tsirikas I, Diakoumis G, Kelesi M, Fasoi G, Kormas T, Lefaki G. Developing an enhanced recovery after surgery program for oncology patients who undergo hip or knee reconstruction surgery. World J Orthop 2021; 12:346-359. [PMID: 34189073 PMCID: PMC8223725 DOI: 10.5312/wjo.v12.i6.346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 02/06/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) protocols are applied in orthopedic surgery and are intended to reduce perioperative stress by implementing combined evidence-based practices with the cooperation of various health professionals as an interdisciplinary team. ERAS pathways include pre-operative patient counselling, regional anesthesia and analgesia techniques, post-operative pain management, early mobilization and early feeding. Studies have shown improvement in the recovery of patients who followed an ERAS program after hip or knee arthroplasty, compared with those who followed a traditional care approach. ERAS protocols reduce post-operative stress, contribute to rapid recovery, shorten length of stay (LOS) without increasing the complications or readmissions, improve patient satisfaction and decrease the hospital costs. We suggest that the ERAS pathway could reduce the LOS in hospital for patients undergoing total hip replacement or total knee replacement. These programs require good organization and handling by the multidisciplinary team. ERAS programs increase patient's satisfaction due to their active participation which they experience as personalized treatment. The aim of the study was to develop an ERAS protocol for oncology patients who undergo bone reconstruction surgeries using massive endoprosthesis, with a view to improving the surgical outcomes.
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Affiliation(s)
- Maria Bourazani
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Eleni Asimakopoulou
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Chrysseida Magklari
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Nikolaos Fyrfiris
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | | | - Giakoumis Diakoumis
- Orthopedic Clinic, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Martha Kelesi
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Georgia Fasoi
- Department of Nursing, University of West Attica, Athens 12243, Attica, Greece
| | - Theodoros Kormas
- Orthopedic Clinic, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
| | - Gunhild Lefaki
- Department of Anesthesiology, “Saint-Savvas” Anticancer Hospital of Athens, Athens 11522, Attica, Greece
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van Wijk L, van Duinhoven S, Liem MSL, Bouman DE, Viddeleer AR, Klaase JM. Risk factors for surgery-related muscle quantity and muscle quality loss and their impact on outcome. Eur J Med Res 2021; 26:36. [PMID: 33892809 PMCID: PMC8063361 DOI: 10.1186/s40001-021-00507-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 04/10/2021] [Indexed: 12/25/2022] Open
Abstract
Background Surgery-related loss of muscle quantity negatively affects postoperative outcomes. However, changes of muscle quality have not been fully investigated. A perioperative intervention targeting identified risk factors could improve postoperative outcome. This study investigated risk factors for surgery-related loss of muscle quantity and quality and outcomes after liver resection for colorectal liver metastasis (CRLM). Methods Data of patients diagnosed with CRLM who underwent liver resection between 2006 and 2016 were analysed. Muscle quantity (psoas muscle index [PMI]), and muscle quality, (average muscle radiation attenuation [AMA] of the psoas), were measured using computed tomography. Changes in PMI and AMA of psoas after surgery were assessed. Results A total of 128 patients were analysed; 67 (52%) had surgery-related loss of muscle quantity and 83 (65%) muscle quality loss. Chronic obstructive pulmonary disease (COPD) (P = 0.045) and diabetes (P = 0.003) were risk factors for surgery-related loss of muscle quantity. A higher age (P = 0.002), open resection (P = 0.003) and longer operation time (P = 0.033) were associated with muscle quality loss. Overall survival was lower in patients with both muscle quantity and quality loss compared to other categories (P = 0.049). The rate of postoperative complications was significantly higher in the group with surgery-related loss of muscle quality. Conclusions Risk factors for surgery-related muscle loss were identified. Overall survival was lowest in patients with both muscle quantity and quality loss. Complication rate was higher in patients with surgery-related loss of muscle quality.
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Affiliation(s)
- Laura van Wijk
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, the Netherlands.
| | - Stijn van Duinhoven
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, the Netherlands
| | - Mike S L Liem
- Department of Surgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, the Netherlands
| | - Donald E Bouman
- Department of Radiology, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, the Netherlands
| | - Alain R Viddeleer
- Department of Radiology, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, the Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Hanzeplein 1, PO Box 30001, 9700 RB, Groningen, the Netherlands.,Department of Surgery, Medisch Spectrum Twente, Koningsplein 1, 7512 KZ, Enschede, the Netherlands
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22
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Argillander TE, Spek D, van der Zaag-Loonen HJ, van Raamt AF, van Duijvendijk P, van Munster BC. Association between postoperative muscle wasting and survival in older patients undergoing surgery for non-metastatic colorectal cancer. J Geriatr Oncol 2021; 12:1052-1058. [PMID: 33858804 DOI: 10.1016/j.jgo.2021.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/19/2021] [Accepted: 04/09/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Preoperative sarcopenia in older patients is a risk factor for adverse outcomes after colorectal cancer (CRC) surgery. Longitudinal changes in muscle mass in this group have not been studied previously although muscle wasting may have prognostic significance regarding survival. We aimed to determine the association between muscle wasting and overall survival (OS) in older patients who underwent surgery for CRC. METHODS Patients ≥70 years who underwent surgery for non-metastatic CRC in Gelre hospitals, The Netherlands, between 2011 and 2015 were included. Cross-sectional area of skeletal muscle was measured at the level of the 3rd lumbar vertebra on preoperative and postoperative abdominal CT-scans. Patients who had >1 standard deviation decrease in muscle mass were considered to have muscle wasting. Cox regression analysis was used to evaluate associations between muscle wasting and OS. RESULTS 233 patients were included (40% female, median age 76 years). Thirty-four patients had muscle wasting. After a median follow-up of 4.7 years, 53 (23%) patients died. The 3-year mortality rate was higher in patients with muscle wasting (27% vs 14%, p = .05). In multivariable analysis adjusted for age, recurrent disease and preoperative muscle mass, muscle wasting was associated with reduced OS (HR 2.8, 95% CI 1.5-5.4, p = .002). CONCLUSION Muscle wasting predicted poorer survival in older patients who underwent CRC surgery. Measuring changes in muscle mass may improve risk prediction in this patient group. Future studies should address the etiology of muscle wasting in older patients with CRC. Whether perioperative exercise interventions can prevent muscle wasting also warrants further study.
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Affiliation(s)
- Tanja E Argillander
- Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands; Department of Geriatric Medicine, Gelre Hospitals, Apeldoorn, the Netherlands; University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Groningen, the Netherlands.
| | - Daniëlle Spek
- Department of Surgery, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Hester J van der Zaag-Loonen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, the Netherlands
| | - A Fleur van Raamt
- Department of Radiology, Gelre Hospitals, Apeldoorn, the Netherlands
| | | | - Barbara C van Munster
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, Groningen, the Netherlands
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Agnes A, Puccioni C, D'Ugo D, Gasbarrini A, Biondi A, Persiani R. The gut microbiota and colorectal surgery outcomes: facts or hype? A narrative review. BMC Surg 2021; 21:83. [PMID: 33579260 PMCID: PMC7881582 DOI: 10.1186/s12893-021-01087-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The gut microbiota (GM) has been proposed as one of the main determinants of colorectal surgery complications and theorized as the "missing factor" that could explain still poorly understood complications. Herein, we investigate this theory and report the current evidence on the role of the GM in colorectal surgery. METHODS We first present the findings associating the role of the GM with the physiological response to surgery. Second, the change in GM composition during and after surgery and its association with colorectal surgery complications (ileus, adhesions, surgical-site infections, anastomotic leak, and diversion colitis) are reviewed. Finally, we present the findings linking GM science to the application of the enhanced recovery after surgery (ERAS) protocol, for the use of oral antibiotics with mechanical bowel preparation and for the administration of probiotics/synbiotics. RESULTS According to preclinical and translational evidence, the GM is capable of influencing colorectal surgery outcomes. Clinical evidence supports the application of an ERAS protocol and the preoperative administration of multistrain probiotics/synbiotics. GM manipulation with oral antibiotics with mechanical bowel preparation still has uncertain benefits in right-sided colic resection but is very promising for left-sided colic resection. CONCLUSIONS The GM may be a determinant of colorectal surgery outcomes. There is an emerging need to implement translational research on the topic. Future clinical studies should clarify the composition of preoperative and postoperative GM and the impact of the GM on different colorectal surgery complications and should assess the validity of GM-targeted measures in effectively reducing complications for all colorectal surgery locations.
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Affiliation(s)
- Annamaria Agnes
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Caterina Puccioni
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
| | - Domenico D'Ugo
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
| | - Alberto Biondi
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy.
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy.
| | - Roberto Persiani
- Università Cattolica del Sacro Cuore, Largo F. Vito n.1, 00168, Rome, Italy
- Dipartimento Di Scienze Mediche E Chirurgiche, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo A. Gemelli n. 8, 00168, Rome, Italy
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Lin MW, Chen CI, Cheng TT, Huang CC, Tsai JW, Feng GM, Hwang TZ, Lam CF. Prolonged preoperative fasting induces postoperative insulin resistance by ER-stress mediated Glut4 down-regulation in skeletal muscles. Int J Med Sci 2021; 18:1189-1197. [PMID: 33526980 PMCID: PMC7847634 DOI: 10.7150/ijms.52701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/21/2020] [Indexed: 01/14/2023] Open
Abstract
Preoperative fasting aims to prevent pulmonary aspiration and improve bowel preparation, but it may induce profound systemic catabolic responses that lead to protein breakdown and insulin-resistant hyperglycemia after operation. However, the molecular mechanisms of catabolic reaction induced by prolonged preoperative fasting and surgical stress are undetermined. In this study, anesthetized rats were randomly assigned to receive a sham operation or laparotomy cecectomy. Fasting groups were restricted from food and water for 12 h before operation, while the feeding group had free access to food throughout the study period. Twenty-four hours after operation, the animals were sacrificed to collect blood samples and soleus muscles for analysis. Postoperative blood glucose level was significantly increased in the fasting group with elevated serum insulin and C-peptide. Continuous feeding reduced serum myoglobin and lactate dehydrogenase concentrations. Preoperative fasting activated inositol-requiring transmembrane kinase/endoribonuclease (IRE)-1α and c-Jun N-terminal kinase (JNK) mediated endoplasmic reticulum (ER)-stress, and reduced glucose transporter type 4 (Glut4) expression in the soleus muscle. Phospholamban phosphorylation was reduced and intracellular calcium levels were increased in the isolated skeletal muscle cells. Similar results were found in ER stress-induced C1C12 myoblasts. The expression of Glut4 was suppressed in the stressed C1C12, but was potentiated following inhibition of ER stress and chelation of intracellular free calcium. This study provides evidence demonstrating that prolonged preoperative fasting induces ER stress and generates insulin resistance in the skeletal muscle through suppression of Glut4 and inactivation of Ca2+-ATPase, leading to intracellular calcium homeostasis disruption and peripheral insulin resistance.
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Affiliation(s)
- Ming-Wei Lin
- Department of Medical Research, E-Da Hospital/E-Da Cancer Hospital, Kaohsiung, Taiwan.,Department of Nursing, I-Shou University College of Medicine, Kaohsiung, Taiwan.,Regenerative Medicine and Cell Therapy Research Center, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-I Chen
- Colorectal Surgery, Department of Surgery, E-Da Hospital/E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Tzu-Ting Cheng
- Department of Anesthesiology, E-Da Hospital/E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chien-Chi Huang
- Department of Medical Research, E-Da Hospital/E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Jen-Wei Tsai
- Department of Pathology, E-Da Hospital, Kaohsiung, Taiwan
| | - Guan-Ming Feng
- Department of Plastic Surgery, E-Da Hospital, Kaohsiung, Taiwan
| | - Tzer-Zen Hwang
- Department of Otolaryngology, E-Da Hospital, Kaohsiung, Taiwan
| | - Chen-Fuh Lam
- Department of Anesthesiology, E-Da Hospital/E-Da Cancer Hospital, Kaohsiung, Taiwan.,School of Medicine, I-Shou University College of Medicine, Kaohsiung, Taiwan
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25
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Oral carbohydrate solution cause an inflammatory response when aspirated into the lungs in mice. J Anesth 2020; 35:86-92. [PMID: 33221959 DOI: 10.1007/s00540-020-02873-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Many studies have been published on the beneficial effects of oral carbohydrate solutions (OCS) administered prior to surgery. However, the risk of pulmonary aspiration cannot be excluded in all patients undergoing anesthesia. But, there are few studies on the safety of OCS at lung aspiration. METHODS Experiments were conducted with mice (Nine- to ten-week-old male BALB/c mice weighted 23-26 g). Lung aspiration was performed by intratracheal administration of OCS and its major constituents, fructose and maltodextrin. Bronchoalveolar lavage fluid (BALF) was collected 3 and 24 h after lung aspiration. The level of Tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) and macrophage inflammatory protein-2 (MIP-2) were measured in BALF. The total white blood cell, neutrophil counts, wet to dry ratio and histological examination were performed in BALF and lung tissue, respectively, at 24 h after aspiration. RESULTS The OCS increased the level of TNF-α, IL-6 and MIP-2 at 3 h and the neutrophil count at 24 h in BALFs, compared to a phosphate-buffered saline (PBS) group. The increase in IL-6 level induced by OCS was maintained for 24 h. The OCS also increased the number of white blood cells and the percentage of neutrophils in BALFs. Compared to fructose, maltodextrin significantly increased the production of MIP-2 in BALFs. OCS and maltodextrin also increased neutrophil recruitment in lung tissue. CONCLUSION Aspiration of OCS may cause inflammation of the lungs. The preoperative use of OCS may require caution under specific clinical conditions, such as patients at risk of lung aspiration.
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26
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Ramirez-Rodriguez JM, Martinez-Ubieto J, Muñoz-Rodes JL, Rodriguez-Fraile JR, Garcia-Erce JA, Blanco-Gonzalez J, Del Valle-Hernandez E, Abad-Gurumeta A, Centeno-Robles E, Martinez-Perez C, Leon-Arellano M, Echazarreta-Gallego E, Elia-Guedea M, Pascual-Bellosta A, Miranda-Tauler E, Manuel-Vazquez A, Balen-Rivera E, Alvarez-Martinez D, Perez-Peña J, Abad-Motos A, Redondo-Villahoz E, Biosta-Perez E, Guadalajara-Labajo H, Ripollés-Melchor J, Latre-Saso C, Cordoba-Diaz de Laspra E, Sanchez-Guillen L, Cabellos-Olivares M, Longas-Valien J, Ortega-Lucea S, Ocon-Breton J, Arroyo-Sebastian A, Garcia-Olmo D. Surgical treatment for colorectal cancer: analysis of the influence of an enhanced recovery programme on long-term oncological outcomes-a study protocol for a prospective, multicentre, observational cohort study. BMJ Open 2020; 10:e040316. [PMID: 33109675 PMCID: PMC7597515 DOI: 10.1136/bmjopen-2020-040316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION The evidence currently available from enhanced recovery after surgery (ERAS) programmes concerns their benefits in the immediate postoperative period, but there is still very little evidence as to whether their correct implementation benefits patients in the long term. The working hypothesis here is that, due to the lower response to surgical aggression and lower rates of postoperative complications, ERAS protocols can reduce colorectal cancer-related mortality. The main objective of this study is to analyse the impact of an ERAS programme for colorectal cancer on 5-year survival. As secondary objectives, we propose to analyse the weight of each of the predefined items in the oncological results as well as the quality of life. METHODS AND ANALYSIS A multicentre prospective cohort study was conducted in patients older than 18 years of age who are scheduled to undergo surgery for colorectal cancer. The study involved 12 hospitals with an implemented enhanced recovery protocol according to the guidelines published by the Spanish National Health Service. The intervention group includes patients with a minimum implementation level of 70%, and the control group includes those who fail to reach this level. Compliance will be studied using 18 key performance indicators, and the results will be analysed using cancer survival indicators, including overall survival, cancer-specific survival and relapse-free survival. The time to recurrence, perioperative morbidity and mortality, hospital stay and quality of life will also be studied, the latter using the validated EuroQol Five questionnaire. The propensity index method will be used to create comparable treatment and control groups, and a multivariate regression will be used to study each variable. The Kaplan-Meier estimator will be used to estimate survival and the log-rank test to make comparisons. A p value of less than 0.05 (two-tailed) will be considered to be significant. ETHICS AND DISSEMINATION Ethical approval for this study was obtained from the Aragon Ethical Committee (C.P.-C.I. PI20/086) on 4 March 2020. The findings of this study will be submitted to peer-reviewed journals (BMJ Open, JAMA Surgery, Annals of Surgery, British Journal of Surgery). Abstracts will be submitted to relevant national and international meetings. TRIAL REGISTRATION NUMBER NCT04305314.
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Affiliation(s)
- Jose-M Ramirez-Rodriguez
- Lozano Blesa University Clinical Hospital, Zaragoza, Aragón, Spain
- Aragon Health Sciences Institute, Zaragoza, Aragón, Spain
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Alba Manuel-Vazquez
- Health Service of Castilla-La Mancha, Guadalajara, Castilla-La Mancha, Spain
| | | | | | | | | | | | - Elena Biosta-Perez
- General University Hospital Consortium of Valencia, Valencia, Comunitat Valenciana, Spain
| | | | | | | | | | | | | | | | | | | | | | - Damian Garcia-Olmo
- Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain
- Universidad Autonoma de Madrid, Madrid, Spain
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Wedin M, Stålberg K, Marcickiewicz J, Ahlner E, Åkesson Å, Lindahl G, Kjølhede P. Incidence of lymphedema in the lower limbs and lymphocyst formation within one year of surgery for endometrial cancer: A prospective longitudinal multicenter study. Gynecol Oncol 2020; 159:201-208. [PMID: 32763108 DOI: 10.1016/j.ygyno.2020.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/08/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The study aimed to determine the incidence of lower limb lymphedema (LLL) after surgery for endometrial cancer (EC) by means of three methods, and to determine the incidence of lymphocysts after one year. METHODS A prospective longitudinal multicenter study was conducted in 14 hospitals in Sweden. Two-hundred-and-thirty-five women with EC were included; 116 underwent surgery that included lymphadenectomy (+LA) and 119 were without lymphadenectomy (-LA). Lymphedema was assessed objectively on four occasions; preoperatively, at 4-6 weeks, six months and one year postoperatively using systematic measurement of leg circumferences, enabling calculation of leg volumes, and a clinical grading of LLL, and subjectively by the patient's perception of lymphedema measured by a lymphedema-specific quality-of-life instrument. Lymphocyst was evaluated by vaginal ultrasonography. RESULTS After one year the incidence of LLL after increase in leg volume adjusted for body mass index was 15.8% in +LA women and 3.4% in -LA women. The corresponding figures for clinical grading were 24.1% and 11.8%, and for patient-reported perceived LLL 10.7% and 5.1%. The agreement between the modalities revealed fair to moderate correlation between patient-reported LLL and clinical grading, but poor agreement between volume increase and patient-reported LLL or clinical grading. Lymphocysts were found in 4.3% after one year. CONCLUSIONS Although the incidence of LLL and lymphocysts after surgery for EC including LA seemed to be relatively high the study demonstrated significant variations in incidence depending on the measurement modality. This emphasizes the need for a 'gold standard' of measurement of LLL in clinical practice and research.
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Affiliation(s)
- Madelene Wedin
- Department of Obstetrics and Gynecology in Linköping, and Department of Biomedical and Clinical Science, Linköping University, Sweden.
| | - Karin Stålberg
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | - Eva Ahlner
- Department of Oncology, and Department of Biomedical and Clinical Science, Linköping University, Sweden
| | - Åsa Åkesson
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, and Institute of clinical sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Gabriel Lindahl
- Department of Oncology, and Department of Biomedical and Clinical Science, Linköping University, Sweden
| | - Preben Kjølhede
- Department of Obstetrics and Gynecology in Linköping, and Department of Biomedical and Clinical Science, Linköping University, Sweden
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Simple Versus Complex Preoperative Carbohydrate Drink to Preserve Perioperative Insulin Sensitivity in Laparoscopic Colectomy: A Randomized Controlled Trial. Ann Surg 2020; 271:819-826. [PMID: 31356274 DOI: 10.1097/sla.0000000000003488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Relationship Between Postoperative Pain and Overall 30-Day Complications in a Broad Surgical Population: An Observational Study. Ann Surg 2020; 269:856-865. [PMID: 29135493 DOI: 10.1097/sla.0000000000002583] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The aim of this study was to establish the relationship between postoperative pain and 30-day postoperative complications. BACKGROUND Only scarce data are available on the association between postoperative pain and a broad range of postoperative complications in a large heterogeneous surgical population. METHODS Having postoperative pain was assessed in 2 ways: the movement-evoked pain score on the Numerical Rating Scale (NRS-MEP) and the patients' opinion whether the pain was acceptable or not. Outcome was the presence of a complication within 30 days after surgery. We used binary logistic regression for the total population and homogeneous subgroups to control for case complexity. Results for homogeneous subgroups were summarized in a meta-analysis using inverse variance weighting. RESULTS In 1014 patients, 55% experienced moderate-to-severe pain on the first postoperative day. The overall complication rate was 34%. The proportion of patients experiencing postoperative complications increased from 0.25 [95% confidence interval (CI) = 0.21-0.31] for NRS-MEP = 0 to 0.45 (95% CI = 0.36-0.55) for NRS-MEP = 10. Patients who found their pain unacceptable had more complications (adjusted odds ratio = 2.17 (95% CI = 1.51-3.10; P < 0.001)). Summary effect sizes obtained with homogeneous groups were similar to those obtained from the total population who underwent very different types of surgery. CONCLUSIONS Higher actual postoperative pain scores and unacceptable pain, even on the first postoperative day, are associated with more postoperative complications. Our findings provide important support for the centrality of personalized analgesia in modern perioperative care.
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SIERRA JESSIKACADAVID, DOCK-NASCIMENTO DIANABORGES, BEHNE THAYSEEMANUELLIGODOY, THÉ MARIANABORGESSILVA, RODRIGUES HADASSAHILLARYNOVAESPEREIRA, ANDREO FRANCILENEOLIVEIRA, PALAURO MARISTELALUFT, DE-AGUILAR-NASCIMENTO JOSÉEDUARDO. Major oncological surgery reduces muscular function in patients with or without nutritional risk. Rev Col Bras Cir 2020; 47:e20202470. [DOI: 10.1590/0100-6991e-20202470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/27/2019] [Indexed: 12/12/2022] Open
Abstract
ABSTRACT Objectives : to investigate the impact of oncological surgical procedures on the muscle function of patients with and without nutritional risk. Methods: cross-sectional study conducted with cancer patients undergoing major operations between July 2018 to March 2019 in Cuiabá, Mato Grosso, Brazil. Patients were assessed preoperatively for the nutritional risk by the Nutricional Risk Screening-2002, and handgrip strength (FPP) was assessed both on the pre- and 2nd and 5th postoperative days (PO). Results: 92 patients were evaluated, of whom 55.4% were men and 44.6% women, with a mean age (SD) of 64 (10.81) for patients at risk and 51 (12.99) for patients without nutritional risk. The preoperative nutritional risk evaluation indicated that 34.8% of the patients had no risk and 65.2% had a nutritional risk. The FPP was lower (p = 0.008) in the group with nutritional risk in the preoperative period. In both groups, there was a significant drop in FPP on the 2nd PO day. The preoperative FPP compared with the 2nd PO FPP was more pronounced in patients without nutritional risk (p = 0.039). Patients with nutritional risk had a longer hospital stay (p = 0.049). Conclusion: surgical trauma causes loss of muscle function in the early PO. Patients without nutritional risk have a more significant decrease in muscle strength after surgical oncological procedures than those with nutritional risk. These results may infer the need to implement pre-habilitation in all patients who will undergo major oncological procedures.
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Morimoto Y, Kinugawa T, Hayashi M, Iida T, Yamamoto T. Effects of preoperative oral carbohydrate intake on catabolism, nutrition and adipocytokines during minor surgery: A randomized, prospective, controlled clinical phase II trial. PLoS One 2019; 14:e0216525. [PMID: 31083704 PMCID: PMC6513065 DOI: 10.1371/journal.pone.0216525] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 04/23/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND We investigated the effects of preoperative oral carbohydrate loading on intraoperative catabolism, nutritional parameters, and adipocytokine levels during anesthesia. METHODS Study participants were randomized to two groups who were allowed to consume either no more than 250 mL of 18% oral carbohydrate solution (Arginaid Water: AW group) or no more than 500 mL of plain water (PW group) within the 2 hours before surgery, with no intraoperative glucose administration. Percentage changes from preoperative values of resting metabolic rate (RMR) and total body water (TBW), determined by bioelectrical impedance analysis (BIA), were compared. Blood levels of serum ketone bodies, free fatty acids (FFAs), insulin, 3-methyl histidine, blood glucose, retinol binding protein, adiponectin, and leptin were measured. BIA measurement and blood sampling were performed on entry to the operating room (M1) and 2 hours after the induction of anesthesia (M2). Chi squared test, Mann-Whitney U test, and Wilcoxon's test were used for comparisons of parameters. P values less than 0.05 constituted a significant difference. RESULTS Seventeen patients per group (34 patients total) were enrolled. RMR and TBW values did not differ between M1 and M2 measurements. Participants in the AW group had lower blood ketone body and FFA levels and higher insulin levels at M1. However, their ketone body and FFA levels rose and insulin levels fell after 2 hours, although ketone body and FFA levels in the AW group were still lower than those in the PW group. Although retinol binding protein, adiponectin, and leptin levels were not different in terms of preoperative oral carbohydrate loading, the levels of these substances in both groups were lower after 2 hours compared with levels on operating room entry. CONCLUSIONS Preoperative oral carbohydrate loading without intraoperative glucose administration appears to suppress catabolism for 2 hours after the start of surgery.
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Affiliation(s)
- Yoshinari Morimoto
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
- * E-mail:
| | - Tomoko Kinugawa
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
| | - Megumi Hayashi
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
| | - Takatoshi Iida
- Department of Critical Care Medicine and Dentistry, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
| | - Tatsuo Yamamoto
- Department of Oral Science, Graduate School of Dentistry, Kanagawa Dental University, Yokosuka, Kanagawa, Japan
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Helander EM, Webb MP, Menard B, Prabhakar A, Helmstetter J, Cornett EM, Urman RD, Nguyen VH, Kaye AD. Metabolic and the Surgical Stress Response Considerations to Improve Postoperative Recovery. Curr Pain Headache Rep 2019; 23:33. [PMID: 30976992 DOI: 10.1007/s11916-019-0770-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE OF REVIEW Enhanced recovery pathways are a multimodal, multidisciplinary approach to patient care that aims to reduce the surgical stress response and maintain organ function resulting in faster recovery and improved outcomes. RECENT FINDINGS A PubMed literature search was performed for articles that included the terms of metabolic surgical stress response considerations to improve postoperative recovery. The surgical stress response occurs due to direct and indirect injuries during surgery. Direct surgical injury can result from the dissection, retraction, resection, and/or manipulation of tissues, while indirect injury is secondary to events including hypotension, blood loss, and microvascular changes. Greater degrees of tissue injury will lead to higher levels of inflammatory mediator and cytokine release, which ultimately drives immunologic, metabolic, and hormonal processes in the body resulting in the stress response. These processes lead to altered glucose metabolism, protein catabolism, and hormonal dysregulation among other things, all which can impede recovery and increase morbidity. Fluid therapy has a direct effect on intravascular volume and cardiac output with a resultant effect on oxygen and nutrient delivery, so a balance must be maintained without excessively loading the patient with water and salt. All in all, attenuation of the surgical stress response and maintaining organ and thus whole-body homeostasis through enhanced recovery protocols can speed recovery and reduce complications. The present investigation summarizes the clinical application of enhanced recovery pathways, and we will highlight the key elements that characterize the metabolic surgical stress response and improved postoperative recovery.
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Affiliation(s)
- Erik M Helander
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Michael P Webb
- Department of Anesthesiology, North Shore Hospital, 124 Shakespeare Rd., Takapuna, Auckland, 0620, New Zealand
| | - Bethany Menard
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Amit Prabhakar
- Department of Anesthesiology and Critical Care Medicine, Emory University Hospital, 550 Peachtree St NE, Atlanta, GA, 30308, USA
| | - John Helmstetter
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Elyse M Cornett
- Department of Anesthesiology, LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA, 71130, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Viet H Nguyen
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA
| | - Alan David Kaye
- Department of Anesthesiology, LSU School of Medicine, Room 656, 1542 Tulane Ave., New Orleans, LA, 70112, USA.
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Pillinger NL, Robson JL, Kam P. Nutritional prehabilitation: physiological basis and clinical evidence. Anaesth Intensive Care 2018; 46:453-462. [PMID: 30189818 DOI: 10.1177/0310057x1804600505] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
In this narrative review, we describe the physiological basis for nutritional prehabilitation and evaluate the clinical evidence for its current roles in the perioperative period. Surgical stress and fasting induce insulin resistance as a result of altered mitochondrial function. Insulin resistance in the perioperative period leads to increased morbidity in a dose-dependent fashion, while preoperative carbohydrate loading attenuates insulin resistance, minimises protein loss and improves postoperative muscle function. Carbohydrate loading is an established practice in many countries and a key component of enhanced recovery after surgery (ERAS) programs, yet its independent effects on clinical outcomes remain unclear. Amino acid supplements may confer additional positive effects on a number of markers of clinical outcomes in the perioperative period, but their current role is also poorly defined. Clinical studies evaluating nutritional interventions have been marred by conflicting data, which may be due to small sample sizes, as well as heterogeneity of patients and surgical procedures. At present, it is known that carbohydrate loading is safe and improves patients' wellbeing, but does not appear to influence length of hospital stay or rate of postoperative complications. This should be appreciated before its routine inclusion in ERAS programs.
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Affiliation(s)
- N L Pillinger
- Department of Anaesthetics, Royal Prince Alfred Hospital; Clinical Lecturer, University of Sydney; Sydney, New South Wales
| | | | - Pca Kam
- Nuffield Professor of Anaesthetics, University of Sydney; Department of Anaesthetics, Royal Prince Alfred Hospital; Sydney, New South Wales
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Perioperative insulin therapy. ASIAN BIOMED 2018. [DOI: 10.1515/abm-2018-0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Surgical patients commonly develop hyperglycemia secondary to the neuroendocrine stress response. Insulin treatment of hyperglycemia is required to overcome the perioperative catabolic state and acute insulin resistance. Besides its metabolic actions on glucose metabolism, insulin also displays nonmetabolic physiological effects. Preoperative glycemic assessment, maintenance of normoglycemia, and avoidance of glucose variability are paramount to optimize surgical outcomes. This review discusses the basic physiology and effects of insulin as well as practical issues pertaining to its management during the perioperative period.
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Schiffner R, Rodríguez-González GL, Rakers F, Nistor M, Nathanielsz PW, Daneva T, Schwab M, Lehmann T, Schmidt M. Effects of Late Gestational Fetal Exposure to Dexamethasone Administration on the Postnatal Hypothalamus-Pituitary-Adrenal Axis Response to Hypoglycemia in Pigs. Int J Mol Sci 2017; 18:ijms18112241. [PMID: 29077038 PMCID: PMC5713211 DOI: 10.3390/ijms18112241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 10/19/2017] [Accepted: 10/21/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Prenatal glucocorticoid administration alters the activity of the fetal hypothalamic-pituitary-adrenocortical axis (HPAA), and correspondingly the adenocorticotropic hormone (ACTH) and cortisol levels after birth. The dosages required for these effects are critically discussed. Activation of the HPAA is related to metabolic syndrome and diabetes mellitus. Hypoglycemia is the classic side effect of antidiabetic treatment. We hypothesized that a low dosage of dexamethasone in late pregnancy alters the HPAA response to hypoglycemia in pigs. METHODS 12 pregnant sows were randomly assigned to two groups which received either a low-dose intramuscular injection (99th and 100th day of gestation) of dexamethasone (0.06 μg/kg body weight) or vehicle. Three months after birth, 18 dexamethasone-treated anaesthetized offspring and 12 control offspring underwent a 75 min hypoglycemic clamp (blood glucose below 4 mmol/L) procedure. Heart rate (HR), blood pressure, ACTH and cortisol levels and body weight (at birth and after three months) were recorded. RESULTS Dexamethasone-treated animals exhibited significantly elevated ACTH (139.9 ± 12.7 pg/mL) and cortisol (483.1 ± 30.3 nmol/L) levels during hypoglycemia as compared to the control group (41.7 ± 6.5 pg/mL and 257.9 ± 26.7 nmol/L, respectively), as well as an elevated HR (205.5 ± 5.7 bpm) and blood pressure (systolic: 128.6 ± 1.5, diastolic: 85.7 ± 0.7 mmHg) response as compared to the control group (153.2 ± 4.5 bpm; systolic: 118.6 ± 1.6, diastolic: 79.5 ± 1.4 mmHg, respectively; p < 0.001). CONCLUSIONS Low-dose prenatal administration of dexamethasone not only exerts effects on the HPAA (ACTH and cortisol concentration) and vital parameters (HR and diastolic blood pressure) under baseline conditions, but also on ACTH, HR and systolic blood pressure during hypoglycemia.
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Affiliation(s)
- René Schiffner
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
- Orthopaedic Department, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | | | - Florian Rakers
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Marius Nistor
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Peter W Nathanielsz
- Department of Animal Science, University of Wyoming, Laramie, 82071 WY, USA.
| | - Teodora Daneva
- Institute of Biology and Immunology of Reproduction, Bulgarian Academy of Sciences, 1113 Sofia, Bulgaria.
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital-Friedrich Schiller University, 07747 Jena, Germany.
| | - Thomas Lehmann
- Institute of Medical Statistics, Computer Sciences and Documentation Science, Jena University Hospital-Friedrich Schiller University, 07743 Jena, Germany.
| | - Martin Schmidt
- Institute for Biochemistry II, Jena University Hospital-Friedrich Schiller University, 07743 Jena, Germany.
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Huang DD, Ji YB, Zhou DL, Li B, Wang SL, Chen XL, Yu Z, Zhuang CL. Effect of surgery-induced acute muscle wasting on postoperative outcomes and quality of life. J Surg Res 2017; 218:58-66. [DOI: 10.1016/j.jss.2017.05.045] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 04/23/2017] [Accepted: 05/11/2017] [Indexed: 12/19/2022]
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McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med (Lond) 2017; 6:8. [PMID: 28413629 PMCID: PMC5390366 DOI: 10.1186/s13741-017-0064-5] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/14/2017] [Indexed: 01/01/2023] Open
Abstract
Background Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver “optimal analgesia,” which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. Methods With input from a multi-disciplinary, international group of clinicians, and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. Discussion As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery ERP. The goal was two-fold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus from the preoperative period to the post-anesthesia care unit. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of optimal analgesia as set forth in this document.
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Affiliation(s)
- Matthew D McEvoy
- Department of Anesthesiology, CIPHER (Center for Innovation in Perioperative Health, Education, and Research) Vanderbilt University Medical Center, 2301VUH, Nashville, TN 37232 USA
| | - Michael J Scott
- Anaesthesia & Intensive Care Medicine, Royal Surrey County NHS Foundation Hospital, Surrey, UK.,Department of Anaesthesia, University of Surrey, Surrey, UK.,University College London, London, UK
| | - Debra B Gordon
- Harborview Integrated Pain Care Program, Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, USA
| | - Stuart A Grant
- Division of Regional Division, Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Julie K M Thacker
- Division of Advanced Oncologic and GI Surgery, Department of Surgery, Duke University Medical Center, Durham, USA
| | - Christopher L Wu
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Suffolk, USA
| | - Monty G Mythen
- UCL/UCLH National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D Shaw
- Department of Anesthesiology, Vanderbilt University, Nashville, USA
| | - Timothy E Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, USA
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Scott MJ, McEvoy MD, Gordon DB, Grant SA, Thacker JKM, Wu CL, Gan TJ, Mythen MG, Shaw AD, Miller TE. American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) Joint Consensus Statement on Optimal Analgesia within an Enhanced Recovery Pathway for Colorectal Surgery: Part 2-From PACU to the Transition Home. Perioper Med (Lond) 2017; 6:7. [PMID: 28413628 PMCID: PMC5390469 DOI: 10.1186/s13741-017-0063-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 03/14/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Within an enhanced recovery pathway (ERP), the approach to treating pain should be multifaceted and the goal should be to deliver "optimal analgesia", which we define in this paper as a technique that optimizes patient comfort and facilitates functional recovery with the fewest medication side effects. METHODS With input from a multidisciplinary, international group of experts and through a structured review of the literature and use of a modified Delphi method, we achieved consensus surrounding the topic of optimal analgesia in the perioperative period for colorectal surgery patients. DISCUSSION As a part of the first Perioperative Quality Improvement (POQI) workgroup meeting, we sought to develop a consensus document describing a comprehensive, yet rational and practical, approach for developing an evidence-based plan for achieving optimal analgesia, specifically for a colorectal surgery within an ERP. The goal was twofold: (a) that application of this process would lead to improved patient outcomes and (b) that investigation of the questions raised would identify knowledge gaps to aid the direction for research into analgesia within ERPs in the years to come. This document details the evidence for a wide range of analgesic components, with particular focus on care in the post-anesthesia care unit, general care ward, and transition to home after discharge. The preoperative and operative consensus statement for analgesia was covered in Part 1 of this paper. The overall conclusion is that the combination of analgesic techniques employed in the perioperative period is not important as long as it is effective in delivering the goal of "optimal analgesia" as set forth in this document.
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Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology, Virginia Commonwealth University Health System, 1200 East Broad Street, P.O. Box 980695, Richmond, Virginia 23298-0695 USA
- University College London, London, UK
| | - Matthew D. McEvoy
- CIPHER (Center for Innovation in Perioperative Health, Education, and Research), Vanderbilt University Medical Center, TN, USA
- Department of Anesthesiology, Vanderbilt University School of Medicine, 2301VUH,, Nashville, TN 37232 USA
| | - Debra B. Gordon
- Department of Anesthesiology & Pain Medicine, Harborview Integrated Pain Care Program, University of Washington, Seattle, WA USA
| | - Stuart A. Grant
- Department of Anesthesiology, Medical Student Education, Division of Regional Division, Duke University Medical Center, Durham, UK
| | - Julie K. M. Thacker
- Department of Surgery, Division of Advanced Oncologic and GI Surgery, Duke University Medical Center, Durham, UK
| | - Christopher L. Wu
- Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Tong J. Gan
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, USA
| | - Monty G. Mythen
- University College London Hospitals National Institute of Health Research Biomedical Research Centre, London, UK
| | - Andrew D. Shaw
- Department of Anesthesiology, Vanderbilt University, TN, USA
| | - Timothy E. Miller
- Division of General, Vascular and Transplant Anesthesia, Duke University Medical Center, Durham, UK
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Binkley N, Coursin D, Krueger D, Iglar P, Heiner J, Illgen R, Squire M, Lappe J, Watson P, Hogan K. Surgery alters parameters of vitamin D status and other laboratory results. Osteoporos Int 2017; 28:1013-1020. [PMID: 27826645 DOI: 10.1007/s00198-016-3819-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 10/24/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Fracture liaison services often perform laboratory testing, but these results may be altered by surgery. In 40 hip arthroplasty patients, many laboratory parameters of bone health relevance were reduced by 8-22% on the first post-operative day. Laboratory results obtained in the immediate post-surgery interval do not reliably ascertain baseline status. INTRODUCTION As secondary causes of osteoporosis are common, fracture liaison services often perform laboratory testing in the immediate post-fracture interval. We hypothesized that laboratory results obtained shortly after surgery may not accurately ascertain baseline status. If true, such alterations might confound subsequent fracture prevention efforts. METHODS Patients undergoing elective total hip arthroplasty were studied as a surrogate for hip fracture patients. Blood and urine were obtained 2 weeks before surgery, before anesthetic induction, on post-operative day one, and 6 weeks after surgery. Serum total and free 25-hydroxyvitamin D (25(OH)D), vitamin D-binding protein (DBP), calcium, creatinine, albumin (Alb), alkaline phosphatase (ALP), plasma hemoglobin (Hgb) and urinary DBP/creatinine ratio (UDBP/Cr) were measured. RESULTS Forty volunteers (28 women; 12 men) with mean age of 65.7 [8.7] years were studied. Laboratory results were stable from 2 weeks before to the day of surgery. On the first day after surgery, total 25(OH)D, DBP, calcium, creatinine, ALP, and Alb declined 8-22% (p < 0.0001); free 25(OH)D and Hgb declined by 8 and 15% (p < 0.01), respectively; and UDBP/Cr increased 32% (p < 0.01). Using a 25(OH)D <30 ng/mL threshold, vitamin D inadequacy prevalence increased from 38% before surgery to 68% the day after (p < 0.001). All laboratory values returned to baseline at 6 weeks after surgery. CONCLUSIONS Laboratory values are reduced immediately following elective total hip arthroplasty. Testing at that time does not accurately ascertain baseline status and may lead to elevated estimates of vitamin D inadequacy, incorrect interventions, and misallocation of healthcare resources.
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Affiliation(s)
- N Binkley
- University of Wisconsin Osteoporosis Clinical Research Program, 2870 University Ave, Madison, WI, 53705, USA.
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - D Coursin
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
| | - D Krueger
- University of Wisconsin Osteoporosis Clinical Research Program, 2870 University Ave, Madison, WI, 53705, USA
| | - P Iglar
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, 707 WARF Building, 610 North Walnut Street, Madison, WI, 53726, USA
| | - J Heiner
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - R Illgen
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - M Squire
- Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, 1685 Highland Avenue, Madison, WI, 53705-2281, USA
| | - J Lappe
- Creighton University Osteoporosis Research Center, 601 N. 30th Street, Suite 4820, Omaha, NE, 68131, USA
| | - P Watson
- Creighton University Osteoporosis Research Center, 601 N. 30th Street, Suite 4820, Omaha, NE, 68131, USA
| | - K Hogan
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Avenue, B6/319 CSC, Madison, WI, 53792-3272, USA
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The glycemic response to insulin as extracted from the DeLiT trial is not an indicator of tissue insulin sensitivity. J Clin Anesth 2016; 34:376. [PMID: 27687415 DOI: 10.1016/j.jclinane.2016.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/18/2016] [Indexed: 11/21/2022]
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Future Perspectives of ERAS: A Narrative Review on the New Applications of an Established Approach. Surg Res Pract 2016; 2016:3561249. [PMID: 27504486 PMCID: PMC4967675 DOI: 10.1155/2016/3561249] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
ERAS approach (Enhanced Recovery After Surgery) is a multimodal, perioperative pathway designed to achieve early recovery after surgery. ERAS has shown documented efficacy in elective surgery, and the concept of "multimodal" and "multidisciplinary" approach seems still to be of higher importance than each single item within ERAS protocols. New perspectives include the use of ERAS in emergency surgery, where efficacy and safety on outcome have been documented, and flexibility of traditional items may add benefits for traditionally high-risk patients. Obstetric surgery, as well, may open wide horizons for future research, since extremely poor data are currently available, and ERAS benefits may translate even on the baby. Finally, the concept of "outcome" may be extended when considering the specific setting of cancer surgery, in which variables like cancer recurrence, early access to adjuvant therapies, and, finally, long-term survival are as important as the reduced perioperative complications. In this perspective, different items within ERAS protocols should be reinterpreted and eventually integrated towards "protective" techniques, to develop cancer-specific ERAS approaches keeping pace with the specific aims of oncologic surgery.
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Buter H, Bakker AJ, Kingma WP, Koopmans M, Boerma EC. Plasma glutamine levels in patients after non-elective or elective ICU admission: an observational study. BMC Anesthesiol 2016; 16:15. [PMID: 26965168 PMCID: PMC4787198 DOI: 10.1186/s12871-016-0180-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 03/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A low plasma glutamine level at the time of acute admission to the intensive care unit (ICU) is an independent predictor of an unfavourable outcome in critically ill patients. The primary objective of this study was to determine whether there are differences in plasma glutamine levels upon non-elective or elective ICU admission. The secondary objective was to compare glutamine levels over time, and to determine correlations between glutamine levels and the severity of illness and presence of infection in ICU patients. METHODS We performed a single-centre observational study in a closed-format, 22-bed, mixed ICU. Plasma glutamine levels were measured at admission and every morning at 6.00 a.m. during the ICU stay. We aimed to include at least 80 patients per group. The study was approved by the local Medical Ethics Committee. RESULTS In 88 patients after elective surgery, the median plasma glutamine level at admission was significantly higher compared with that in 90 non-elective patients (0.43 mmol/l [0.33-0.55 mmol/l] versus 0.25 mmol/l [0.09-0.37 mmol/l], P = 0.001). During the ICU stay, plasma glutamine levels remained significantly higher in elective patients than in non-elective patients. There was a significant correlation between the APACHE IV score and glutamine levels (R = 0.52, P < 0.001). Moreover, backward linear regression analysis showed that this correlation was independently associated with the APACHE IV score and the presence of infection, but not with the type of admission. CONCLUSIONS Plasma glutamine levels are significantly lower after non-elective admission compared with elective admission to the ICU. A considerable amount of elective and non-elective patients have decreased plasma glutamine levels, but this is not independently associated with the type of admission. In contrast to previous studies, we found that plasma glutamine levels were determined by the severity of illness and the presence of an infection. TRIAL REGISTRATION ClinicalTrials.gov, number NCT02310035.
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Affiliation(s)
- Hanneke Buter
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.
| | - Andries J Bakker
- Department of Clinical Chemistry, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - W Peter Kingma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Matty Koopmans
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Cozowicz C, Poeran J, Memtsoudis S. Epidemiology, trends, and disparities in regional anaesthesia for orthopaedic surgery. Br J Anaesth 2015; 115 Suppl 2:ii57-67. [DOI: 10.1093/bja/aev381] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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