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Obradovic M, Luf F, Reiterer C, Schoppmann S, Kurz A, Fleischmann E, Kabon B. The effect of goal-directed crystalloid versus colloid administration on postoperative spirometry parameters: a substudy of a randomized controlled clinical trial. Perioper Med (Lond) 2024; 13:28. [PMID: 38622671 PMCID: PMC11020978 DOI: 10.1186/s13741-024-00381-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 03/21/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND Pulmonary function is impaired after major abdominal surgery and might be less impaired by restrictive fluid administration. Under the assumption of a fluid-sparing effect of colloids, we tested the hypothesis that an intraoperative colloid-based goal-directed fluid management strategy impairs postoperative pulmonary function parameters less compared to goal-directed crystalloid administration. METHODS We performed a preplanned, single-center substudy within a recently published trial evaluating the effect of goal-directed crystalloids versus colloids on a composite of major complications. Sixty patients undergoing major open abdominal surgery were randomized to Doppler-guided intraoperative fluid replacement therapy with lactated Ringer's solution (n = 31) or unbalanced 6% hydroxyethyl starch 130/0.4 (n = 29). A blinded investigator performed bedside spirometry (Spirobank-G, Medical International Research, Rome, Italy) preoperatively as well as 6, 24, and 48 h postoperatively. RESULTS Median total intraoperative fluid requirements were significantly higher during crystalloid administration compared to patients receiving colloids (4567 ml vs. 3044 ml, p = 0.01). Six hours after surgery, pulmonary function parameters did not differ significantly between the crystalloid - and the colloid group: forced vital capacity (FVC): 1.6 l (1.2-2 l) vs. 1.9 l (1.5-2.4 l), p = 0.15; forced expiratory volume in 1 second (FEV1): 1.1 l (0.9-1.6 l) vs. 1.4 l (1.2-1.7 l), p = 0.18; and peak expiratory flow (PEF): 2 l.sec-1 (1.5 - 3.6 l.sec -1) vs. 2.3 l.sec -1 (1.8 - 3.4 l.sec -1), p = 0.23. Moreover, postoperative longitudinal time × group interactions of FVC, FEV1, and PEF between 6 and 48 postoperative hours did not differ significantly. CONCLUSION Postoperative pulmonary function parameters were similarly impaired in patients receiving goal-directed crystalloid administration as compared to goal-directed colloid administration during open abdominal surgery. TRIAL REGISTRATION ClinicalTrials.gov ( NCT00517127 , registered on August 16, 2007) and EudraCT (2005-004602-86).
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Affiliation(s)
- Mina Obradovic
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Florian Luf
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
- Department of Anesthesiology and Intensive Care, Hanusch Hospital, Heinrich-Collin-Straße 30, 1140 Wien, Vienna, Austria
| | - Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Sebastian Schoppmann
- Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Andrea Kurz
- Department of Outcomes Research and General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Jomrich G, Gruber M, Gruber ES, Mühlbacher J, Radosavljevic S, Wilfing L, Winkler D, Prager G, Reiterer C, Kabon B, Haslacher H, Sahora K, Schindl M. Prognostic significance of mean corpuscular volume in patients with pancreatic ductal adenocarcinoma and multimodal treatment. J Visc Surg 2024; 161:99-105. [PMID: 37391288 DOI: 10.1016/j.jviscsurg.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
AIM OF THE STUDY Mean corpuscular volume (MCV) has shown mounting evidence as a prognostic indicator in a number of malignancies. The aim of this study was to examine the prognostic potential of pretherapeutic MCV among patients with pancreatic ductal adenocarcinoma (PDAC) who underwent upfront resection or resection after neoadjuvant treatment (NT). PATIENTS AND METHODS Consecutive patients with PDAC who underwent pancreatic resection between 1997 and 2019 were included in this study. Neoadjuvantly treated patients' serum MCV was measured before NT and before surgery. In patients undergoing upfront resection serum MCV was measured before surgery. Median MCV values were used as cut-off to distinguish high from low MCV values. RESULTS Five hundred and forty-nine (438 upfront resected and 111 neoadjuvantly treated) patients were included in this study. Multivariate analysis revealed, that high MCV before and after NT, were independent negative prognostic factors for overall survival (P<0.01, respectively). Furthermore, the median MCV value from before to after NT increased significantly (P<0.001, Wilcoxon signed-rank test) and was (P=0.03, Wilcoxon rank sum test) associated with tumor response to NT. CONCLUSION High MCV is an independent adverse prognostic factor in patients with resectable neoadjuvantly treated PDAC and may qualify as useful indicator to help physicians to provide personalized prognostication.
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Affiliation(s)
- Gerd Jomrich
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Maximilian Gruber
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Elisabeth S Gruber
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Jakob Mühlbacher
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Sanja Radosavljevic
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Lavinia Wilfing
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Daniel Winkler
- Vienna University of Economics and Business, Vienna, Austria
| | - Gerald Prager
- Department of Medicine 1, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Vienna, Austria
| | - Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Helmuth Haslacher
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Klaus Sahora
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria
| | - Martin Schindl
- Department of General Surgery, Comprehensive Cancer Center (CCC), Medical University of Vienna and Pancreatic Cancer Unit, Spitalgasse 23, 1090 Vienna, Austria.
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Arynov A, Kaidarova D, Kabon B. Alternative blood transfusion triggers: a narrative review. BMC Anesthesiol 2024; 24:71. [PMID: 38395758 PMCID: PMC10885388 DOI: 10.1186/s12871-024-02447-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Anemia, characterized by low hemoglobin levels, is a global public health concern. Anemia is an independent factor worsening outcomes in various patient groups. Blood transfusion has been the traditional treatment for anemia; its triggers, primarily based on hemoglobin levels; however, hemoglobin level is not always an ideal trigger for blood transfusion. Additionally, blood transfusion worsens clinical outcomes in certain patient groups. This narrative review explores alternative triggers for red blood cell transfusion and their physiological basis. MAIN TEXT The review delves into the physiology of oxygen transport and highlights the limitations of using hemoglobin levels alone as transfusion trigger. The main aim of blood transfusion is to optimize oxygen delivery, necessitating an individualized approach based on clinical signs of anemia and the balance between oxygen delivery and consumption, reflected by the oxygen extraction rate. The narrative review covers different alternative triggers. It presents insights into their diagnostic value and clinical applications, emphasizing the need for personalized transfusion strategies. CONCLUSION Anemia and blood transfusion are significant factors affecting patient outcomes. While restrictive transfusion strategies are widely recommended, they may not account for the nuances of specific patient populations. The search for alternative transfusion triggers is essential to tailor transfusion therapy effectively, especially in patients with comorbidities or unique clinical profiles. Investigating alternative triggers not only enhances patient care by identifying more precise indicators but also minimizes transfusion-related risks, optimizes blood product utilization, and ensures availability when needed. Personalized transfusion strategies based on alternative triggers hold the potential to improve outcomes in various clinical scenarios, addressing anemia's complex challenges in healthcare. Further research and evidence are needed to refine these alternative triggers and guide their implementation in clinical practice.
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Affiliation(s)
- Ardak Arynov
- Department of Anesthesiology and Intensive Care, Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan.
| | - Dilyara Kaidarova
- Kazakh Institute of Oncology and Radiology, Abay av. 91, Almaty, Kazakhstan
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Medicine and Pain Medicine Medical, University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Conen D, Ke Wang M, Popova E, Chan MTV, Landoni G, Cata JP, Reimer C, McLean SR, Srinathan SK, Reyes JCT, Grande AM, Tallada AG, Sessler DI, Fleischmann E, Kabon B, Voltolini L, Cruz P, Maziak DE, Gutiérrez-Soriano L, McIntyre WF, Tandon V, Martínez-Téllez E, Guerra-Londono JJ, DuMerton D, Wong RHL, McGuire AL, Kidane B, Roux DP, Shargall Y, Wells JR, Ofori SN, Vincent J, Xu L, Li Z, Eikelboom JW, Jolly SS, Healey JS, Devereaux PJ. Effect of colchicine on perioperative atrial fibrillation and myocardial injury after non-cardiac surgery in patients undergoing major thoracic surgery (COP-AF): an international randomised trial. Lancet 2023; 402:1627-1635. [PMID: 37640035 DOI: 10.1016/s0140-6736(23)01689-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/06/2023] [Accepted: 08/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Higher levels of inflammatory biomarkers are associated with an increased risk of perioperative atrial fibrillation and myocardial injury after non-cardiac surgery (MINS). Colchicine is an anti-inflammatory drug that might reduce the incidence of these complications. METHODS COP-AF was a randomised trial conducted at 45 sites in 11 countries. Patients aged 55 years or older and undergoing major non-cardiac thoracic surgery were randomly assigned (1:1) to receive oral colchicine 0·5 mg twice daily or matching placebo, starting within 4 h before surgery and continuing for 10 days. Randomisation was done with use of a computerised, web-based system, and was stratified by centre. Health-care providers, patients, data collectors, and adjudicators were masked to treatment assignment. The coprimary outcomes were clinically important perioperative atrial fibrillation and MINS during 14 days of follow-up. The main safety outcomes were a composite of sepsis or infection, and non-infectious diarrhoea. The intention-to-treat principle was used for all analyses. This trial is registered with ClinicalTrials.gov, NCT03310125. FINDINGS Between Feb 14, 2018, and June 27, 2023, we enrolled 3209 patients (mean age 68 years [SD 7], 1656 [51·6%] male). Clinically important atrial fibrillation occurred in 103 (6·4%) of 1608 patients assigned to colchicine, and 120 (7·5%) of 1601 patients assigned to placebo (hazard ratio [HR] 0·85, 95% CI 0·65 to 1·10; absolute risk reduction [ARR] 1·1%, 95% CI -0·7 to 2·8; p=0·22). MINS occurred in 295 (18·3%) patients assigned to colchicine and 325 (20·3%) patients assigned to placebo (HR 0·89, 0·76 to 1·05; ARR 2·0%, -0·8 to 4·7; p=0·16). The composite outcome of sepsis or infection occurred in 103 (6·4%) patients in the colchicine group and 83 (5·2%) patients in the placebo group (HR 1·24, 0·93-1·66). Non-infectious diarrhoea was more common in the colchicine group (134 [8·3%] events) than the placebo group (38 [2·4%]; HR 3·64, 2·54-5·22). INTERPRETATION In patients undergoing major non-cardiac thoracic surgery, administration of colchicine did not significantly reduce the incidence of clinically important atrial fibrillation or MINS but increased the risk of mostly benign non-infectious diarrhoea. FUNDING Canadian Institutes of Health Research, Accelerating Clinical Trials Consortium, Innovation Fund of the Alternative Funding Plan for the Academic Health Sciences Centres of Ontario, Population Health Research Institute, Hamilton Health Sciences, Division of Cardiology at McMaster University, Canada; Hanela Foundation, Switzerland; and General Research Fund, Research Grants Council, Hong Kong.
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Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ekaterine Popova
- Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute University San Raffaele, Milan, Italy
| | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cara Reimer
- Department of Anesthesiology, Queen's University, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Sean R McLean
- Vancouver Acute Department of Anesthesia and Perioperative Medicine, Vancouver General Hospital, Vancouver, BC, Canada
| | | | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, University Hospital Careggi, Florence, Italy
| | - Patrícia Cruz
- Service of Anesthesiology and Reanimation, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Donna E Maziak
- Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Laura Gutiérrez-Soriano
- Anesthesiology Department, Anesthesiology Research Group, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - William F McIntyre
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Juan Jose Guerra-Londono
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anna L McGuire
- Division of Thoracic Surgery, Vancouver General Hospital, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Biniam Kidane
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
| | | | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Sandra N Ofori
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Lizhen Xu
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, ON, Canada
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Sanjit S Jolly
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Pichler A, Kurz A, Eichlseder M, Graf A, Eichinger M, Taschner A, Kabon B, Fleischmann E, Reiterer C. PerIoperative iNflammatory reSponse assessment In hiGH-risk patienTs undergoing non-cardiac surgery (INSIGHT): study protocol of a prospective non-interventional observational study. BMJ Open 2023; 13:e065469. [PMID: 37474184 PMCID: PMC10357807 DOI: 10.1136/bmjopen-2022-065469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
INTRODUCTION Increased inflammatory processes after non-cardiac surgery are very common. The association between postoperative inflammation and the occurrence of cardiovascular complications after non-cardiac surgery are still not entirely clear. Therefore, we will evaluate the association between postoperative inflammation and the occurrence of major cardiovascular complications in patients at-risk for cardiovascular complications undergoing non-cardiac surgery. We will further evaluate the association of postoperative inflammation and days-at-home within 30 days after surgery (DAH30), the incidence of acute kidney injury, postoperative N-terminal probrain natriuretic peptide (NT-proBNP) concentrations and neurocognitive decline. METHODS AND ANALYSIS In this multicentre study, we will include 1400 patients at-risk for cardiovascular complications undergoing non-cardiac surgery. Our primary aim is to evaluate the association of postoperative maximum C-reactive protein concentration and the occurrence of a composite of five major cardiovascular complications (myocardial infarction, myocardial injury after non-cardiac surgery, new onset of atrial fibrillation, stroke and death) within 30 days after surgery using a Mann-Whitney-U test as well as a logistic regression model. As our secondary aim, we will evaluate the association of a composite of three inflammatory biomarkers (interleukin 6, procalcitonin and copeptin) on the occurrence of our composite of five cardiovascular complications within 30 days and 1 year after surgery, acute kidney injury, DAH30 and NT-proBNP concentrations using linear or logistic regression models. We will measure inflammatory biomarkers before surgery, and on the first, second, third and fifth postoperative day. We will check medical records and conduct a telephone survey 30 days and 1 year after surgery. We evaluate neurocognitive function, using a Montreal Cognitive Assessment, before and 1 year after surgery. ETHICS AND DISSEMINATION This study was approved by the ethics committees at the Medical University of Vienna (2458/2020) and at the Medical University of Graz (33-274 ex 20/21). TRIAL REGISTRATION NUMBER NCT04753307.
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Affiliation(s)
- Alexander Pichler
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Andrea Kurz
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Michael Eichlseder
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Michael Eichinger
- Division of Anaesthesiology and Intensive Care Medicine 1, Medical University of Graz, Graz, Austria
- Outcome Research Consortium, Cleveland, Ohio, USA
| | - Alexander Taschner
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Christian Reiterer
- Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria
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Garg AX, Cuerden M, Cata J, Chan MTV, Devereaux PJ, Fleischmann E, Grande AM, Kabon B, Landoni G, Maziak DE, McLean S, Parikh C, Popova E, Reimer C, Trujillo Reyes JC, Roshanov P, Sessler DI, Srinathan S, Sontrop JM, Gonzalez Tallada A, Wang MK, Wells JR, Conen D. Effect of Colchicine on the Risk of Perioperative Acute Kidney Injury: Clinical Protocol of a Substudy of the Colchicine for the Prevention of Perioperative Atrial Fibrillation Randomized Clinical Trial. Can J Kidney Health Dis 2023; 10:20543581231185427. [PMID: 37457622 PMCID: PMC10338661 DOI: 10.1177/20543581231185427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
Background Inflammation during and after surgery can lead to organ damage including acute kidney injury. Colchicine, an established inexpensive anti-inflammatory medication, may help to protect the organs from pro-inflammatory damage. This protocol describes a kidney substudy of the colchicine for the prevention of perioperative atrial fibrillation (COP-AF) study, which is testing the effect of colchicine versus placebo on the risk of atrial fibrillation and myocardial injury among patients undergoing thoracic surgery. Objective Our kidney substudy of COP-AF will determine whether colchicine reduces the risk of perioperative acute kidney injury compared with a placebo. We will also examine whether colchicine has a larger absolute benefit in patients with pre-existing chronic kidney disease, the most prominent risk factor for acute kidney injury. Design and Setting Randomized, superiority clinical trial conducted in 40 centers in 11 countries from 2018 to 2023. Patients Patients (~3200) aged 55 years and older having major thoracic surgery. Intervention Patients are randomized 1:1 to receive oral colchicine (0.5 mg tablet) or a matching placebo, given twice daily starting 2 to 4 hours before surgery for a total of 10 days. Patients, health care providers, data collectors, and outcome adjudicators will be blinded to the randomized treatment allocation. Methods Serum creatinine concentrations will be measured before surgery and on postoperative days 1, 2, and 3 (or until hospital discharge). The primary outcome of the substudy is perioperative acute kidney injury, defined as an increase (from the prerandomization value) in serum creatinine concentration of either ≥26.5 μmol/L (≥0.3 mg/dL) within 48 hours of surgery or ≥50% within 7 days of surgery. The primary analysis (intention-to-treat) will examine the relative risk of acute kidney injury in patients allocated to receive colchicine versus placebo. We will repeat the primary analysis using alternative definitions of acute kidney injury and examine effect modification by pre-existing chronic kidney disease, defined as a prerandomization estimated glomerular filtration rate (eGFR) <60 mL/min per 1.73 m2. Limitations The substudy will be underpowered to detect small effects on more severe forms of acute kidney injury treated with dialysis. Results Substudy results will be reported in 2024. Conclusions This substudy will estimate the effect of colchicine on the risk of perioperative acute kidney injury in older adults undergoing major thoracic surgery. Clinical trial registration number NCT03310125.
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Affiliation(s)
| | | | - Juan Cata
- MD Anderson Cancer Center, Houston, TX, USA
| | | | | | | | | | | | | | | | - Sean McLean
- Vancouver Acute Department of Anesthesiology, Vancouver General Hospital, BC, Canada
| | - Chirag Parikh
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | - Pavel Roshanov
- London Health Sciences Centre, ON, Canada
- Division of Nephrology, Department of Medicine, Western University, London, ON, Canada
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | | | | | | | | | | | | | - David Conen
- Population Health Research Institute, Hamilton, ON, Canada
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Reiterer C, Fleischmann E, Kabon B, Taschner A, Kurz A, Adamowitsch N, von Sonnenburg MF, Fraunschiel M, Graf A. Hemodynamic effects of intraoperative 30% versus 80% oxygen concentrations: an exploratory analysis. Front Med (Lausanne) 2023; 10:1200223. [PMID: 37324125 PMCID: PMC10265637 DOI: 10.3389/fmed.2023.1200223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/05/2023] [Indexed: 06/17/2023] Open
Abstract
Background Supplemental oxygen leads to an increase in peripheral vascular resistance which finally increases systemic blood pressure in healthy subjects and patients with coronary artery disease, heart failure, undergoing heart surgery, and with sepsis. However, it is unknown whether this effect can also be observed in anesthetized patients having surgery. Thus, we evaluated in this exploratory analysis of a randomized controlled trial the effect of 80% versus 30% oxygen on intraoperative blood pressure and heart rate. Methods We present data from a previous study including 258 patients, who were randomized to a perioperative inspiratory FiO2 of 0.8 (128 patients) versus 0.3 (130 patients) for major abdominal surgery. Continuous arterial blood pressure values were recorded every three seconds and were exported from the electronic anesthesia record system. We calculated time-weighted average (TWA) and Average Real Variability (ARV) of mean arterial blood pressure and of heart rate. Results There was no significant difference in TWA of mean arterial pressure between the 80% (80 mmHg [76, 85]) and 30% (81 mmHg [77, 86]) oxygen group (effect estimate -0.16 mmHg, CI -1.83 to 1.51; p = 0.85). There was also no significant difference in TWA of heart rate between the 80 and 30% oxygen group (median TWA of heart rate in the 80% oxygen group: 65 beats.min-1 [58, 72], and in the 30% oxygen group: 64 beats.min-1 [58; 70]; effect estimate: 0.12 beats.min-1, CI -2.55 to 2.8, p = 0.94). Also for ARV values, no significant differences between groups could be detected. Conclusion In contrast to previous results, we did not observe a significant increase in blood pressure or a significant decrease in heart rate in patients, who received 80% oxygen as compared to patients, who received 30% oxygen during surgery and for the first two postoperative hours. Thus, hemodynamic effects of supplemental oxygen might play a negligible role in anesthetized patients. Clinical Trail Registration https://clinicaltrials.gov/ct2/show/NCT03366857?term=vienna&cond=oxygen&draw=2&rank=1.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Alexander Taschner
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
- Outcome Research Consortium, Cleveland, OH, United States
| | - Andrea Kurz
- Outcome Research Consortium, Cleveland, OH, United States
- Department of General Anesthesiology, Cleveland Clinic, Anesthesia Institute, Cleveland, OH, United States
- Department of General Anesthesiology, Emergency Medicine and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Nikolas Adamowitsch
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - Alexandra Graf
- Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
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Conen D, Popova E, Wang MK, Chan MTV, Landoni G, Reimer C, Srinathan SK, Cata JP, McLean SR, Trujillo Reyes JC, Grande AM, Gonzalez Tallada A, Sessler DI, Fleischmann E, Maziak DE, Kabon B, Voltolini L, Gutiérrez-Soriano L, Tandon V, DuMerton D, Kidane B, Rajaram R, Shargall Y, Neary JD, Wells JR, McIntyre WF, Blum S, Ofori SN, Vincent J, Xu L, Li Z, Healey JS, Garg AX, Devereaux PJ. Rationale and design of the colchicine for the prevention of perioperative atrial fibrillation in patients undergoing major noncardiac thoracic surgery (COP-AF) trial. Am Heart J 2023; 259:87-96. [PMID: 36754105 DOI: 10.1016/j.ahj.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Perioperative atrial fibrillation (AF) and myocardial injury after noncardiac surgery (MINS) are common complications after noncardiac surgery. Inflammation has been implicated in the pathogenesis of both disorders. The COP-AF trial tests the hypothesis that colchicine reduces the incidence of perioperative AF and MINS in patients undergoing major noncardiac thoracic surgery. METHODS AND RESULTS The 'COlchicine for the Prevention of Perioperative Atrial Fibrillation' (COP-AF) trial is an international, blinded, randomized trial that compares colchicine to placebo in patients aged at least 55 years and undergoing major noncardiac thoracic surgery with general anesthesia. Exclusion criteria include a history of AF and a contraindication to colchicine (eg, severe renal dysfunction). Oral colchicine at a dose of 0.5 mg or matching placebo is given within 4 hours before surgery. Thereafter, patients receive colchicine 0.5 mg or placebo twice daily for a total of 10 days. The 2 independent co-primary outcomes are clinically important perioperative AF (including atrial flutter) and MINS during 14 days of follow-up. The main safety outcomes are sepsis or infection and non-infectious diarrhea. We aim to enroll 3,200 patients from approximately 40 sites across 11 countries to have at least 80% power for the independent evaluation of the 2 co-primary outcomes. The COP-AF main results are expected in 2023. CONCLUSIONS COP-AF is a large randomized and blinded trial designed to determine whether colchicine reduces the risk of perioperative AF or MINS in patients who have major noncardiac thoracic surgery.
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Affiliation(s)
- David Conen
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Ekaterine Popova
- Biomedical Research Institute (IIB Sant Pau), Barcelona, Spain; Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Michael Ke Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Matthew T V Chan
- The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Cara Reimer
- Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | | | - Juan P Cata
- Department of Anesthesiology and Perioperative Medicine, The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Sean R McLean
- Department of Anesthesia, Vancouver Acute (Vancouver General Hospital and UBC Hospital), The University of British Columbia, Vancouver, British Columbia, Canada; Department of Anesthesia, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Barbara Kabon
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Luca Voltolini
- Thoracic Surgery Unit, Careggi University Hospital, Florence, Italy
| | - Laura Gutiérrez-Soriano
- Department of Anesthesiology, Fundación CardioInfantil - Instituto de Cardiología, Bogotá, Colombia
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Biniam Kidane
- Departments of Surgery, Physiology and Pathophysiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ravi Rajaram
- Department of Cardiothoracic Surgery, The University of Texas - MD Anderson Cancer Center, Houston, TX
| | - Yaron Shargall
- Division of Thoracic Surgery, Department of Surgery, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John D Neary
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Steffen Blum
- Population Health Research Institute, Hamilton, Ontario, Canada; Cardiovascular Research Institute Basel, University Hospital Basel, Basel, Switzerland
| | - Sandra N Ofori
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; University of Port Harcourt, Choba, Nigeria
| | - Jessica Vincent
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Lizhen Xu
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Zhuoru Li
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Amit X Garg
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Departments of Medicine, Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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Taschner A, Kabon B, Graf A, Adamowitsch N, Falkner von Sonnenburg M, Fraunschiel M, Horvath K, Fleischmann E, Reiterer C. Perioperative Supplemental Oxygen and Postoperative Copeptin Concentrations in Cardiac-Risk Patients Undergoing Major Abdominal Surgery-A Secondary Analysis of a Randomized Clinical Trial. J Clin Med 2022; 11:jcm11082085. [PMID: 35456178 PMCID: PMC9025821 DOI: 10.3390/jcm11082085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 01/25/2023] Open
Abstract
Noncardiac surgery is associated with hemodynamic perturbations, fluid shifts and hypoxic events, causing stress responses. Copeptin is used to assess endogenous stress and predict myocardial injury. Myocardial injury is common after noncardiac surgery, and is often caused by myocardial oxygen demand-and-supply mismatch. In this secondary analysis, we included 173 patients at risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients were randomly assigned to receive 80% or 30% oxygen throughout surgery and the first two postoperative hours. We evaluated the effect of supplemental oxygen on postoperative Copeptin concentrations. Copeptin concentrations were measured preoperatively, within two hours after surgery, on the first and third postoperative days. In total, 85 patients received 0.8 FiO2, and 88 patients received 0.3 FiO2. There was no significant difference in postoperative Copeptin concentrations between both study groups (p = 0.446). Copeptin increased significantly within two hours after surgery, compared with baseline in the overall study population (estimated effect: −241.7 pmol·L−1; 95% CI −264.4, −219.1; p < 0.001). Supplemental oxygen did not significantly attenuate postoperative Copeptin release. Copeptin concentrations showed a more immediate postoperative increase compared with previously established biomarkers. Nevertheless, Copeptin concentrations did not surpass Troponin T in early determination of patients at risk for developing myocardial injury after noncardiac surgery.
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Affiliation(s)
- Alexander Taschner
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Alexandra Graf
- Centre for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Nikolas Adamowitsch
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria;
| | - Katharina Horvath
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
| | - Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (A.T.); (B.K.); (N.A.); (M.F.v.S.); (K.H.); (E.F.)
- Outcome Research Consortium, Cleveland, OH 44195, USA
- Correspondence: ; Tel.: +43-1-40400-20760
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10
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Reiterer C, Kabon B, Taschner A, Adamowitsch N, Graf A, Fraunschiel M, Horvath K, Kuhrn M, Clement T, Treskatsch S, Berger C, Fleischmann E. Effect of perioperative levosimendan administration on postoperative N-terminal pro-B-type natriuretic peptide concentration in patients with increased cardiovascular risk factors undergoing non-cardiac surgery: protocol for the double-blind, randomised, placebo-controlled IMPROVE trial. BMJ Open 2022; 12:e058216. [PMID: 35063963 PMCID: PMC8785196 DOI: 10.1136/bmjopen-2021-058216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION Elevated N-terminal pro-brain natriuretic peptide (NT-pro-BNP) after non-cardiac surgery is a strong predictor for cardiovascular complications and reflects increased myocardial strain. NT-pro-BNP concentrations significantly rise after non-cardiac surgery within the first 3 days. Levosimendan is a potent inotropic drug that increases calcium sensitivity to cardiac myocytes, which results in improved cardiac contractility that last for approximately 7 days. Thus, we will test the effect of a pre-emptive perioperative administration of levosimendan on postoperative NT-pro-BNP concentration as compared with the administration of a placebo in patients undergoing moderate-risk to high-risk major abdominal surgery. METHODS AND ANALYSIS We will conduct a double-blinded prospective randomised trial at the Medical University of Vienna, Vienna, Austria (and potentially a second centre in Germany), including 230 patients at-risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. Patients will be randomly assigned to receive a single dose of 12.5 mg levosimendan versus placebo after induction of anaesthesia. The primary outcome will be the postoperative maximum NT-pro-BNP concentration between both group within the first three postoperative days. Our secondary outcomes will be the incidence of myocardial ischaemia, myocardial injury after non-cardiac surgery and a composite of myocardial infarction and death within 30 days and 1 year after surgery between both groups. Our further secondary outcome will be stratification of NT-pro-BNP values according to previously thresholds to predict mortality of myocardial infarction after surgery. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of the Medical University of Vienna on 14 July 2020 (EK 2187/2019). Written informed consent will be obtained from all patients a day before surgery. Results of this study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04329624.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Wien, Austria
| | - Melanie Fraunschiel
- ITSC - IT Systems & Communications, Medical University of Vienna, Wien, Austria
| | - Katharina Horvath
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Melanie Kuhrn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Theresa Clement
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
| | - Sascha Treskatsch
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian Berger
- Department of Anesthesiology and Intensive Care Medicine, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Edith Fleischmann
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Outcome Research Consortium, Cleveland, Ohio, USA
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Wien, Austria
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11
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Reiterer C, Fleischmann E, Taschner A, Adamowitsch N, von Sonnenburg MF, Graf A, Fraunschiel M, Starlinger P, Goschin J, Kabon B. Perioperative supplemental oxygen and oxidative stress in patients undergoing moderate- to high-risk major abdominal surgery - A subanalysis of randomized clinical trial. J Clin Anesth 2021; 77:110614. [PMID: 34856530 DOI: 10.1016/j.jclinane.2021.110614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/31/2021] [Accepted: 11/17/2021] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Oxidative stress plays a pivotal role in the development and aggravation of cardiovascular diseases. The influence of intraoperative inspired oxygen concentrations on oxidative stress is still not entirely known. Therefore, we evaluated in this sub-study if supplemental oxygen affects the oxidation-reduction potential in patients at-risk for cardiovascular complications undergoing moderate- to high-risk major abdominal surgery. DESIGN Sub-study of a prospective parallel-arm double-blinded single-center superiority randomized trial. SETTING Operating room and postoperative recovery area. INTERVENTION Administration of 0.8 FiO2 versus 0.3 FiO2 throughout surgery and for the first two postoperative hours. MEASUREMENTS The primary outcome was the static oxidation-reduction potential (sORP) and the oxidation-reduction potential capacity (cORP) between both groups. The secondary outcome was the trend of sORP and cORP in the overall study population. We assessed sORP and cORP before induction of anesthesia, 2 h after induction of anesthesia, within 2 h after surgery and on the first and third postoperative day. MAIN RESULTS 258 patients were analyzed. 128 patients were randomly assigned to the 80% oxygen group and 130 patients were randomly assigned to the 30% oxygen group. Postoperative sORP values did not differ significantly between the 80% and 30% oxygen group (effect estimate: -1.162 mV,95% CI: -2.584 to 0.260; p = 0.109). On average, we observed a change in sORP of 5.288 mV (95% CI:4.633 to 5.913, p < 0.001) per day. cORP values did not differ significantly between the 80% and 30% oxygen group (effect estimate: -0.015μC, (95%CI: -0.062 to 0.032; p = 0.524). On average, we observed a change in cORP values of -0.170μC (95%CI: -0.194 to -0.147, p < 0.001) per day. CONCLUSION In contrast to previous reports, we could not find any evidence of an association between intraoperative supplemental oxygen and perioperative oxidative stress assessed by sORP and cORP. TRIAL REGISTRATION clinicaltrials.gov: NCT03366857https://clinicaltrials.gov/ct2/show/NCT03366857?term=vienna&cond=oxygen&draw=2&rank=1.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrick Starlinger
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Julius Goschin
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria; Outcomes Research Consortium, Cleveland, OH, USA
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Reiterer C, Kabon B, Taschner A, von Sonnenburg MF, Graf A, Adamowitsch N, Starlinger P, Goschin J, Fraunschiel M, Fleischmann E. Corrigendum to "Perioperative supplemental oxygen and NT-proBNP concentrations after major abdominal surgery - A prospective randomized clinical trial" [Journal of Clinical Anaesthesia volume 73 (2021) article 110379]. J Clin Anesth 2021; 76:110579. [PMID: 34773870 DOI: 10.1016/j.jclinane.2021.110579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria.
| | - Alexander Taschner
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrick Starlinger
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Julius Goschin
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, 1090 Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
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Maheshwari K, Pu X, Rivas E, Saugel B, Turan A, Schmidt MT, Ruetzler K, Reiterer C, Kabon B, Kurz A, Sessler DI. Association between intraoperative mean arterial pressure and postoperative complications is independent of cardiac index in patients undergoing noncardiac surgery. Br J Anaesth 2021; 127:e102-e104. [PMID: 34281718 DOI: 10.1016/j.bja.2021.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/16/2021] [Accepted: 06/19/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kamal Maheshwari
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA.
| | - Xuan Pu
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Eva Rivas
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Bernd Saugel
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alparslan Turan
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Marc T Schmidt
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Christian Reiterer
- Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Andrea Kurz
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA; Department of General Anaesthesiology, Emergency and Intensive Care Medicine, Medical University Graz, Austria
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
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Reiterer C, Kabon B, Taschner A, Falkner von Sonnenburg M, Graf A, Adamowitsch N, Starlinger P, Goshin J, Fraunschiel M, Fleischmann E. Perioperative supplemental oxygen and NT-proBNP concentrations after major abdominal surgery - A prospective randomized clinical trial. J Clin Anesth 2021; 73:110379. [PMID: 34087659 DOI: 10.1016/j.jclinane.2021.110379] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 01/09/2023]
Abstract
STUDY OBJECTIVE Supplemental oxygen is a simple method to improve arterial oxygen saturation and might therefore improve myocardial oxygenation. Thus, we tested whether intraoperative supplemental oxygen reduces the risk of impaired cardiac function diagnosed with NT-proBNP and myocardial injury after noncardiac surgery (MINS) diagnosed with high-sensitivity Troponin T. DESIGN Parallel-arm double-blinded single-centre superiority randomized trial. SETTING Operating room and postoperative recovery area. PATIENTS 260 patients over the age of 45 years at-risk for cardiovascular complications undergoing major abdominal surgery. INTERVENTION Administration of 80% versus 30% oxygen throughout surgery and for the first two postoperative hours. MEASUREMENTS The primary outcome was the postoperative maximum NT-proBNP concentration in both groups, which was assessed within 2 h after surgery, and on the first and third postoperative day. The secondary outcome was the incidence of MINS in both groups. MAIN RESULTS 128 patients received 80% oxygen and 130 received 30% oxygen throughout surgery and for the first two postoperative hours. There was no significant difference in the median postoperative maximum NT-proBNP concentration between the 80% and the 30% oxygen group (989 pg.mL-1 [IQR 499; 2005] and 810 pg.mL-1 [IQR 409; 2386], effect estimate: 159 pg.mL-1, 95%CI -123, 431, p = 0.704). There was no difference in the incidence of MINS between both groups. (p = 0.703). CONCLUSIONS There was no beneficial effect of perioperative supplemental oxygen administration on postoperative NT-proBNP concentration and MINS. It seems likely that supplemental oxygen has no effect on the release of NT-proBNP in patients at-risk for cardiovascular complications undergoing major abdominal surgery. TRIAL REGISTRATION ClinicalTrials.gov: NCT03366857. https://clinicaltrials.gov/ct2/results?cond=NCT+03366857&term=&cntry=&state=&city=&dist=.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria.
| | - Alexander Taschner
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Alexandra Graf
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Nikolas Adamowitsch
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrick Starlinger
- Department of Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Julius Goshin
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Melanie Fraunschiel
- IT Systems and Communications, Medical University of Vienna, 1090 Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
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Gratz J, Zotti O, Pausch A, Wiegele M, Fleischmann E, Gruenberger T, Krenn CG, Kabon B. Effect of Goal-Directed Crystalloid versus Colloid Administration on Perioperative Hemostasis in Partial Hepatectomy: A Randomized, Controlled Trial. J Clin Med 2021; 10:jcm10081651. [PMID: 33924407 PMCID: PMC8068812 DOI: 10.3390/jcm10081651] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
The use of colloids may impair hemostatic capacity. However, it remains unclear whether this also holds true when colloids are administered in a goal-directed manner. The aim of the present study was to assess the effect of goal-directed fluid management with 6% hydroxyethyl starch 130/0.4 on hemostasis compared to lactated Ringer’s solution in patients undergoing partial hepatectomy. We included 50 patients in this prospective, randomized, controlled trial. According to randomization, patients received boluses of either hydroxyethyl starch or lactated Ringer’s solution within the scope of goal-directed fluid management. Minimum perioperative FIBTEM maximum clot firmness (MCF) served as the primary outcome parameter. Secondary outcome parameters included fibrinogen levels and estimated blood loss. In the hydroxyethyl starch (HES) group the minimum FIBTEM MCF value was significantly lower (effect size −6 mm, 95% CI −10 to −3, p < 0.001) in comparison to the lactated Ringer’s solution (RL) group. These results returned to normal within 24 h. We observed no difference in plasma fibrinogen levels (RL 3.08 ± 0.37 g L−1 vs HES 2.65 ± 0.64 g L−1, p = 0.18) or the amount of blood loss between the two groups (RL 470 ± 299 mL vs HES 604 ± 351 mL, p = 0.18). We showed that goal-directed use of HES impairs fibrin polymerization in a dose-dependent manner when compared with RL. Results returned to normal on the first postoperative day without administration of procoagulant drugs and no differences in blood loss were observed.
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Affiliation(s)
- Johannes Gratz
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Oliver Zotti
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - André Pausch
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Marion Wiegele
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
- Correspondence:
| | - Thomas Gruenberger
- Department of Surgery, HPB-Center, Kaiser Franz Josef Hospital Vienna, Kundratstrasse 3, 1100 Vienna, Austria;
| | - Claus G. Krenn
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; (J.G.); (O.Z.); (A.P.); (M.W.); (C.G.K.); (B.K.)
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Reiterer C, Hu K, Sljivic S, Falkner von Sonnenburg M, Fleischmann E, Kabon B. The effect of mannitol on oxidation-reduction potential in patients undergoing deceased donor renal transplantation-A randomized controlled trial. Acta Anaesthesiol Scand 2021; 65:162-168. [PMID: 32966587 PMCID: PMC7821012 DOI: 10.1111/aas.13713] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Mannitol, an osmotic diuretic, is proposed to be an oxygen radical scavenger. Mannitol is often used in renal transplantation to attenuate oxidative stress and thus to protect renal graft function. We tested the hypothesis that mannitol reduces overall oxidative stress during deceased donor renal transplantation. METHODS We randomly assigned 34 patients undergoing deceased donor renal transplantation to receive a solution of mannitol or placebo shortly before graft reperfusion until the end of surgery. We evaluated oxidative stress by measuring the static oxidative-reduction potential (sORP) and the capacity of the oxidative-reduction potential (cORP). sORP and cORP were measured pre-operatively, before and within 10 minutes after graft reperfusion, and post-operatively. RESULTS Seventeen patients were enrolled in the mannitol group and 17 patients were enrolled in the placebo group. Mannitol had no significant effect on sORP (148.5 mV [136.2; 160.2]) as compared to placebo (143.6 mV [135.8; 163.2], P = .99). There was also no significant difference in cORP between the mannitol (0.22 µC [0.16; 0.36]) and the placebo group (0.22 µC [0.17; 0.38], P = .76). CONCLUSION Mannitol showed no systemic redox scavenging effects during deceased donor renal transplantation. To evaluate the direct effect of mannitol on the renal graft further studies are needed. TRIAL REGISTRATION ClinicalTrials.gov NCT02705573.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | - Karin Hu
- Clinical Department of Nephrology and Dialysis Medical University of Vienna Vienna Austria
| | - Samir Sljivic
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | | | - Edith Fleischmann
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
| | - Barbara Kabon
- Department of Anaesthesia Intensive Care Medicine and Pain Medicine Medical University of Vienna Vienna Austria
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Mühlbacher J, Luf F, Zotti O, Herkner H, Fleischmann E, Kabon B. Effect of Intraoperative Goal-Directed Fluid Management on Tissue Oxygen Tension in Obese Patients: a Randomized Controlled Trial. Obes Surg 2020; 31:1129-1138. [PMID: 33244655 PMCID: PMC7921017 DOI: 10.1007/s11695-020-05106-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 12/17/2022]
Abstract
Background Perioperative subcutaneous tissue oxygen tension (PsqO2) is substantially reduced in obese surgical patients. Goal-directed fluid therapy optimizes cardiac performance and thus tissue perfusion and oxygen delivery. We therefore tested the hypothesis that intra- and postoperative PsqO2 is significantly reduced in obese patients undergoing standard fluid management compared to goal-directed fluid administration. Methods We randomly assigned 60 obese patients (BMI ≥ 30 kg/m2) undergoing laparoscopic bariatric surgery to receive either esophageal Doppler-guided goal-directed fluid management or conventional fluid treatment. Our primary outcome parameter was intra- and postoperative PsqO2 measured with a polarographic electrode in the subcutaneous tissue of the upper arm. A random effects linear regression model was used to analyze the effect of intervention. Results Overall, mean (± SD) PsqO2 was significantly higher in obese patients receiving goal-directed therapy compared to conventional fluid therapy (65.8 ± 28.0 mmHg vs. 53.7 ± 21.7, respectively; repeated measures design adjusted difference: 13.0 mmHg [95% CI 2.3 to 23.7; p = 0.017]). No effect was seen intraoperatively (69.6 ± 27.9 mmHg vs. 61.4 ± 28.8, difference: 9.7 mmHg [95% CI -3.8 to 23.2; p = 0.160]); however, goal-directed fluid management improved PsqO2 in the early postoperative phase (63.1 ± 27.9 mmHg vs. 48.4 ± 12.5, difference: 14.5 mmHg [95% CI 4.1 to 24.9; p = 0.006]). Intraoperative fluid requirements did not differ between the two groups. Conclusions Goal-directed fluid therapy improved subcutaneous tissue oxygenation in obese patients. This effect was more pronounced in the early postoperative period. Clinical Trial Number and Registry The study was registered at ClinicalTrials.gov (NCT 01052519).
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Affiliation(s)
- Jakob Mühlbacher
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Florian Luf
- Department of Anaesthesiology and Intensive Care, Hanusch Hospital, Heinrich-Collin-Strasse 30, 1140, Vienna, Austria
| | - Oliver Zotti
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Edith Fleischmann
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria. .,Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University Vienna, Spitalgasse 23, A-1090, Vienna, Austria.
| | - Barbara Kabon
- Department of Emergency Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
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Obradovic M, Kurz A, Kabon B, Roth G, Kimberger O, Zotti O, Bayoumi A, Reiterer C, Stift A, Fleischmann E. The effect of intraoperative goal-directed crystalloid versus colloid administration on perioperative inflammatory markers - a substudy of a randomized controlled trial. BMC Anesthesiol 2020; 20:210. [PMID: 32825817 PMCID: PMC7441663 DOI: 10.1186/s12871-020-01126-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 08/11/2020] [Indexed: 01/01/2023] Open
Abstract
Background Excessive perioperative fluid administration may result in iatrogenic endothelial dysfunction and tissue edema, transducing inflammatory markers into the bloodstream. Colloids remain longer in the circulation, requiring less volume to reach similar hemodynamic endpoints compared to crystalloids. Thus, we tested the hypothesis that a goal-directed colloid regimen attenuates the inflammatory response compared to a goal-directed crystalloid regime. Methods Patients undergoing moderate- to high-risk open abdominal surgery were randomly assigned to goal-directed lactated Ringer’s solution (n = 58) or a hydroxyethyl starch 6% 130/0.4 (n = 62) fluid regimen. Our primary outcome was perioperative levels of pro- and anti-inflammatory cytokines. Secondary outcome was perioperative levels of white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT) and lipopolysaccharide-binding protein (LBP). Measurements were performed preoperatively, immediate postoperatively, on postoperative day one, two and four. Results The areas under the curve of Interleukin (IL) 6 (p = 0.60), IL 8 (p = 0.46), IL 10 (p = 0.68) and tumor necrosis factor α (p = 0.47) levels did not differ significantly between the groups. WBC, CRP and PCT values were also comparable. LBP, although significantly higher in the crystalloid group, remained in the normal range. Patients assigned to crystalloids received a median (IQR) amount of 3905 mL (2880–5288) of crystalloid. Patients assigned to colloids received 1557 mL (1207–2116) of crystalloid and 1250 mL (750–1938) of colloid. Conclusion Cytokine and inflammatory marker levels did not differ between goal-directed crystalloid and colloid administration after moderate to high-risk abdominal surgery. Trial registration ClinicalTrials.gov (NCT00517127). Registered 16th August 2007.
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Affiliation(s)
- Mina Obradovic
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Andrea Kurz
- Department of Outcomes Research and General Anesthesiology, Anesthesiology Institute, 9500 Euclid Avenue, Cleveland Clinic, Cleveland, OH, USA
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Georg Roth
- Department of Anesthesiology and General Intensive Care, Franziskus Hospital, Nikolsdorfergasse 32, 1050, Vienna, Austria
| | - Oliver Kimberger
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Oliver Zotti
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Ahamed Bayoumi
- Department of Gynecology, Klinik Ottakring, Montleartstrasse 37, 1160, Vienna, Austria
| | - Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Anton Stift
- Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Reiterer C, Kabon B, Taschner A, Zotti O, Kurz A, Fleischmann E. A comparison of intraoperative goal-directed intravenous administration of crystalloid versus colloid solutions on the postoperative maximum N-terminal pro brain natriuretic peptide in patients undergoing moderate- to high-risk noncardiac surgery. BMC Anesthesiol 2020; 20:192. [PMID: 32753064 PMCID: PMC7405415 DOI: 10.1186/s12871-020-01104-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 07/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND N-terminal pro brain natriuretic peptide (NT-proBNP) and troponin T are released during myocardial wall stress and/or ischemia and are strong predictors for postoperative cardiovascular complications. However, the relative effects of goal-directed, intravenous administration of crystalloid compared to colloid solutions on NT-proBNP and troponin T, especially in relatively healthy patients undergoing moderate- to high-risk noncardiac surgery, remains unclear. Thus, we evaluated in this sub-study the effect of a goal-directed crystalloid versus a goal-directed colloid fluid regimen on postoperative maximum NT-proBNP concentration. We further evaluated the incidence of myocardial injury after noncardiac surgery (MINS) between both study groups. METHODS Thirty patients were randomly assigned to receive additional intravenous fluid boluses of 6% hydroxyethyl starch 130/0.4 and 30 patients to receive lactated Ringer's solution. Intraoperative fluid management was guided by oesophageal Doppler-according to a previously published algorithm. The primary outcome were differences in postoperative maximum NT-proBNP (maxNT-proBNP) between both groups. As our secondary outcome we evaluated the incidence of MINS between both study groups. We defined maxNT-proBNP as the maximum value measured within 2 h after surgery and on the first and second postoperative day. RESULTS In total 56 patients were analysed. There was no significant difference in postoperative maximum NT-proBNP between the colloid group (258.7 ng/L (IQR 199.4 to 782.1)) and the crystalloid group (440.3 ng/L (IQR 177.9 to 691.2)) during the first 2 postoperative days (P = 0.29). Five patients in the colloid group and 7 patients in the crystalloid group developed MINS (P = 0.75). CONCLUSIONS Based on this relatively small study goal-directed colloid administration did not decrease postoperative maxNT-proBNP concentration as compared to goal-directed crystalloid administration. TRIAL REGISTRATION ClinicalTrials.gov ( NCT01195883 ) Registered on 6th September 2010.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Alexander Taschner
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Oliver Zotti
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Andrea Kurz
- Department of Outcomes Research and General Anaesthesiology, Anaesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Edith Fleischmann
- Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Reiterer C, Kabon B, von Sonnenburg MF, Starlinger P, Taschner A, Zotti O, Goshin J, Drlicek G, Fleischmann E. The effect of supplemental oxygen on perioperative brain natriuretic peptide concentration in cardiac risk patients - a protocol for a prosprective randomized clinical trial. Trials 2020; 21:400. [PMID: 32398119 PMCID: PMC7218565 DOI: 10.1186/s13063-020-04336-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 04/23/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Elevated postoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations are predictive for cardiac adverse events in noncardiac surgery. Studies indicate that supplemental oxygen decreases sympathetic nerve activity and might, therefore, improve cardiovascular function. Thus, we will test the effect of perioperative supplemental oxygen administration on NT-proBNP release after surgery. METHODS/DESIGN We will conduct a single-center, double-blinded, randomized trial at the Medical University of Vienna, including 260 patients with increased cardiac risk factors undergoing moderate- to high-risk noncardiac surgery. Patients will be randomly assigned to receive 80% versus 30% oxygen during surgery and for 2 h postoperatively. The primary outcome will be the difference in maximum NT-proBNP release after surgery. As secondary outcomes we will assess the effect of supplemental oxygen on postoperative maximum troponin T concentration, oxidation-reduction potential, von Willebrand factor concentration and perioperative fluid requirements. We will perform outcome measurements 2 h after surgery, on postoperative day 1 and on postoperative day 3. The NT-proBNP concentration and the oxidation-reduction potential will also be measured within 72 h before discharge. DISCUSSION Our trial should determine whether perioperative supplemental oxygen administration will reduce the postoperative release of NT-proBNP in patients with preoperative increased cardiovascular risk factors undergoing noncardiac surgery. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03366857. Registered on 8th December 2017.
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Affiliation(s)
- Christian Reiterer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Barbara Kabon
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Markus Falkner von Sonnenburg
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Patrick Starlinger
- Department of Surgery, Medical University of Vienna, 1090, Vienna, Austria
| | - Alexander Taschner
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Oliver Zotti
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Julius Goshin
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Gregor Drlicek
- Franziskus Spital, Anaesthesia and Intensive Care, 1050, Vienna, Austria
| | - Edith Fleischmann
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
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Reiterer C, Kabon B, Zotti O, Obradovic M, Kurz A, Fleischmann E. Effect of goal-directed crystalloid- versus colloid-based fluid strategy on tissue oxygen tension: a randomised controlled trial. Br J Anaesth 2019; 123:768-776. [DOI: 10.1016/j.bja.2019.08.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 08/16/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022] Open
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Holzer A, Sitter B, Kimberger O, Wenzl R, Fleischmann E, Marhofer D, Kabon B. Body Mass Index does not affect intraoperative goal-directed fluid requirements. Minerva Anestesiol 2019; 85:1071-1079. [PMID: 30994313 DOI: 10.23736/s0375-9393.19.13396-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Perioperative normovolemia is a major determinant of tissue oxygen availability and postoperative outcome. Thus, adequate volume replacement therapy remains an essential part of perioperative management. Nevertheless, volume optimization in overweight and obese surgical patients with alterations in cardiovascular function, peripheral perfusion, and body composition remains challenging. We, therefore, tested the hypothesis that Body Mass Index (BMI) correlates with fluid requirements during goal-directed management. Furthermore, we evaluated subcutaneous tissue oxygen tension (PsqO2) as an indicator of intravascular volume status and peripheral perfusion. METHODS Ninety women, undergoing open gynecologic surgery, were assigned to three groups according to their BMI, (lean: BMI 18.5 to 24.9 kg/m2, overweight: BMI 25 to 29.9 kg/m2, obese: BMI>30 kg/m2). Esophageal Doppler monitoring guided intraoperative crystalloid administration. Tissue oxygen tension was measured with a polarographic electrode in the subcutaneous tissue of the upper arm and served as a secondary outcome parameter. RESULTS BMI and fluid requirements did not correlate (r=0.093, P=0.384). Total amounts of administered crystalloids were comparable. Lean patients received 2223±1811 mL in total, while overweight patients received 1866±1261 mL. Obese patients required 2416±1143 mL of total crystalloids (P=0.327). Intra- and postoperative PsqO2 did not differ significantly (97.3 vs. 86.8 vs. 79.6 mmHg, P=0.06 and 74.5 vs. 83 vs. 81.5 mmHg, P=0.63, respectively). CONCLUSIONS BMI did not affect intraoperative fluid requirements. Doppler-guided intravascular volume optimization was associated with well-maintained subcutaneous tissue oxygen availability in all BMI groups.
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Affiliation(s)
- Andrea Holzer
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Sitter
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Oliver Kimberger
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - René Wenzl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria -
| | - Daniela Marhofer
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
| | - Barbara Kabon
- Unit of General Intensive Care and Pain Medicine, Department of Anesthesiology, Medical University of Vienna, Vienna, Austria
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Paireder M, Asari R, Kristo I, Rieder E, Zacherl J, Kabon B, Fleischmann E, Schoppmann SF. Morbidity in open versus minimally invasive hybrid esophagectomy (MIOMIE): Long-term results of a randomized controlled clinical study. Eur Surg 2018; 50:249-255. [PMID: 30546384 PMCID: PMC6267426 DOI: 10.1007/s10353-018-0552-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Accepted: 07/12/2018] [Indexed: 12/12/2022]
Abstract
Background The minimally invasive esophagectomy (MIE) for esophageal cancer was introduced assuming a reduction of morbidity and operation time. After implementation of MIE at our institution, a randomized controlled trial was designed. Methods This is a prospective randomized controlled study comparing open (OE) and laparoscopic gastric tube (MIE) formation in Ivor Lewis esophagectomy. Primary endpoints were morbidity and 30-day mortality. Secondary endpoints included the duration of intensive care unit stay, length of hospital stay, operative time as well as relapse-free and overall survival. Results Twenty patients (76.9%) were male, median age was 63 years (40-77). Median operation time was 290 (215-385) minutes in OE and 292.5 (200-450) minutes in MIE group, p = 0.421. Major complications occurred in 4 (33.3%) patients in the OE group and in 6 (35.7%) patients in the MIE group. Anastomotic leakage was seen in 2 (16.6%) and 3 (21.4%) patients, respectively (OR 1.364; CI = 0.188-9.912; p = 0.759). Due to an alarming number of consecutive anastomotic leakages, the trial was stopped after inclusion of 26 patients. Median follow-up was 41.5 (1-62.6) months. 5‑year survival rate was 50%. Thirty-eight percent developed recurrence of disease in the study period. There was no significant difference in overall and relapse-free survival regarding the type of surgery. Conclusion This study shows that hybrid MIE is a feasible alternative for esophageal resection. Morbidity, mortality, and oncological long-term results were equal in both groups, but the interpretation has to be done carefully due to premature termination of the trial. Interrupting a trial because of patient benefit should not be a reason to discard results but rather to improve technical aspects and strive for novel studies.
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Affiliation(s)
- Matthias Paireder
- 1Department of Surgery, Upper-GI-Service Comprehensive Cancer Center, GET-Unit Medical, University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Reza Asari
- 1Department of Surgery, Upper-GI-Service Comprehensive Cancer Center, GET-Unit Medical, University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Ivan Kristo
- 1Department of Surgery, Upper-GI-Service Comprehensive Cancer Center, GET-Unit Medical, University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Erwin Rieder
- 1Department of Surgery, Upper-GI-Service Comprehensive Cancer Center, GET-Unit Medical, University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Johannes Zacherl
- Department of Surgery, St. Josef Hospital of Vienna, Vienna, Austria
| | - Barbara Kabon
- 3Department of Anesthesia, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- 3Department of Anesthesia, Medical University of Vienna, Vienna, Austria
| | - Sebastian F Schoppmann
- 1Department of Surgery, Upper-GI-Service Comprehensive Cancer Center, GET-Unit Medical, University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
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Biccard BM, Sigamani A, Chan MTV, Sessler DI, Kurz A, Tittley JG, Rapanos T, Harlock J, Szalay D, Tiboni ME, Popova E, Vásquez SM, Kabon B, Amir M, Mrkobrada M, Mehra BR, El Beheiry H, Mata E, Tena B, Sabaté S, Zainal Abidin MK, Shah VR, Balasubramanian K, Devereaux PJ. Effect of aspirin in vascular surgery in patients from a randomized clinical trial (POISE-2). Br J Surg 2018; 105:1591-1597. [PMID: 30019751 DOI: 10.1002/bjs.10925] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/13/2018] [Accepted: 05/31/2018] [Indexed: 01/30/2023]
Abstract
BACKGROUND In the POISE-2 (PeriOperative ISchemic Evaluation 2) trial, perioperative aspirin did not reduce cardiovascular events, but increased major bleeding. There remains uncertainty regarding the effect of perioperative aspirin in patients undergoing vascular surgery. The aim of this substudy was to determine whether there is a subgroup effect of initiating or continuing aspirin in patients undergoing vascular surgery. METHODS POISE-2 was a blinded, randomized trial of patients having non-cardiac surgery. Patients were assigned to perioperative aspirin or placebo. The primary outcome was a composite of death or myocardial infarction at 30 days. Secondary outcomes included: vascular occlusive complications (a composite of amputation and peripheral arterial thrombosis) and major or life-threatening bleeding. RESULTS Of 10 010 patients in POISE-2, 603 underwent vascular surgery, 319 in the continuation and 284 in the initiation stratum. Some 272 patients had vascular surgery for occlusive disease and 265 had aneurysm surgery. The primary outcome occurred in 13·7 per cent of patients having aneurysm repair allocated to aspirin and 9·0 per cent who had placebo (hazard ratio (HR) 1·48, 95 per cent c.i. 0·71 to 3·09). Among patients who had surgery for occlusive vascular disease, 15·8 per cent allocated to aspirin and 13·6 per cent on placebo had the primary outcome (HR 1·16, 0·62 to 2·17). There was no interaction with the primary outcome for type of surgery (P = 0·294) or aspirin stratum (P = 0·623). There was no interaction for vascular occlusive complications (P = 0·413) or bleeding (P = 0·900) for vascular compared with non-vascular surgery. CONCLUSION This study suggests that the overall POISE-2 results apply to vascular surgery. Perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications. Registration number: NCT01082874 ( http://www.clinicaltrials.gov).
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Affiliation(s)
- B M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - A Sigamani
- Narayana Hrudayalaya Limited, Bangalore, India
| | - M T V Chan
- Department of Anaesthetics, Chinese University of Hong Kong, Hong Kong, China
| | - D I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
| | - A Kurz
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - J G Tittley
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - T Rapanos
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - J Harlock
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - D Szalay
- Division of Vascular Surgery, McMaster University, Hamilton, Ontario, Canada
| | - M E Tiboni
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - E Popova
- Biomedical Research Institute (IIB - Sant Pau), Barcelona, Spain
| | - S M Vásquez
- Grupo de Cardiología Preventiva Universidad Autónoma de Bucaramanga, Bucaramanga, Colombia
| | - B Kabon
- Department of Anaesthesiology, Medical University of Vienna, Vienna, Austria
| | - M Amir
- Department of Surgery, Shifa International Hospital/Shifa Tameer-e-Millat University, Islamabad, Pakistan
| | - M Mrkobrada
- Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - B R Mehra
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, India
| | - H El Beheiry
- University of Toronto, Trillium Health Partners, Toronto, Ontario, Canada
| | - E Mata
- Hospital Universitario La Princesa, Madrid, Spain
| | - B Tena
- Department of Anaesthesiology, Hospital Clinic, Barcelona, Spain
| | - S Sabaté
- Department of Anaesthesiology, Fundació Puigvert (IUNA), Barcelona, Spain
| | - M K Zainal Abidin
- Department of Anaesthesiology and Intensive Care, Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | | | | | - P J Devereaux
- Population Health Research Institute, Hamilton, Ontario, Canada
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Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
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Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
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Pfortmueller C, Funk GC, Potura E, Reiterer C, Luf F, Kabon B, Druml W, Fleischmann E, Lindner G. Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation : Prospective, randomized, controlled trial. Wien Klin Wochenschr 2017; 129:598-604. [PMID: 28255797 PMCID: PMC5599439 DOI: 10.1007/s00508-017-1180-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 02/06/2017] [Indexed: 12/31/2022]
Abstract
Background Infusion therapy is one of the most frequently prescribed medications in hospitalized patients. Currently used crystalloid solutes have a variable composition and may therefore influence acid-base status, intracellular and extracellular water content and plasma electrolyte compositions and have a major impact on organ function and outcome. The aim of our study was to investigate whether use of acetate-based balanced crystalloids leads to better hemodynamic stability compared to 0.9% saline. Methods We performed a sub-analysis of a prospective, randomized, controlled trial comparing effects of 0.9% saline or an acetate-buffered, balanced crystalloid during the perioperative period in patients with end-stage renal disease undergoing cadaveric renal transplantation. Need for catecholamine therapy and blood pressure were the primary measures. Results A total of 150 patients were included in the study of which 76 were randomized to 0.9% saline while 74 received an acetate-buffered balanced crystalloid. Noradrenaline for cardiocirculatory support during surgery was significantly more often administered in the normal saline group, given earlier and with a higher cumulative dose compared to patients receiving an acetate-buffered balanced crystalloid (30% versus 15%, p = 0.027; 68 ± 45 µg/kg versus 75 ± 60 µg/kg, p = 0.0055 and 0.000492 µg/kg body weight/min, ±0.002311 versus 0.000107 µg/kg/min, ±0.00039, p = 0.04, respectively). Mean minimum arterial blood pressure was significantly lower in patients randomized to 0.9% saline than in patients receiving the balanced infusion solution (57.2 [SD 8.7] versus 60.3 [SD 10.2] mm Hg, p = 0.024). Conclusion The use of an acetate-buffered, balanced infusion solution results in reduced need for use of catecholamines and cumulative catecholamine dose for hemodynamic support and in less occurrence of arterial hypotension in the perioperative period. Further research in the field is strongly encouraged.
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Affiliation(s)
- Carmen Pfortmueller
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.
| | - Georg-Christian Funk
- Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital Vienna and Ludwig-Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria
| | - Eva Potura
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Christian Reiterer
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Florian Luf
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Wilfred Druml
- Department of Nephrology, Medical University of Vienna, Vienna, Austria
| | - Edith Fleischmann
- Department of Anesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria
| | - Gregor Lindner
- Department of Emergency Medicine, Hirslanden - Klinik Im Park, Zurich, Switzerland
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Abstract
BACKGROUND Vocal cords visualization is a major determinant for successful tracheal intubation. The aim of our study was to compare vocal cord visualization by using conventional direct laryngoscopy with retromolar direct laryngoscopy in patients with an existing retromolar gap at the right mandible. METHODS We enrolled 100 adults needing endotracheal intubation for elective surgery. In each patient, the vocal cords were visualized and scored according to Cormack and Lehane with a Macintosh blade #3 for conventional technique and with a Miller blade #4 for the retromolar technique in a randomized sequence. Finally, tracheal intubation was performed primarily by conventional laryngoscopy and in the case of failing retromolar laryngoscopy was used as the rescue method. RESULTS Overall 100 laryngoscopies with the conventional method and 100 laryngoscopies with the retromolar method were scored according to Cormack and Lehane. The retromolar technique achieved significant (P=0.000003) lower Cormack and Lehane scores compared to the conventional technique. In eleven patients, intubation by conventional laryngoscopy failed and seven of those patients were successfully intubated by the retromolar technique. A BURP-maneuver significantly improved vocal cord visualization during both methods. CONCLUSIONS In summary, laryngoscopy via the retromolar method by using a Miller blade #4 lead to a significantly better vocal cord visualization compared to the conventional method performed with a Macintosh blade #3 in patients with an existing retromolar gap on the right side.
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Affiliation(s)
- Christian Reiterer
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna General Hospital, Vienna, Austria -
| | - Barbara Waltl
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Barbara Kabon
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Wolfgang Schramm
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
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Pfortmueller CA, Funk GC, Potura E, Reitere C, Kabon B, Druml W, Fleischmann E, Lindner G. Balanced Crystalloid Use Is Associated With Haemodynamic Stability And Less Need For Vasopressors in Patients Receiving Renal Transplantation Compared To 0.9% Saline. Intensive Care Med Exp 2015. [PMCID: PMC4796209 DOI: 10.1186/2197-425x-3-s1-a18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Kurz A, Fleischmann E, Sessler D, Buggy D, Apfel C, Akça O, Fleischmann E, Erdik E, Eredics K, Kabon B, Herbst F, Kazerounian S, Kugener A, Marschalek C, Mikocki P, Niedermayer M, Obewegeser E, Ratzenboeck I, Rozum R, Sindhuber S, Schlemitz K, Schebesta K, Stift A, Kurz A, Sessler DI, Bala E, Chen ST, Devarajan J, Maheshwari A, Mahboobi R, Mascha E, Nagem H, Rajogopalan S, Reynolds L, Alvarez A, Stocchi L, Doufas AG, Govinda R, Kasuya Y, Komatsu R, Lenhardt R, Orhan-Sungur M, Sengupta P, Wadhwa A, Galandiuk S, Buggy D, Arain M, Burke S, McGuire B, Ragheb J, Taguchi A. Effects of supplemental oxygen and dexamethasone on surgical site infection: a factorial randomized trial ‡. Br J Anaesth 2015; 115:434-43. [DOI: 10.1093/bja/aev062] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2014] [Indexed: 11/13/2022] Open
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Potura E, Lindner G, Biesenbach P, Funk GC, Reiterer C, Kabon B, Schwarz C, Druml W, Fleischmann E. An acetate-buffered balanced crystalloid versus 0.9% saline in patients with end-stage renal disease undergoing cadaveric renal transplantation: a prospective randomized controlled trial. Anesth Analg 2015; 120:123-129. [PMID: 25185593 DOI: 10.1213/ane.0000000000000419] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Recent studies have shown a decline in glomerular filtration rate and increased renal vasoconstriction after administration of normal saline when compared with IV solutions with less chloride. In this study, we investigated the impact of normal saline versus a chloride-reduced, acetate-buffered crystalloid on the incidence of hyperkalemia during cadaveric renal transplantation. The incidence of metabolic acidosis and kidney function were secondary aims. METHODS In this prospective randomized controlled trial, 150 patients received normal saline or an acetate-buffered balanced crystalloid during and after cadaveric renal transplantation. Venous blood gases were obtained at the start of anesthesia and every 30 minutes until discharge from the postoperative surveillance unit. Serum creatinine and 24-hour urine output were obtained on postoperative days 1, 3, and 7. RESULTS Patients received a similar amount of fluid (median: 2625mL [interquartile range: 2000 to 3100] vs 2500 mL [2000 to 3050], P = 0.83). Hyperkalemia, defined as serum potassium >5.9 mmol/L, occurred in 13 patients (17%) in the saline and 15 (21%) in the balanced group (P = 0.56; difference between proportions -0.037 [-16.5% to 8.9%]). Minimum base excess was lower in the saline group compared with the balanced regimen (-4.5 mmol/L [-6 to -2.4] vs -2.6 mmol/L [-4 to -1], P < 0.001) and maximum chloride was significantly higher in the saline group (109 mmol/L [107 to 111] vs 107 mmol/L [105 to 109], P < 0.001). No difference in creatinine or urine output was seen postoperatively. Significantly more patients needed catecholamines in the saline group (30% vs 15%, P = 0.03). CONCLUSIONS The incidence of hyperkalemia differed by less than 17% between groups. Use of balanced crystalloid resulted in less hyperchloremia and metabolic acidosis. Significantly more patients in the saline group required administration of catecholamines for circulatory support.
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Affiliation(s)
- Eva Potura
- From the *Department of Anaesthesiology, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria; †Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital Vienna, Sozialmedizinisches Zentrum Baumgartner Höhe, Vienna, Austria; ‡Department of Nephrology, Medical University of Vienna, Vienna, Austria; §Department of Respiratory and Critical Care Medicine, Otto Wagner Hospital Vienna, Austria; ∥Ludwig-Boltzmann Institute for COPD and Respiratory Epidemiology, Vienna, Austria; and ¶Department of Nephrology, Landeskrankenhaus Steyr, Steyr, Austria
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Ernstbrunner M, Kostner L, Kimberger O, Wabel P, Säemann M, Markstaller K, Fleischmann E, Kabon B, Hecking M. Bioimpedance spectroscopy for assessment of volume status in patients before and after general anaesthesia. PLoS One 2014; 9:e111139. [PMID: 25360698 PMCID: PMC4215896 DOI: 10.1371/journal.pone.0111139] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 09/27/2014] [Indexed: 12/27/2022] Open
Abstract
Background Technically assisted assessment of volume status before surgery may be useful to direct intraoperative fluid administration. We therefore tested a recently developed whole-body bioimpedance spectroscopy device to determine pre- to postoperative fluid distribution. Methods Using a three-compartment physiologic tissue model, the body composition monitor (BCM, Fresenius Medical Care, Germany) measures total body fluid volume, extracellular volume, intracellular volume and fluid overload as surplus or deficit of ‘normal’ extracellular volume. BCM-measurements were performed before and after standardized general anaesthesia for gynaecological procedures (laparotomies, laparoscopies and vaginal surgeries). BCM results were blinded to the attending anaesthesiologist and data analysed using the 2-sided, paired Student’s t-test and multiple linear regression. Results In 71 females aged 45±15 years with body weight 67±13 kg and duration of anaesthesia 154±68 min, pre- to postoperative fluid overload increased from −0.7±1.1 L to 0.1±1.0 L, corresponding to −5.1±7.5% and 0.8±6.7% of normal extracellular volume, respectively (both p<0.001), after patients had received 1.9±0.9 L intravenous crystalloid fluid. Perioperative urinary excretion was 0.4±0.3 L. The increase in extracellular volume was paralleled by an increase in total body fluid volume, while intracellular volume increased only slightly and without reaching statistical significance (p = 0.15). Net perioperative fluid balance (administered fluid volume minus urinary excretion) was significantly associated with change in extracellular volume (r2 = 0.65), but was not associated with change in intracellular volume (r2 = 0.01). Conclusions Routine intraoperative fluid administration results in a significant, and clinically meaningful increase in the extracellular compartment. BCM-measurements yielded plausible results and may become useful to guide intraoperative fluid therapy in future studies.
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Affiliation(s)
- Matthäus Ernstbrunner
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Lisa Kostner
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Oliver Kimberger
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Peter Wabel
- Fresenius Medical Care, Bad Homburg, Germany
| | - Marcus Säemann
- Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Vienna, Austria
| | - Klaus Markstaller
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Edith Fleischmann
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Barbara Kabon
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
| | - Manfred Hecking
- Medical University of Vienna, Department of Anaesthesiology and Critical Care Medicine, Vienna, Austria
- Medical University of Vienna, Department of Internal Medicine III, Clinical Division of Nephrology & Dialysis, Vienna, Austria
- * E-mail:
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Wadhwa A, Kabon B, Fleischmann E, Kurz A, Sessler DI. Supplemental Postoperative Oxygen Does Not Reduce Surgical Site Infection and Major Healing-Related Complications from Bariatric Surgery in Morbidly Obese Patients. Anesth Analg 2014; 119:357-365. [DOI: 10.1213/ane.0000000000000318] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Machata AM, Kabon B, Willschke H, Prayer D, Marhofer P. Upper airway size and configuration during propofol-based sedation for magnetic resonance imaging: an analysis of 138 infants and children. Paediatr Anaesth 2010; 20:994-1000. [PMID: 20880156 DOI: 10.1111/j.1460-9592.2010.03419.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Propofol is widely used for pediatric sedation. However, increasing depth of propofol sedation is associated with airway narrowing and obstruction. The aim of this study was to objectively assess airway patency during a low-dose propofol-based sedation regimen by measuring upper airway size and configuration with magnetic resonance imaging (MRI) in spontaneously breathing infants and children. METHODS Magnetic resonance images of the upper airway were obtained in 138 infants and children, aged up to 6 years. Cross-sectional area, anteroposterior dimension, and transverse dimension were measured at the level of the soft palate, the base of the tongue, and the tip of the epiglottis. Sedation was induced with i.v. midazolam 0.1 mg·kg(-1) , nalbuphine 0.1 mg·kg(-1) , and propofol 1 mg·kg(-1) and maintained with propofol 5 mg·kg(-1) ·h(-1) . RESULTS Median (IQR) age was 36 (15, 48) months, and mean body weight was 13.7 ± 5.6 kg. Airway patency was maintained in all infants and children. The narrowest part of the pharyngeal airway was measured at the level of the base of the tongue. Anteroposterior dimensions were narrower than transverse dimensions in all age groups at all measurement sites. Transverse dimensions increased with age at all measurement sites, while anteroposterior dimensions did not increase comparably. No patient demonstrated respiratory or cardiovascular adverse events. All MRI were completed successfully without sedation failure. CONCLUSION Airway patency was maintained in all infants and children sedated with this low-dose propofol-based sedation regimen.
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Affiliation(s)
- Anette-Marie Machata
- Department of Anesthesia, General Intensive Care and Pain Therapy, Medical University of Vienna, Vienna, Austria.
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Schoppmann SF, Prager G, Langer FB, Riegler FM, Kabon B, Fleischmann E, Zacherl J. Open versus minimally invasive esophagectomy: a single-center case controlled study. Surg Endosc 2010; 24:3044-53. [PMID: 20464423 DOI: 10.1007/s00464-010-1083-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2009] [Accepted: 04/02/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recent advances in laparoscopic and thoracoscopic surgery have made it possible to perform esophagectomy using minimally invasive techniques. Although technically complex, recent case studies showed that minimally invasive approaches to esophagectomy are feasible and have the potential to improve mortality, hospital stay, and functional outcome. METHODS We have performed a case controlled pair-matched study comparing 62 patients who had undergone either minimally invasive (MIE) or open esophagectomy (OE) between 2004 and 2007. Patients were matched by tumor stage and localization, sex, age, and preoperative ASA score. Pathologic stage, operative time, blood loss, transfusion requirements, hospital length of stay, postoperative morbidity, and mortality were recorded. RESULTS Statistically significant differences were seen in the overall number of patients with surgical morbidity (MIE: 25% vs. OE: 74%, p = 0.014), the transfusion rate (MIE: 12.9% vs. OE: 41.9%, p = 0.001), and the rate of postoperative respiratory complications (MIE: 9.7% vs. OE: 38.7%, p = 0.008). There was no difference with respect to the duration of surgery. The number of resected lymph nodes and rate of pathologic complete resection were comparable. ICU stay [MIE: 3 days (range = 0-15) vs. OE: 6 days (range = 1-40), p = 0.03] and hospital stay [MIE: 12 days (range = 8-46) vs. OE: 24 days (range = 10-79), p = 0.001] were significantly shorter in the MIE group. CONCLUSION The results of this case-controlled study provide further evidence for the feasibility and possible improvements in the postoperative morbidity of minimally invasive esophagectomy. Our data are comparable to those from other centers and lead us to initiate the first prospectively randomized study comparing the morbidity of total minimally invasive esophagectomy with the open technique.
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Affiliation(s)
- Sebastian F Schoppmann
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Lahner D, Kabon B, Marschalek C, Chiari A, Pestel G, Kaider A, Fleischmann E, Hetz H. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness intraoperatively. Br J Anaesth 2009; 103:346-51. [DOI: 10.1093/bja/aep200] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Machata AM, Kabon B, Willschke H, Fäßler K, Gustorff B, Marhofer P, Curatolo M. A new instrument for pain assessment in the immediate postoperative period. Anaesthesia 2009; 64:392-8. [DOI: 10.1111/j.1365-2044.2008.05798.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Machata AM, Willschke H, Kabon B, Prayer D, Marhofer P. Effect of brain magnetic resonance imaging on body core temperature in sedated infants and children. Br J Anaesth 2009; 102:385-9. [PMID: 19174372 DOI: 10.1093/bja/aen388] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Children undergoing magnetic resonance imaging (MRI) under sedation are at risk of hypo- or hyperthermia. The effect of brain MRI at differing magnetic field strengths on body core temperature in sedated infants and young children has not been reported previously. METHODS Two groups of 38 infants and children (aged 1 month to 6 yr 5 months) underwent brain MRI for different indications related to cerebral diseases, at 1.5 Tesla (T) and 3 T MRI units, respectively. All patients received deep sedation comprising midazolam, nalbuphine, and propofol. Pre-scan and post-scan temperatures were measured at the right tympanic and at rectal sites. No active warming devices were used during the procedures. RESULTS Body core temperature measurements were similar between right tympanic and rectal site before and after the scans. After 1.5 T scans, the median (IQR) increase from pre-scan to post-scan tympanic temperature was 0.2 degrees C (0.1-0.3), and the median (IQR) rectal temperature increase was 0.2 degrees C (0-0.3) (P<0.001). After 3 T scans, the median (IQR) tympanic temperature increase was 0.5 degrees C (0.4-0.7), and the median (IQR) rectal temperature increase was 0.5 degrees C (0.3-0.6) (P<0.001). CONCLUSIONS Body core temperature increased significantly during 1.5 and 3 T examinations; this increase was more profound during 3 T MRI. Patient heating occurred despite minimal efforts to reduce passive heat loss under sedation and without the use of warming devices.
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Affiliation(s)
- A-M Machata
- Department of Anaesthesia, General Intensive Care and Pain Therapy, Medical University of Vienna, General Hospital, Waehringer Guertel 18-20, A-1090 Vienna, Austria.
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Machata AM, Willschke H, Kabon B, Kettner S, Marhofer P. Propofol-based sedation regimen for infants and children undergoing ambulatory magnetic resonance imaging. Br J Anaesth 2008; 101:239-43. [DOI: 10.1093/bja/aen153] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kabon B, Kugener A, Gruenberger T, Niedermayr M, Fleischmann E, Freissmuth M, Kurz A. Effects of continuous remifentanil administration on intra-operative subcutaneous tissue oxygen tension. Anaesthesia 2007; 62:1101-9. [DOI: 10.1111/j.1365-2044.2007.05228.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kimberger O, Fleischmann E, Brandt S, Kugener A, Kabon B, Hiltebrand L, Krejci V, Kurz A. Supplemental oxygen, but not supplemental crystalloid fluid, increases tissue oxygen tension in healthy and anastomotic colon in pigs. Anesth Analg 2007; 105:773-9. [PMID: 17717239 DOI: 10.1213/01.ane.0000277490.90387.96] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Low tissue oxygen tension is an important factor leading to the development of wound dehiscence and anastomotic leakage after colon surgery. We tested whether supplemental fluid and supplemental oxygen can increase tissue oxygen tension in healthy and injured, perianastomotic, and anastomotic colon in an acutely instrumented pig model of anastomosis surgery. METHODS Sixteen Swiss Landrace pigs were anesthetized (isoflurane 0.8%-1%) and their lungs ventilated. The animals were randomly assigned to low fluid treatment ("low" group, 3 mL x kg(-1) x h(-1) lactated Ringer's solution) or high fluid treatment ("high" group, 10 mL/kg bolus, 18 mL x kg(-1) x h(-1) lactated Ringer's solution) during colon anastomosis surgery and a subsequent measurement period (4 h). Two-and-half hours after surgery, tissue oxygen tension was recorded for 30 min during ventilation with 30% oxygen. Three hours after surgery, the animals' lungs were ventilated with 100% oxygen for 60 min. Tissue oxygen tension was recorded in the last 30 min. Tissue oxygen tension was measured with polarographic Clark-type electrodes, positioned in healthy colonic wall, close (2 cm) to the anastomosis, and in the anastomosis. RESULTS In every group, tissue oxygen tension during ventilation with 100% oxygen was approximately twice as high as during ventilation with 30% oxygen, a statistically significant result. High or low volume crystalloid fluid treatment had no effect on colon tissue oxygen tension. CONCLUSIONS Supplemental oxygen, but not supplemental crystalloid fluid, increased tissue oxygen tension in healthy, perianastomotic, and anastomotic colon tissue.
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Abstract
Abstract
Background
Wound infection remains a common and serious complication after colonic surgery. Although many colonic operations are performed laparoscopically, it remains unclear whether this has any impact on the incidence of wound infection. Subcutaneous tissue oxygenation is an excellent predictor of surgical wound infection. The impact of open and laparoscopic colonic surgery on tissue oxygenation was compared.
Methods
Fifty-two patients undergoing elective open and laparoscopic left-sided colonic resections were evaluated in a prospective observational study. Anaesthesia management was standardized and intraoperative arterial partial pressure of oxygen was kept at 150 mmHg in both groups. Oxygen tension was measured in the subcutaneous tissue of the right upper arm.
Results
At the start of surgery subcutaneous tissue oxygen tension (Psqo2) was similar in both groups (mean(s.d.) 65·8(17·2) and 63·7(23·6) mmHg for open and laparoscopic operations respectively; P = 0·714). Tissue oxygen remained stable in the open group, but dropped significantly in the laparoscopic group during the course of surgery (Psqo2 after operation 53·4(12·9) and 45·5(11·6) mmHg, respectively; P = 0·012).
Conclusion
Laparoscopic colonic surgery significantly decreases Psqo2, an effect that occurs early in the course of surgery. As tissue oxygen tension is a predictor of wound infection, these results may explain why the risk of wound infection after laparoscopic surgery remains higher than expected.
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Affiliation(s)
- E Fleischmann
- Department of Anaesthesia and Intensive Care, Medical University Vienna, Vienna, Austria.
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Fleischmann E, Herbst F, Kugener A, Kabon B, Niedermayr M, Sessler DI, Kurz A. Mild Hypercapnia Increases Subcutaneous and Colonic Oxygen Tension in Patients Given 80% Inspired Oxygen during Abdominal Surgery. Anesthesiology 2006; 104:944-9. [PMID: 16645445 DOI: 10.1097/00000542-200605000-00009] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background
Supplemental perioperative oxygen increases tissue oxygen tension and decreases incidence of wound infection in colorectal surgery patients. Mild intraoperative hypercapnia also increases subcutaneous tissue oxygen tension. However, the effect of hypercapnia in patients already receiving supplemental oxygen is unknown, as is the effect of mild hypercapnia on intestinal oxygenation in humans-although the intestines are presumably the tissue of interest for colon surgeries. The authors tested the hypothesis that mild intraoperative hypercapnia increases both subcutaneous tissue and intramural intestinal oxygen tension in patients given supplemental oxygen.
Methods
Patients undergoing elective colon resection were randomly assigned to normocapnia (n = 15, end-tidal carbon dioxide tension 35 mmHg) or mild hypercapnia (n = 15, end-tidal carbon dioxide tension 50 mmHg). Intraoperative inspired oxygen concentration was 80%. The authors measured subcutaneous tissue oxygen tension in the right upper arm and intramural oxygen tension in the left colon. Measurements were averaged over time within each patient and, subsequently, among patients. Data were compared with chi-square, unpaired t, or Mann-Whitney rank sum tests; P < 0.05 was significant.
Results
Morphometric characteristics and other possible confounding factors were similar in the groups. Intraoperative tissue oxygen tension in hypercapnic patients was significantly greater in the arm (mean +/- SD: 116 +/- 29 mmHg vs. 84 +/- 25 mmHg; P = 0.006) and colon (median [interquartile range]: 107 [81-129] vs. 53 [41-104] mmHg; P = 0.020).
Conclusions
During supplemental oxygen administration, mild intraoperative hypercapnia increased tissue oxygen tension in the arm and colon. Previous work suggests that improved tissue oxygenation will reduce infection risk via the proposed pathomechanism, although only an outcome study can confirm this.
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Affiliation(s)
- Edith Fleischmann
- Department of Anesthesia and Intensive Care, Medical University Vienna, Austria
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Abstract
PURPOSE OF REVIEW During anesthesia and surgery oxygen is routinely administered to all patients. Inspired oxygen concentrations, however, vary between 30 and 100%, and oxygen is often administered in a seemingly random manner. During the last decade it has been shown in several randomized trials that perioperative supplemental oxygen administration might improve outcome after certain surgical procedures. The purpose of this review is to provide an overview about the benefits and risks of supplemental oxygen administration in the perioperative period. RECENT FINDINGS Supplemental oxygen improves immune function. Furthermore, 80% inspired oxygen fraction almost doubles subcutaneous tissue oxygen tension and halves the rate of postoperative wound infections. Some studies have shown that supplemental oxygen also decreases the rate of postoperative nausea and vomiting after laparoscopic and open abdominal surgical procedures. Preconditioning with oxygen might improve organ function after liver transplantation and outcome after spinal ischemic insults. Supplemental perioperative oxygen administration is not associated with clinically important side effects. SUMMARY Supplemental oxygen administration during the perioperative period might be a simple, inexpensive and well-tolerated treatment option to improve patient outcome. The optimal inspired oxygen concentration still needs to be evaluated.
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Affiliation(s)
- Barbara Kabon
- Department of Anesthesiology and General Intensive Care, Vienna General Hospital, University of Vienna, Austria
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Kabon B, Akça O, Taguchi A, Nagele A, Jebadurai R, Arkilic CF, Sharma N, Ahluwalia A, Galandiuk S, Fleshman J, Sessler DI, Kurz A. Supplemental intravenous crystalloid administration does not reduce the risk of surgical wound infection. Anesth Analg 2005; 101:1546-1553. [PMID: 16244030 PMCID: PMC1388094 DOI: 10.1213/01.ane.0000180217.57952.fe] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Wound perfusion and oxygenation are important determinants of the development of postoperative wound infections. Supplemental fluid administration significantly increases tissue oxygenation in surrogate wounds in the subcutaneous tissue of the upper arm in perioperative surgical patients. We tested the hypothesis that supplemental fluid administration during and after elective colon resections decreases the incidence of postoperative wound infections. Patients undergoing open colon resection were randomly assigned to small-volume (n = 124, 8 mL.kg(-1).h(-1)) or large-volume (n = 129, 16-18 mL.kg(-1).h(-1)) fluid management. Our major outcomes were two distinct criteria for diagnosis of surgical wound infections: 1) purulent exudate combined with a culture positive for pathogenic bacteria, and 2) Center for Disease Control criteria for diagnosis of surgical wound infections. All wound infections diagnosed using either criterion by a blinded observer in the 15 days after surgery were considered in the analysis. Wound healing was evaluated with the ASEPSIS scoring system. Of the patients given small fluid administration, 14 had surgical wound infections; 11 given large fluid therapy had infections, P = 0.46. ASEPSIS wound-healing scores were similar in both groups: 7 +/- 16 (small volume) versus 8 +/- 14 (large volume), P = 0.70. Our results suggest that supplemental hydration in the range tested does not impact wound infection rate.
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Affiliation(s)
- Barbara Kabon
- Research Fellow, Department of Anesthesiology, Washington University
- Attending Anesthesiologist, Department of Anesthesiology and General Intensive Care,Vienna General Hospital, University of Vienna
| | - Ozan Akça
- Assistant Professor, Department of Anesthesiology & Perioperative Medicine and Outcomes Research™ Institute, University of Louisville
| | - Akiko Taguchi
- Research Fellow, Department of Anesthesiology, Washington University
| | - Angelika Nagele
- Research Fellow, Department of Anesthesiology, Washington University
| | - Ratnaraj Jebadurai
- Attending Anesthesiologist, Department of Anesthesiology, Washington University
| | - Cem F. Arkilic
- Research Fellow, Department of Anesthesiology, Washington University
| | - Neeru Sharma
- Research Fellow, Department of Anesthesiology, Washington University
| | | | | | - James Fleshman
- Associate Professor and Director of the Division of Colon-Rectal Surgery, Department of Surgery, Washington University
| | - Daniel I. Sessler
- Vice Dean for Research and Associate Vice President for Health Affairs, Director Outcomes Research™ Institute, and Interim Chair and Lolita & Samuel Weakley Distinguished Professor of Anesthesiology, University of Louisville
| | - Andrea Kurz
- Professor and Chair, Department of Anesthesiology, University of Bern; Professor and Associate Director Outcomes Research™ Institute, University of Louisville
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Fleischmann E, Kurz A, Niedermayr M, Schebesta K, Kimberger O, Sessler DI, Kabon B, Prager G. Tissue oxygenation in obese and non-obese patients during laparoscopy. Obes Surg 2005; 15:813-9. [PMID: 15978153 PMCID: PMC1351376 DOI: 10.1381/0960892054222867] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Wound infection risk is inversely related to subcutaneous tissue oxygenation, which is reduced in obese patients and may be reduced even more during laparoscopic procedures. METHODS We evaluated subcutaneous tissue oxygenation (PsqO(2)) in 20 patients with a body mass index (BMI) > or=40 kg/m(2) (obese group) and 15 patients with BMI <30 kg/m(2) (non-obese group) undergoing laparoscopic surgery with standardized anaesthesia technique and fluid administration. Arterial oxygen tension was maintained near 150 mmHg. PsqO(2) was measured from a surrogate wound on the upper arm. RESULTS A mean FIO(2) of 51% (13%) was required in obese patients to reach an arterial oxygen tension of 150 mmHg; however, a mean FIO(2) of only 40% (7%) was required to reach the same oxygen tension in non-obese patients (P=0.007). PsqO(2) was significantly less in obese patients: 41 (10) vs 57 (15) mmHg (P<0.001). CONCLUSION Obese patients having laparoscopic surgery require a significantly greater FIO(2) to reach an arterial oxygen tension of about 150 mmHg than non-obese patients; they also have significantly lower subcutaneous oxygen tensions. Both factors probably contribute to an increased infection risk in obese patients.
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Affiliation(s)
- Edith Fleischmann
- Department of Anesthesia and Intensive Care, Medical University Vienna, Austria
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Abstract
Oxidative killing by neutrophils, a primary defense against surgical pathogens, is directly related to tissue oxygenation. We tested the hypothesis that supplemental inspired oxygen or mild hypercapnia (end-tidal PCO2 of 50 mm Hg) improves intestinal oxygenation. Pigs (25 +/- 2.5 kg) were used in 2 studies in random order: 1) Oxygen Study: 30% versus 100% inspired oxygen concentration at an end-tidal PCO2 of 40 mm Hg, and 2) Carbon Dioxide Study: end-tidal PCO2 of 30 mm Hg versus 50 mm Hg with 30% oxygen. Within each study, treatment order was randomized. Treatments were maintained for 1.5 h; measurements were averaged over the final hour. A tonometer inserted in the subcutaneous tissue of the left upper foreleg measured subcutaneous oxygen tension. Tonometers inserted into the intestinal wall measured intestinal intramural oxygen tension from the small and large intestines. Oxygen 100% administration doubled subcutaneous oxygen partial pressure (PO2) (57 +/- 10 to 107 +/- 48 mm Hg, P = 0.006) and large intestine intramural PO2 (53 +/- 14 to 118 +/- 72 mm Hg, P = 0.014); intramural PO2 increased 40% in the small intestine (37 +/- 10 to 52 +/- 25 mm Hg, P = 0.004). An end-tidal PCO2 of 50 mm Hg increased large intestinal PO2 approximately 16% (49 +/- 10 to 57 +/- 12 mm Hg, P = 0.039), whereas intramural PO2 increased by 45% in the small intestine (31 +/- 12 to 44 +/- 16 mm Hg, P = 0.002). Supplemental oxygen and mild hypercapnia each increased subcutaneous and intramural tissue PO2, with supplemental oxygen being most effective.
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Affiliation(s)
- Jebadurai Ratnaraj
- Departments of *Anesthesiology and †Veterinary Surgical Services, Washington University, St. Louis, MO; the ‡Outcomes Research Institute and Departments of Anesthesiology and Pharmacology, University of Louisville, Louisville, KY; and §the Department of Anesthesiology, University of Bern, Switzerland and the Department of Anesthesiology and Intensive Care Medicine, University of Vienna, Vienna, Austria
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Taguchi A, Ratnaraj J, Kabon B, Sharma N, Lenhardt R, Sessler DI, Kurz A. Effects of a Circulating-water Garment and Forced-air Warming on Body Heat Content and Core Temperature. Anesthesiology 2004; 100:1058-64. [PMID: 15114200 PMCID: PMC1409744 DOI: 10.1097/00000542-200405000-00005] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background
Forced-air warming is sometimes unable to maintain perioperative normothermia. Therefore, the authors compared heat transfer, regional heat distribution, and core rewarming of forced-air warming with a novel circulating-water garment.
Methods
Nine volunteers were each evaluated on two randomly ordered study days. They were anesthetized and cooled to a core temperature near 34 degrees C. The volunteers were subsequently warmed for 2.5 h with either a circulating-water garment or a forced-air cover. Overall, heat balance was determined from the difference between cutaneous heat loss (thermal flux transducers) and metabolic heat production (oxygen consumption). Average arm and leg (peripheral) tissue temperatures were determined from 18 intramuscular needle thermocouples, 15 skin thermal flux transducers, and "deep" hand and foot thermometers.
Results
Heat production (approximately 60 kcal/h) and loss (approximately 45 kcal/h) were similar with each treatment before warming. The increases in heat transfer across anterior portions of the skin surface were similar with each warming system (approximately 65 kcal/h). Forced-air warming had no effect on posterior heat transfer, whereas circulating-water transferred 21+/-9 kcal/h through the posterior skin surface after a half hour of warming. Over 2.5 h, circulating water thus increased body heat content 56% more than forced air. Core temperatures thus increased faster than with circulating water than forced air, especially during the first hour, with the result that core temperature was 1.1 degrees +/- 0.7 degrees C greater after 2.5 h (P < 0.001). Peripheral tissue heat content increased twice as much as core heat content with each device, but the core-to-peripheral tissue temperature gradient remained positive throughout the study.
Conclusions
The circulating-water system transferred more heat than forced air, with the difference resulting largely from posterior heating. Circulating water rewarmed patients 0.4 degrees C/h faster than forced air. A substantial peripheral-to-core tissue temperature gradient with each device indicated that peripheral tissues insulated the core, thus slowing heat transfer.
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Affiliation(s)
- Akiko Taguchi
- Department of Anesthesiology, Washington University, St. Louis, Missouri, USA
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Abstract
BACKGROUND Obesity is an important risk factor for surgical site infections. The incidence of surgical wound infections is directly related to tissue perfusion and oxygenation. Fat tissue mass expands without a concomitant increase in blood flow per cell, which might result in a relative hypoperfusion with decreased tissue oxygenation. Consequently, the authors tested the hypotheses that perioperative tissue oxygen tension is reduced in obese surgical patients. Furthermore, they compared the effect of supplemental oxygen administration on tissue oxygenation in obese and nonobese patients. METHODS Forty-six patients undergoing major abdominal surgery were assigned to one of two groups according to their body mass index: body mass index less than 30 kg/m2 (nonobese) or 30 kg/m2 or greater (obese). Intraoperative oxygen administration was adjusted to arterial oxygen tensions of approximately 150 mmHg and approximately 300 mmHg in random order. Anesthesia technique and perioperative fluid management were standardized. Subcutaneous tissue oxygen tension was measured with a polarographic electrode positioned within a subcutaneous tonometer in the lateral upper arm during surgery, in the recovery room, and on the first postoperative day. Postoperative tissue oxygen was also measured adjacent to the wound. Data were compared with unpaired two-tailed t tests and Wilcoxon rank sum test; P < 0.05 was considered statistically significant. RESULTS Intraoperative subcutaneous tissue oxygen tension was significantly less in the obese patients at baseline (36 vs. 57 mmHg; P = 0.002) and with supplemental oxygen administration (47 vs. 76 mmHg; P = 0.014). Immediate postoperative tissue oxygen tension was also significantly less in subcutaneous tissue of the upper arm (43 vs. 54 mmHg; P = 0.011) as well as near the incision (42 vs. 62 mmHg; P = 0.012) in obese patients. In contrast, tissue oxygen tension was comparable in each group on the first postoperative morning. CONCLUSION Wound and tissue hypoxia were common in obese patients in the perioperative period and most pronounced during surgery. Even with supplemental oxygen tissue, oxygen tension in obese patients was reduced to levels that are associated with a substantial increase in infection risk.
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Affiliation(s)
- Barbara Kabon
- Research Fellow, Department of Anesthesiology, Washington University; Resident, Department of Anesthesiology and General Intensive Care, Vienna General Hospital, University of Vienna
| | - Angelika Nagele
- Research Assistant, Department of Anesthesiology, Washington University
| | - Dayakar Reddy
- Research Assistant, Department of Anesthesiology, Washington University
| | - Chris Eagon
- Assistant Professor, Department of Surgery, Washington University
| | - James W. Fleshman
- Associate Professor and Director of the Division of Colon-Rectal Surgery, Department of Surgery, Washington University
| | - Daniel I. Sessler
- Associate Dean for Research, Director Outcomes Research™ Institute, Lolita & Samuel Weakley Distinguished University Research Chair, and Professor of Anesthesiology and Pharmacology, University of Louisville
| | - Andrea Kurz
- Professor and Chair, Department of Anesthesiology, University of Bern; Associate Professor, Department of Anesthesiology, Washington University; Professor and Associate Director, Outcomes Research™ Institute, University of Louisville
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Abstract
UNLABELLED Intraoperative surgical stress may markedly increase adrenergic nerve activity and plasma catecholamine concentrations, which causes peripheral vasoconstriction and decreased tissue oxygen partial pressure possibly leading to tissue hypoxia. Tissue hypoxia is associated with an increased incidence of surgical wound infections. Thoracic epidural anesthesia blocks afferent neural stimuli and inhibits efferent sympathetic outflow in response to painful stimuli. Consequently, we tested the hypothesis that supplemental thoracic epidural anesthesia during major abdominal surgery improves tissue perfusion and subcutaneous oxygen tension. Thirty patients were randomly assigned to two groups: general (n = 15) or combined general and epidural anesthesia (n = 15). Anesthesia technique and fluid management were standardized. Subcutaneous tissue oxygen tension was measured continuously in the upper arm with a Clark type electrode. Data were compared with unpaired, two-tailed t-tests, Wilcoxon's ranked sum test, or repeated-measures analysis of variance and Scheffé F tests as appropriate; P < 0.05 was considered statistically significant. After 60 min, intraoperative tissue oxygen tension was significantly larger during combined anesthesia than during general anesthesia (54.3 +/- 7.4 mm Hg versus 42.1 +/- 8.6 mm Hg; P = 0.0002). Subcutaneous tissue oxygen tension remained significantly higher in the combined general/epidural anesthesia group throughout the observation period. Hemodynamic responses and global oxygen variables were similar in the groups. Thoracic epidural anesthesia improved intraoperative tissue oxygen tension outside the area of the epidural block. Thus, our results give evidence that supplemental neural nociceptive block blunts generalized vasoconstriction caused by surgical stress and adrenergic responses. IMPLICATIONS Thoracic epidural anesthesia blunts the decrease of subcutaneous tissue oxygen tension caused by surgical stress and adrenergic vasoconstriction during major abdominal surgery. Consequently, combined general and epidural anesthesia helps to provide sufficient tissue oxygenation.
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Affiliation(s)
- Barbara Kabon
- *Department of Anesthesiology, Washington University, St. Louis, Missouri, †Department of Anesthesiology and General Intensive Care and ‡Anesthesiology and Intensive Care Medicine, Vienna General Hospital, University of Vienna, Austria; §Department of Anesthesiology, University of Berne, Switzerland; and ∥Outcomes Research Institute™, University of Louisville, Kentucky
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