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Abstract
BACKGROUND Anesthesiologists are experiencing unprecedented levels of workplace stress and staffing shortages. This analysis aims to assess how U.S. attending anesthesiologist burnout changed since the onset of the COVID-19 pandemic and target well-being efforts. METHODS The authors surveyed the American Society of Anesthesiologists' U.S. attending anesthesiologist members in November 2022. Burnout was assessed using the Maslach Burnout Inventory Human Services Survey with additional questions relating to workplace and demographic factors. Burnout was categorized as high risk for burnout (exhibiting emotional exhaustion and/or depersonalization) or burnout syndrome (demonstrating all three burnout dimensions concurrently). The association of burnout with U.S. attending anesthesiologist retention plans was analyzed, and associated factors were identified. RESULTS Of 24,680 individuals contacted, 2,698 (10.9%) completed the survey, with 67.7% (1,827 of 2,698) at high risk for burnout and 18.9% (510 of 2,698) with burnout syndrome. Most (78.4%, n = 2,115) respondents have experienced recent staffing shortages, and many (36.0%, n = 970) were likely to leave their job within the next 2 yr. Those likely to leave their job in the next 2 yr had higher prevalence of high risk for burnout (78.5% [760 of 970] vs. 55.7% [651 of 1,169], P < 0.001) and burnout syndrome (24.3% [236 of 970] vs. 13.3% [156 of 1,169], P < 0.001) compared to those unlikely to leave. On multivariable analysis, perceived lack of support at work (odds ratio, 9.2; 95% CI, 7.0 to 12.1), and staffing shortages (odds ratio, 1.96; 95% CI, 1.57 to 2.43) were most strongly associated with high risk for burnout. Perceived lack of support at work (odds ratio, 6.3; 95% CI, 3.81 to 10.4) was the factor most strongly associated with burnout syndrome. CONCLUSIONS Burnout is more prevalent in anesthesiology since early 2020, with workplace factors of perceived support and staffing being the predominant associated variables. Interventions focused on the drivers of burnout are needed to improve well-being among U.S. attending anesthesiologists. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Anoushka M. Afonso
- Department of Anesthesiology & Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua B. Cadwell
- Department of Anesthesiology & Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Steven J. Staffa
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Jina L. Sinskey
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA
| | - Amy E. Vinson
- Department of Anesthesiology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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Chen O, Cadwell JB, Matsoukas K, Hagen J, Afonso AM. Perioperative gabapentin usage in pediatric patients: A scoping review. Paediatr Anaesth 2023; 33:598-608. [PMID: 37073498 PMCID: PMC10464522 DOI: 10.1111/pan.14674] [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: 07/18/2022] [Revised: 03/08/2023] [Accepted: 04/01/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population. DATA SOURCES Pubmed, CINAHL, Embase, Scopus, and Web of Science Review. METHODS This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results. RESULTS Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance. CONCLUSIONS The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.
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Affiliation(s)
- Olivia Chen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Joshua B. Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Konstantina Matsoukas
- Medical Library, Information Systems, Memorial Sloan Kettering Cancer Center, New York, NY
| | - John Hagen
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
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3
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Chakravarthy VB, Laufer I, Amin AG, Cohen MA, Reiner AS, Vuong C, Persaud PS, Ruppert LM, Puttanniah VG, Afonso AM, Tsui VS, Brallier JW, Malhotra VT, Bilsky MH, Barzilai O. Patient outcomes following implementation of an enhanced recovery after surgery pathway for patients with metastatic spine tumors. Cancer 2022; 128:4109-4118. [PMID: 36219485 PMCID: PMC10859187 DOI: 10.1002/cncr.34484] [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] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Metastatic spine tumor surgery consists of palliative operations performed on frail patients with multiple medical comorbidities. Enhanced recovery after surgery (ERAS) programs involve an evidence-based, multidisciplinary approach to improve perioperative outcomes. This study presents clinical outcomes of a metastatic spine tumor ERAS pathway implemented at a tertiary cancer center. METHODS The metastatic spine tumor ERAS program launched in April 2019, and data from January 2018 to May 2020 were reviewed. Measured outcomes included the following: hospital length of stay (LOS), time to ambulation, urinary catheter duration, time to resumption of diet, intraoperative fluid intake, estimated blood loss (EBL), and intraoperative and postoperative day 0-5 cumulative opioid use (morphine milligram equivalent [MME]). RESULTS A total of 390 patients were included in the final analysis: 177 consecutive patients undergoing metastatic spine tumor surgery enrolled in the ERAS program and 213 consecutive pre-ERAS patients. Although the mean case durations were similar in the ERAS and pre-ERAS cohorts (265 vs. 274 min; p = .22), the ERAS cohort had decreased EBL (157 vs. 215 ml; p = .003), decreased postoperative day 0-5 cumulative mean opioid use (178 vs. 396 MME; p < .0001), earlier ambulation (mean, 34 vs. 57 h; p = .0001), earlier discontinuation of urinary catheters (mean, 36 vs. 56 h; p < .001), and shorter LOS (5.4 vs. 7.5 days; p < .0001). CONCLUSIONS The implementation of a multidisciplinary ERAS program designed for metastatic spine tumor surgery led to improved clinical quality metrics, including shorter hospitalizations and significant reductions in opioid consumption.
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Affiliation(s)
- Vikram B. Chakravarthy
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ilya Laufer
- Neurological Surgery, New York University Medical Center, New York, New York, USA
| | - Anubhav G. Amin
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Marc A. Cohen
- Surgery (Head and Neck), Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anne S. Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Cindy Vuong
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Petal‐Ann S. Persaud
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lisa M. Ruppert
- Rehabilitation Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay G. Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Van S. Tsui
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Jess W. Brallier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vivek T. Malhotra
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Mark H. Bilsky
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ori Barzilai
- Department of Neurological Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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De Camilli AR, Cadwell JB, Weiss H, Tollinche LE, McFarlane D, Broach V, Leitao MM, Kitzler R, Afonso AM. Perioperative considerations for cancer patients with obesity: A narrative review. Trends Anaesth Crit Care 2022; 46:33-41. [PMID: 38741664 PMCID: PMC11090210 DOI: 10.1016/j.tacc.2022.09.003] [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] [Indexed: 12/01/2022]
Abstract
Cancer in patients with obesity has become increasingly common throughout much of the world. Based on our experiences in a specialized cancer center, we have developed a set of standards and expectations that should streamline the surgical journey for this patient population. These recommendations should inform the perioperative management of oncology patients with obesity and help raise awareness of this critical and under-discussed topic.
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Affiliation(s)
- Alessandro R. De Camilli
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Joshua B. Cadwell
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hallie Weiss
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Luis E. Tollinche
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
| | - Dianne McFarlane
- Perioperative Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vance Broach
- Weill Cornell Medicine, New York, NY, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mario M. Leitao
- Weill Cornell Medicine, New York, NY, USA
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Robina Kitzler
- Clinical Nursing, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medicine, New York, NY, USA
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Afonso AM, Tokita HK, Simon B. In Response. Anesth Analg 2022; 135:e2-e3. [PMID: 35709454 DOI: 10.1213/ane.0000000000005958] [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: 11/05/2022]
Affiliation(s)
- Anoushka M Afonso
- Department of Anesthesiology and Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, New York,
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Reece-Nguyen T, Afonso AM, Vinson AE. Burnout, Mental Health, and Workplace Discrimination in Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex, and Asexual Anesthesiologists. Anesthesiol Clin 2022; 40:245-255. [PMID: 35659398 DOI: 10.1016/j.anclin.2022.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 06/15/2023]
Abstract
Increasing attention is being paid to both anesthesiologist well-being and commitments to diversity, equity, and inclusion. Sexual minorities (ie, members of the lesbian, gay, bisexual, transgender, queer/questioning, intersex, and asexual [LGBTQIA] communities) face many challenges in society and the workplace, including mental health conditions, discrimination, and increased risk for burnout. In this review, we outline the current state of mental health conditions and burnout in sexual minority individuals, discrimination and harassment faced both in society and the workplace, and steps that workplaces can take to become more inclusive and welcoming.
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Affiliation(s)
- Travis Reece-Nguyen
- Department of Anesthesiology, Perioperative, and Pain Medicine, Division of Pediatric Anesthesiology, Stanford Medicine, 453 Quarry Road, MC: 5663, Stanford, CA 94305, USA
| | - Anoushka M Afonso
- Department of Anesthesiology & Critical Care, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, C-336, New York, NY 10065, USA
| | - Amy E Vinson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, 300 Longwood Avenue, Bader 3, Boston, MA 02115, USA.
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Majumdar JR, Assel MJ, Lang SA, Vickers AJ, Afonso AM. Implementation of an Enhanced Recovery Protocol in Patients Undergoing Mastectomies for Breast Cancer: an interrupted time-series design. Asia Pac J Oncol Nurs 2022; 9:100047. [PMID: 35647224 PMCID: PMC9133751 DOI: 10.1016/j.apjon.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Jennifer R. Majumdar
- Departments of Anesthesiology and Critical Care Medicine, New York, NY, USA
- Corresponding author.
| | | | - Stephanie A. Lang
- Breast Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Anoushka M. Afonso
- Departments of Anesthesiology and Critical Care Medicine, New York, NY, USA
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Oskar S, Nelson JA, Hicks ME, Seier KP, Tan KS, Chu JJ, West S, Allen RJ, Barrio AV, Matros E, Afonso AM. The Impact of Race on Perioperative and Patient-Reported Outcomes following Autologous Breast Reconstruction. Plast Reconstr Surg 2022; 149:15-27. [PMID: 34936598 PMCID: PMC9099419 DOI: 10.1097/prs.0000000000008633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/03/2023]
Abstract
BACKGROUND Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining whether such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction. METHODS A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into three groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes. RESULTS Overall, 404 patients, including 259 white (64 percent), 63 African American (16 percent), and 82 patients from other minority groups (20 percent), were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively. CONCLUSIONS African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical well-being outcomes may not differ between groups. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Sabine Oskar
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jonas A. Nelson
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Madeleine E.V. Hicks
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kenneth P. Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jacqueline J. Chu
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Scott West
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Robert J. Allen
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Andrea V. Barrio
- Breast Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Evan Matros
- Plastic and Reconstructive Surgical Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M. Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY
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Afonso AM, McCormick PJ, Assel MJ, Rieth E, Barnett K, Tokita HK, Masson G, Laudone V, Simon BA, Twersky RS. Enhanced Recovery Programs in an Ambulatory Surgical Oncology Center. Anesth Analg 2021; 133:1391-1401. [PMID: 34784326 PMCID: PMC8568332 DOI: 10.1213/ane.0000000000005356] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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] [Accepted: 11/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND We describe the implementation of enhanced recovery after surgery (ERAS) programs designed to minimize postoperative nausea and vomiting (PONV) and pain and reduce opioid use in patients undergoing selected procedures at an ambulatory cancer surgery center. Key components of the ERAS included preoperative patient education regarding the postoperative course, liberal preoperative hydration, standardized PONV prophylaxis, appropriate intraoperative fluid management, and multimodal analgesia at all stages. METHODS We retrospectively reviewed data on patients who underwent mastectomy with or without immediate reconstruction, minimally invasive hysterectomy, thyroidectomy, or minimally invasive prostatectomy from the opening of our institution on January 2016 to December 2018. Data collected included use of total intravenous anesthesia (TIVA), rate of PONV rescue, time to first oral opioid, and total intraoperative and postoperative opioid consumption. Compliance with ERAS elements was determined for each service. Quality outcomes included time to first ambulation, postoperative length of stay (LOS), rate of reoperation, rate of transfer to acute care hospital, 30-day readmission, and urgent care visits ≤30 days. RESULTS We analyzed 6781 ambulatory surgery cases (2965 mastectomies, 1099 hysterectomies, 680 thyroidectomies, and 1976 prostatectomies). PONV rescue decreased most appreciably for mastectomy (28% decrease; 95% confidence interval [CI], -36 to -22). TIVA use increased for both mastectomies (28%; 95% CI, 20-40) and hysterectomies (58%; 95% CI, 46-76). Total intraoperative opioid administration decreased over time across all procedures. Time to first oral opioid decreased for all surgeries; decreases ranged from 0.96 hours (95% CI, 2.1-1.4) for thyroidectomies to 3.3 hours (95% CI, 4.5 to -1.7) for hysterectomies. Total postoperative opioid consumption did not change by a clinically meaningful degree for any surgery. Compliance with ERAS measures was generally high but varied among surgeries. CONCLUSIONS This quality improvement study demonstrates the feasibility of implementing ERAS at an ambulatory surgery center. However, the study did not include either a concurrent or preintervention control so that further studies are needed to assess whether there is an association between implementation of ERAS components and improvements in outcomes. Nevertheless, we provide benchmarking data on postoperative outcomes during the first 3 years of ERAS implementation. Our findings reflect progressive improvement achieved through continuous feedback and education of staff.
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Affiliation(s)
- Anoushka M. Afonso
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Patrick J. McCormick
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | | | - Elizabeth Rieth
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Kara Barnett
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Hanae K. Tokita
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Geema Masson
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Vincent Laudone
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Urology, Weill Cornell Medical College, New York, New York
| | - Brett A. Simon
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - Rebecca S. Twersky
- From the Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
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Lopez-Betancourt R, Afonso AM. Carbohydrate loading and fluid management within enhanced recovery. Seminars in Colon and Rectal Surgery 2021. [DOI: 10.1016/j.scrs.2021.100828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Afonso AM, Sastow D, Cadwell JB, Downey RJ, Fischer GW, Shahrokni A. Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer. J Perioper Pract 2021; 32:301-309. [PMID: 34134558 DOI: 10.1177/17504589211012351] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored. METHODS Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission. RESULTS Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission. CONCLUSION Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.
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Affiliation(s)
- Anoushka M Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Dahniel Sastow
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Joshua B Cadwell
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Robert J Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
| | - Armin Shahrokni
- Geriatrics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, USA
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Zammarrelli WA, Afonso AM, Broach V, Sonoda Y, Zivanovic O, Mueller JJ, Leitao MM, Chan A, Abu-Rustum NR. Sentinel lymph node biopsy in patients with endometrial cancer and an indocyanine green or iodinated contrast reaction - A proposed management algorithm. Gynecol Oncol 2021; 162:262-267. [PMID: 33992449 DOI: 10.1016/j.ygyno.2021.05.009] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 05/09/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe the incidence of adverse reactions to indocyanine green (ICG) administered during sentinel lymph node (SLN) biopsy for endometrial cancer, and to propose an ICG management algorithm for these patients. METHODS All patients who underwent surgery for endometrial cancer with SLN biopsy using ICG from 1/2017 to 8/2020 were identified using a single-institution prospective database. Surgical adverse events (SAEs) related to the procedure were identified. A review of the literature was performed. RESULTS In all, 1414 patients met inclusion criteria and were evaluated. Sixty-seven (4.7%) patients had a history of either an iodine or contrast allergy. No patients had a history of documented ICG allergy. Among patients with an iodine or contrast allergy, 65 (97%) received a corticosteroid with or without diphenhydramine prior to ICG administration. One hundred five patients (7.4%) experienced 116 SAEs. Among these patients, 3 experienced potentially allergic SAEs possibly related to ICG administration. After thorough chart review, however, the likelihood these SAEs were due to ICG appeared low. No patients experienced an anaphylactic response after ICG admission. CONCLUSION There were no anaphylactic reactions to ICG intracervical administration during 1414 consecutive SLN biopsies, including in patients with a documented iodine or contrast allergy. Intracervical injection of ICG is safe, and premedication using corticosteroids with or without diphenhydramine prior to SLN biopsy is a reasonable strategy in patients with iodinated contrast allergy.
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Affiliation(s)
- William A Zammarrelli
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Anoushka M Afonso
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Vance Broach
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Yukio Sonoda
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Oliver Zivanovic
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Jennifer J Mueller
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Mario M Leitao
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA
| | - Amelia Chan
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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13
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Polanco TO, Shamsunder MG, Hicks MEV, Seier KP, Tan KS, Oskar S, Dayan JH, Disa JJ, Mehrara BJ, Allen RJ, Nelson JA, Afonso AM. Goal-directed fluid therapy in autologous breast reconstruction results in less fluid and more vasopressor administration without outcome compromise. J Plast Reconstr Aesthet Surg 2021; 74:2227-2236. [PMID: 33745850 DOI: 10.1016/j.bjps.2021.01.017] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 12/03/2020] [Accepted: 01/24/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Aggressive or restricted perioperative fluid management has been shown to increase complications in patients undergoing microsurgery. Goal-directed fluid therapy (GDFT) aims to administer fluid, vasoactive agents, and inotropes according to each patient's hemodynamic indices. This study assesses GDFT impact on perioperative outcomes of autologous breast reconstruction (ABR) patients, as there remains a gap in management understanding. We hypothesize that GDFT will have lower fluid administration and equivocal outcomes compared to patients not on GDFT. METHODS A single-center retrospective review was conducted on ABR patients from January 2010-April 2017. An enhanced recovery after surgery (ERAS) using GDFT was implemented in April 2015. With GDFT, patients were administered intraoperative fluids and vasoactive agents according to hemodynamic indices. Patients prior to April 2015 were included in the pre-ERAS cohort. Primary outcomes included the amount and rate of fluid delivery, urine output (UOP), vasopressor administration, major (i.e., flap failure) and minor (i.e., seroma) complications, and length of stay (LOS). RESULTS Overall, 777 patients underwent ABR (ERAS: 312 and pre-ERAS: 465). ERAS patients received significantly less total fluid volume (ERAS median: 3750 mL [IQR: 3000-4500 mL]; pre-ERAS median: 5000 mL [IQR 4000-6400 mL]; and p<0.001), had lower UOP, were more likely to receive vasopressor agents (47% vs 35% and p<0.001), and had lower LOS (ERAS: 4 days [4-5]; pre-ERAS: 5 [4-6]; and p<0.001) as compared to pre-ERAS patients. Complications did not differ between cohorts. CONCLUSIONS GDFT, as part of ERAS, and the prudent use of vasopressors were found to be safe and did not increase morbidity in ABR patients. GDFT provides individualized perioperative care to the ABR patient.
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Affiliation(s)
- Thais O Polanco
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Meghana G Shamsunder
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Madeleine E V Hicks
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kenneth P Seier
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kay See Tan
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Sabine Oskar
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph H Dayan
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Joseph J Disa
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Babak J Mehrara
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Robert J Allen
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States
| | - Jonas A Nelson
- Department of Surgery, Plastic and Reconstructive Surgery Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, Mailbox 24, New York, NY 10065, United States.
| | - Anoushka M Afonso
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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14
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Boerner T, Tanner E, Filippova O, Zhou QC, Iasonos A, Tew WP, O'Cearbhaill RE, Grisham RN, Gardner GJ, Sonoda Y, Abu-Rustum NR, Zivanovic O, Long Roche K, Afonso AM, Fischer M, Chi DS. Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecol Oncol 2021; 160:51-55. [PMID: 33213899 PMCID: PMC8378264 DOI: 10.1016/j.ygyno.2020.10.042] [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] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 10/31/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. METHODS We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012-04/2017). Standard statistical tests were used. RESULTS There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618-1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317-1.092); p = 0.093]. CONCLUSIONS ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.
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Affiliation(s)
- Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Edward Tanner
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Olga Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - William P Tew
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Roisin E O'Cearbhaill
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA
| | - Anoushka M Afonso
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary Fischer
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA; Department of Anesthesia, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Joan & Sanford I. Weill Medical College of Cornell University, New York, NY, USA.
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15
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Chai CM, Seier K, Tan KS, Chu I, Isbell JM, Fischer GW, Afonso AM. Pericardial Effusions in Patients With Cancer: Anesthetic Management and Survival Outcomes. J Cardiothorac Vasc Anesth 2020; 35:571-577. [PMID: 32967792 DOI: 10.1053/j.jvca.2020.08.049] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/20/2020] [Accepted: 08/21/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to describe practice patterns of anesthetic management during pericardial window creation. DESIGN Retrospective observational cohort study. SETTING Single tertiary cancer center. PARTICIPANTS A total of 150 patients treated for cancer between 2011 and 2015 were included in the study. MEASUREMENTS AND MAIN RESULTS The primary objective was to evaluate anesthetic management in pericardial window creation. Secondary outcomes were 30-day mortality and overall survival after pericardial window creation. Thirty-day mortality was 19.3%, and median survival was 5.84 months. Higher American Society of Anesthesiologists (ASA) physical status of patients was associated with preinduction arterial line placement (51% ASA 3 v 79% ASA 4; p = 0.002) and use of etomidate for anesthetic induction (34% ASA 3 v 60% ASA 4; p = 0.003). However, there was no association between anesthetic management and presence of tamponade in these patients. Cardiac aspirate volume (per 10 mL: odds ratio [OR], 1.02 [95% CI, 1.0-1.04]; p = 0.026) and intraoperative arrhythmia (atrial fibrillation: OR, 6.76 [95% CI, 1.2-37.49]; p = 0.029; sinus tachycardia: OR, 4.59 [95% CI, 1.25-16.90]; p = 0.022) were associated independently with increased 30-day mortality. High initial heart rate (per 10 beats per minute: hazard ratio [HR], 1.18 [95% CI, 1.05-1.33]; p = 0.005) in the operating room and intraoperative sinus tachycardia (HR, 1.86 [95% CI, 1.15-3.03]; p = 0.012) were associated independently with worse overall survival. CONCLUSION Risk of death after pericardial window creation remains high in patients with cancer. Variations in anesthetic management did not affect survival in oncologic patients with pericardial effusions.
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Affiliation(s)
- Casey M Chai
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - Kenneth Seier
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Iris Chu
- Department of Anesthesiology, New York Presbyterian Hospital-Weill Cornell Medicine, New York, NY
| | - James M Isbell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Gregory W Fischer
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Anoushka M Afonso
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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16
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Wu JX, Assel M, Vickers A, Afonso AM, Twersky RS, Simon BA, Cohen MA, Rieth EF, Cracchiolo JR. Impact of intraoperative remifentanil on postoperative pain and opioid use in thyroid surgery. J Surg Oncol 2019; 120:1456-1461. [PMID: 31680250 DOI: 10.1002/jso.25746] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 10/01/2019] [Accepted: 10/12/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Remifentanil infusion is used as an intraoperative anesthetic for thyroidectomy, but has been associated with acute opioid tolerance and hyperalgesia. A national shortage of remifentanil provided an opportunity to study postoperative pain in patients undergoing thyroidectomy. METHODS Retrospective review of prospectively collected data from an outpatient surgery center. Primary analysis compared patients treated before and after remifentanil shortage. RESULTS Median postoperative opioid consumption was 20 morphine milligram equivalents (MMEs) among those treated in the high-dose period and 15 MMEs in the low-dose period. Remifentanil/weight received was a significant predictor of requiring a postoperative narcotic (P = .006). Total non-remifentanil narcotics administered were equivalent but patients in the low dose period received higher amounts of intraoperative long-acting narcotics. CONCLUSIONS Remifentanil infusion for thyroid surgery is associated with higher postoperative pain and postoperative narcotics requirement. While a hyperalgesia state is possible, shifting of longer-acting narcotics from intraoperative to postoperatively is also supported.
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Affiliation(s)
- James X Wu
- Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa Assel
- Department of Epidemiology & Statistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Andrew Vickers
- Department of Epidemiology & Statistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anoushka M Afonso
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Rebecca S Twersky
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Brett A Simon
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc A Cohen
- Head and Neck Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elizabeth F Rieth
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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17
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Abstract
Although enhanced recovery pathways were initially implemented in inpatients, their principles are relevant in the ambulatory setting. Opioid minimization and addressing pain and nausea through multimodal analgesia, regional anesthesia, and robust preoperative education programs are integral to the success of ambulatory enhanced recovery programs. Rather than measurements of length of stay as in traditional inpatient programs, the focus of enhanced recovery programs in ambulatory surgery should be on improved quality of recovery, pain management, and early ambulation.
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Affiliation(s)
- Anoushka M Afonso
- Enhanced Recovery Programs (ERP), Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, M-301, New York, NY 10065, USA.
| | - Hanae K Tokita
- Department of Anesthesiology & Critical Care, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Patrick J McCormick
- Department of Anesthesiology & Critical Care Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Rebecca S Twersky
- Department of Anesthesiology & Critical Care Medicine, Josie Robertson Surgery Center, Memorial Sloan Kettering Cancer Center, 1133 York Avenue, Suite 312, New York, NY 10065, USA
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18
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Tseng JH, Cowan RA, Afonso AM, Zhou Q, Iasonos A, Ali N, Thompson E, Sonoda Y, O'Cearbhaill RE, Chi DS, Abu-Rustum NR, Long Roche K. Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer. Gynecol Oncol 2018; 151:287-293. [PMID: 30185381 DOI: 10.1016/j.ygyno.2018.08.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 08/16/2018] [Accepted: 08/19/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Epidurals are associated with improved outcomes in some solid tumors, presumably due to their effect on surgical stress response. There are limited data on the prognostic significance of epidural anesthesia in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer. We sought to assess the impact of epidural anesthesia on the survival outcomes of patients undergoing PDS for advanced ovarian cancer. METHODS In this retrospective study, consecutive patients with stage IIIB-IV epithelial ovarian, fallopian tube, or peritoneal carcinoma who underwent PDS at our institution from 01/2005-12/2013 were identified. Progression-free survival (PFS) and overall survival (OS) with regard to epidural use were analyzed. RESULTS Of 648 patients, 435 received an epidural and 213 did not. Patients in the former group were more likely to have higher stage disease (stage IV disease, 26% vs. 16%, respectively; P = .005), carcinomatosis (87% vs. 80%, respectively; P = .027), and bulky upper abdominal disease (66% vs. 58%, respectively; P = .046). Complete gross resection was achieved in 48% and 32%, respectively (P < .001). For the epidural vs. non-epidural groups, median PFS was 20.8 months and 13.9 months, respectively (P = .021); median OS was 62.4 months and 41.9 months, respectively (P < .001). After controlling for confounding factors, including residual disease, epidural use was independently associated with a decreased risk of progression (HR = 1.327; 95% CI, 1.066-1.653) and death (HR = 1.588; 95% CI, 1.224-2.06). CONCLUSIONS Perioperative epidural use was independently associated with improved PFS and OS in these patients. Epidural anesthesia at the time of PDS may be warranted in this setting.
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Affiliation(s)
- Jill H Tseng
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Renee A Cowan
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Anoushka M Afonso
- Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, NY, United States of America
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Narisha Ali
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Errika Thompson
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Roisin E O'Cearbhaill
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America.
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19
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Afonso AM, Newman MI, Seeley N, Hutchins J, Smith KL, Mena G, Selber JC, Saint-Cyr MH, Gadsden JC. Multimodal Analgesia in Breast Surgical Procedures: Technical and Pharmacological Considerations for Liposomal Bupivacaine Use. Plast Reconstr Surg Glob Open 2017; 5:e1480. [PMID: 29062649 PMCID: PMC5640354 DOI: 10.1097/gox.0000000000001480] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [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: 12/05/2016] [Accepted: 07/12/2017] [Indexed: 02/05/2023]
Abstract
Enhanced recovery after surgery is a multidisciplinary perioperative clinical pathway that uses evidence-based interventions to improve the patient experience as well as increase satisfaction, reduce costs, mitigate the surgical stress response, accelerate functional recovery, and decrease perioperative complications. One of the most important elements of enhanced recovery pathways is multimodal pain management. Herein, aspects relating to multimodal analgesia following breast surgical procedures are discussed with the understanding that treatment decisions should be individualized and guided by sound clinical judgment. A review of liposomal bupivacaine, a prolonged-release formulation of bupivacaine, in the management of postoperative pain following breast surgical procedures is presented, and technical guidance regarding optimal administration of liposomal bupivacaine is provided.
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Affiliation(s)
- Anoushka M. Afonso
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Martin I. Newman
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Neil Seeley
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jacob Hutchins
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Kevin L. Smith
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Gabriel Mena
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jesse C. Selber
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Michel H. Saint-Cyr
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
| | - Jeffrey C. Gadsden
- From the Departments of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering, New York, N.Y.; Department of Plastic Surgery, Cleveland Clinic Florida, Weston, Fla.; Department of Anesthesiology, Cancer Treatment Centers of America, Newnan, Ga.; Departments of Anesthesiology and Surgery, University of Minnesota, Minneapolis, Minn.; Charlotte Plastic Surgery, Charlotte, N.C.; Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, Tex.; Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Tex; Division of Plastic Surgery, Baylor Scott & White Health, Temple, Tex.; Department of Plastic Surgery, University of Texas Southwestern, Dallas, Tex.; and Department of Anesthesiology, Duke University Medical Center, Durham, N.C
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20
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Schiavone MB, Moukarzel L, Leong K, Zhou QC, Afonso AM, Iasonos A, Roche KL, Leitao MM, Chi DS, Abu-Rustum NR, Zivanovic O. Surgical site infection reduction bundle in patients with gynecologic cancer undergoing colon surgery. Gynecol Oncol 2017; 147:115-119. [PMID: 28734498 DOI: 10.1016/j.ygyno.2017.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 07/03/2017] [Accepted: 07/06/2017] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery. METHODS We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery. RESULTS Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm3, SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001). CONCLUSIONS The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss.
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Affiliation(s)
- Maria B Schiavone
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Lea Moukarzel
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kam Leong
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Anoushka M Afonso
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States
| | - Mario M Leitao
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States.
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21
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Pino V, Ayala JH, Afonso AM, González V. Determination of polycyclic aromatic hydrocarbons in seawater by high-performance liquid chromatography with fluorescence detection following micelle-mediated preconcentration. J Chromatogr A 2002; 949:291-9. [PMID: 11999746 DOI: 10.1016/s0021-9673(01)01589-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [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: 11/28/2022]
Abstract
In this work, the nonionic surfactant polyoxyethylene-10-lauryl ether has been used for the extraction and preconcentration of 14 polycyclic aromatic hydrocarbons, classified as priority pollutants by the US Environmental Protection Agency, from seawater samples. The cloud-point preconcentration previous separation by HPLC and quantification using fluorimetric detection and wavelength programming allow to determine these pollutants with detection limits ranging from 1.0 to 1.5 x 10(2) ng/l with RSDs better than 10.4%. The methodology is evaluated using well-established extraction and preconcentration methods and GC-MS.
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Affiliation(s)
- V Pino
- Department of Analytical Chemistry, Nutrition and Food Science, University of La Laguna, Spain
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22
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Pino V, Ayala JH, Afonso AM, González V. Cloud-point preconcentration and HPLC determination of polycyclic aromatic hydrocarbons in marine sediments. Fresenius J Anal Chem 2001; 371:526-31. [PMID: 11760064 DOI: 10.1007/s002160101009] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cloud-point methodology has been used to develop a new procedure for preconcentration of polycyclic aromatic hydrocarbons previously extracted from marine sediment with a micellar polyoxyethylene-10-lauryl ether medium by microwave- or ultrasound-assisted extraction. The optimum conditions for preconcentration and determination of PAH by HPLC with UV detection were established. The optimized procedure was applied to determination of these analytes in fortified marine sediment. The mean recoveries obtained after extraction and preconcentration by use of microwave- or ultrasound-assisted extraction were 105.8 and 99.5%, respectively. Precision, however, is considerably higher when extraction is performed ultrasonically.
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Affiliation(s)
- V Pino
- Department of Analytical Chemistry, University of La Laguna, Spain
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Abstract
OBJECTIVE The rapid growth of the rubella virus in RC-IAL2 with development of cytopathic effect, in response to rubella virus infection, is described. For purposes of comparison, the rubella virus RA-27/3 strain was titered simultaneously in the RC-IAL, Vero, SIRC and RK13 cell lines. METHODS Rubella virus RA-27/3 strain are inoculated in the RC-IAL cell line (rabbit Kidney, Institute Adolfo Lutz). Plates containing 1.5x10(5) cells/ml of RC-IAL line were inoculated with 0.1ml s RA-27/3 strain virus containing 1x 10(4)TCID50/0.1ml. A 25% cytopathic effect was observed after 48 hours and 100% after 96 hours. The results obtained were compared to those observed with the SIRC, Vero and RK13 cell lines. Rubella virus was detected by immunohistochemistry. RESULTS With the results, it was possible to conclude that the RC-IAL cell line is a very good substrate for culturing rubella virus. The cells inoculated with rubella virus were examined by phase contrast microscopy and showed the characteristic rounded, bipolar and multipolar cells. The CPE in RC-IAL was observed in the first 48 hours and the curve of the increased infectivity was practically the same as observed in other cell lines. CONCLUSIONS These findings are important since this is one the few cell lines described in the literature with a cytopathic effect. So it can be used for antigen preparation and serological testing for the diagnosis of specific rubella antibodies.
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Affiliation(s)
- C A Figueiredo
- Serviço de Virologia, Instituto Adolfo Lutz, São Paulo, SP, Brasil.
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24
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Pino V, Ayala JH, Afonso AM, González V. Determination of polycyclic aromatic hydrocarbons in marine sediments by high-performance liquid chromatography after microwave-assisted extraction with micellar media. J Chromatogr A 2000; 869:515-22. [PMID: 10720265 DOI: 10.1016/s0021-9673(99)01220-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.3] [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: 10/18/2022]
Abstract
A simple and rapid method is developed for extraction and determination of polycyclic aromatic hydrocarbons (PAHs) in marine sediments. The procedure was based on the microwave-assisted extraction of PAHs in marine sediment samples using a micellar medium of Polyoxyethylene 10 lauryl ether as extractant. Two-level factorial designs have been used to optimize the microwave extraction process. The analysis of extracts has been carried out by HPLC with UV detection. Fortified sediments gave an average recovery between 85.70 and 100.73%, with a relative standard deviation of 1.77-7.0% for PAHs with a ring number higher than three.
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Affiliation(s)
- V Pino
- Department of Analytical Chemistry, Nutrition and Food Science, University of La Laguna, Spain
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25
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Black JB, Durigon E, Kite-Powell K, de Souza L, Curli SP, Afonso AM, Theobaldo M, Pellett PE. Seroconversion to human herpesvirus 6 and human herpesvirus 7 among Brazilian children with clinical diagnoses of measles or rubella. Clin Infect Dis 1996; 23:1156-8. [PMID: 8922816 DOI: 10.1093/clinids/23.5.1156] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [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: 02/03/2023] Open
Abstract
We collected acute-phase and convalescent-phase serum samples from Brazilian patients who presented with exanthem of unknown origin and evaluated these samples by means of an immunoblot assay for seroconversion to human herpesvirus 6 (HIV-6) or human herpesvirus 7 (HIV-7). Measles or rubella had been clinically diagnosed in all these patients, but their sera were negative for antibodies to both measles virus and rubella virus. Twenty percent of the patients clearly seroconverted to HHV-6 after manifestation of the exanthem, and 8% seroconverted to HHV-7. All seroconversions to HHV-6 occurred in children aged < or = 5 years; a 41% frequency of seroconversion to HHV-6 was noted among children between 3 months and 23 months of age, whereas seroconversions to HHV-7 were detected during infancy and through adulthood. Our data indicate that primary infections due to HHV-6 or HHV-7 can be misdiagnosed as measles or rubella.
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Affiliation(s)
- J B Black
- Centers for Disease Control and Prevention, Atlanta, Georgia
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26
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Pereira MC, Sobrinho LG, Afonso AM, Ferreira JM, Santos MA, Sousa MF. Is idiopathic hyperprolactinemia a transitional stage toward prolactinoma? Obstet Gynecol 1987; 70:305-8. [PMID: 3114691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The basal prolactin (PRL) levels on five different days, the PRL responses to thyrotropin-releasing hormone and to domperidone, and the thyroid-stimulating hormone (TSH) responses to domperidone were studied in 75 regularly menstruating women and 44 patients with moderate hyperprolactinemia. It was found that, for the entire sample, the responses to each of the stimuli could be described by a continuous function of the basal PRL levels. The present work provides evidence for the following conclusions: 1) The PRL responses to thyrotropin-releasing hormone and to domperidone merely bring additional diagnostic information relative to basal PRL levels in the occasional patients with macroprolactinemia; 2) there is a continuous spectrum of lactotroph activities in women, ranging from normal secretors through an intermediate group of hypersecretors (with progressively increased serum PRL levels and decreased responsiveness to stimuli) to full-blown prolactinomas; and 3) idiopathic hyperprolactinemia is a heterogeneous entity that includes the above intermediate group of patients, women with macroprolactinemia, and patients with undiagnosed prolactinomas.
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Sobrinho LG, Nunes MC, Calhaz-Jorge C, Afonso AM, Pereira MC, Santos MA. Hyperprolactinemia in women with paternal deprivation during childhood. Obstet Gynecol 1984; 64:465-8. [PMID: 6541327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
It was reported that most females with prolactinoma, idiopathic hyperprolactinemia, or euprolactinemic galactorrhea were reared either without their father or with an alcoholic, violent father. To gain further insight into this association, a group of sisters of patients with prolactinoma (generally exposed to the same environment as the patients') and a control group were studied. Women with paternal deprivation during childhood differed from the women who had normal childhoods in that they had: 1) higher mean serum prolactin concentration (14.7 versus 9.4 ng/mL; P less than .001); 2) higher incidence of hyperprolactinemia (12 of 50 versus three of 59; P less than .005); and 3) higher incidence of galactorrhea (14 of 50 versus seven of 59: P less than .03). These observations support the contention that paternal deprivation during childhood is associated, in a minority of women, with a predisposition to develop hyperprolactinemia and presumably, prolactinoma later in life. A hypothesis on the possible mechanisms of a casual relationship is presented.
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Abstract
Glycopeptides were isolated from pronase digests of human Tamm-Horsfall glycoprotein and its asialo derivative. The carbohydrate moiety of the major glycopeptide preparation isolated from the former digests had an apparent molecular weight of 4300, and those of two glycopeptides isolated from the latter digests had molecular weights of 3600 and 2300. These data, together with the compositions of the glycopeptides, indicate that the Tamm-Horsfall glycoprotein has at least five asparagine residues substituted by complex carbohydrate moieties, three being of one type, relatively rich in galactose, and two containing more sialic acid but less galactose. A small amount of a mannose-rich glycopeptide was also recovered from the digests of the Tamm-Horsfall glycoprotein.
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29
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Afonso AM, Marshall RD. Observations on the structure of the carbohydrate moieties of the Tamm-Horsfall glycoprotein [proceedings]. Biochem Soc Trans 1979; 7:170-3. [PMID: 437268 DOI: 10.1042/bst0070170] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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30
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Abstract
1. The hemoglobin of Biomphalaria glabrata is a glycoprotein which contains 3% sugars. 2. The sugar moiety is composed of 2 mol of hexose and one mol of hexosamine per mol of monomer. 3. The hexosamine in the molecule is glucosamine. 4. Mannose, galactose and fucose are present in the molecule in a ratio of 2:1:1. 5. No sialic and uronic acids were detected in this hemoglobin.
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