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Palmer S, Plymale M, Mangino A, Davenport D, Roth JS. Prescription opioid use increases resource utilization following ventral hernia repair. J Gastrointest Surg 2024; 28:483-487. [PMID: 38583899 DOI: 10.1016/j.gassur.2024.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Previous studies showed that preoperative opioid use is associated with increased postoperative opioid use and surgical site infection (SSI) in patients undergoing ventral hernia repair (VHR). Orthopedic surgery literature cites increased resource utilization with opioid use. This study aimed to determine the effect of preoperative opioid use on resource utilization after open VHR. METHODS A retrospective institutional review board-approved study of VHRs from a single tertiary care practice between 2013 and 2020 was performed. Medical records, the National Surgical Quality Improvement Program database, and Kentucky All Schedule Prescription Electronic Reporting data were reviewed for patient demographics, comorbidities, dispensed opiate prescriptions, hernia characteristics, and outcomes. Univariate logistic regression analyses assessed the effect of each patient's demographic and clinical characteristics. Multivariate logistic regression models analyzed significant factors from the univariate analyses. The primary outcome was resource utilization measured as readmission, emergency department visit, or >2 postoperative clinic visits within 45 days after VHR. RESULTS Overall, 381 patients who underwent VHR were identified; of which 101 patients had preoperative dispensed opioids. Multivariate analysis demonstrated that patient gender at birth, any new-onset SSI, and any preoperative opioid use were associated with increased postoperative resource utilization (odds ratio, 1.76; P = .026). CONCLUSION Preoperative opioid use was determined as a risk factor that increased resource utilization after open VHR. An understanding of the drivers of the increased use of resources is essential in developing strategies to improve healthcare value. Future research will focus on strategies to reduce the utilization of resources among patients who use opioids.
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Affiliation(s)
- Skyler Palmer
- College of Medicine, University of Kentucky, Lexington, Kentucky, United States
| | - Margaret Plymale
- Division of General, Endocrine, and Metabolic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky, United States
| | - Anthony Mangino
- Department of Biostatistics, University of Kentucky, Lexington, Kentucky, United States
| | - Daniel Davenport
- Division of Healthcare Outcomes and Optimal Patient Services, Department of Surgery, University of Kentucky, Lexington, Kentucky, United States
| | - John Scott Roth
- Division of General, Endocrine, and Metabolic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky, United States.
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Fan Chiang Y, Lee Y, Lam F, Liao C, Chang C, Lin C. Smoking increases the risk of postoperative wound complications: A propensity score-matched cohort study. Int Wound J 2022; 20:391-402. [PMID: 35808947 PMCID: PMC9885463 DOI: 10.1111/iwj.13887] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Cigarette smoking is associated with surgical complications, including wound healing and surgical site infection. However, the association between smoking status and postoperative wound complications is not completely understood. Our objective was to investigate the effect of smoking on postoperative wound complications for major surgeries. Data were collected from the 2013 to 2018 participant use files of the American College of Surgeons National Surgical Quality Improvement Program database. A propensity score matching procedure was used to create the balanced smoker and nonsmoker groups. Multivariable logistic regression was used to calculate the odds ratios (ORs) with 95% confidence intervals (CIs) for postoperative wound complications, pulmonary complications, and in-hospital mortality associated with smokers. A total of 1 156 002 patients (578 001 smokers and 578 001 nonsmokers) were included in the propensity score matching analysis. Smoking was associated with a significantly increased risk of postoperative wound disruption (OR 1.65, 95% CI 1.56-1.75), surgical site infection (OR 1.31, 95% CI 1.28-1.34), reintubation (OR 1.47, 95% CI 1.40-1.54), and in-hospital mortality (OR 1.13, 95% CI 1.07-1.19) compared with nonsmoking. The length of hospital stay was significantly increased in smokers compared with nonsmokers. Our analysis indicates that smoking is associated with an increased risk of surgical site infection, wound disruption, and postoperative pulmonary complications. The results may drive the clinicians to encourage patients to quit smoking before surgery.
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Affiliation(s)
| | - Yuan‐Wen Lee
- Department of AnesthesiologyTaipei Medical University HospitalTaipeiTaiwan,Department of Anesthesiology, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan,Anesthesiology and Health Policy Research CenterTaipei Medical University HospitalTaipeiTaiwan
| | - Fai Lam
- Department of AnesthesiologyTaipei Medical University HospitalTaipeiTaiwan
| | - Chien‐Chang Liao
- Department of AnesthesiologyTaipei Medical University HospitalTaipeiTaiwan,Department of Anesthesiology, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan,Anesthesiology and Health Policy Research CenterTaipei Medical University HospitalTaipeiTaiwan
| | - Chuen‐Chau Chang
- Department of AnesthesiologyTaipei Medical University HospitalTaipeiTaiwan,Department of Anesthesiology, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan,Anesthesiology and Health Policy Research CenterTaipei Medical University HospitalTaipeiTaiwan
| | - Chao‐Shun Lin
- Department of AnesthesiologyTaipei Medical University HospitalTaipeiTaiwan,Department of Anesthesiology, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan,Anesthesiology and Health Policy Research CenterTaipei Medical University HospitalTaipeiTaiwan
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3
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Balamohan SM, Sawhney R, Lang DM, Cherabuddi K, Varadarajan VV, Bernard SH, Mackinnon LM, Boyce BJ, Antonelli PJ, Efron PA, Dziegielewski PT. Prophylactic antibiotics in head and neck free flap surgery: A novel protocol put to the test. Am J Otolaryngol 2019; 40:102276. [PMID: 31447185 DOI: 10.1016/j.amjoto.2019.102276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 08/14/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Recent evidence supports the use of ampicillin-sulbactam as a favored choice for antibiotic prophylaxis following head and neck free flap reconstructive surgery. However, there is a paucity of evidence guiding the optimal duration of antibiotic prophylaxis. The aim of this study is to compare the infection rates of short courses of ampicillin-sulbactam versus extended courses of various antibiotics in head and neck free flap reconstructive surgery. METHODS This is a retrospective cohort study conducted from 2012 to 2017 at a tertiary academic center on 266 consecutive patients undergoing head and neck surgery with free flap reconstruction. The primary outcome measure was the rate of any infection within 30 days of surgery. RESULTS There were 149 patients who received antibiotic prophylaxis for an extended duration of at least seven days. 117 patients received a short course of antibiotics defined as 24 h for non-radiated patients and 72 h for radiated patients. Postoperative infections occurred in 45.9% of patients, of which 92.6% occurred at surgical sites. There was no significant difference in terms of postoperative infection rate between patients receiving an extended duration of antibiotics versus a short duration (p = 0.80). This held true for subgroups of surgical site infections (p = 0.38) and distant infections (p = 0.59 for pneumonia and p = 0.76 for UTI). Risk factors for infections were identified as hypothyroidism (p = 0.047) and clean contaminated wound classification (p = 0.0002). CONCLUSION Shorter duration of ampicillin-sulbactam prophylaxis in free flap reconstruction of head and neck defects does not negatively affect postoperative infection rates. LEVEL OF EVIDENCE Level 2b.
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Affiliation(s)
| | - Raja Sawhney
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Dustin M Lang
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Kartik Cherabuddi
- Division of Infectious Disease, Department of Medicine, University of Florida, Gainesville, FL, USA
| | | | - Stewart H Bernard
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Lauren M Mackinnon
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | - Brian J Boyce
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA
| | | | - Philip A Efron
- Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Peter T Dziegielewski
- Department of Otolaryngology, University of Florida, Gainesville, FL, USA; University of Florida Health Cancer Center, Gainesville, FL, USA.
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4
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Papadopoulos NA, Lam PH, Murrell GA. The Effects of Smoking on Shoulder Stiffness Following Arthroscopic Rotator Cuff Repair. TECHNIQUES IN SHOULDER AND ELBOW SURGERY 2018. [DOI: 10.1097/bte.0000000000000146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2014. [PMID: 24671929 DOI: 10.1002/14651858.cd002294.pub4.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. OBJECTIVES The objectives of this review are to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively, and on the incidence of postoperative complications. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialized Register in January 2014. SELECTION CRITERIA Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking or the incidence of postoperative complications or both outcomes. DATA COLLECTION AND ANALYSIS The review authors independently assessed studies to determine eligibility, and discussed the results between them. MAIN RESULTS Thirteen trials enrolling 2010 participants met the inclusion criteria. One trial did not report cessation as an outcome. Seven reported some measure of postoperative morbidity. Most studies were judged to be at low risk of bias but the overall quality of evidence was moderate due to the small number of studies contributing to each comparison.Ten trials evaluated the effect of behavioural support on cessation at the time of surgery; nicotine replacement therapy (NRT) was offered or recommended to some or all participants in eight of these. Two trials initiated multisession face-to-face counselling at least four weeks before surgery and were classified as intensive interventions, whilst seven used a brief intervention. One further study provided an intensive intervention to both groups, with the intervention group additionally receiving a computer-based scheduled reduced smoking intervention. One placebo-controlled trial examined the effect of varenicline administered one week preoperatively followed by 11 weeks postoperative treatment, and one placebo-controlled trial examined the effect of nicotine lozenges from the night before surgery as an adjunct to brief counselling at the preoperative evaluation. There was evidence of heterogeneity between the effects of trials using intensive and brief interventions, so we pooled these separately. An effect on cessation at the time of surgery was apparent in both subgroups, but the effect was larger for intensive intervention (pooled risk ratio (RR) 10.76; 95% confidence interval (CI) 4.55 to 25.46, two trials, 210 participants) than for brief interventions (RR 1.30; 95% CI 1.16 to 1.46, 7 trials, 1141 participants). A single trial did not show evidence of benefit of a scheduled reduced smoking intervention. Neither nicotine lozenges nor varenicline were shown to increase cessation at the time of surgery but both had wide confidence intervals (RR 1.34; 95% CI 0.86 to 2.10 (1 trial, 46 participants) and RR 1.49; 95% CI 0.98 to 2.26 (1 trial, 286 participants) respectively). Four of these trials evaluated long-term smoking cessation and only the intensive intervention retained a significant effect (RR 2.96; 95% CI 1.57 to 5.55, 2 trials, 209 participants), whilst there was no evidence of a long-term effect following a brief intervention (RR 1.09; 95% CI 0.68 to 1.75, 2 trials, 341 participants). The trial of varenicline did show a significant effect on long-term smoking cessation (RR 1.45; 95% CI 1.01 to 2.07, 1 trial, 286 participants).Seven trials examined the effect of smoking intervention on postoperative complications. As with smoking outcomes, there was evidence of heterogeneity between intensive and brief behavioural interventions. In subgroup analyses there was a significant effect of intensive intervention on any complications (RR 0.42; 95% CI 0.27 to 0.65, 2 trials, 210 participants) and on wound complications (RR 0.31; 95% CI 0.16 to 0.62, 2 trials, 210 participants). For brief interventions, where the impact on smoking had been smaller, there was no evidence of a reduction in complications (RR 0.92; 95% CI 0.72 to 1.19, 4 trials, 493 participants) for any complication (RR 0.99; 95% CI 0.70 to 1.40, 3 trials, 325 participants) for wound complications. The trial of varenicline did not detect an effect on postoperative complications (RR 0.94; 95% CI 0.52 to 1.72, 1 trial, 286 participants). AUTHORS' CONCLUSIONS There is evidence that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline begun shortly before surgery has shown a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling and use NRT are more likely to have an impact on complications and on long-term smoking cessation.
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Affiliation(s)
- Thordis Thomsen
- Abdominal Centre, 3133, Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark, 2100
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Abstract
BACKGROUND Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. OBJECTIVES The objectives of this review are to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively, and on the incidence of postoperative complications. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialized Register in January 2014. SELECTION CRITERIA Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking or the incidence of postoperative complications or both outcomes. DATA COLLECTION AND ANALYSIS The review authors independently assessed studies to determine eligibility, and discussed the results between them. MAIN RESULTS Thirteen trials enrolling 2010 participants met the inclusion criteria. One trial did not report cessation as an outcome. Seven reported some measure of postoperative morbidity. Most studies were judged to be at low risk of bias but the overall quality of evidence was moderate due to the small number of studies contributing to each comparison.Ten trials evaluated the effect of behavioural support on cessation at the time of surgery; nicotine replacement therapy (NRT) was offered or recommended to some or all participants in eight of these. Two trials initiated multisession face-to-face counselling at least four weeks before surgery and were classified as intensive interventions, whilst seven used a brief intervention. One further study provided an intensive intervention to both groups, with the intervention group additionally receiving a computer-based scheduled reduced smoking intervention. One placebo-controlled trial examined the effect of varenicline administered one week preoperatively followed by 11 weeks postoperative treatment, and one placebo-controlled trial examined the effect of nicotine lozenges from the night before surgery as an adjunct to brief counselling at the preoperative evaluation. There was evidence of heterogeneity between the effects of trials using intensive and brief interventions, so we pooled these separately. An effect on cessation at the time of surgery was apparent in both subgroups, but the effect was larger for intensive intervention (pooled risk ratio (RR) 10.76; 95% confidence interval (CI) 4.55 to 25.46, two trials, 210 participants) than for brief interventions (RR 1.30; 95% CI 1.16 to 1.46, 7 trials, 1141 participants). A single trial did not show evidence of benefit of a scheduled reduced smoking intervention. Neither nicotine lozenges nor varenicline were shown to increase cessation at the time of surgery but both had wide confidence intervals (RR 1.34; 95% CI 0.86 to 2.10 (1 trial, 46 participants) and RR 1.49; 95% CI 0.98 to 2.26 (1 trial, 286 participants) respectively). Four of these trials evaluated long-term smoking cessation and only the intensive intervention retained a significant effect (RR 2.96; 95% CI 1.57 to 5.55, 2 trials, 209 participants), whilst there was no evidence of a long-term effect following a brief intervention (RR 1.09; 95% CI 0.68 to 1.75, 2 trials, 341 participants). The trial of varenicline did show a significant effect on long-term smoking cessation (RR 1.45; 95% CI 1.01 to 2.07, 1 trial, 286 participants).Seven trials examined the effect of smoking intervention on postoperative complications. As with smoking outcomes, there was evidence of heterogeneity between intensive and brief behavioural interventions. In subgroup analyses there was a significant effect of intensive intervention on any complications (RR 0.42; 95% CI 0.27 to 0.65, 2 trials, 210 participants) and on wound complications (RR 0.31; 95% CI 0.16 to 0.62, 2 trials, 210 participants). For brief interventions, where the impact on smoking had been smaller, there was no evidence of a reduction in complications (RR 0.92; 95% CI 0.72 to 1.19, 4 trials, 493 participants) for any complication (RR 0.99; 95% CI 0.70 to 1.40, 3 trials, 325 participants) for wound complications. The trial of varenicline did not detect an effect on postoperative complications (RR 0.94; 95% CI 0.52 to 1.72, 1 trial, 286 participants). AUTHORS' CONCLUSIONS There is evidence that preoperative smoking interventions providing behavioural support and offering NRT increase short-term smoking cessation and may reduce postoperative morbidity. One trial of varenicline begun shortly before surgery has shown a benefit on long-term cessation but did not detect an effect on early abstinence or on postoperative complications. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling and use NRT are more likely to have an impact on complications and on long-term smoking cessation.
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Affiliation(s)
- Thordis Thomsen
- RigshospitaletAbdominal Centre, 3133Blegdamsvej 9CopenhagenDenmark2100
- Lund UniversityClinical Health Promotion Centre, Faculty of MedicineLundSweden
| | - Nete Villebro
- Danish Nurses OrganizationSankt Annæ plads 30Copenhagen KDenmark12503
| | - Ann Merete Møller
- University of Copenhagen Herlev HospitalThe Cochrane Anaesthesia Review Group, Rigshospitalet & Department of AnaesthesiologyHerlev RingvejHerlevDenmark2730
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Abstract
The success of hernia repair is measured by absence of recurrence, appearance of the surgical scar, and perioperative morbidity. Perioperative surgical site occurrence (SSO), defined as infection, seroma, wound ischemia, and dehiscence, increases the risk of recurrent hernia by at least 3-fold. The surgeon should optimize all measures that promote healing, reduce infection, and enhance early postoperative recovery. In the population with ventral hernia, the most common complication in the immediate perioperative period is surgical site infection. This article reviews several preoperative measures that have been reported to decrease SSOs and shorten length of hospital stay.
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8
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Abstract
BACKGROUND Smokers have a substantially increased risk of postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence, and surgery may constitute a unique opportunity for smoking cessation interventions. OBJECTIVES The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation at the time of surgery and 12 months postoperatively and on the incidence of postoperative complications. SEARCH STRATEGY The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) or (operation) or (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search April 2010. SELECTION CRITERIA Randomized controlled trials that recruited people who smoked prior to surgery, offered a smoking cessation intervention, and measured preoperative and long-term abstinence from smoking and/or the incidence of postoperative complications. DATA COLLECTION AND ANALYSIS The authors independently assessed studies to determine eligibility. Results were discussed between the authors. MAIN RESULTS Eight trials enrolling a total of 1156 people met the inclusion criteria. One of these did not report cessation as an outcome. Two trials initiated multisession face to face counselling at least 6 weeks before surgery whilst six used a brief intervention. Nicotine replacement therapy (NRT) was offered or recommended to some or all participants in seven trials. Six trials detected significantly increased smoking cessation at the time of surgery, and one approached significance. Subgroup analyses showed that both intensive and brief intervention significantly increased smoking cessation at the time of surgery; pooled RR 10.76 (95% confidence interval (CI) 4.55 to 25.46, two trials) and RR 1.41 (95% CI 1.22 to 1.63, five trials) respectively. Four trials evaluating the effect on long-term smoking cessation found a significant effect; pooled RR 1.61 (95% CI 1.12 to 2.33). However, when pooling intensive and brief interventions separately, only intensive intervention retained a significant effect on long-term smoking cessation; RR 2.96 (95% CI 1.57 to 5.55, two trials).Five trials examined the effect of smoking intervention on postoperative complications. Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for developing any complication; and 0.70 (95% CI 0.51 to 0.95) for wound complications. Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications; RR 0.42 (95% CI 0.27 to 0.65) and on wound complications RR 0.31 (95% CI 0.16 to 0.62). For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication, RR 0.99 (95%CI 0.70 to 1.40) for wound complications). AUTHORS' CONCLUSIONS There is evidence that preoperative smoking interventions including NRT increase short-term smoking cessation and may reduce postoperative morbidity. The optimal preoperative intervention intensity remains unknown. Based on indirect comparisons and evidence from two small trials, interventions that begin four to eight weeks before surgery, include weekly counselling, and use NRT are more likely to have an impact on complications and on long-term smoking cessation.
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Affiliation(s)
- Thordis Thomsen
- Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej 75, Herlev, Denmark, 2730
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Bernstein WK, Deshpande S. Preoperative evaluation for thoracic surgery. Semin Cardiothorac Vasc Anesth 2009; 12:109-21. [PMID: 18635562 DOI: 10.1177/1089253208319868] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.
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Affiliation(s)
- Wendy K Bernstein
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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10
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Abstract
The understanding of acute and chronic wound pathophysiology has progressed considerably over the past decades. Unfortunately, improvement in clinical practice has not followed suit, although new trends and developments have improved the outcome of wound treatment in many ways. This review focuses on promising clinical development in major wound problems in general and on postoperative infections in particular.
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Affiliation(s)
- F Gottrup
- Copenhagen Wound Healing Center, Department of Dermatology, Bispebjerg Hospital Copenhagen, Denmark.
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11
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Abstract
BACKGROUND Smokers have a substantially increased risk of intra- and postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence. The preoperative period may be a well chosen time to offer smoking cessation interventions due to increased patient motivation. OBJECTIVES The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation in the postoperative period and longer term. We also set out to determine the effect of smoking cessation on the incidence of postoperative complications. SEARCH STRATEGY The specialized register of the Cochrane Tobacco Addiction Group was searched using the free text and keywords (surgery) OR (operation) OR (anaesthesia) or (anesthesia). MEDLINE, EMBASE and CINAHL were also searched, combining tobacco- and surgery-related terms. Most recent search February 2005. SELECTION CRITERIA We considered randomized trials which recruited smokers prior to surgery, offered a smoking cessation intervention, and measured abstinence from smoking in the preoperative and postoperative periods. We also considered randomized trials of the effect of smoking cessation on the incidence of intra- and postoperative complications. DATA COLLECTION AND ANALYSIS The authors independently assessed studies to determine eligibility. The results were discussed between the authors. MAIN RESULTS Four trials met the inclusion criteria. All trials significantly reduced preoperative smoking but the effect sizes were heterogeneous so a pooled effect was not estimated. Only two trials reported the effect of the smoking intervention on wound complications, and the results were heterogeneous, with a significant reduction in wound-related complications, cardiopulmonary complications and the overall risk of any complication in one trial, and no evidence of a difference in complications in the other. The effect on longer term smoking cessation was not significant in either of the two trials with follow up beyond the perioperative period. AUTHORS' CONCLUSIONS Preoperative smoking interventions are effective for changing smoking behaviour perioperatively. Direct evidence that reducing or stopping smoking reduces the risk of complications is based on two small trials with differing results. The impact on complications may depend on how long before surgery the smoking behaviour is changed, whether smoking is reduced or stopped completely, and the type of surgery.
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Affiliation(s)
- A Møller
- Department of Anaesthesiology, Herlev University Hospital, Herlev Ringvej 75, Herlev, Denmark, 2730.
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Moore S, Mills BB, Moore RD, Miklos JR, Mattox TF. Perisurgical smoking cessation and reduction of postoperative complications. Am J Obstet Gynecol 2005; 192:1718-21. [PMID: 15902184 DOI: 10.1016/j.ajog.2004.11.048] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine if a perisurgical smoking cessation program reduces smoking-related postoperative complications in urogynecologic surgery. STUDY DESIGN A review of patients that underwent pelvic reconstructive surgery from 1998 to 2003 was performed. All smokers underwent a perisurgical smoking cessation program of their choice for at least 1 month before surgery, and continued for 1 month after surgery. Complications unrelated to smoking (cystotomy, enterotomy, urethral obstruction, etc) were excluded in the smoking-potentiated complications. Problems considered to be potentiated by smoking were: wound, pulmonary, cardiac, and febrile morbidity. RESULTS Eight hundred eighty-seven patients were included. There were 233 smoker cessation patients (SC) and 654 nonsmokers (NS). The total number of complications in the SC group was 61 (61/233, 26%) compared with 172 (172/654, 29%) in the NS group: (chi-square, P = .97). When looking at smoking-potentiated complications only, there were 34 (34/61, 56%) patients in the SC group and 90 (90/172, 52%) in the NS group (chi-square, P = .75). CONCLUSION There are no differences in smoking-potentiated complications between nonsmoking patients and patients who undergo a perisurgical smoking cessation program.
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Affiliation(s)
- Susan Moore
- Center for Women's Medicine, Greenville Hospital System, SC 29605, USA.
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13
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Abstract
It is a fundamental clinical observation that wounds do not heal in tissue that does not bleed, and they almost always heal in tissue that bleeds extensively. Continuous supply of oxygen to the tissue through microcirculation is vital for the healing process and for resistance to infection. Evaluation of tissue perfusion and oxygenation is important in all types of wound patients. Monitoring systems should measure the hemodynamic situation and the ability of the cardiovascular system to deliver an adequate volume of oxygen to meet the metabolic demands of the peripheral tissue. Oxygen therapy is important in relation to both healing and resistance to infections. External factors have been shown to significantly decrease the peripheral oxygen supply, and supplementary perioperative oxygen to reduce the surgical wound infection rate by one- half in patients undergoing colorectal resection. Hyperbaric oxygen therapy may be beneficial in situations where the nutritive flow and oxygen supply to the healing tissue are compromised by local injury, and particularly if anaerobic infection is present. However, the definitive proof for the effect and indications of this therapy in wound healing still has to be established. It can be concluded that adequate delivery of oxygen to the wound tissue is vital for optimal healing and resistance to infection. Assessment of perfusion and oxygenation is essential for the wound patient, as well as the treating personnel. The indication for hyperbaric oxygen treatment still needs to be defined. During wound healing the continuity and function of the damaged tissue are re-established. This is only possible through a restoration of the microcirculation and thereby the nutrition to the tissue. The main component of the nutrition is oxygen, which is critically important for healing a wound by production of granulation tissue and for ensuring resistance against infection. This has been shown experimentally, but recently a short period of supplementary oxygen has been shown to decrease wound complications in clinical practice as well.
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Affiliation(s)
- Finn Gottrup
- The University Center of Wound Healing, Department of Plastic and Reconstructive Surgery, Odense University Hospital, DK-5000 Odense, Denmark.
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