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Wan JX, Lin C, Wu ZQ, Feng D, Wang Y, Wang FJ. The median effective concentration of epidural ropivacaine with different doses of dexmedetomidine for motor blockade: an up-down sequential allocation study. Front Med (Lausanne) 2024; 11:1413191. [PMID: 39161411 PMCID: PMC11330782 DOI: 10.3389/fmed.2024.1413191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 07/26/2024] [Indexed: 08/21/2024] Open
Abstract
Study objective Recent studies have shown that dexmedetomidine can be safely used in peripheral nerve blocks and spinal anesthesia. Epidural administration of dexmedetomidine produces analgesia and sedation, prolongs motor and sensory block time, extends postoperative analgesia, and reduces the need for rescue analgesia. This investigation seeks to identify the median effective concentration (EC50) of ropivacaine for epidural motor blockade, and assess how incorporating varying doses of dexmedetomidine impacts this EC50 value. Design Prospective, double-blind, up-down sequential allocation study. Setting Operating room, post-anesthesia care unit, and general ward. Interventions One hundred and fifty patients were allocated into five groups in a randomized, double-blinded manner as follows: NR (normal saline combined with ropivacaine) group, RD0.25 (0.25 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.5 (0.5 μg/kg dexmedetomidine combined with ropivacaine) group, RD0.75 (0.75 μg/kg dexmedetomidine combined with ropivacaine) group, RD1.0 (1.0 μg/kg dexmedetomidine combined with ropivacaine) group. The concentration of epidural ropivacaine for the first patient in each group was 0.5%. Following administration, the patients were immediately placed in a supine position for observation, and the lower limb motor block was assessed every 5 min using the modified Bromage score within 30 min after drug administration. According to the sequential method, the concentration of ropivacaine in the next patient was adjusted according to the reaction of the previous patient: effective motor block was defined as the modified Bromage score > 0 within 30 min after epidural administration. If the modified Bromage score of the previous patient was >0 within 30 min after drug administration, the concentration of ropivacaine in the next patient was decreased by 1 gradient. Conversely, if the score did not exceed 0, the concentration of ropivacaine in the next patient was increased by 1 gradient. The up-down sequential allocation method and probit regression were used to calculate the EC50 of epidural ropivacaine. Measurements Adverse events, hemodynamic changes, demographic data and clinical characteristics. Main results The EC50 of epidural ropivacaine required to achieve motor block was 0.677% (95% CI, 0.622-0.743%) in the NR group, 0.624% (95% CI, 0.550-0.728%) in the RD0.25 group, 0.549% (95% CI, 0.456-0.660%) in the RD0.5 group, 0.463% (95% CI, 0.408-0.527%) in the RD0.75 group, and 0.435% (95% CI, 0.390-0.447%) in the RD1.0 group. The EC50 of the NR group and the RD0.25 group were significantly higher than that of the RD0.75 and the RD1.0 groups, and the EC50 of the RD0.5 group was significantly higher than that of the RD1.0 group. Conclusion The EC50 of epidural ropivacaine required to achieve motor block was 0.677% in the NR group, 0.624% in the RD0.25 group, 0.549% in the RD0.5 group, 0.463% in the RD0.75 group, and 0.435% in the RD1.0 group. Dexmedetomidine as an adjuvant for ropivacaine dose-dependently reduce the EC50 of epidural ropivacaine for motor block and shorten the onset time of epidural ropivacaine block. The optimal dose of dexmedetomidine combined with ropivacaine for epidural anesthesia was 0.5 μg/kg.
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Affiliation(s)
| | | | | | | | | | - Fang-Jun Wang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Hou Z, Liu T, Li X, Lv H, Sun Q. Risk factors for postoperative ileus in hysterectomy: A systematic review and meta-analysis. PLoS One 2024; 19:e0308175. [PMID: 39088416 PMCID: PMC11293682 DOI: 10.1371/journal.pone.0308175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Accepted: 07/18/2024] [Indexed: 08/03/2024] Open
Abstract
OBJECTIVE The study intended to evaluate the risk factors of postoperative ileus in hysterectomy patients. STUDY DESIGN Systematic review and meta-analysis. METHODS This study conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Program for Systematic Review and Meta-analysis statement. PubMed, Web of Science, Embase, the Cochrane Library and China National Knowledge Internet were searched. The search period was restricted from the earliest records to March 2024. Key words used were: (hysterectomy) AND (postoperative ileus OR postoperative intestinal obstruction OR ileus OR intestinal obstruction). Two researchers screened literatures and extracted data, and used Newcastle-Ottawa scale and Joanna Briggs Institute critical appraisal checklist for analytical cross-sectional studies to evaluate their quality. Then, Stata17 software was used for statistical analysis. RESULT A total of 11 literatures were included. Personal factors and previous history of disease factors of postoperative ileus in hysterectomy patients included use opioids (OR = 3.91, 95%CI: 1.08-14.24), dysmenorrhea (OR = 2.51, 95%: 1.25-5.05), smoking (OR = 1.55, 95%: 1.18-2.02), prior abdominal or pelvic surgery (OR = 1.46, 95%CI: 1.16-1.83) and age (OR = 1.03, 95%: 1.02-1.04). Surgery-related factors included perioperative transfusion (OR = 4.50, 95%CI: 3.29-6.16), concomitant bowel surgery (OR = 3.79, 95%CI: 1.86-7.71), anesthesia technique (general anesthesia) (OR = 2.73, 95%CI: 1.60, 4.66), adhesiolysis (OR = 1.97, 95%CI: 1.52-2.56), duration of operation (OR = 1.78, 95%CI: 1.32-2.40), operation approach (laparoscopic hysterectomy) (OR = 0.43, 95%CI: 0.29-0.64) and operation approach (vaginal hysterectomy) (OR = 0.35, 95%CI: 0.18-0.69). CONCLUSIONS The results of this study were personal factors and previous history of disease factors, surgery-related factors, which may increase the risk of postoperative ileus in hysterectomy patients. After the conclusion of risk factors, more accurate screening and identification of high-risk groups can be conducted and timely preventive measures can be taken to reduce the incidence of postoperative ileus. TRIAL REGISTRATION The study protocol for this meta-analysis was registered (CRD42023407167) with the PROSPERO database (www.crd.york.ac.uk/prospero).
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Affiliation(s)
- Zhuoer Hou
- The School of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Ting Liu
- The School of Basic Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaoyan Li
- The School of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
| | - Hangpeng Lv
- Baotou Medical College, Inner Mongolia Medical University, Hohhot, China
| | - Qiuhua Sun
- The School of Nursing, Zhejiang Chinese Medical University, Hangzhou, China
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Passi NN, Gupta A, Lusby E, Scott S, Sehmbi H, Hare S, Oliver CM. Analgesia for emergency laparotomy: a systematic review. Br J Hosp Med (Lond) 2024; 85:1-9. [PMID: 38941975 DOI: 10.12968/hmed.2023.0409] [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] [Indexed: 06/30/2024]
Abstract
Aims/Background Poorly controlled pain is common after emergency laparotomy. It causes distress, hinders rehabilitation, and predisposes to complications: prolonged hospitalisation, persistent pain, and reduced quality of life. The aim of this systematic review was to compare the relative efficacies of pre-emptive analgesia for emergency laparotomy to inform practice. Methods We performed a search of MEDLINE, MEDLINE In-Process, Embase, PubMed, Web of Science and SCOPUS for comparator studies of preoperative/intraoperative interventions to control/reduce postoperative pain in adults undergoing emergency laparotomy (EL) for general surgical pathologies. Exclusion criteria: surgery including non-abdominal sites; postoperative sedation and/or intubation; non-formal assessment of pain; non-English manuscripts. All manuscripts were screened by two investigators. Results We identified 2389 papers. Following handsearching and removal of duplicates, 1147 were screened. None were eligible for inclusion, with many looking at elective and/or laparoscopic surgeries. Conclusion Our findings indicate there is no evidence base for pre-emptive analgesic strategies in emergency laparotomy. This contrasts substantially with elective cohorts. Potential reasons include variation in practice, management of physiological derangement taking priority, and perceived contraindications to neuraxial techniques. We urge a review of contemporary practice, with analysis of clinical data, to generate expert consensus.
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Affiliation(s)
- Neha N Passi
- Department of Anaesthesia, Whipps Cross Hospital, London, UK
| | - Aayushi Gupta
- Department of Anaesthesia, Royal Free Hospital, London, UK
| | - Eimear Lusby
- Department of Anaesthesia, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Sara Scott
- Department of Anaesthesia, Queen Elizabeth Hospital, Gateshead, UK
| | - Herman Sehmbi
- London Health Sciences Centre, Western University, London, Canada
| | - Sarah Hare
- Department of Anaesthesia, Medway Maritime Hospital, Gillingham, Kent, UK
| | - Charles M Oliver
- Centre for Perioperative Medicine, University College London, London, UK
- Department of Anaesthesia, University College London Hospital, London, UK
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Pandraklakis A, Haidopoulos D, Lappas T, Stamatakis E, Valsamidis D, Oikonomou MD, Loutradis D, Rodolakis A, Bisch SP, Nelson G, Thomakos N. Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study. Int J Gynecol Cancer 2023; 33:1794-1799. [PMID: 37652530 DOI: 10.1136/ijgc-2023-004621] [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] [Indexed: 09/02/2023] Open
Abstract
OBJECTIVE To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy. METHODS We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates. RESULTS Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53-68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients' demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3-5 vs 4-5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001). CONCLUSION In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.
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Affiliation(s)
- Anastasios Pandraklakis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Lappas
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Emmanouil Stamatakis
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Dimitrios Valsamidis
- Department of Anesthesiology and Pain Management, "Alexandra" General Hospital, Athens, Greece
| | - Maria D Oikonomou
- The Fertility Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Dimitrios Loutradis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Steven P Bisch
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Gregg Nelson
- Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada
| | - Nikolaos Thomakos
- Division of Gynecologic Oncology, 1st Department of Obstetrics and Gynecology, "Alexandra" General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Van Boxstael S, Peene L, Dylst D, Penders J, Hadzic A, Meex I, Corten K, Mesotten D, Thiessen S. The effect of spinal versus general anaesthesia on perioperative muscle weakness in patients having bilateral total hip arthroplasty: a single center randomized clinical trial. Eur J Med Res 2023; 28:450. [PMID: 37864209 PMCID: PMC10588152 DOI: 10.1186/s40001-023-01435-6] [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: 08/29/2022] [Accepted: 10/07/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Perioperative neuro-endocrine stress response may contribute to acquired muscle weakness. Regional anaesthesia has been reported to improve the outcome of patients having total hip arthroplasty. In this study, it was hypothesized that spinal anaesthesia (SA) decreases the perioperative neuro-endocrine stress response and perioperatively acquired muscle weakness (PAMW), as compared to general anaesthesia (GA). METHODS Fifty subjects undergoing bilateral total hip arthroplasty (THA) were randomly allocated to receive a standardized SA (n = 25) or GA (n = 25). Handgrip strength was assessed preoperatively, on the first postoperative day (primary endpoint) and on day 7 and 28. Respiratory muscle strength was measured by maximal inspiratory pressure (MIP). Stress response was assessed by measuring levels of Adrenocorticotropic hormone (ACTH), cortisol and interleukin-6 (IL-6). RESULTS Handgrip strength postoperatively (day 1) decreased by 5.4 ± 15.9% in the SA group, versus 15.2 ± 11.7% in the GA group (p = 0.02). The handgrip strength returned to baseline at day 7 and did not differ between groups at day 28. MIP increased postoperatively in patients randomized to SA by 11.7 ± 48.3%, whereas it decreased in GA by 12.2 ± 19.9% (p = 0.04). On day 7, MIP increased in both groups, but more in the SA (49.0 ± 47.8%) than in the GA group (14.2 ± 32.1%) (p = 0.006). Postoperatively, the levels of ACTH, cortisol and IL-6 increased in the GA, but not in the SA group (p < 0.004). CONCLUSION In patients having bilateral THA, SA preserved the postoperative respiratory and peripheral muscle strength and attenuated the neuro-endocrine and inflammatory responses. TRIAL REGISTRATION clinicaltrials.gov NCT03600454.
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Affiliation(s)
- Sam Van Boxstael
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.
- Faculty of Medicine and Life Sciences & Limburg Clinical Research Center, UHasselt, Diepenbeek, Belgium.
| | - Laurens Peene
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Dimitri Dylst
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Joris Penders
- Laboratory of Clinical Biology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Admir Hadzic
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Ingrid Meex
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Kristoff Corten
- Department of Orthopaedic Surgery, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
- Faculty of Medicine and Life Sciences & Limburg Clinical Research Center, UHasselt, Diepenbeek, Belgium
| | - Steven Thiessen
- Critical Care Department, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
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Liang Q, Wang JW, Bai YR, Li RL, Wu CJ, Peng W. Targeting TRPV1 and TRPA1: A feasible strategy for natural herbal medicines to combat postoperative ileus. Pharmacol Res 2023; 196:106923. [PMID: 37709183 DOI: 10.1016/j.phrs.2023.106923] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 09/11/2023] [Accepted: 09/12/2023] [Indexed: 09/16/2023]
Abstract
Under physiological or pathological conditions, transient receptor potential (TRP) channel vanilloid type 1 (TRPV1) and TRP ankyrin 1 (TRPA1) possess the ability to detect a vast array of stimuli and execute diverse functions. Interestingly, increasing works have reported that activation of TRPV1 and TRPA1 could also be beneficial for ameliorating postoperative ileus (POI). Increasing research has revealed that the gastrointestinal (GI) tract is rich in TRPV1/TRPA1, which can be stimulated by capsaicin, allicin and other compounds. This activation stimulates a variety of neurotransmitters, leading to increased intestinal motility and providing protective effects against GI injury. POI is the most common emergent complication following abdominal and pelvic surgery, and is characterized by postoperative bowel dysfunction, pain, and inflammatory responses. It is noteworthy that natural herbs are gradually gaining recognition as a potential therapeutic option for POI due to the lack of effective pharmacological interventions. Therefore, the focus of this paper is on the TRPV1/TRPA1 channel, and an analysis and summary of the processes and mechanism by which natural herbs activate TRPV1/TRPA1 to enhance GI motility and relieve pain are provided, which will lay the foundation for the development of natural herb treatments for this disease.
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Affiliation(s)
- Qi Liang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Jing-Wen Wang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Yu-Ru Bai
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Ruo-Lan Li
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China
| | - Chun-Jie Wu
- Institute of Innovation, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
| | - Wei Peng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu 611137, PR China.
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Brearley SG, Varey S, Krige A. Patients' expectations, experience and acceptability of postoperative analgesia: a nested qualitative study within a randomised controlled trial comparing rectus sheath catheter and thoracic epidural analgesia. Anaesthesia 2023; 78:1249-1255. [PMID: 37423620 DOI: 10.1111/anae.16087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/11/2023]
Abstract
Adequate postoperative analgesia is a key element of enhanced recovery programmes. Thoracic epidural analgesia is associated with superior postoperative analgesia but can lead to complications. Rectus sheath catheter analgesia may provide an alternative. In a nested qualitative study (within a two-year randomised controlled trial) focussing on the acceptability, expectations and experiences of receiving the interventions, participants (n = 20) were interviewed 4 weeks post-intervention using a grounded theory approach. Constant comparative analysis, with patient and public involvement, enabled emerging findings to be pursued through subsequent data collection. We found no notable differences regarding postoperative acceptability or the experience of pain management. Pre-operatively, however, thoracic epidural analgesia was a source of anticipatory fear and anxiety. Both interventions resulted in some experienced adverse events (proportionately more with thoracic epidural analgesia). Participants had negative experiences of the insertion of thoracic epidural analgesia; others receiving the rectus sheath catheter lacked confidence in staff members' ability to manage the local anaesthetic infusion pump. The anticipation of the technique of thoracic epidural analgesia, and concerns about its impact on mobility, represented an additional, unpleasant experience for patients already managing an illness experience, anticipating a life-changing operation and dealing with concerns about the future. The anticipation of rectus sheath catheter analgesia was not associated with such anxieties. Patients' experiences start far earlier than the experience of the intervention itself through anticipatory anxieties and fears about receiving a technique and its potential implications. Complex pain packages can take on greater meaning than their actual efficacy in relieving postoperative pain. Future research into patient acceptability and experience should not focus solely on efficacy of pain relief but should include anticipatory fears, anxieties and experiences.
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Affiliation(s)
- S G Brearley
- Division of Heath Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - S Varey
- Division of Heath Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - A Krige
- Department of Anaesthesia and Critical Care, Royal Blackburn Teaching Hospital, Blackburn, UK
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Ajayan N, Hrishi AP, Mathew O, Saravanan G. Evaluation and correlation of nociceptive response index and spectral entropy indices as monitors of nociception in anesthetized patients. J Neurosci Rural Pract 2023; 14:440-446. [PMID: 37692802 PMCID: PMC10483196 DOI: 10.25259/jnrp_75_2023] [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: 02/16/2023] [Accepted: 04/12/2023] [Indexed: 09/12/2023] Open
Abstract
Objectives During anesthesia, the response to these stimuli depends on the balance between nociception and antinociception. Recently, various monitoring systems based on the variables derived from electroencephalography, plethysmography, autonomic tone, reflex pathways, and composite algorithms have been introduced for monitoring nociception. The main aim of our study was to evaluate and correlate the physiological variables which reflect the autonomic nervous system response to nociception, such as heart rate (HR), systolic blood pressure (SBP), perfusion index (PI), and nociceptive response index (NRI), with the spectral entropy indices response entropy (RE) and RE-state entropy (SE), which reflects electromyographic (EMG) activation as a response to pain. Materials and Methods This is a retrospective analysis of the data from a prospective study on the hypnotic and analgesic effects and the recovery profile of sevoflurane-based general anesthesia. Eighty-six patients undergoing single-agent sevoflurane anesthesia were recruited in the study. The study parameters, HR, SBP, SE, RE, RE-SE, PI, and NRI, were recorded at predefined time points before and after a standardized noxious stimulus. Correlation between the variables was carried out by applying the Pearson correlation equation for normal and the Spearman correlation equation for non-normally distributed data. Receiver operating characteristic (ROC) graphs were plotted, and the area under the curve was calculated to assess the diagnostic accuracy of post-stimulus NRI in detecting pain which was defined as RE-SE >10. Results There was a significant increase in the SBP, HR, NRI, RE, SE, and RE-SE and a considerable decrease in PI values during the post-noxious period compared to the pre-noxious period. There was no correlation between the absolute values of NRI and entropy indices at T2. However, among the reaction values, there was a weak correlation between the reaction values of NRI and RE (r = 0.30; P = 0.05). The area under the ROC curve for NRI to detect pain as defined by RE-SE >10 was 0.56. Conclusion During sevoflurane anesthesia, the application of noxious stimulus causes significant changes in variables reflecting sympathetic response and EMG activity. However, NRI failed to detect nociception, and there was only a weak correlation between the reaction values of NRI and RE-SE.
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Affiliation(s)
- Neeraja Ajayan
- Department of Neuroanesthesia and Critical Care, National Institute for Neurology and Neurosurgery, University College of London NHS Hospital Trust, London, United Kingdom
| | - Ajay Prasad Hrishi
- Department of Neuroanesthesia and Critical Care, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India
| | - Oommen Mathew
- Department of Biostatics, University of Kerala, Thiruvananthapuram, Kerala, India
| | - Gourinandan Saravanan
- Department of Chemistry and Biochemistry, University of Maryland, Baltimore, United States
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Knežević D, Ćurko-Cofek B, Batinac T, Laškarin G, Rakić M, Šoštarič M, Zdravković M, Šustić A, Sotošek V, Batičić L. Endothelial Dysfunction in Patients Undergoing Cardiac Surgery: A Narrative Review and Clinical Implications. J Cardiovasc Dev Dis 2023; 10:jcdd10050213. [PMID: 37233179 DOI: 10.3390/jcdd10050213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/27/2023] Open
Abstract
Cardiac surgery is one of the highest-risk procedures, usually involving cardiopulmonary bypass and commonly inducing endothelial injury that contributes to the development of perioperative and postoperative organ dysfunction. Substantial scientific efforts are being made to unravel the complex interaction of biomolecules involved in endothelial dysfunction to find new therapeutic targets and biomarkers and to develop therapeutic strategies to protect and restore the endothelium. This review highlights the current state-of-the-art knowledge on the structure and function of the endothelial glycocalyx and mechanisms of endothelial glycocalyx shedding in cardiac surgery. Particular emphasis is placed on potential strategies to protect and restore the endothelial glycocalyx in cardiac surgery. In addition, we have summarized and elaborated the latest evidence on conventional and potential biomarkers of endothelial dysfunction to provide a comprehensive synthesis of crucial mechanisms of endothelial dysfunction in patients undergoing cardiac surgery, and to highlight their clinical implications.
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Affiliation(s)
- Danijel Knežević
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Božena Ćurko-Cofek
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Tanja Batinac
- Department of Clinical Medical Sciences I, Faculty of Health Studies, University of Rijeka, Viktora Cara Emina 2, 51000 Rijeka, Croatia
| | - Gordana Laškarin
- Department of Physiology, Immunology and Pathophysiology, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Marijana Rakić
- Hospital for Medical Rehabilitation of Hearth and Lung Diseases and Rheumatism "Thalassotherapia-Opatija", M. Tita 188, 51410 Opatija, Croatia
| | - Maja Šoštarič
- Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiac Anesthesiology and Intensive Therapy, University Clinical Center Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia
- Department of Anesthesiology and Reanimatology, Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000 Ljubljana, Slovenia
| | - Marko Zdravković
- Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia
| | - Alan Šustić
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Vlatka Sotošek
- Department of Anesthesiology, Reanimatology, Emergency and Intensive Care Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
| | - Lara Batičić
- Department of Medical Chemistry, Biochemistry and Clinical Chemistry, Faculty of Medicine, University of Rijeka, Braće Branchetta 20, 51000 Rijeka, Croatia
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Gerner P, Cozowicz C, Memtsoudis SG. Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice? Anesthesiol Clin 2022; 40:433-444. [PMID: 36049872 DOI: 10.1016/j.anclin.2022.04.001] [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] [Indexed: 06/15/2023]
Abstract
The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.
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Affiliation(s)
- Philipp Gerner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02143, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria.
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11
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Abstract
The idea that perioperative outcomes may be improved through the implementation of measures that modify the surgical stress response has been around for several decades. Many techniques have been trialled with varying success. In addition, how the response to modification is measured, what constitutes a positive result and how this translates into clinical practice is the subject of debate. Modification of the stress response is the principal tenet behind the enhanced recovery after surgery (ERAS) movement which has seen the development of guidelines for perioperative care across a variety of surgical specialties bringing with them significant improvements in outcomes.
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Affiliation(s)
- Leigh J S Kelliher
- Department of Anaesthetics, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, Surrey GU2 7AS, UK.
| | - Michael Scott
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA; Surgical Outcomes Research Centre, University College London, London, UK
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12
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Müller MH. Mechanische Obstruktion, paralytischer Ileus, postoperativer Ileus, Ileuskrankheit. SPRINGER REFERENCE MEDIZIN 2022:1-10. [DOI: 10.1007/978-3-662-61724-3_59-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 09/02/2023]
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13
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Huisman DE, Reudink M, van Rooijen SJ, Bootsma BT, van de Brug T, Stens J, Bleeker W, Stassen LPS, Jongen A, Feo CV, Targa S, Komen N, Kroon HM, Sammour T, Lagae EAGL, Talsma AK, Wegdam JA, de Vries Reilingh TS, van Wely B, van Hoogstraten MJ, Sonneveld DJA, Veltkamp SC, Verdaasdonk EGG, Roumen RMH, Slooter GD, Daams F. LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Ann Surg 2022; 275:e189-e197. [PMID: 32511133 PMCID: PMC8683256 DOI: 10.1097/sla.0000000000003853] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess potentially modifiable perioperative risk factors for anastomotic leakage in adult patients undergoing colorectal surgery. SUMMARY BACKGROUND DATA Colorectal anastomotic leakage (CAL) is the single most important denominator of postoperative outcome after colorectal surgery. To lower the risk of CAL, the current research focused on the association of potentially modifiable risk factors, both surgical and anesthesiological. METHODS A consecutive series of adult patients undergoing colorectal surgery with primary anastomosis was enrolled from January 2016 to December 2018. Fourteen hospitals in Europe and Australia prospectively collected perioperative data by carrying out the LekCheck, a short checklist carried out in the operating theater as a time-out procedure just prior to the creation of the anastomosis to check perioperative values on 1) general condition 2) local perfusion and oxygenation, 3) contamination, and 4) surgery related factors. Univariate and multivariate logistic regression analysis were performed to identify perioperative potentially modifiable risk factors for CAL. RESULTS There were 1562 patients included in this study. CAL was reported in 132 (8.5%) patients. Low preoperative hemoglobin (OR 5.40, P < 0.001), contamination of the operative field (OR 2.98, P < 0.001), hyperglycemia (OR 2.80, P = 0.003), duration of surgery of more than 3 hours (OR 1.86, P = 0.010), administration of vasopressors (OR 1.80, P = 0.010), inadequate timing of preoperative antibiotic prophylaxis (OR 1.62, P = 0.047), and application of epidural analgesia (OR, 1.81, P = 0. 014) were all associated with CAL. CONCLUSIONS This study identified 7 perioperative potentially modifiable risk factors for CAL. The results enable the development of a multimodal and multidisciplinary strategy to create an optimal perioperative condition to finally lower CAL rates.
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Affiliation(s)
- Daitlin E Huisman
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Muriël Reudink
- Department of Surgery, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | - Stefanus J van Rooijen
- Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - Boukje T Bootsma
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Tim van de Brug
- Department of Epidemiology and Biostatistics, VU Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Jurre Stens
- Department of Anesthesiology, VU Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Wim Bleeker
- Wilhelmina Ziekenhuis, Assen, The Netherlands
| | | | - Audrey Jongen
- Department of Surgery, Maastricht Universitair Medisch Centrum, Maastricht, The Netherlands
| | - Carlo V Feo
- Ospedale del Delta, Lagosanto, Ferrara, Italy
| | | | - Niels Komen
- Antwerp University Hospital, Antwerp, Belgium
| | - Hidde M Kroon
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Tarik Sammour
- Colorectal Unit, Department of Surgery, Royal Adelaide Hospital, Adelaide, Australia
| | | | | | | | | | | | | | | | | | | | - Rudi M H Roumen
- Department of Surgery, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Center Veldhoven, Veldhoven, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
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Ray K, Hamed M, Imsirovic A, Swaminathan C, Sajid MS. Intraperitoneal local anaesthesia for post-operative pain management in patients undergoing laparoscopic colorectal surgery: a systematic review and meta-analysis. Minerva Surg 2021; 77:57-64. [PMID: 34047532 DOI: 10.23736/s2724-5691.21.08789-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Intraperitoneal instillation of local anaesthetic agents has been reported as an effective adjunct to pain management and early functional recovery in colorectal surgery. Laparoscopic colorectal resection (LCR) is considered as the gold standard approach to resect benign and malignant lesions of the colon and rectum due to the advantages of reduced pain score, quicker recovery, and shorter hospitalization. The objective of this study is to systematically analyze the published RCTs evaluating the effectiveness of intraperitoneal local anesthetic (IPLA) instillation versus standard analgesia in patients undergoing LCR. EVIDENCE ANALYSIS Electronic databases such as Embase, Medline, PubMed, PubMed Central and the Cochrane library pertaining to the use of IPLA infiltration after LCR were systematically reviewed using the principles of meta-analysis. EVIDENCE SYNTHESIS Five RCTs on 292 patients undergoing LCR were either given IPLA or standard post-operative analgesia. In the random-effects model analysis using the statistical software Review Manager, statistically 2-4 hours pain score (Standardized mean difference (SMD), -1.72; 95% CI, -2.62, -0.81; z = 3.71; P = 0.0002) was significantly ower in the IPLA group. The 12 hours post-operative pain score (P = 0.23) was also lower in the IPLA group but failed to reach the statistical significance. Opioid analgesia requirement was lower in the IPLA group (SMD -7.60; 95% CI, -11.21, -3.90; z = 4.12; P = 0.0001) but the time to flatus, length of stay and the frequency of nausea/vomiting were statistically similar in both groups. CONCLUSIONS IPLA instillation is an effective modality to reduce the post-operative pain score and lower the opioid analgesic requirements in patients undergoing LCR without influencing the time to first flatus, length of stay, and post-operative nausea/vomiting.
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Affiliation(s)
- Kausik Ray
- Department of Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK -
| | - Moaz Hamed
- Department of Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Anja Imsirovic
- Department of Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Christie Swaminathan
- Department of Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Muhammad S Sajid
- Department of Gastrointestinal Surgery, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
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Han X, Lu Y, Fang Q, Fang P, Wong GTC, Liu X. Effects of Epidural Anesthesia on Quality of Life in Elderly Patients Undergoing Esophagectomy. Semin Thorac Cardiovasc Surg 2021; 33:276-285. [DOI: 10.1053/j.semtcvs.2020.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/02/2020] [Indexed: 11/12/2022]
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16
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Comment on "LekCheck: A Prospective Study to Identify Perioperative Modifiable Risk Factors for Anastomotic Leakage in Colorectal Surgery". Ann Surg 2020; 274:e851-e852. [PMID: 33351459 DOI: 10.1097/sla.0000000000004667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Zhang Y, Geng G, Chen Z, Wu W, Xu J, Ding X, Liu C, Gui B. Association Between Intercostal Nerve Block and Postoperative Glycemic Control in Patients With Diabetes Undergoing Video-Assisted Thoracoscopic Pulmonary Resection: A Retrospective Study. J Cardiothorac Vasc Anesth 2020; 35:2303-2310. [PMID: 33234467 DOI: 10.1053/j.jvca.2020.10.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The present study was performed to investigate the possible association between intercostal nerve block (INB) and postoperative glycemic control in patients with diabetes undergoing video-assisted thoracoscopic pulmonary resection. DESIGN A retrospective study. SETTING Single-center tertiary academic hospital. PARTICIPANTS Patients with diabetes, ages 18 to 79 years, who had undergone elective video-assisted thoracoscopic pulmonary resection (segmentectomy or lobectomy) from January 1, 2015, to December 31, 2018. INTERVENTIONS Postoperative blood glucose levels and insulin dosage were extracted from the record. MEASUREMENTS AND MAIN RESULTS Patients with diabetes who received INB before closure of surgical incisions were compared with those who did not receive INB. The primary outcome was the daily blood glucose (BG) level. Univariate analyses and multivariate regression analysis were performed to explore risk factors of hyperglycemia within 48 hours after the surgery. Baseline characteristics were comparable between the two groups. Patients who received INB had a lower maximum BG level and amplitude of glycemic excursion from zero-to-24 hours after surgery (p = 0.007 and p = 0.041, respectively) and lower maximum and minimum BG levels from 24-to-48 hours after surgery (p = 0.023 and p = 0.006, respectively). Meanwhile, the daily insulin dose increment during zero-to-24 hours and 24-to-48 hours after surgery decreased (p = 0.010 and p = 0.003, respectively), the white blood cell counts within 48 hours after surgery were lower (p = 0.021), and the length of postoperative stay decreased in the INB group (p = 0.044). Multivariate regression analysis further confirmed that INB was an independent protective factor of postoperative hyperglycemia (Nagelkerke R2 value 0.229; odds ratio 0.298; 95% confidence interval 0.099-0.901; p = 0.032). CONCLUSION INB, performed before closure of surgical incisions, was associated with improved glycemic control in patients with diabetes within 48 hours after video-assisted thoracoscopic pulmonary resection.
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Affiliation(s)
- Yang Zhang
- Department of Anesthesiology and Perioperative Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Guangxing Geng
- Department of Anesthesiology, Huai'an Fourth People's Hospital, Huai'an, Jiangsu, China
| | - Zixuan Chen
- Department of Anesthesiology and Perioperative Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Weibing Wu
- Department of Thoracic Surgery, 1st Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jing Xu
- Department of Thoracic Surgery, 1st Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiahao Ding
- Department of Anesthesiology and Perioperative Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Cunming Liu
- Department of Anesthesiology and Perioperative Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Bo Gui
- Department of Anesthesiology and Perioperative Medicine, First Affiliated Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
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Incidence and risk factors of postoperative ileus after hysterectomy for benign indications. Int J Colorectal Dis 2020; 35:2105-2112. [PMID: 32699935 DOI: 10.1007/s00384-020-03698-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative ileus (POI) after abdominal surgery is associated with prolonged hospital stay and increased costs. The aim of this study is to investigate the incidence of, risk factors for, and outcomes associated with POI in patients undergoing hysterectomy for benign indications. METHODS A retrospective review of 1017 consecutive patients undergoing benign hysterectomy over the period 2012-2017 in a single center was performed. POI was predefined as absence of flatus and defecation for more than 2 days with the presence of one or more of the following symptoms: nausea, vomiting, and abdominal distention. The association between perioperative variables and the risk of POI was evaluated by univariate analysis. Independent risk factors were identified by multivariate logistic regression analysis. RESULTS Overall incidence of POI was 9.2%. Incidence of POI did not differ significantly among three different surgical approaches (abdominal hysterectomy, 10.6%; laparoscopic hysterectomy, 7.8%; vaginal hysterectomy, 11.3%; P = 0.279). Independent risk factors of POI identified by multivariate analysis included anesthesia technique (odds ratio [OR] 2.662, 95% interval [CI] 1.533-4.622, P = 0.001), adhesiolysis (odds ratio [OR] 1.818, 95% interval [CI] 1.533-4.622, P = 0.011), duration of operation (odds ratio [OR] 1.005, 95% interval [CI] 0.942-6.190, P = 0.029), previous cancer (odds ratio [OR] 4.789, 95% interval [CI] 1.232-18.626, P = 0.024), and dysmenorrhea (odds ratio [OR] 1.859, 95% interval [CI] 1.182-2.925, P = 0.007). CONCLUSION POI is a common complication after hysterectomy. This study identified risk factors of POI specifically for gynecologic patients. Patients exposed to these factors should be monitored closely for the development POI.
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Chen W, Feng Y, Chen X, Jiang F, Miao J, Chen S, Chen H. Comparison of Three Normalization Methods in Monitoring Analgesic Depth with Photoplethysmographic Diastolic Interval. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:5971-5975. [PMID: 33019332 DOI: 10.1109/embc44109.2020.9175443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of the present study was to investigate the ability of three different normalization methods, namely root mean square (RMS) value, mean value, and maximum which referred to pulse beat interval (PBI), based on photoplethysmographic diastolic interval (DI) in response to laryngeal mask airway (LMA) insertion under various remifentanil concentrations during general anesthesia. Sixty patients were randomly allocated to one of the four groups to receive a possible remifentanil effect-compartment target concentration (Ceremi) of 0, 1, 3, or 5 ng/ml, and an effect-compartment target controlled infusion of propofol to maintain the state entropy (SE) at 40~60. Three normalized measures DIRMS, DIMean, and DIPBI were compared with the DI values without normalization. Before LMA insertion, only DI showed a considerable correlation with remifentanil concentrations. DIRMS and DIMean performed better than DI in discriminating 'insufficient' concentrations (0 and 1 ng/ml) from 'sufficient' concentrations (3 and 5 ng/ml). DIRMS was superior to all other variables in grading analgesic depth after nociceptive event occurred with PK value of 0.836. These results demonstrate that the normalization using RMS value, compared to using mean value and maximum, seems to provide a more effective approach for signal pre-processing.
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Acute Kidney Injury After Esophageal Cancer Surgery: Incidence, Risk Factors, and Impact on Oncologic Outcomes. Ann Surg 2020; 275:e683-e689. [PMID: 32740248 DOI: 10.1097/sla.0000000000004146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the incidence, risk factors, and consequences of AKI in patients undergoing surgery for esophageal cancer. SUMMARY OF BACKGROUND DATA Esophageal cancer surgery is an exemplar of major operative trauma, with well-defined risks of respiratory, cardiac, anastomotic, and septic complications. However, there is a paucity of literature regarding AKI. METHODS Consecutive patients undergoing curative-intent surgery for esophageal cancer from 2011 to 2017 in 3 high-volume centers were studied. AKI was defined according to the AKI Network criteria. AKI occurred if, within 48 hours postoperatively, serum creatinine rose by 50% or by 0.3 mg/dL (26.5 μmol/L) from preoperative baseline. Complications were recorded prospectively. Multivariable logistic regression determined factors independently predictive of AKI. RESULTS A total of 1135 patients (24.7%:75.3% female:male, with a mean age of 64, a baseline BMI of 27 kg m, and dyslipidemia in 10.2%), underwent esophageal cancer surgery, 85% having an open thoracotomy. Overall in-hospital mortality was 2.1%. Postoperative AKI was observed in 208 (18.3%) patients, with AKI Network 1, 2, and 3 in 173 (15.2%), 28 (2.5%), and 7 (0.6%), respectively. Of these, 70.3% experienced improved renal function within 48 hours. Preoperative factors independently predictive of AKI were age [P = 0.027, odds ratio (OR) 1.02 (1.00-1.04)], male sex [P = 0.015, OR 1.77 (1.10-2.81)], BMI at diagnosis [P < 0.001, OR 1.10 (1.07-1.14)], and dyslipidemia [P = 0.002, OR 2.14 (1.34-3.44)]. Postoperatively, AKI was associated with atrial fibrillation (P = 0.013) and pneumonia (P = 0.005). Postoperative AKI did not impact survival outcomes. CONCLUSION AKI is common but mostly self-limiting after esophageal cancer surgery. It is associated with age, male sex, increased BMI, dyslipidemia, and postoperative morbidity.
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Risk score for major complications after total hip arthroplasty: the beneficial effect of neuraxial anesthesia. A retrospective observational study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Foss NB, Kehlet H. Challenges in optimising recovery after emergency laparotomy. Anaesthesia 2020; 75 Suppl 1:e83-e89. [PMID: 31903571 DOI: 10.1111/anae.14902] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2019] [Indexed: 12/19/2022]
Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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High Compliance to an Enhanced Recovery Pathway for Patients ≥65 Years Undergoing Major Small and Large Intestinal Surgery Is Associated With Improved Postoperative Outcomes. Ann Surg 2019; 270:1117-1123. [DOI: 10.1097/sla.0000000000002872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Liu R, Qin H, Wang M, Li K, Zhao G. Transversus abdominis plane block with general anesthesia blunts the perioperative stress response in patients undergoing radical gastrectomy. BMC Anesthesiol 2019; 19:205. [PMID: 31699052 PMCID: PMC6839132 DOI: 10.1186/s12871-019-0861-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
Background Surgical stress induces the release of neuroendocrine mediators and cytokines during perioperative period, which may have adverse effects on cancer patients. While the surgical stress responsse can be affected by anesthetic technique. Therefore, we designed this study to assess whether subcostal transversus abdominis plane (TAP) block can affect perioperative neuroendocrine stress response, postoperative analgesia and postoperative recovery in patients undergoing radical gastrectomy under general anesthesia. Methods Sixty-five patients were recruited. Patients randomly received general anesthesia (control group), or general anesthesia combined with TAP block (40 mL of 0.375% ropivacaine) (TAP group). The primary outcome was neuroendocrine levels including norepinephrine (NE), epinephrine (E), cortisol (Cor), glucose (Glu), interleukin (IL)-6 and IL-10 during 48 h after surgery. Secondary outcomes included pain score, hemodynamic variables and recovery characteristics. Results Data from 61 of 65 patients were analyzed. The levels of NE, E, Cor, and Glu were blunt by TAP block during perioperative period. The levels of IL-6 and IL-10 were significantly lower in TAP group than in control group. TAP block efficiently relieved postoperative acute pain up to 12 h postoperatively with more stable perioperative hemodynamics compared with control group. Conclusions Subcostal TAP block blunts perioperative stress response and provides efficient analgesia, with good hemodynamic stability and minimal adverse effects.
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Affiliation(s)
- Ruizhu Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Road, Changchun, 130000, Jilin Province, China
| | - Haiyan Qin
- Department of Plastic Surgery, China-Japan Union Hospital of Jilin University, Changchun, 130000, Jilin Province, China
| | - Meng Wang
- Department of Cardiology, No. 965 Hospital of PLA, Jilin, 132000, Jilin Province, China
| | - Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Road, Changchun, 130000, Jilin Province, China.
| | - Guoqing Zhao
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, No. 126 Xiantai Road, Changchun, 130000, Jilin Province, China.
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Hayden J, Gupta A, Thörn S, Thulin P, Block L, Oras J. Does intraperitoneal ropivacaine reduce postoperative inflammation? A prospective, double-blind, placebo-controlled pilot study. Acta Anaesthesiol Scand 2019; 63:1048-1054. [PMID: 31206591 DOI: 10.1111/aas.13410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/11/2019] [Accepted: 05/07/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Postoperative inflammation is a common consequence of surgery and the ensuing stress response. Local anesthetics have anti-inflammatory properties. The primary aim of this study was to evaluate if LA administrated intraperitoneally perioperatively might inhibit expression of inflammatory cytokines. METHODS This was a, randomized, double blind, placebo-controlled study (ClinicalTrial.gov reg no: NCT02256228) in patients undergoing surgery for ovarian cancer. Patients were randomized to receive: intraperitoneal ropivacaine (Group IPLA) or saline (Group P) perioperatively. Except for study drug, patients were treated similarly. At the end of surgery, a multi-port catheter was inserted intraperitoneally, and ropivacaine 2 mg/mL or 0.9% saline, 10 mL was injected intermittently every other hour during 72 hours postoperatively. Systemic expression of cytokines and plasma ropivacaine were determined before and 6, 24, and 48 hours after surgery. Stress response was measured by serum glucose, cortisol, and insulin. RESULTS Forty patients were recruited, 20 in each group. There was no statistical significant difference in systemic cytokine between the groups at any time point. Serum cortisol was significantly lower in the IPLA group at 6 hours, median 103 nmol/L (IQR 53-250) compared to placebo, median 440 nmol/L (IQR 115-885), P = 0.023. Serum glucose and insulin were similar between the groups. Total and free serum concentrations of ropivacaine were well below toxic concentrations. CONCLUSION In this small study, perioperative intraperitoneal ropivacaine did not reduce the systemic inflammatory response associated with major abdominal surgery. Total and free ropivacaine concentrations were below known toxic concentrations in humans.
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Affiliation(s)
- Jane Hayden
- Department of Anesthesiology and Intensive Care, Institute of Clinical sciences Sahlgrenska Academy, University of Gothenburg, Västra Götalandsregionen, Sahlgrenska University Hospital Gothenburg Sweden
| | - Anil Gupta
- Institute of Physiology and Pharmacology Karolinska Institutet, Karolinska University Hospital Solna Stockholm Sweden
| | - Sven‐Egron Thörn
- Department of Anesthesiology and Intensive Care, Institute of Clinical sciences Sahlgrenska Academy, University of Gothenburg, Västra Götalandsregionen, Sahlgrenska University Hospital Gothenburg Sweden
| | - Pontus Thulin
- Department of Clinical Immunology and Transfusion Medicine Region Västra Götaland, Sahlgrenska University Hospital Gothenburg Sweden
| | - Linda Block
- Department of Anesthesiology and Intensive Care, Institute of Clinical sciences Sahlgrenska Academy, University of Gothenburg, Västra Götalandsregionen, Sahlgrenska University Hospital Gothenburg Sweden
| | - Jonatan Oras
- Department of Anesthesiology and Intensive Care, Institute of Clinical sciences Sahlgrenska Academy, University of Gothenburg, Västra Götalandsregionen, Sahlgrenska University Hospital Gothenburg Sweden
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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: 33] [Impact Index Per Article: 6.6] [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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Decreasing the Surgical Stress Response and an Initial Experience from the Enhanced Recovery After Surgery Colorectal Surgery Program at an Academic Institution. Int Anesthesiol Clin 2019; 55:163-178. [PMID: 28901989 DOI: 10.1097/aia.0000000000000162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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A Deep Neural Network-Based Pain Classifier Using a Photoplethysmography Signal. SENSORS 2019; 19:s19020384. [PMID: 30669327 PMCID: PMC6358962 DOI: 10.3390/s19020384] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/13/2019] [Accepted: 01/15/2019] [Indexed: 11/16/2022]
Abstract
Side effects occur when excessive or low doses of analgesics are administered compared to the required amount to mediate the pain induced during surgery. It is important to accurately assess the pain level of the patient during surgery. We proposed a pain classifier based on a deep belief network (DBN) using photoplethysmography (PPG). Our DBN learned about a complex nonlinear relationship between extracted PPG features and pain status based on the numeric rating scale (NRS). A bagging ensemble model was used to improve classification performance. The DBN classifier showed better classification results than multilayer perceptron neural network (MLPNN) and support vector machine (SVM) models. In addition, the classification performance was improved when the selective bagging model was applied compared with the use of each single model classifier. The pain classifier based on DBN using a selective bagging model can be helpful in developing a pain classification system.
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Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LHJ, Hahnenkamp K, Hollmann MW, Poepping DM, Schnabel A, Kranke P. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018; 6:CD009642. [PMID: 29864216 PMCID: PMC6513586 DOI: 10.1002/14651858.cd009642.pub3] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The management of postoperative pain and recovery is still unsatisfactory in a number of cases in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects, including nausea and constipation, preventing smooth postoperative recovery. Not all patients are suitable for, and benefit from, epidural analgesia that is used to improve postoperative recovery. The non-opioid, lidocaine, was investigated in several studies for its use in multimodal management strategies to reduce postoperative pain and enhance recovery. This review was published in 2015 and updated in January 2017. OBJECTIVES To assess the effects (benefits and risks) of perioperative intravenous (IV) lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, and reference lists of articles in January 2017. We searched one trial registry contacted researchers in the field, and handsearched journals and congress proceedings. We updated this search in February 2018, but have not yet incorporated these results into the review. SELECTION CRITERIA We included randomized controlled trials comparing the effect of continuous perioperative IV lidocaine infusion either with placebo, or no treatment, or with thoracic epidural analgesia (TEA) in adults undergoing elective or urgent surgery under general anaesthesia. The IV lidocaine infusion must have been started intraoperatively, prior to incision, and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. Our primary outcomes were: pain score at rest; gastrointestinal recovery and adverse events. Secondary outcomes included: postoperative nausea and postoperative opioid consumption. We used GRADE to assess the quality of evidence for each outcome. MAIN RESULTS We included 23 new trials in the update. In total, the review included 68 trials (4525 randomized participants). Two trials compared IV lidocaine with TEA. In all remaining trials, placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (22), laparoscopic abdominal (20), or various other surgical procedures (26). The application scheme of systemic lidocaine strongly varies between the studies related to both dose (1 mg/kg/h to 5 mg/kg/h) and termination of the infusion (from the end of surgery until several days after).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting, the quality assessment yielded low risk of bias for only approximately 20% of the included studies.IV Lidocaine compared to placebo or no treatment We are uncertain whether IV lidocaine improves postoperative pain compared to placebo or no treatment at early time points (1 to 4 hours) (standardized mean difference (SMD) -0.50, 95% confidence interval (CI) -0.72 to -0.28; 29 studies, 1656 participants; very low-quality evidence) after surgery. Due to variation in the standard deviation (SD) in the studies, this would equate to an average pain reduction of between 0.37 cm and 2.48 cm on a 0 to 10 cm visual analogue scale . Assuming approximately 1 cm on a 0 to 10 cm pain scale is clinically meaningful, we ruled out a clinically relevant reduction in pain with lidocaine at intermediate (24 hours) (SMD -0.14, 95% CI -0.25 to -0.04; 33 studies, 1847 participants; moderate-quality evidence), and at late time points (48 hours) (SMD -0.11, 95% CI -0.25 to 0.04; 24 studies, 1404 participants; moderate-quality evidence). Due to variation in the SD in the studies, this would equate to an average pain reduction of between 0.10 cm to 0.48 cm at 24 hours and 0.08 cm to 0.42 cm at 48 hours. In contrast to the original review in 2015, we did not find any significant subgroup differences for different surgical procedures.We are uncertain whether lidocaine reduces the risk of ileus (risk ratio (RR) 0.37, 95% CI 0.15 to 0.87; 4 studies, 273 participants), time to first defaecation/bowel movement (mean difference (MD) -7.92 hours, 95% CI -12.71 to -3.13; 12 studies, 684 participants), risk of postoperative nausea (overall, i.e. 0 up to 72 hours) (RR 0.78, 95% CI 0.67 to 0.91; 35 studies, 1903 participants), and opioid consumption (overall) (MD -4.52 mg morphine equivalents , 95% CI -6.25 to -2.79; 40 studies, 2201 participants); quality of evidence was very low for all these outcomes.The effect of IV lidocaine on adverse effects compared to placebo treatment is uncertain, as only a small number of studies systematically analysed the occurrence of adverse effects (very low-quality evidence).IV Lidocaine compared to TEAThe effects of IV lidocaine compared with TEA are unclear (pain at 24 hours (MD 1.51, 95% CI -0.29 to 3.32; 2 studies, 102 participants), pain at 48 hours (MD 0.98, 95% CI -1.19 to 3.16; 2 studies, 102 participants), time to first bowel movement (MD -1.66, 95% CI -10.88 to 7.56; 2 studies, 102 participants); all very low-quality evidence). The risk for ileus and for postoperative nausea (overall) is also unclear, as only one small trial assessed these outcomes (very low-quality evidence). No trial assessed the outcomes, 'pain at early time points' and 'opioid consumption (overall)'. The effect of IV lidocaine on adverse effects compared to TEA is uncertain (very low-quality evidence). AUTHORS' CONCLUSIONS We are uncertain whether IV perioperative lidocaine, when compared to placebo or no treatment, has a beneficial impact on pain scores in the early postoperative phase, and on gastrointestinal recovery, postoperative nausea, and opioid consumption. The quality of evidence was limited due to inconsistency, imprecision, and study quality. Lidocaine probably has no clinically relevant effect on pain scores later than 24 hours. Few studies have systematically assessed the incidence of adverse effects. There is a lack of evidence about the effects of IV lidocaine compared with epidural anaesthesia in terms of the optimal dose and timing (including the duration) of the administration. We identified three ongoing studies, and 18 studies are awaiting classification; the results of the review may change when these studies are published and included in the review.
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Affiliation(s)
- Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Yvonne Jelting
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Nathan L Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Antonia Helf
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Leopold HJ Eberhart
- Philipps‐University MarburgDepartment of Anaesthesiology & Intensive Care MedicineBaldingerstrasse 1MarburgGermany35043
| | - Klaus Hahnenkamp
- University HospitalDepartment of AnesthesiologyGreifswaldGermany17475
| | - Markus W Hollmann
- Academic Medical Center (AMC) University of AmsterdamDepartment of AnaesthesiologyMeibergdreef 9AmsterdamNetherlands1105 DD
| | - Daniel M Poepping
- University Hospital MünsterDepartment of Anesthesiology and Intensive CareAlbert Schweitzer Str. 33MünsterGermany48149
| | - Alexander Schnabel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
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Feltracco P, Bortolato A, Barbieri S, Michieletto E, Serra E, Ruol A, Merigliano S, Ori C. Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review. Dis Esophagus 2018; 31:4683666. [PMID: 29211841 DOI: 10.1093/dote/dox135] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/26/2017] [Indexed: 12/11/2022]
Abstract
Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.
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Affiliation(s)
- P Feltracco
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Bortolato
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - S Barbieri
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Michieletto
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Serra
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Ruol
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - S Merigliano
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - C Ori
- Departments of Medicine, UO Anesthesia and Intensive Care
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31
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Gonfiotti A, Viggiano D, Bongiolatti S, Bertolaccini L, Solli P, Bertani A, Voltolini L, Crisci R, Droghetti A. Enhanced Recovery After Surgery (ERAS®) in thoracic surgical oncology. Future Oncol 2018; 14:33-40. [DOI: 10.2217/fon-2017-0471] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Enhanced recovery after surgery (ERAS®) is a strategy that seeks to reduce patients’ perioperative stress response, thereby reducing potential complications, decreasing hospital length of stay and enabling patients to return more quickly to their baseline functional status. The concept was introduced in the late 1990s and was first adopted for use with patients undergoing open colorectal surgery. Since that time, the concept of ERAS has spread to multiple surgical specialties. This article explores the key elements for patient care using an ERAS protocol applied to minimally invasive thoracic surgery.
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Affiliation(s)
| | - Domenico Viggiano
- Thoracic Surgery Unit, Careggi University Hospital, Florence 50134, Italy
| | | | - Luca Bertolaccini
- Thoracic Surgery Unit – AUSL Romagna Teaching Hospital, Ravenna 48121, Italy
| | - Piergiorgio Solli
- Thoracic Surgery Unit – AUSL Romagna Teaching Hospital, Ravenna 48121, Italy
| | - Alessandro Bertani
- Department of Thoracic Surgery, IRCCS ISMETT-UPMC, University of Pittsburgh, Palermo 90145, Italy
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence 50134, Italy
| | - Roberto Crisci
- Department of Thoracic Surgery, University of L'Aquila, L'Aquila 67100, Italy
| | - Andrea Droghetti
- Department of Thoracic Surgery, ASST Mantova, Mantova 46100, Italy
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Chapman SJ, Pericleous A, Downey C, Jayne DG. Postoperative ileus following major colorectal surgery. Br J Surg 2018; 105:797-810. [PMID: 29469195 DOI: 10.1002/bjs.10781] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 10/04/2017] [Accepted: 11/05/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative ileus (POI) is characterized by delayed gastrointestinal recovery following surgery. Current knowledge of pathophysiology, clinical interventions and methodological challenges was reviewed to inform modern practice and future research. METHODS A systematic search of MEDLINE and Embase databases was performed using search terms related to ileus and colorectal surgery. All RCTs involving an intervention to prevent or reduce POI published between 1990 and 2016 were identified. Grey literature, non-full-text manuscripts, and reanalyses of previous RCTs were excluded. Eligible articles were assessed using the Cochrane tool for assessing risk of bias. RESULTS Of 5614 studies screened, 86 eligible articles describing 88 RCTs were identified. Current knowledge of pathophysiology acknowledges neurogenic, inflammatory and pharmacological mechanisms, but much of the evidence arises from animal studies. The most common interventions tested were chewing gum (11 trials) and early enteral feeding (11), which are safe but of unclear benefit for actively reducing POI. Others, including thoracic epidural analgesia (8), systemic lidocaine (8) and peripheral μ antagonists (5), show benefit but require further investigation for safety and cost-effectiveness. CONCLUSION POI is a common condition with no established definition, aetiology or treatment. According to current literature, minimally invasive surgery, protocol-driven recovery (including early feeding and opioid avoidance strategies) and measures to avoid major inflammatory events (such as anastomotic leak) offer the best chances of reducing POI.
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Affiliation(s)
- S J Chapman
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds LS9 7TF, UK
| | - A Pericleous
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds LS9 7TF, UK
| | - C Downey
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds LS9 7TF, UK
| | - D G Jayne
- Section of Translational Anaesthesia and Surgery, Leeds Institute of Biomedical and Clinical Sciences, University of Leeds, Leeds LS9 7TF, UK
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Bragg DD, Edis H, Clark S, Parsons SL, Perumpalath B, Lobo DN, Maxwell-Armstrong CA. Development of a telehealth monitoring service after colorectal surgery: A feasibility study. World J Gastrointest Surg 2017; 9:193-199. [PMID: 29081902 PMCID: PMC5633533 DOI: 10.4240/wjgs.v9.i9.193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/25/2017] [Accepted: 09/04/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the feasibility of a text-messaging system to remotely monitor and support patients after discharge following elective colorectal surgery, within an enhanced recovery protocol.
METHODS Florence (FLO) is a National Health Service telehealth solution utilised for monitoring chronic health conditions, such as hypertension, using text-messaging. New algorithms were designed to monitor the well-being, basic physiological observations and any patient-reported symptoms, and provide support messages to patients undergoing colorectal surgery within an enhanced recovery after surgery protocol for 30 d after discharge. All interactions with FLO and physiological readings were recorded and patients were invited to provide feedback.
RESULTS Over a four-week period, 16 out of 17 patients used the FLO telehealth service at home. These patients did not receive telephone follow-up at three days, as per our standard protocol, unless they reported being unwell or did not make use of the technology. Three patients were readmitted within 30 d, and two of these were identified as being unwell by FLO prior to readmission. No adverse events attributable to the use of the technology were encountered.
CONCLUSION The utilisation of telehealth in the early follow-up of patients who have undergone major colorectal surgery after discharge is feasible. The use of this technology may assist in the early recognition and management of complications after discharge.
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Affiliation(s)
- Damian D Bragg
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Helena Edis
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Sian Clark
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Simon L Parsons
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Binoy Perumpalath
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Dileep N Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
| | - Charles A Maxwell-Armstrong
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute of Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham NG7 2UH, United Kingdom
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Pillinger NL, Kam P. Endothelial glycocalyx: basic science and clinical implications. Anaesth Intensive Care 2017; 45:295-307. [PMID: 28486888 DOI: 10.1177/0310057x1704500305] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The classic Starling principle proposed that microvascular fluid exchange was determined by a balance of hydrostatic and oncotic pressures relative to the vascular wall and this movement of water was regulated by gaps in the intercellular spaces. However, current literature on the endothelial glycocalyx (a jelly-like protective layer covering the luminal surface of the endothelium) has revised Starling's traditional concepts. This article aims to summarise the literature on the glycocalyx related to its basic science, clinical settings inciting injury, protective strategies and clinical perspectives. Perioperative damage to the glycocalyx structure can increase vascular permeability leading to interstitial fluid shifts, oedema, and increased surgical morbidity. Pathological shedding of the glycocalyx occurs in response to mechanical cellular stress, endotoxins, inflammatory mediators, atrial natriuretic peptide, ischaemia-reperfusion injury, free oxygen radicals and hyperglycaemia. Increased understanding of the endothelial glycocalyx may change perioperative fluid management, and therapeutic strategies aimed at its preservation may improve patient outcomes.
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Affiliation(s)
- N L Pillinger
- Staff Specialist Anaesthetist, Department of Anaesthetics, Royal Prince Alfred Hospital, 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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Cho JS, Kim HI, Lee KY, Son T, Bai SJ, Choi H, Yoo YC. Comparison of the effects of patient-controlled epidural and intravenous analgesia on postoperative bowel function after laparoscopic gastrectomy: a prospective randomized study. Surg Endosc 2017; 31:4688-4696. [PMID: 28389801 DOI: 10.1007/s00464-017-5537-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/20/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND Although laparoscopic surgery significantly reduces surgical trauma compared to open surgery, postoperative ileus is a frequent and significant complication after abdominal surgery. Unlike laparoscopic colorectal surgery, the effects of epidural analgesia on postoperative recovery after laparoscopic gastrectomy are not well established. We compared the effects of epidural analgesia to those of conventional intravenous (IV) analgesia on the recovery of bowel function after laparoscopic gastrectomy. METHOD Eighty-six patients undergoing laparoscopic gastrectomy randomly received either patient-controlled epidural analgesia with ropivacaine and fentanyl (Epi PCA group) or patient-controlled IV analgesia with fentanyl (IV PCA group), beginning immediately before incision and continuing for 48 h thereafter. The primary endpoint was recovery of bowel function, evaluated by the time to first flatus. The balance of the autonomic nervous system, pain scores, duration of postoperative hospital stay, and complications were assessed. RESULTS The time to first flatus was shorter in the epidural PCA group compared with the IV PCA group (61.3 ± 11.1 vs. 70.0 ± 12.3 h, P = 0.001). Low-frequency/high-frequency power ratios during surgery were significantly higher in the IV PCA group, compared with baseline and those in the epidural PCA group. The epidural PCA group had lower pain scores during the first 1 h postoperatively and required less analgesics during the first 6 h postoperatively. CONCLUSIONS Compared with IV PCA, epidural PCA facilitated postoperative recovery of bowel function after laparoscopic gastrectomy without increasing the length of hospital stay or PCA-related complications. This beneficial effect of epidural analgesia might be attributed to attenuation of sympathetic hyperactivation, improved analgesia, and reduced opioid use.
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Affiliation(s)
- Jin Sun Cho
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung-Il Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Ki-Young Lee
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Taeil Son
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Sun Joon Bai
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Haegi Choi
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Young Chul Yoo
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea. .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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Rahiri J, Tuhoe J, Svirskis D, Lightfoot N, Lirk P, Hill A. Systematic review of the systemic concentrations of local anaesthetic after transversus abdominis plane block and rectus sheath block. Br J Anaesth 2017; 118:517-526. [DOI: 10.1093/bja/aex005] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Garulli G, Lucchi A, Berti P, Gabbianelli C, Siani LM. "Ultra" E.R.A.S. in laparoscopic colectomy for cancer: discharge after the first flatus? A prospective, randomized trial. Surg Endosc 2016; 31:1806-1813. [PMID: 27519593 DOI: 10.1007/s00464-016-5177-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 08/08/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Enhanced Recovery After Surgery (E.R.A.S.) programs are now widely accepted in colonic laparoscopic resections because of faster recovery and less perioperative complications. The aim of this study was to assess safety and feasibility of discharging patients operated on by laparoscopic colectomy on postoperative day 2, so long as the first flatus has passed and in the absence of complication-related symptoms. METHODS This study was a non-inferiority, open-label, single-center, prospective, randomized study comparing "Ultra" to Classic E.R.A.S. with discharge on POD 2 and 4, respectively. Seven hundred and sixty-five patients with resectable non-metastatic colonic cancer were analyzed: 384 patients were assigned to "Ultra" E.R.A.S. and 381 to Classic E.R.A.S. Primary end-point was mortality; secondary end-points were morbidity, readmission and reoperation rate. Limitations are: it is a single-center experience; it is not double-blind, with the intrinsic risk of intentional or unconscious bias; exclusion criteria because of "non-compliance" may be considered arbitrary. RESULTS Mortality was 0.89 % in "Ultra" E.R.A.S. group and 0.59 % in Classic E.R.A.S. (p = 0.571). Morbidity was 34.1 % for "Ultra" E.R.A.S. arm and 35.4 % for Classic E.R.A.S. (p = 0.753). Readmissions were 5.6 % for "Ultra" E.R.A.S. and 5.9 % for Classic E.R.A.S. (p = 0.359). Reoperation rate was 3.8 % for "Ultra" ERAS and 4.7 % for Classic E.R.A.S. (p = 0.713). Multivariate regression analyses using Cox's proportional hazard model showed that mortality (primary end-point), morbidity, reoperation and readmission (secondary end-points) were not significantly influenced by the two different perioperative regimens; conversely, the global cost of "Ultra" E.R.A.S. regimen was more economically effective. CONCLUSION "Ultra" E.R.A.S. showed to be safe, actual and effective; discharge on postoperative day 2 after the first flatus passage, in the absence of complication-related symptoms, should be actively considered in a modern, multidisciplinary, multimodal laparoscopic management of colonic cancer.
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Affiliation(s)
- Gianluca Garulli
- General, Thoracic and Minimally Invasive Surgery,, Ceccarini Hospital, Via Dante n. 255, Riccione, Italy
| | - Andrea Lucchi
- General, Thoracic and Minimally Invasive Surgery,, Ceccarini Hospital, Via Dante n. 255, Riccione, Italy
| | - Pierluigi Berti
- General, Thoracic and Minimally Invasive Surgery,, Ceccarini Hospital, Via Dante n. 255, Riccione, Italy
| | - Carlo Gabbianelli
- General, Thoracic and Minimally Invasive Surgery,, Ceccarini Hospital, Via Dante n. 255, Riccione, Italy
| | - Luca Maria Siani
- General, Thoracic and Minimally Invasive Surgery,, Ceccarini Hospital, Via Dante n. 255, Riccione, Italy.
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Ahmadi A, Bazargan-Hejazi S, Heidari Zadie Z, Euasobhon P, Ketumarn P, Karbasfrushan A, Amini-Saman J, Mohammadi R. Pain management in trauma: A review study. J Inj Violence Res 2016; 8:89-98. [PMID: 27414816 PMCID: PMC4967367 DOI: 10.5249/jivr.v8i2.707] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Accepted: 06/09/2016] [Indexed: 11/28/2022] Open
Abstract
Background: Pain in trauma has a role similar to the double-edged sword. On the one hand, pain is a good indicator to determine the severity and type of injury. On the other hand, pain can induce sever complications and it may lead to further deterioration of the patient. Therefore, knowing how to manage pain in trauma patients is an important part of systemic approach in trauma. The aim of this manuscript is to provide information about pain management in trauma in the Emergency Room settings. Methods: In this review we searched among electronic and manual documents covering a 15-yr period between 2000 and 2016. Our electronic search included Pub Med, Google scholar, Web of Science, and Cochrane databases. We looked for articles in English and in peer-reviewed journals using the following keywords: acute pain management, trauma, emergency room and injury. Results: More than 3200 documents were identified. After screening based on the study inclusion criteria, 560 studies that had direct linkage to the study aim were considered for evaluation based World Health Organization (WHO) pain ladder chart. Conclusions: To provide adequate pain management in trauma patients require: adequate assessment of age-specific pharmacologic pain management; identification of adequate analgesic to relieve moderate to severe pain; cognizance of serious adverse effects of pain medications and weighting medications against their benefits, and regularly reassessing patients and reevaluating their pain management regimen. Patient-centered trauma care will also require having knowledge of barriers to pain management and discussing them with the patient and his/her family to identify solutions.
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Affiliation(s)
- Alireza Ahmadi
- Department of Anesthesiology, Critical Care and Pain Management, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran.
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Li Y, Wang B, Zhang LL, He SF, Hu XW, Wong GTC, Zhang Y. Dexmedetomidine Combined with General Anesthesia Provides Similar Intraoperative Stress Response Reduction When Compared with a Combined General and Epidural Anesthetic Technique. Anesth Analg 2016; 122:1202-10. [DOI: 10.1213/ane.0000000000001165] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Sidiropoulou I, Tsaousi GG, Pourzitaki C, Logotheti H, Tsantilas D, Vasilakos DG. Impact of anesthetic technique on the stress response elicited by laparoscopic cholecystectomy: a randomized trial. J Anesth 2016; 30:522-5. [PMID: 26882921 DOI: 10.1007/s00540-016-2148-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/28/2016] [Indexed: 11/30/2022]
Abstract
The aim of this randomized, double-blind clinical trial was to elucidate the impact of general anesthesia alone (GA) or supplemented with epidural anesthesia (EpiGA) on surgical stress response during laparoscopic cholecystectomy, using stress hormones, glucose, and C-reactive protein (CRP), as potential markers. Sixty-two patients scheduled to undergo elective laparoscopic cholecystectomy were randomly assigned into two groups to receive either GA or EpiGA. Stress hormones [cortisol (COR), human growth hormone (hGH), prolactine (PRL)], glucose, and CRP were determined 1 day before surgery, intraoperatively, and upon first postoperative day (POD1). Plasma COR, hGH, PRL, and glucose levels were maximized intraoperatively in GA and EpiGA groups and reverted almost to baseline on POD1. Significant between-group differences were detected for COR and glucose either intraoperatively or postoperatively, but this was not the case for hGH. PRL was elevated in GA group only intraoperatively. Although, CRP was minimally affected intraoperatively, a notable augmentation on POD1, comparable in both groups, was recorded. These results indicate that hormonal and metabolic stress response is slightly modulated by the use of epidural block supplemented by general anesthesia, in patients undergoing laparoscopic cholecystectomy cholecystectomy. Nevertheless, inflammatory reaction as assessed by CRP seems to be unaffected by the anesthesia regimen.
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Affiliation(s)
- Irine Sidiropoulou
- Department of Anesthesiology, School of Medicine, Aristotle University of Thessaloniki, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Georgia G Tsaousi
- Department of Anesthesiology, School of Medicine, Aristotle University of Thessaloniki, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece.
| | - Chryssa Pourzitaki
- Department of Anesthesiology, School of Medicine, Aristotle University of Thessaloniki, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Helen Logotheti
- Department of Anesthesiology, School of Medicine, Aristotle University of Thessaloniki, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece
| | - Dimitrios Tsantilas
- Department of Surgery, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Vasilakos
- Department of Anesthesiology, School of Medicine, Aristotle University of Thessaloniki, Stilponos Kiriakidi 1, 54636, Thessaloniki, Greece
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Abstract
Radical cystectomy (RC) with pelvic lymph node dissection (PLND) followed by urinary diversion is the treatment of choice for muscle-invasive bladder cancer (BC) and non-invasive BC refractory to transurethral resection of the bladder (TUR-B) and/or intravesical instillation therapies. Since the morbidity and possible mortality of this surgery are relevant, care must be taken in the preoperative selection of patients for the various organ-sparing procedures (e.g., bladder-sparing, nerve sparing, seminal vesicle sparing) and various types of urinary diversion. The patient's performance status and comorbidities, along with individual tumor characteristics, determine possible surgical steps during RC. This individualized approach to RC in each patient can maximize oncological safety and minimize avoidable side effects, rendering 'standard' cystectomy a surgery of the past.
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Affiliation(s)
- Beat Roth
- Department of Urology, University of Bern, Bern, Switzerland
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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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Abstract
Abstract
Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including enhanced recovery programs and perioperative nutrition support, can mitigate the surgically induced metabolic response, promoting optimal patient recovery following major surgery. Clinical therapies should identify those who are poorly nourished before surgery and aim to attenuate catabolism while preserving the processes that promote recovery and immunoprotection after surgery. This review will address the impact of surgery on intermediary metabolism and describe the clinical consequences that ensue. It will also focus on the role of perioperative nutrition, including preoperative nutrition risk, carbohydrate loading, and early initiation of oral feeding (centered on macronutrients) in modulating surgical stress, as well as highlight the contribution of the anesthesiologist to nutritional care. Emerging therapeutic concepts such as preoperative glycemic control and prehabilitation will be discussed.
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Arunkumar S, Hemanth Kumar VR, Krishnaveni N, Ravishankar M, Jaya V, Aruloli M. Comparison of dexmedetomidine and clonidine as an adjuvant to ropivacaine for epidural anesthesia in lower abdominal and lower limb surgeries. Saudi J Anaesth 2015; 9:404-8. [PMID: 26543457 PMCID: PMC4610084 DOI: 10.4103/1658-354x.159464] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The quality and duration of analgesia is improved when a local anesthetic is combined with alpha 2 adrenergic agonist. Though, the effects of clonidine on local anesthetics have been extensively studied, there are limited studies demonstrating the effects of epidural dexmedetomidine on local anesthetics. The aim of our study is to compare the effect of clonidine and dexmedetomidine when used as an adjuvant to epidural ropivacaine in lower abdominal and lower limb surgeries. MATERIALS AND METHODS Patients were randomized into two groups-group ropivacaine with clonidine (RC) received 15 ml of 0.75% ropivacaine with 1 μg/kg clonidine and group ropivacaine with dexmedetomidine (RD) received 15 ml of 0.75% ropivacaine with 1 μg/kg dexmedetomidine epidurally. Onset of sensory analgesia using cold swab, onset of motor blockade using Bromage scale, time to 2 dermatome regression of sensory level, time to first demand for analgesia, sedation using Ramsay sedation scale, intra operative hemodynamic parameters and complications were assessed. RESULTS The onset (RD-8.53 ± 1.81, RC-11.93 ± 1.96) and duration of sensory blockade (RD-316 ± 31.5, RC-281 ± 37, sedation were found to be significantly better in the dexmedetomidine group. No significant difference was found in terms of onset of motor blockade and hemodynamic changes. CONCLUSION Dexmedetomidine at doses of 1 μg/kg is an effective adjuvant to ropivacaine for epidural anesthesia, which is comparable to clonidine.
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Affiliation(s)
- Sruthi Arunkumar
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - V R Hemanth Kumar
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - N Krishnaveni
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - M Ravishankar
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - Velraj Jaya
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
| | - M Aruloli
- Department of Anaesthesiology and Critical Care, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth University, Puducherry, India
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Initiating an Enhanced Recovery Pathway Program: An Anesthesiology Department’s Perspective. Jt Comm J Qual Patient Saf 2015; 41:447-56. [DOI: 10.1016/s1553-7250(15)41058-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Day AR, Smith RVP, Scott MJP, Fawcett WJ, Rockall TA. Randomized clinical trial investigating the stress response from two different methods of analgesia after laparoscopic colorectal surgery. Br J Surg 2015; 102:1473-9. [DOI: 10.1002/bjs.9936] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 07/08/2015] [Accepted: 08/13/2015] [Indexed: 12/29/2022]
Abstract
Abstract
Background
One of the key elements of managed recovery is thought to be suppression of the neuroendocrine response using regional analgesics. This may be superfluous in laparoscopic colorectal surgery with small wounds. This trial assessed the effects of spinal analgesia versus intravenous patient-controlled analgesia (PCA) on neuroendocrine responses in that setting.
Methods
A randomized clinical trial was conducted with participation of patients undergoing laparoscopic colorectal surgery within a managed recovery programme. Consenting patients were allocated randomly to spinal analgesia or morphine PCA as primary postoperative analgesia. The primary outcome was interleukin (IL) 6 levels; secondary outcomes were levels of cortisol, glucose, insulin and other cytokines, pain scores, morphine use and length of hospital stay. Stress response analysis was conducted before operation, and 3, 6, 12, 24 and 48 h after surgery.
Results
Of 143 eligible patients, 133 were randomized and 120 completed the study. Baseline patient characteristics were similar in the two groups. There were no significant differences in median levels of insulin, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, interferon γ, tumour necrosis factor α or vascular endothelial growth factor between the spinal analgesia and PCA groups at any time point. Three hours after surgery (but at no other time point) median (i.q.r.) levels of cortisol (468 (329–678) versus 701 (429–820) nmol/l; P = 0·004) and glucose (6·1 (5·4–7·5) versus 7·0 (6·0–7·7) mmol/l; P = 0·012) were lower in the spinal analgesia group than in the PCA group. Median (i.q.r.) levels of total intravenous morphine were lower in the spinal analgesia group (10·0 (3·3–15·8) versus 45·5 (34·0–60·5) mg; P < 0·001).
Conclusion
Spinal analgesia reduced early neuroendocrine responses and overall parenteral morphine use. Registration number: NCT01128088 (http://www.clinicaltrials.gov).
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Affiliation(s)
- A R Day
- Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK
| | - R V P Smith
- Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK
| | - M J P Scott
- Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK
| | - W J Fawcett
- Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, UK
| | - T A Rockall
- Minimal Access Therapy Training Unit (MATTU), Postgraduate Medical School, University of Surrey, Guildford, UK
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Fast-Track Programs for Liver Surgery: A Meta-Analysis. J Gastrointest Surg 2015; 19:1640-52. [PMID: 26160321 DOI: 10.1007/s11605-015-2879-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 06/22/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES Plentiful publications have inspected the feasibility of fast-track surgery programs during hepatic surgery, but the potency of these studies has not been discussed profoundly so far. Our goal was to assess the effects of fast-track programs on surgical outcomes compared with traditional surgical plans for liver surgery. METHODS The following databases were searched: PubMed, Cochrane library, Embase, Science Citation Index Expanded, etc. Studies meeting our inclusion criteria were included. All interrelated data and the methodological quality of included studies were extracted and assessed. We applied risk ratio and weighted mean difference as the estimated effect measures. Sensitivity analysis was performed to perceive the reliability of our findings. RESULTS Altogether, 14 studies with 1400 patients were analyzed. Meta-analysis of randomized controlled trials demonstrated that implementation of fast-track surgery programs could observably decrease the total length of hospital stay, complication rate, postoperative first flatus time, and hospitalization expense, and did not compromise mortality and readmission rate. The above findings were also in line with the results of case-control studies. CONCLUSIONS Fast-track surgery programs are feasible and effective for liver surgery. Future studies should optimize fast-track surgery programs catering to liver surgery.
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Kranke P, Jokinen J, Pace NL, Schnabel A, Hollmann MW, Hahnenkamp K, Eberhart LHJ, Poepping DM, Weibel S. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery. Cochrane Database Syst Rev 2015:CD009642. [PMID: 26184397 DOI: 10.1002/14651858.cd009642.pub2] [Citation(s) in RCA: 116] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The management of postoperative pain and recovery is still unsatisfactory in clinical practice. Opioids used for postoperative analgesia are frequently associated with adverse effects including nausea and constipation. These adverse effects prevent smooth postoperative recovery. On the other hand not all patients may be suited to, and take benefit from, epidural analgesia used to enhance postoperative recovery. The non-opioid lidocaine was investigated in several studies for its use in multi-modal management strategies to reduce postoperative pain and enhance recovery. OBJECTIVES The aim of this review was to assess the effects (benefits and risks) of perioperative intravenous lidocaine infusion compared to placebo/no treatment or compared to epidural analgesia on postoperative pain and recovery in adults undergoing various surgical procedures. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 5 2014), MEDLINE (January 1966 to May 2014), EMBASE (1980 to May 2014), CINAHL (1982 to May 2014), and reference lists of articles. We searched the trial registry database ClinicalTrials.gov, contacted researchers in the field, and handsearched journals and congress proceedings. We did not apply any language restrictions. SELECTION CRITERIA We included randomized controlled trials comparing the effect of continuous perioperative intravenous lidocaine infusion either with placebo, or no treatment, or with epidural analgesia in adults undergoing elective or urgent surgery under general anaesthesia. The intravenous lidocaine infusion must have been started intraoperatively prior to incision and continued at least until the end of surgery. DATA COLLECTION AND ANALYSIS Trial quality was independently assessed by two authors according to the methodological procedures specified by the Cochrane Collaboration. Data were extracted by two independent authors. We collected trial data on postoperative pain, recovery of gastrointestinal function, length of hospital stay, postoperative nausea and vomiting (PONV), opioid consumption, patient satisfaction, surgical complication rates, and adverse effects of the intervention. MAIN RESULTS We included 45 trials involving 2802 participants. Two trials compared intravenous lidocaine versus epidural analgesia. In all the remaining trials placebo or no treatment was used as a comparator. Trials involved participants undergoing open abdominal (12), laparoscopic abdominal (13), or various other surgical procedures (20).The risk of bias was low with respect to selection bias (random sequence generation), performance bias, attrition bias, and detection bias in more than 50% of the included studies. For allocation concealment and selective reporting the quality assessment yielded low risk of bias for only approximately 20% of the included studies.We found evidence of effect for intravenous lidocaine on the reduction of postoperative pain (visual analogue scale, 0 to 10 cm) compared to placebo or no treatment at 'early time points (one to four hours)' (mean difference (MD) -0.84 cm, 95% confidence interval (CI) -1.10 to -0.59; low-quality evidence) and at 'intermediate time points (24 hours)' (MD -0.34 cm, 95% CI -0.57 to -0.11; low-quality evidence) after surgery. However, no evidence of effect was found for lidocaine to reduce pain at 'late time points (48 hours)' (MD -0.22 cm, 95% CI -0.47 to 0.03; low-quality evidence). Pain reduction was most obvious at 'early time points' in participants undergoing laparoscopic abdominal surgery (MD -1.14, 95% CI -1.51 to -0.78; low-quality evidence) and open abdominal surgery (MD -0.72, 95% CI -0.96 to -0.47; moderate-quality evidence). No evidence of effect was found for lidocaine to reduce pain in participants undergoing all other surgeries (MD -0.30, 95% CI -0.89 to 0.28; low-quality evidence). Quality of evidence is limited due to inconsistency and indirectness (small trial sizes).Evidence of effect was found for lidocaine on gastrointestinal recovery regarding the reduction of the time to first flatus (MD -5.49 hours, 95% CI -7.97 to -3.00; low-quality evidence), time to first bowel movement (MD -6.12 hours, 95% CI -7.36 to -4.89; low-quality evidence), and the risk of paralytic ileus (risk ratio (RR) 0.38, 95% CI 0.15 to 0.99; low-quality evidence). However, no evidence of effect was found for lidocaine on shortening the time to first defaecation (MD -9.52 hours, 95% CI -23.24 to 4.19; very low-quality evidence).Furthermore, we found evidence of positive effects for lidocaine administration on secondary outcomes such as reduction of length of hospital stay, postoperative nausea, intraoperative and postoperative opioid requirements. There was limited data on the effect of IV lidocaine on adverse effects (e.g. death, arrhythmias, other heart rate disorders or signs of lidocaine toxicity) compared to placebo treatment as only a limited number of studies systematically analysed the occurrence of adverse effects of the lidocaine intervention.The comparison of intravenous lidocaine versus epidural analgesia revealed no evidence of effect for lidocaine on relevant outcomes. However, the results have to be considered with caution due to imprecision of the effect estimates. AUTHORS' CONCLUSIONS There is low to moderate evidence that this intervention, when compared to placebo, has an impact on pain scores, especially in the early postoperative phase, and on postoperative nausea. There is limited evidence that this has further impact on other relevant clinical outcomes, such as gastrointestinal recovery, length of hospital stay, and opioid requirements. So far there is a scarcity of studies that have systematically assessed the incidence of adverse effects; the optimal dose; timing (including the duration of the administration); and the effects when compared with epidural anaesthesia.
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Affiliation(s)
- Peter Kranke
- Department of Anaesthesia and Critical Care, University of Würzburg, Oberdürrbacher Str. 6, Würzburg, Germany, 97080
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Taupyk Y, Cao X, Zhao Y, Wang C, Wang Q. Fast-track laparoscopic surgery: A better option for treating colorectal cancer than conventional laparoscopic surgery. Oncol Lett 2015; 10:443-448. [PMID: 26171048 DOI: 10.3892/ol.2015.3166] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 04/08/2015] [Indexed: 12/20/2022] Open
Abstract
Fast-track surgery (FTS), a multimodal rehabilitation technique, has been recommended as surgical therapy for colorectal cancer. The objective of the present study was to compare the outcomes of FTS and conventional laparoscopic surgery. This study was a blinded randomized trial. A total of 70 patients with colorectal cancer were divided into two groups and underwent laparoscopic colorectal resection. The FTS group consisted of 31 patients and the control group consisted of 39 patients. Protocols for the treatment of the FTS group included skipping pre-operative mechanical bowel preparation, early restoration of diet and early post-operative ambulation. Outcome measures, length of hospital stay, post-operative surgical stress response [C-reactive protein (CRP)] and post-operative complications were compared between the two groups. The average length of total hospital stay for the FTS and the control groups was 5.9±0.8 and 10.9±1.3 days, respectively (P<0.05), and the length of post-operative hospital stay for the FTS and control group was 4.3±0.8 and 8.0±1.1 days, respectively. (P<0.05) First flatus time for the FTS and control groups was 1.6±0.8 and 2.5±0.9 days, respectively (P<0.05). Defecation time for the FTS and control groups was 2.2±0.7 and 4.5±0.7 days, respectively (P<0.05). The time to restoration of a solid diet also showed a significant difference between the FTS and control groups (1.1±0.3 vs. 3.6±0.9 days; P<0.05). Following surgery, due to post-operative surgical stress, the two groups CRP levels increased significantly, but the levels of the FTS group were lower than those of the conventional control group (P<0.05). There was no difference in post-operative complications between the FTS and control groups. This study confirms that FTS shortens hospital stay and accelerates the recovery of bowel function without increase of post-operative complications. FTS is safe, improves post-operative recovery and is a better option than conventional laparoscopic surgery for treating colorectal cancer patients.
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Affiliation(s)
- Yerlan Taupyk
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Xueyuan Cao
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Yinquan Zhao
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Chao Wang
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
| | - Quan Wang
- Department of Gastric and Colorectal Surgery, First Hospital of Jilin University, Changchun, Jilin 130021, P.R. China
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