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Lau FF, Agerskov M, Thusholdt ANW, Højlund J, Meyhoff CS, Jans Ø, Foss NB. Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study. J Clin Anesth 2024; 95:111472. [PMID: 38613938 DOI: 10.1016/j.jclinane.2024.111472] [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: 12/29/2023] [Revised: 03/20/2024] [Accepted: 04/08/2024] [Indexed: 04/15/2024]
Abstract
STUDY OBJECTIVE Evidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. DESIGN Multicenter cohort study. SETTING Bispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. PATIENTS We included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. INTERVENTIONS No interventions were carried out. MEASUREMENTS Principal values collected included measurements of peripheral perfusion index and hemoglobin values. METHODS The study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. MAIN RESULTS We included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231). Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62-5.45]) and 90-day mortality (3.13, [1.45-7.11]). A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57-162.10]). CONCLUSION High PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.
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Affiliation(s)
- Frederik F Lau
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Marianne Agerskov
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anna N W Thusholdt
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Øivind Jans
- Department of Anesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hristovska AM, Andersen LB, Uldall-Hansen B, Kehlet H, Troelsen A, Gromov K, Foss NB. Postoperative orthostatic intolerance following fast-track unicompartmental knee arthroplasty: incidence and hemodynamics-a prospective observational cohort study. J Orthop Surg Res 2024; 19:214. [PMID: 38561817 PMCID: PMC10983746 DOI: 10.1186/s13018-024-04639-6] [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: 10/11/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Early postoperative mobilization is essential for early functional recovery but can be inhibited by postoperative orthostatic intolerance (OI). Postoperative OI is common after major surgery, such as total knee arthroplasty (TKA). However, limited data are available after less extensive surgery, such as unicompartmental knee arthroplasty (UKA). We, therefore, investigated the incidence of OI as well as cardiovascular and tissue oxygenation responses during early mobilization after UKA. METHODS This prospective single-centre observational study included 32 patients undergoing primary UKA. Incidence of OI and cardiovascular and tissue oxygenation responses during mobilization were evaluated preoperatively, at 6 and 24 h after surgery. Perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain during mobilization and opioid usage were recorded. RESULTS During mobilization at 6 h after surgery, 4 (14%, 95%CI 4-33%) patients experienced OI; however, no patients terminated the mobilization procedure prematurely. Dizziness and feeling of heat were the most common symptoms. OI was associated with attenuated systolic and mean arterial blood pressure responses in the sitting position (all p < 0.05). At 24 h after surgery, 24 (75%) patients had already been discharged, including three of the four patients with early OI. Only five patients were available for measurements, two of whom experienced OI; one terminated the mobilization procedure due to intolerable symptoms. We observed no statistically significant differences in perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain, or opioid usage between orthostatic intolerant and tolerant patients. CONCLUSIONS The incidence of orthostatic intolerance after fast-track unicompartmental knee arthroplasty is low (~ 15%) and is associated with decreased orthostatic pressure responses. Compared to the previously described orthostatic intolerance incidence of ~ 40% following total knee arthroplasty, early orthostatic intolerance is uncommon after unicompartmental knee arthroplasty, suggesting a procedure-specific component. TRIAL REGISTRATION Prospectively registered at ClinicalTrials.gov; registration number: NCT04195360, registration date: 13.12.2019.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark.
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, 2650, Hvidovre, Copenhagen, Denmark
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Springborg AH, Visby L, Kehlet H, Foss NB. Psychological predictors of acute postoperative pain after total knee and hip arthroplasty: A systematic review. Acta Anaesthesiol Scand 2023; 67:1322-1337. [PMID: 37400963 DOI: 10.1111/aas.14301] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/08/2023] [Accepted: 06/14/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Identifying patients at high risk of acute postoperative pain after total knee or hip arthroplasty (TKA/THA) will facilitate individualized pain management and research on the efficacy of treatment options. Numerous studies have reported that psychological patient factors may influence acute postoperative pain, but most reviews have focused on chronic pain and functional outcomes. This systematic review aims to evaluate which psychological metrics are associated with acute postoperative pain after TKA and THA. METHODS A systematic search was conducted using the databases PubMed, EMBASE, Web of Science, and Cochrane Library until June 2022. Full-text articles reporting associations of preoperative psychological factors with acute pain within 48 h of TKA or THA surgery were identified. Quality was assessed using the Quality in Prognostic Studies tool. RESULTS Eighteen studies containing 16 unique study populations were included. TKA was the most common procedure, and anxiety and depression were the most evaluated psychological metrics. Several different anesthetic techniques and analgesic regimens were used. The studies were generally rated as having a low to moderate risk of bias. Catastrophizing was associated with acute pain in six studies (of nine), mainly after TKA. In contrast, three studies (of 13) and two studies (of 13) found anxiety and depression, respectively, to be associated with acute postoperative pain. CONCLUSION Pain catastrophizing seemed to be the most consistent psychological predictor of acute postoperative pain after TKA. The results for other psychological factors and THA were inconsistent. However, the interpretation of results was limited by considerable methodological heterogeneity.
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Affiliation(s)
- Anders H Springborg
- Department of Anesthesiology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Lasse Visby
- Department of Anesthesiology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Springborg AH, Nielsen NI, Foss NB. Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia. Comment on Br J Anaesth 2023; 130: 773-9. Br J Anaesth 2023; 131:e156-e157. [PMID: 37689539 DOI: 10.1016/j.bja.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/01/2023] [Accepted: 08/02/2023] [Indexed: 09/11/2023] Open
Affiliation(s)
- Anders H Springborg
- Department of Anaesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.
| | - Niklas I Nielsen
- Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
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Thy SA, Johansen AO, Thy A, Sørensen HH, Mølgaard J, Foss NB, Toft P, Meyhoff CS, Aasvang EK. Associations between clinical interventions and transcutaneous blood gas values in postoperative patients. J Clin Monit Comput 2023; 37:1255-1264. [PMID: 36808596 DOI: 10.1007/s10877-023-00982-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/15/2022] [Accepted: 01/29/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Postoperative monitoring of circulation and respiration is pivotal to guide intervention strategies and ensure patient outcomes. Transcutaneous blood gas monitoring (TCM) may allow for noninvasive assessment of changes in cardiopulmonary function after surgery, including a more direct assessment of local micro-perfusion and metabolism. To form the basis for studies assessing the clinical impact of TCM complication detection and goal-directed-therapy, we examined the association between clinical interventions in the postoperative period and changes in transcutaneous blood gasses. METHODS Two-hundred adult patients who have had major surgery were enrolled prospectively and monitored with transcutaneous blood gas measurements (oxygen (TcPO2) and carbon dioxide (TcPCO2)) for 2 h in the post anaesthesia care unit, with recording of all clinical interventions. The primary outcome was changes in TcPO2, secondarily TcPCO2, from 5 min before a clinical intervention versus 5 min after, analysed with paired t-test. RESULTS Data from 190 patients with 686 interventions were analysed. During clinical interventions, a mean change in TcPO2 of 0.99 mmHg (95% CI-1.79-0.2, p = 0.015) and TcPCO2 of-0.67 mmHg (95% CI 0.36-0.98, p < 0.001) was detected. CONCLUSION Clinical interventions resulted in significant changes in transcutaneous oxygen and carbon dioxide. These findings suggest future studies to assess the clinical value of changes in transcutaneous PO2 and PCO2 in a postoperative setting. TRIAL REGISTRY Clinical trial number: NCT04735380. CLINICAL TRIAL REGISTRY https://clinicaltrials.gov/ct2/show/NCT04735380.
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Affiliation(s)
- Sandra A Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark.
| | - Andreas O Johansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - André Thy
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Henrik H Sørensen
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Jesper Mølgaard
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Palle Toft
- Department of Anesthesiology, Odense University Hospital and Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Eske K Aasvang
- Department of Anesthesiology, Center for Cancer and Organ Dysfunction, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High dose dexamethasone in high pain responders undergoing total hip arthroplasty: A randomized controlled trial. Eur J Anaesthesiol 2023; 40:737-746. [PMID: 37166257 DOI: 10.1097/eja.0000000000001853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/12/2023]
Abstract
BACKGROUND Postoperative pain after total hip arthroplasty (THA) may delay postoperative mobilization and discharge. Postoperative pain has been shown to be higher in pain catastrophisers and patients receiving opioids. A single dose of glucocorticoid reduces pain after THA, and an increased dose of glucocorticoids has been found to be effective in patients at high risk of postoperative pain after total knee arthroplasty (TKA), however, the ideal dose in THA remains unknown. OBJECTIVE To evaluate the effect of a high dose (1 mg kg -1 ) vs. intermediate dose (0.3 mg kg -1 ) of dexamethasone on pain after THA. DESIGN A randomized double-blind controlled study. SETTING A two-centre study including two large arthroplasty sites in Denmark was conducted from February 2019 to August 2020. PATIENTS A total of 160 patients undergoing THA by neuraxial block with multimodal analgesia, having a Pain Catastrophising Scale score >20 and/or preoperative opioid use were included. INTERVENTION Patients were randomly assigned to receive dexamethasone 1 mg kg -1 or 0.3 mg kg -1 before THA. MAIN OUTCOME MEASURES Primary outcome was percentage of patients experiencing moderate to severe pain (visual analogue scale, VAS > 30 mm on a 0 to 100 mm scale) on ambulating 24 h after surgery. Secondary outcomes included cumulated pain scores, C-reactive protein (CRP), opioid use, postoperative recovery scores, length of stay, complications, and re-admission within 30 and 90 days. RESULTS No difference was found in percentage of VAS >30 mm 24 h after surgery in the 5-m walk test (VAS > 30/VAS ≤ 30%); 33/42 (44%) vs. 32/43 (43%), relative risk = 1.04 (95% confidence interval 0.72-1.51; P = 0.814) in 1 mg kg -1vs. 0.3 mg kg -1 respectively. No differences were found in CRP and opioid use between groups. Also, no intergroup differences were found in recovery scores, re-admissions, or complications. CONCLUSION 1 mg kg -1vs. 0.3 mg kg -1 dexamethasone improved neither postoperative pain nor recovery in THA in a cohort of predicted high pain responders. TRIAL REGISTRATION ClinicalTrials.gov ID-number NCT03763760 and EudraCT-number 2018-2636-25.
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Affiliation(s)
- Niklas I Nielsen
- From the Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (NIN, NBF), Section of Surgical Pathophysiology, University of Copenhagen, Blegdamsvej 9, Denmark (HK), Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark (KG, AT, HH), Department of Orthopaedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark (CV, PK-A, LER), Department of Anaesthesiology, Lillebaelt Hospital - Vejle, Vejle, Denmark (LP)
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Hristovska AM, Uldall-Hansen B, Mehlsen J, Andersen LB, Kehlet H, Foss NB. Orthostatic intolerance after acute mild hypovolemia: incidence, pathophysiologic hemodynamics, and heart-rate variability analysis-a prospective observational cohort study. Can J Anaesth 2023; 70:1587-1599. [PMID: 37752379 PMCID: PMC10600298 DOI: 10.1007/s12630-023-02556-6] [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: 08/04/2022] [Revised: 02/05/2023] [Accepted: 02/13/2023] [Indexed: 09/28/2023] Open
Abstract
PURPOSE Early postoperative mobilization can be hindered by orthostatic intolerance (OI). Postoperative OI has multifactorial pathogenesis, possibly involving both postoperative hypovolemia and autonomic dysfunction. We aimed to investigate the effect of mild acute blood loss from blood donation simulating postoperative hypovolemia, on both autonomic function and OI, thus eliminating confounding perioperative factors such as inflammation, residual anesthesia, pain, and opioids. METHODS This prospective observational cohort study included 26 blood donors. Continuous electrocardiogram data were collected during mobilization and night sleep, both before and after blood donation. A Valsalva maneuver and a standardized mobilization procedure were performed immediately before and after blood donation, during which cardiovascular and tissue oxygenation variables were continuously measured by LiDCOrapid™ and Massimo Root™, respectively. The incidence of OI, hemodynamic responses during mobilization and Valsalva maneuver, as well as heart rate variability (HRV) responses during mobilization and sleep were compared before and 15 min after blood donation. RESULTS Prior to blood donation, no donors experienced OI during mobilization. After blood donation, 6/26 (23%; 95% CI, 9 to 44) donors experienced at least one OI symptom. Three out of 26 donors (12%; 95% CI, 2 to 30) terminated the mobilization procedure prematurely because of severe OI symptoms. Cardiovascular and cerebral tissue oxygenation responses were reduced in patients with severe OI. After blood loss, HRV indices of total autonomic power remained unchanged but increased sympathetic and decreased parasympathetic outflow was observed during mobilization, but also during sleep, indicating a prolonged autonomic effect of hypovolemia. CONCLUSION We describe a specific hypovolemic component of postoperative OI, independent of postoperative autonomic dysfunction, inflammation, opioids, and pain. STUDY REGISTRATION ClinicalTrials.gov (NCT04499664); registered 5 August 2020.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark.
| | - Bodil Uldall-Hansen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Jesper Mehlsen
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital, Hvidovre Hospital, Kettegård Alle 30, Hvidovre, 2650, Copenhagen, Denmark
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8
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Hristovska AM, Uldall-Hansen B, Mehlsen J, Kehlet H, Foss NB. Orthostatic intolerance after intravenous administration of morphine: incidence, haemodynamics and heart rate variability analysis. Anaesthesia 2023; 78:526-528. [PMID: 36517996 DOI: 10.1111/anae.15945] [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] [Accepted: 11/20/2022] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - J Mehlsen
- Copenhagen University Hospital, Copenhagen, Denmark
| | - H Kehlet
- Copenhagen University Hospital, Copenhagen, Denmark
| | - N B Foss
- Copenhagen University Hospital, Copenhagen, Denmark
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Cihoric M, Kehlet H, Højlund J, Lauritsen ML, Kanstrup K, Foss NB. Bioimpedance spectroscopy fluid analysis in acute high-risk abdominal surgery, a prospective clinician-blinded observational feasibility study. J Clin Monit Comput 2023; 37:619-627. [PMID: 36333575 PMCID: PMC9638275 DOI: 10.1007/s10877-022-00934-x] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
Objective assessment of fluid status in critical surgical care may help optimize perioperative fluid administration and prevent postoperative fluid retention. We evaluated the feasibility of hydration status and fluid distribution assessment by Bioimpedance spectroscopy Analysis (BIA) in patients undergoing acute high-risk abdominal (AHA) surgery. This observational study included 73 patients undergoing AHA surgery. During the observational period (0-120 h), we registered BIA calculated absolute fluid overload (AFO) and relative fluid overload (RFO), defined as AFO/extracellular water ratio, as well as cumulative fluid balance and weight. Based on RFO values, hydration status was classified into three categories: dehydrated (RFO < - 10%), normohydrated (- 10% ≤ RFO ≤ + 15%), overhydrated RFO > 15%. We performed a total of 365 BIA measurements. Preoperative overhydration was found in 16% of patients, increasing to 66% by postoperative day five. The changes in BIA measured AFO correlated with the cumulative fluid balance (r2 = 0.44, p < .001), and change in weight (r2 = 0.55, p < .0001). Perioperative overhydration measured with BIA was associated with worse outcome compared to patients with normo- or dehydration. We have demonstrated the feasibility of obtaining perioperative bedside BIA measurements in patients undergoing AHA surgery. BIA measurements correlated with fluid balance, weight changes, and postoperative clinical complications. BIA-assessed fluid status might add helpful information to guide fluid management in patients undergoing AHA surgery.
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Affiliation(s)
- M Cihoric
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark.
| | - H Kehlet
- Section for Surgical Pathophysiology, JMC, Rigshospitalet, Copenhagen, Capital Region of Denmark, Denmark
| | - J Højlund
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
| | - M L Lauritsen
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - K Kanstrup
- Gastrounit, Surgical Section, Hvidovre University Hospital, Hvidovre, Capital Region of Denmark, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegaard allé 30, 2650, Hvidovre, Capital Region of Denmark, Denmark
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10
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Foss NB, Aasvang EK. Bypassing the post-anaesthesia care unit after elective hip and knee arthroplasty: a reply. Anaesthesia 2023; 78:787-788. [PMID: 36896701 DOI: 10.1111/anae.15995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 03/11/2023]
Affiliation(s)
- N I Nielsen
- Copenhagen University Hospital Hvidovre, Denmark
| | - H Kehlet
- Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - K Gromov
- Copenhagen University Hospital Hvidovre, Denmark
| | - A Troelsen
- Copenhagen University Hospital Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital Hvidovre, Denmark
| | - E K Aasvang
- Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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11
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High-dose dexamethasone in low pain responders undergoing total knee arthroplasty: a randomised double-blind trial. Br J Anaesth 2023; 130:322-330. [PMID: 36526481 DOI: 10.1016/j.bja.2022.10.038] [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: 08/30/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Postoperative pain after total knee arthroplasty (TKA) is a continuing problem despite optimised multimodal analgesia. Previous studies have shown preoperative glucocorticoids to reduce postoperative pain, but knowledge about specific doses and effects in specific patient groups is lacking. METHODS A two-centre, double-blind, two-arm study comparing preoperative dexamethasone (1 mg kg-1vs 0.3 mg kg-1 i.v.) on postoperative pain in 160 planned TKA subjects with low preoperative pain catastrophising and no opioid use. Subjects received multimodal analgesia with paracetamol, cyclooxygenase-2 inhibitors, local anaesthetic infiltration analgesia, and rescue opioids. The primary outcome was percentage of subjects experiencing moderate to severe pain (visual analogue scale >30 mm) upon ambulation at 24 h. Secondary outcomes included pain scores, postoperative inflammation (C-reactive protein), opioid and antiemetics use, and 'Quality of Recovery-15' and 'Opioid-Related Symptom Distress Scale', length of stay, readmissions, and complications up to Day 90. RESULTS A total of 157 subjects (80 vs 77) were included. No difference was found between groups in the incidence of subjects experiencing visual analogue scale >30 on ambulation 24 h after surgery (56% vs 53%, relative risk =1.07, confidence interval: 0.8-1.4, P=0.65). No differences in other pain outcomes or use of rescue opioids and antiemetics, in Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, length of stay, readmissions, or complications. C-reactive protein values were comparable at 24 h (13 [6-25] mg L-1vs 16 [9-38] mg L-1, P = 0.07), but lower at 48 h (26 [9-52] mg L-1vs 50 [30-72] mg L-1, P<0.01) in the high-dose group. CONCLUSION Use of 1 mg kg-1vs 0.3 mg kg-1 i.v. dexamethasone in low pain responders after TKA did not improve early postoperative pain or other outcomes in contrast to benefits in a high pain responder population. CLINICAL TRIAL REGISTRATION NCT03758170 (first registration 29-11-2018).
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Affiliation(s)
- Niklas I Nielsen
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Lasse E Rasmussen
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Hvidovre, Denmark
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12
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van Veenendaal N, Foss NB, Miserez M, Pawlak M, Zwaans WAR, Aasvang EK. A narrative review on the non-surgical treatment of chronic postoperative inguinal pain: a challenge for both surgeon and anaesthesiologist. Hernia 2023; 27:5-14. [PMID: 36315351 PMCID: PMC9931782 DOI: 10.1007/s10029-022-02693-9] [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: 07/31/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic pain is one of the most frequent clinical problems after inguinal hernia surgery. Despite more than two decades of research and numerous publications, no evidence exists to allow for chronic postoperative inguinal pain (CPIP) specific treatment algorithms. METHODS This narrative review presents the current knowledge of the non-surgical management of CPIP and makes suggestions for daily practice. RESULTS There is a paucity for high-level evidence of non-surgical options for CPIP. Different treatment options and algorithms have been published for chronic pain patients in the last decades. DISCUSSION AND CONCLUSION It is suggested that non-surgical treatment is introduced in the management of all CPIP patients. The overall approach to interventions should be pragmatic, tiered and multi-interventional, starting with least invasive and only moving to more invasive procedures upon lack of effect. Evaluation should be multidisciplinary and should take place in specialized centres. We strongly suggest to follow general guidelines for treatment of persistent pain and to build a database allowing for establishing CPIP specific evidence for optimal analgesic treatments.
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Affiliation(s)
- N van Veenendaal
- Department of Anesthesiology, University Medical Center Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - N B Foss
- Department of Anaesthesia and Intensive Care, Hvidovre University Hospital, Copenhagen, Denmark
| | - M Miserez
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M Pawlak
- North Devon Comprehensive Hernia Centre, North Devon District Hospital, Royal Devon University Healthcare NHS Foundation Trust, Barnstaple, UK
| | - W A R Zwaans
- Department of General Surgery, Máxima Medical Center, Veldhoven, Eindhoven, The Netherlands.,SolviMáx Center of Excellence for Abdominal Wall and Groin Pain, Eindhoven, The Netherlands.,NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, The Netherlands
| | - E K Aasvang
- Department of Anesthesiology, Center for Cancer and Organ Diseases, Rigshopitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Copenhagen University, Copenhagen, Denmark
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13
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Springborg AH, Varnum C, Nielsen NI, Rasmussen LE, Kjaersgaard-Andersen P, Pleckaitiene L, Gromov K, Troelsen A, Kehlet H, Foss NB. Repeat dose steroid in high pain responders after total knee arthroplasty: A study protocol. Acta Anaesthesiol Scand 2023; 67:675-681. [PMID: 36695403 DOI: 10.1111/aas.14207] [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: 01/03/2023] [Accepted: 01/12/2023] [Indexed: 01/26/2023]
Abstract
Pain after total knee arthroplasty (TKA) is a well-known clinical problem potentially delaying ambulation and recovery. Perioperative glucocorticoids reduce pain and facilitate early recovery, but the optimal timing and dose are still unknown. High pain catastrophizers have an increased risk of poorly controlled postoperative pain, and moderate to severe pain at 24 h is associated with a risk of pain relapse at 48 h. To evaluate the effect of a repeat moderate dose of glucocorticoids after TKA in high pain catastrophizers presenting with moderate to severe pain 24 h postoperatively, having received preoperative high-dose glucocorticoids. High pain catastrophizers (Pain Catastrophizing Scale > 20) undergoing TKA are screened 24 h postoperatively and are included if they experience moderate to severe pain (VAS > 30) during a 5 m walk test. The included patients will receive either oral 24 mg dexamethasone (n = 55) or placebo (n = 55) on the evening of Day 1 (~30-37 h) after surgery. In addition, patients receive a standard multimodal analgesic regimen, including paracetamol, celecoxib, local infiltration analgesia, and preoperative dexamethasone (1 mg/kg). Patients will fill out a pain diary for 7 days after surgery. The primary outcome is moderate to severe pain (VAS > 30) during a 5 m walk test on the morning of Day 2 after surgery. The secondary outcomes include cumulated pain at rest and during ambulation, cumulated use of rescue analgesics, quality of sleep, lethargy, dizziness, nausea, satisfaction with the analgesic regimen, length of stay, morbidity, mortality, and reasons for readmissions. Follow-up is at 8 and 30 days. The data from this study will provide evidence for the effect of a repeated dose of dexamethasone as an analgesic adjuvant in patients undergoing TKA with a high risk of postoperative pain.
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Affiliation(s)
- Anders H Springborg
- Department of Anesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Claus Varnum
- Department of Orthopedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Niklas I Nielsen
- Department of Anesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark
| | - Lasse E Rasmussen
- Department of Orthopedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Per Kjaersgaard-Andersen
- Department of Orthopedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Lina Pleckaitiene
- Department of Orthopedic Surgery, Lillebaelt Hospital - Vejle, Vejle, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Section of Surgical Pathophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology, Copenhagen University Hospital - Amager and Hvidovre, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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Hristovska AM, Andersen LB, Grentoft M, Mehlsen J, Gromov K, Kehlet H, Foss NB. Orthostatic intolerance after fast-track knee arthroplasty: Incidence and hemodynamic pathophysiology. Acta Anaesthesiol Scand 2022; 66:934-943. [PMID: 35680697 DOI: 10.1111/aas.14098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 05/04/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Early postoperative mobilization can be hindered by orthostatic intolerance (OI) due to failed orthostatic cardiovascular regulation. The underlying mechanisms are not fully understood and specific data after total knee arthroplasty (TKA) are lacking. Therefore, we evaluated the incidence of OI and the cardiovascular response to mobilization in fast-track TKA. METHODS This prospective observational cohort study included 45 patients scheduled for primary TKA in spinal anesthesia with a multimodal opioid-sparing analgesic regime. OI and the cardiovascular response to sitting and standing were evaluated with a standardized mobilization procedure preoperatively, and at 6h and 24h postoperatively. Hemodynamic variables were measured non-invasively (LiDCO™ Rapid). Perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, opioid use and pain during mobilization were recorded. RESULTS Eighteen (44%) and 8 (22%) patients demonstrated OI at 6 and 24h after surgery respectively. Four (10%) and 2 (5%) patients experienced severe OI and terminated the mobilization procedure prematurely. Dizziness was the most common OI symptom during mobilization at 6h. OI was associated with decreased orthostatic responses in systolic, diastolic, mean arterial pressures and heart rate (all p<0.05), while severe OI patients demonstrated impaired diastolic, mean arterial pressures, heart rate and cardiac output responses (all p<0.05). No statistically significant differences in perioperative bleeding, fluid balance, surgery duration, postoperative hemoglobin, pain or opioid use were observed between orthostatic tolerant and intolerant patients. CONCLUSION Early postoperative OI is common following fast-track TKA. Pathophysiologic mechanisms include impaired orthostatic cardiovascular responses. The progression to severe OI symptoms appears to be primarily due to inadequate heart rate response.
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Affiliation(s)
- Ana-Marija Hristovska
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Louise B Andersen
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Mette Grentoft
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Jesper Mehlsen
- Department of Surgical Pathophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
| | - Henrik Kehlet
- Department of Surgical Pathophysiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark
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15
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Agerskov M, Sørensen H, Højlund J, Kjær S, Secher NH, Foss NB. The effect of vasoconstriction on intestinal perfusion is determined by preload dependency: A prospective observational study. Acta Anaesthesiol Scand 2022; 66:713-721. [PMID: 35338646 DOI: 10.1111/aas.14059] [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: 10/07/2021] [Revised: 02/21/2022] [Accepted: 03/12/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The effects of vasoconstriction on cardiac stroke volume (SV) and indices of peripheral and intestinal perfusion are insufficiently described. METHODS In a non-randomized clinical study, 30 patients undergoing elective rectal surgery were exposed to modulation of preload. The primary endpoint was intestinal perfusion (flux), measured by single-point laser Doppler flowmetry. Secondary endpoints were central cardiovascular variables obtained by the LiDCO rapid monitor, the peripheral perfusion index (PPI) derived from the pulse oximetry signal and muscle (StO2 ) and cerebral oxygenation (ScO2 ) determined by near-infrared spectroscopy. RESULTS For the whole cohort (n = 30), administration of Phenylephrine during HUT induced a median [IQR] increase in SV by 22% [14-41], p = .003 and in mean arterial pressure (MAP) by 54% [31-62], p < .001, with no change in PPI, StO2 and ScO2 or flux. In patients who were preload dependent during HUT (stroke volume variation; SSV >10%; n = 23), administration of phenylephrine increased SV by 29% [12-43], p = .01 and MAP by 54% [33-63], p < .001, followed by an increase in intestinal perfusion flux by 60% [15-289], p = .05, while PPI, StO2 and ScO2 remained unchanged. For non-preload dependent patients (SSV <10%; n = 7), no changes in hemodynamic indices were seen besides an increase in MAP by 54% [33-58], p = .002. CONCLUSION The reflection of vasoconstrictive modulation of preload in systemic cardiovascular variables and indices of perfusion was dependent on preload responsiveness. Administration of phenylephrine to increase preload did not appear to compromise organ perfusion.
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Affiliation(s)
- Marianne Agerskov
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Henrik Sørensen
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Søren Kjær
- Gastroenterology Surgical Section Hvidovre Hospital University of Copenhagen Copenhagen Denmark
| | - Niels H. Secher
- Department of Anaesthesiology Centre for Cancer and Organ Diseases Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Hvidovre Hospital University of Copenhagen Copenhagen Denmark
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16
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Agerskov M, Thusholdt AN, Holm-Sørensen H, Wiberg S, Meyhoff CS, Højlund J, Secher NH, Foss NB. Erratum to ‘Association of the intraoperative peripheral perfusion index with postoperative morbidity and mortality in acute surgical patients: a retrospective observational multicentre cohort study’ (Br J Anaesth 2021; 127: 396-404). Br J Anaesth 2022; 128:744. [PMID: 35067368 PMCID: PMC9074787 DOI: 10.1016/j.bja.2022.01.003] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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17
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard-Andersen P, Rasmussen LE, Pleckaitiene L, Foss NB. High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial. Br J Anaesth 2021; 128:150-158. [PMID: 34749994 PMCID: PMC8787770 DOI: 10.1016/j.bja.2021.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [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: 09/01/2021] [Revised: 10/01/2021] [Accepted: 10/03/2021] [Indexed: 01/31/2023] Open
Abstract
Background Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking. Methods A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg kg−1 or intermediate-dose dexamethasone 0.3 mg kg−1 in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and Opioid-Related Symptom Distress Scale, readmission, and complications. Results Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P=0.02 and 12% vs 31%, P=0.03, respectively). C-reactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01). Conclusions When compared with preoperative dexamethasone 0.3 mg kg−1 i.v., dexamethasone 1 mg kg−1 reduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects. Clinical trial registration NCT03763734.
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Affiliation(s)
- Niklas I Nielsen
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark.
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
| | - Claus Varnum
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Lasse E Rasmussen
- Department of Orthopaedic Surgery, Lillebaelt Hospital, Vejle, Denmark
| | | | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University, Hvidovre Hospital, Copenhagen, Denmark
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18
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Agerskov M, Thusholdt ANW, Holm-Sørensen H, Wiberg S, Meyhoff CS, Højlund J, Secher NH, Foss NB. Association of the intraoperative peripheral perfusion index with postoperative morbidity and mortality in acute surgical patients: a retrospective observational multicentre cohort study. Br J Anaesth 2021; 127:396-404. [PMID: 34226038 PMCID: PMC8451236 DOI: 10.1016/j.bja.2021.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/02/2021] [Indexed: 12/02/2022] Open
Abstract
Background We hypothesised that in acute high-risk surgical patients, a lower intraoperative peripheral perfusion index (PPI) would indicate a higher risk of postoperative complications and mortality. Methods This retrospective observational study included 1338 acute high-risk surgical patients from November 2017 until October 2018 at two University Hospitals in Denmark. Intraoperative PPI was the primary exposure variable and the primary outcome was severe postoperative complications defined as a Clavien–Dindo Class ≥III or death, within 30 days. Results intraoperative PPI was associated with severe postoperative complications or death: odds ratio (OR) 1.12 (95% confidence interval [CI] 1.05–1.19; P<0.001), with an association of intraoperative mean PPI ≤0.5 and PPI ≤1.5 with the primary outcome: OR 1.79 (95% CI 1.09–2.91; P=0.02) and OR 1.65 (95% CI 1.20–2.27; P=0.002), respectively. Each 15-min increase in intraoperative time spend with low PPI was associated with the primary outcome (per 15 min with PPI ≤0.5: OR 1.11 (95% CI 1.05–1.17; P<0.001) and with PPI ≤1.5: OR 1.06 (95% CI 1.02–1.09; P=0.002)). Thirty-day mortality in patients with PPI ≤0.5 was 19% vs 10% for PPI >0.5, P=0.003. If PPI was ≤1.5, 30-day mortality was 16% vs 8% in patients with a PPI >1.5 (P<0.001). In contrast, intraoperative mean MAP ≤65 mm Hg was not significantly associated with severe postoperative complications or death (OR 1.21 [95% CI 0.92–1.58; P=0.2]). Conclusions Low intraoperative PPI was associated with severe postoperative complications or death in acute high-risk surgical patients. To guide intraoperative haemodynamic management, the PPI should be further investigated.
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Affiliation(s)
- Marianne Agerskov
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
| | - Anna N W Thusholdt
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Holm-Sørensen
- Department of Integrative Physiology, NEXS, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Wiberg
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jakob Højlund
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Secher
- Department of Anaesthesiology, Centre for Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
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19
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Cihoric M, Kehlet H, Lauritsen ML, Højlund J, Kanstrup K, Foss NB. Inflammatory response, fluid balance and outcome in emergency high-risk abdominal surgery. Acta Anaesthesiol Scand 2021; 65:730-739. [PMID: 33548067 DOI: 10.1111/aas.13792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 11/08/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND The main disease etiologies requiring emergency high-risk abdominal surgery are intestinal obstruction and perforated viscus and the differences in immune response to these pathologies are largely unexplored. In search of improvement of patient assessment in the perioperative phase, we examined the inflammatory response in this setting, focusing on potential difference in pathophysiology. METHODS The electronic medical records of 487 patients who underwent emergency abdominal surgery from year 2013-2015 for intestinal obstruction and perforated viscus were reviewed. We evaluated the relationship between pre- and postoperative C-reactive protein (CRP) trajectory, fluid balance, and perioperative morbidity and mortality according to type of surgery, intervention, and surgical pathology. RESULTS A total of 418 patients were included. Pre- and postoperative absolute CRP values were significantly higher in patients with perforated viscus (n = 203) than in intestinal obstruction (n = 215) (P < .0001). Relative changes at hour 6 and POD 1 were non-significant (P = .716 and P = .816 respectively). There was significant association between both pre- (quartile 1 vs 4, OR 5.11; P < .01) and postoperative (quartile 1 vs 4, OR 4.10; P < .001) CRP and adverse outcome, along with fluid balance and adverse outcome in patients with obstruction but not in those with perforation. Fluid balance and CRP had statistically significant positive correlation in patients with obstruction. CONCLUSIONS In this explorative study, a high pre- and postoperative CRP and a high positive fluid balance were associated with worse outcome in patients with intestinal obstruction, but not in patients with perforated viscus. Future studies should address the different inflammatory and fluid trajectories in these specific pathologies.
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Affiliation(s)
- Mirjana Cihoric
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Henrik Kehlet
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Morten L. Lauritsen
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Jakob Højlund
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Katrine Kanstrup
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
| | - Nicolai B. Foss
- Department of Anesthesiology and Intensive Care Medicine Hvidovre University Hospital Copenhagen Denmark
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20
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Sort R, Brorson S, Gögenur I, Hald LL, Nielsen JK, Salling N, Hougaard S, Foss NB, Tengberg PT, Klausen TW, Møller AM. Peripheral nerve block anaesthesia and postoperative pain in acute ankle fracture surgery: the AnAnkle randomised trial. Br J Anaesth 2021; 126:881-888. [PMID: 33546844 DOI: 10.1016/j.bja.2020.12.037] [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: 10/05/2020] [Revised: 12/07/2020] [Accepted: 12/29/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) are increasingly popular in acute ankle fracture surgery but rebound pain may outweigh the benefits. The AnAnkle Trial was designed to assess the postoperative pain profile of PNB anaesthesia compared with spinal anaesthesia (SA). METHODS The AnAnkle Trial was a randomised, two-centre, blinded outcome analysis trial. Eligible adults booked for primary ankle fracture surgery were randomised to PNB or SA. The PNBs were ultrasound-guided popliteal sciatic and saphenous blocks with ropivacaine and SAs were with hyperbaric bupivacaine. Postoperatively, all subjects received paracetamol, ibuprofen, and patient-controlled i.v. morphine for pain. The primary endpoint was 27 h Pain Intensity and Opioid Consumption (PIOC) score. Secondary endpoints included longitudinal pain scores and morphine consumption separately, and questionnaires on quality of recovery. RESULTS This study enrolled 150 subjects, and the PNB success rate was >94%. PIOC was lower with PNB anaesthesia (median, -26.5% vs +54.3%; P<0.001) and the probability of a better PIOC score with PNB than with SA was 74.8% (95% confidence interval, 67.0-82.6). Pain scores and morphine consumption analysed separately also yielded a clear benefit with PNB, despite substantial rebound pain when PNBs subsided. Quality of recovery scores were similar between groups, but 99% having PNB vs 90% having SA would choose the same anaesthesia form again (P=0.03). CONCLUSIONS PNB anaesthesia was efficient and provided a superior postoperative pain profile compared with SA for acute ankle fracture surgery, despite potentially intense rebound pain after PNB. CLINICAL TRIAL REGISTRATION Clinicaltrialsregister.eu, EudraCT number: 2015-001108-76.
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Affiliation(s)
- Rune Sort
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark.
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- Department of Surgery, Centre for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Lasse L Hald
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
| | - Jesper K Nielsen
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
| | - Nanna Salling
- Department of Orthopaedic Surgery, Herlev and Gentofte University Hospital, Herlev, Denmark; Department of Orthopaedic Surgery, Nykøbing Falster Hospital, Nykøbing Falster, Denmark
| | - Sine Hougaard
- Department of Anaesthesiology, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Peter T Tengberg
- Department of Orthopaedic Surgery, Amager and Hvidovre University Hospital, Hvidovre, Denmark
| | - Tobias W Klausen
- Department of Haematology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | - Ann M Møller
- Department of Anaesthesiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
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21
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Gromov K, Grassin-Delyle S, Foss NB, Pedersen LM, Nielsen CS, Lamy E, Troelsen A, Urien S, Husted H. Population pharmacokinetics of ropivacaine used for local infiltration anaesthesia during primary total unilateral and simultaneous bilateral knee arthroplasty. Br J Anaesth 2021; 126:872-880. [PMID: 33455802 DOI: 10.1016/j.bja.2020.11.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 11/02/2020] [Accepted: 11/06/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Ropivacaine is commonly used in local infiltration anaesthesia (LIA) as pain management after total knee arthroplasty (TKA). Although considered safe, no studies evaluated the pharmacokinetics of high-dose ropivacaine infiltration in simultaneous bilateral TKA. METHODS We studied 13 patients undergoing unilateral and 15 undergoing bilateral TKA. Standard LIA technique was used with ropivacaine 0.2%, 200 ml (400 mg) injected peri-articularly in each knee. Free and total plasma concentrations of ropivacaine were measured within 24 h using liquid chromatography-mass spectrometry. A population pharmacokinetic model was built using non-linear mixed-effects models. RESULTS Peak free ropivacaine concentration was 0.030 (0.017-0.071) μg ml-1 (mean [99% confidence interval]) vs 0.095 (0.047-0.208) μg ml-1, and peak total ropivacaine concentration was 0.756 (0.065-1.222) μg ml-1vs 1.695 (0.077-3.005) μg ml-1 for unilateral and bilateral TKA, respectively. The pharmacokinetics was ascribed a one-compartment model with first-order absorption. The main identified covariates were protein binding, allometrically scaled body weight on clearance and volume, and unilateral or bilateral surgery on volume. CONCLUSIONS This is the first study to investigate the pharmacokinetics of free and total ropivacaine after unilateral and bilateral TKA. A population model was successfully built and peak free ropivacaine concentration stayed below previously proposed toxic thresholds in patients undergoing unilateral and bilateral TKA receiving LIA with high-dose ropivacaine. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04702282.
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Affiliation(s)
- Kirill Gromov
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.
| | - Stanislas Grassin-Delyle
- Université Paris-Saclay, UVSQ, INSERM, Infection et Inflammation, Département de Biotechnologie de la Santé, Montigny le Bretonneux, France; Hôpital Foch, Département des Maladies des Voies Respiratoires, Suresnes, France
| | - Nicolai B Foss
- Department of Anesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lars Møller Pedersen
- Department of Anesthesiology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Christian S Nielsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Elodie Lamy
- Université Paris-Saclay, UVSQ, INSERM, Infection et Inflammation, Département de Biotechnologie de la Santé, Montigny le Bretonneux, France
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Saik Urien
- Unité de Recherche Clinique Necker-Cochin, Inserm, Université de Paris, Paris, France
| | - Henrik Husted
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Ronit A, Berg RMG, Bay JT, Haugaard AK, Ahlström MG, Burgdorf KS, Ullum H, Rørvig SB, Tjelle K, Foss NB, Benfield T, Marquart HV, Plovsing RR. Compartmental immunophenotyping in COVID-19 ARDS: A case series. J Allergy Clin Immunol 2020; 147:81-91. [PMID: 32979342 PMCID: PMC7581505 DOI: 10.1016/j.jaci.2020.09.009] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [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: 06/17/2020] [Revised: 08/27/2020] [Accepted: 09/03/2020] [Indexed: 12/18/2022]
Abstract
Background Severe immunopathology may drive the deleterious manifestations that are observed in the advanced stages of coronavirus disease 2019 (COVID-19) but are poorly understood. Objective Our aim was to phenotype leukocyte subpopulations and the cytokine milieu in the lungs and blood of critically ill patients with COVID-19 acute respiratory distress syndrome (ARDS). Methods We consecutively included patients less than 72 hours after intubation following informed consent from their next of kin. Bronchoalveolar lavage fluid was evaluated by microscopy; bronchoalveolar lavage fluid and blood were assessed by 10-color flow cytometry and a multiplex cytokine panel. Results Four mechanically ventilated patients (aged 40-75 years) with moderate-to-severe COVID-19 ARDS were included. Immature neutrophils dominated in both blood and lungs, whereas CD4 and CD8 T-cell lymphopenia was observed in the 2 compartments. However, regulatory T cells and TH17 cells were found in higher fractions in the lung. Lung CD4 and CD8 T cells and macrophages expressed an even higher upregulation of activation markers than in blood. A wide range of cytokines were expressed at high levels both in the blood and in the lungs, most notably, IL-1RA, IL-6, IL-8, IP-10, and monocyte chemoattactant protein-1, consistent with hyperinflammation. Conclusion COVID-19 ARDS exhibits a distinct immunologic profile in the lungs, with a depleted and exhausted CD4 and CD8 T-cell population that resides within a heavily hyperinflammatory milieu.
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Affiliation(s)
- Andreas Ronit
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ronan M G Berg
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Physiology, Nuclear Medicine and PET and Centre for Physical Activity Research, University of Copenhagen, Copenhagen, Denmark; Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, United Kingdom
| | - Jakob T Bay
- Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
| | - Anna K Haugaard
- Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
| | - Magnus G Ahlström
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark
| | | | - Henrik Ullum
- Department of Clinical Immunology, University of Copenhagen, Copenhagen, Denmark
| | - Sara B Rørvig
- Department of Pathology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Tjelle
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Ronni R Plovsing
- Department of Anesthesiology and Intensive Care, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark.
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Nielsen NI, Kehlet H, Gromov K, Troelsen A, Husted H, Varnum C, Kjærsgaard‐Andersen P, Rasmussen LE, Mandøe H, Foss NB. Preoperative high-dose Steroids in Total Knee and Hip Arthroplasty - Protocols for three randomized controlled trials. Acta Anaesthesiol Scand 2020; 64:1350-1356. [PMID: 32533723 DOI: 10.1111/aas.13656] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients undergoing total knee arthroplasty (TKA)/ total hip arthroplasty (THA) still experience moderate-severe postoperative pain despite optimized pain management regimes. The patients already on opioid treatment and pain catastrophizers (PCs) have a higher risk of postoperative pain. The use of preoperative intravenous high-dose glucocorticoids decreases postoperative pain after TKA and THA, but optimal dose is yet to be found, and the effect on subpopulations at high pain risk is unknown. AIM To investigate the effect of a higher than previously used dose of glucocorticoids (dexamethasone (DXM)), administered intravenously before surgery, as part of standardized fast-track regimen, on postoperative pain in TKA/THA subgroups. METHOD Three separate randomized, double-blinded, controlled trials were planned to compare a new higher dose DXM (1 mg/kg) to the earlier used high-dose DXM (0.3 mg/kg). Study 1: predicted Low Pain TKA; study 2: predicted High Pain Responder (HPR) TKA; study 3: predicted HPR THA. Predicted HPR groups consist of either PCs with PCS-score of ≥ 21 and/or history of ongoing opioid-treatment of 30 mg/day of morphine or equivalents > 30 days. In total, 408 patients were planned for inclusion (160 Low Pain TKA, 88 HPR TKA, 160 HPR THA). PRIMARY OUTCOME Pain upon ambulation in a 5-meter walk test 24 hours after surgery. Secondary outcomes include use of analgesics, rescue-opioids, antiemetics, cumulated pain, CRP, OR-SDS, QoR-15, quality of sleep, length of stay (LOS), reasons for hospitalization, readmission, morbidity, and mortality. Patients completed follow-up on day 90. Recruiting commenced February 2019 and is expected to finish in September 2020.
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Affiliation(s)
- Niklas I. Nielsen
- Department of Anaesthesiology Copenhagen UniversityHvidovre Hospital Hvidovre Denmark
| | - Henrik Kehlet
- Section of Surgical Pathophysiology 7621, RigshospitaletUniversity of Copenhagen Blegdamsvej Denmark
| | - Kirill Gromov
- Department of Orthopedic Surgery Copenhagen UniversityHvidovre Hospital Hvidovre Denmark
| | - Anders Troelsen
- Department of Orthopedic Surgery Copenhagen UniversityHvidovre Hospital Hvidovre Denmark
| | - Henrik Husted
- Department of Orthopedic Surgery Copenhagen UniversityHvidovre Hospital Hvidovre Denmark
| | - Claus Varnum
- Department of Orthopedic Surgery Lillebaelt Hospital ‐ Vejle Vejle Denmark
| | | | - Lasse E. Rasmussen
- Department of Orthopedic Surgery Lillebaelt Hospital ‐ Vejle Vejle Denmark
| | - Hans Mandøe
- Department of Anaesthesiology Lillebaelt Hospital –Vejle Vejle Denmark
| | - Nicolai B. Foss
- Department of Anaesthesiology Copenhagen UniversityHvidovre Hospital Hvidovre Denmark
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24
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
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25
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Abstract
Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.
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Affiliation(s)
- N B Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - H Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Baumgarten M, Brødsgaard A, Bunkenborg G, Foss NB, Nørholm V. Nurse and Physician Perceptions of Working With Goal-Directed Therapy in the Perioperative Period. J Perianesth Nurs 2019; 35:198-205. [PMID: 31843240 DOI: 10.1016/j.jopan.2019.09.005] [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: 04/08/2019] [Revised: 08/26/2019] [Accepted: 09/04/2019] [Indexed: 11/17/2022]
Abstract
PURPOSE To explore nurse and physician perceptions of working with and collaborating about arterial wave analysis for goal-directed therapy to identify barriers and facilitators for use in anesthesia departments, postanesthesia care units, and intensive care units. DESIGN A qualitative study drawing on ethnographic principles in a field study using the technique of nonparticipating observation and semistructured interviews. METHODS Data collection occurred using semistructured interviews with nurses (n = 23) and physicians (n = 12) and field observations in three anesthetic departments. An inductive approach for content analysis was used. FINDINGS The results showed one overarching theme Interprofessional collaboration encourage and impede based on three categories: (1) interprofessional and professional challenges; (2) obtaining competencies; and (3) understanding optimal fluid treatment. CONCLUSIONS Several barriers identified related to interprofessional collaboration. Nurses and physicians were dependent on each other's skills and capabilities to use arterial wave analysis. Education of nurses and physicians is important to secure optimal use of goal-directed therapy.
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Affiliation(s)
- Mette Baumgarten
- Department of Anaesthesiology, Copenhagen University Hospital Amagaer Hvidovre, Copenhagen, Denmark.
| | - Anne Brødsgaard
- Department of Pediatrics and Adolescent Medicine, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
| | - Gitte Bunkenborg
- Department of Anaesthesiology, Holbaek University Hospital, Region Zealand, Denmark
| | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University Hospital Amagaer Hvidovre, Copenhagen, Denmark
| | - Vibeke Nørholm
- Clinical Research Center, Copenhagen University Hospital Amager Hvidovre, Copenhagen, Denmark
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Clemmesen CG, Palm H, Foss NB. Delay in detection and treatment of perioperative anemia in hip fracture surgery and its impact on postoperative outcomes. Injury 2019; 50:2034-2039. [PMID: 31537309 DOI: 10.1016/j.injury.2019.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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] [Received: 03/19/2019] [Revised: 08/18/2019] [Accepted: 09/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elderly patients with hip fractures are at high risk for perioperative anemia as a result of fracture- and surgery-related blood loss. The detection of anemia is dependent on intermittent blood samples and therefore might be delayed, potentially leading to a significant delay in transfusion. This study aimed to investigate the possible delay in perioperative anemia detection, accumulated perioperative anemia-associated burden, peripheral perfusion, and their association with patient outcomes in elderly patients with hip fracture. METHODS Elderly patients with acute hip fracture scheduled for surgery were enrolled in this prospective study from August 2016 to December 2016. All patients were monitored continuously for hemoglobin concentration (SpHb) and perfusion index (PI) with the Radical-7® Pulse CO-Oximeter® and Rainbow® R1 Adhesive Multi-parameter Sensors (Masimo Corp., Irvine, CA, US) from 12 h presurgery to 24 h postsurgery. RESULTS Fifty-one patients were enrolled, and 41 were included in the final analyses. Mean delay in the detection of low Hb (<10 g/dL) using intermittent blood samples, when compared with SpHb, was 1.07 h (standard deviation, ±2.84 h). Median perioperative cumulated time with low SpHb (<10 g/dL for at least one min) was 25 min (interquartile range [IQR]: 21-690). There was a significant association between perioperative time with low SpHb and the occurrence of postoperative delirium (median cumulated time with low SpHb: 162 min in patients with delirium vs 22 min in patients without delirium, P = 0.034) and a nonsignificant trend for an association between perioperative time with low SpHb and 90-day mortality or medical complications (median cumulated time with low SpHb: 119 min for patients with mortality or severe complication vs 22 min for patients without mortality or severe complication, P = 0.104). PI values during the perioperative period were not significantly associated with patient outcomes. Cumulated time with low PI (<0.5) preoperatively (but not perioperatively) was significantly associated with the occurrence of postoperative delirium (P = 0.047). CONCLUSIONS This study showed a delay in transfusion threshold detection, and the presence of significant associations between low SpHb or time with low SpHb and postoperative outcomes.
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Affiliation(s)
- Christopher G Clemmesen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark.
| | - H Palm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 København NV, Denmark.
| | - Nicolai B Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark.
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Clemmesen CG, Tavenier J, Andersen O, Palm H, Foss NB. Methylprednisolone and inflammatory stress response in older people undergoing surgery for hip fracture: a secondary analysis of a randomized controlled trial. Eur Geriatr Med 2019; 10:913-921. [DOI: 10.1007/s41999-019-00231-y] [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: 06/09/2019] [Accepted: 08/21/2019] [Indexed: 01/13/2023]
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Foss NB, Kehlet H. Perioperative haemodynamics and vasoconstriction: time for reconsideration? Br J Anaesth 2019; 123:100-103. [PMID: 31153629 DOI: 10.1016/j.bja.2019.04.052] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 12/15/2022] Open
Affiliation(s)
- Nicolai B Foss
- Department of Anesthesiology, Hvidovre University Hospital, Hvidovre, Denmark.
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
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Abstract
As longevity increases globally, the number of older, frailer, comorbid patients requiring fragility fracture surgery will increase. Fundamentally, anaesthesia should aim to maintain these patients' pre-fracture cognitive and physiological trajectories and facilitate early (ie day 1) postoperative recovery. This review describes the 10 general principles of anaesthesia for fragility fracture surgery that best achieve these aims: multidisciplinary care, 'getting it right first time', timely surgery, standardisation, sympathetic anaesthesia, avoiding ischaemia, sympathetic analgesia, re-enablement, data collection and training.
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Affiliation(s)
- S M White
- FRCA, Brighton and Sussex University Hospitals NHS Trust, Eastern Road, Brighton, East Sussex, BN2 5BE, United Kingdom.
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Hvidovre University Hospital, Kettegård Allé 30, Hvidovre, Denmark
| | - R Griffiths
- North West Anglia Hospitals NHS FT, Bretton Gate, Peterborough, PE3 9GZ, United Kingdom
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Holler CP, Lohse N, Foss NB. Anaesthesia practice in Denmark for relocation of the dislocated hip after total hip arthroplasty. Dan Med J 2018; 65:A5480. [PMID: 29726317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The prevalence of hip dislocations after total hip arthroplasty (THA) is 2-4% in Denmark. Patients with a dislocated THA are often elderly citizens with comorbidities and severe pain in the pre-reposition phase. Evidence as to which method of anaesthesia and airway management is best for hip relocation is lacking. The aim of this study was to determine how anaesthesiologists in Denmark provide anaesthesia for relocation of THAs, and if a local guideline is available. METHODS A questionnaire was distributed by e-mail to all members of the Danish Association of Anaesthesiology and Intensive Care and the Danish Society of Young Anaesthesiologists. RESULTS A total of 480 doctors completed the questionnaire. Of these, 61% (291/480) worked at a department providing anaesthesia for relocation of THAs of whom 85% (248/291) had provided anaesthesia during at least one hip dislocation during the past two years. A total of 27% (67/248) had access to a local guideline of whom 72% (48/67) followed the guideline. In all, 55% (134/248) preferred the patient to be fasting before anaesthesia. The preferred methods of anaesthesia were general anaesthesia with laryngeal mask 43% (106/248) and endotracheal intubation 45% (112/248). 5% (12/248) had experienced complications to anaesthesia. Cardiovascular complications and aspiration were the most frequently reported complications. CONCLUSIONS Provision of anaesthesia for relocation of a dislocated THA varies across Denmark. Few anaesthesi-ologists have access to a local guideline. FUNDING none. TRIAL REGISTRATION not relevant.
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Abstract
Background and purpose - An enhanced treatment program may decrease 30-day mortality below 20% after lower extremity amputations (LEA). The potential and limitations for further reduction are unknown. We analyzed postoperative causes of 30-day mortality, and assessed failure to rescue (FTR) rate in LEA patients who followed an enhanced treatment program. Patients and methods - Medical charts of 195 primary LEA procedures were reviewed independently by 3 of the authors, and deaths during hospitalization following amputation were classified according to consensus. Results - 31 patients died within 30 days after surgery. 4 deaths were classified as "definitely unavoidable," 4 as "probably unavoidable," and 23 as "FTR." Patients who died had a higher incidence of sepsis, pneumonia, and acute myocardial infarction compared with those alive. A log binominal regression analysis adjusted for age, sex, ASA score, diabetes, nursing home admission, transfemoral amputation (TFA), and BMI showed that the risk of 30-day mortality was increased for TFA (RR =2.3, 95% CI 1.1-4.8) and for patients with diabetes (RR =2.7, 95% CI 1.3-5.6). The FTR rate (patients with 30-day mortality/all patients with a severe postoperative complication) was 30%. Of the FTR deaths, 20 at some point had active lifesaving care curtailed. Interpretation - Future initiatives should be directed at enhanced sepsis and pneumonia prophylactic actions, in addition to close monitoring of hemodynamics in anemic patients, with the potential to further reduce morbidity and mortality rates.
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Affiliation(s)
- Christian Wied
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre,Correspondence:
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre
| | - Peter T Tengberg
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
| | - Gitte Holm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre
| | - Morten T Kristensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre,Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital Hvidovre, Denmark
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Clemmesen CG, Pedersen LM, Hougaard S, Andersson ML, Rosenkvist V, Nielsen HB, Palm H, Foss NB. Cerebral oximetry during preoperative resuscitation in elderly patients with hip fracture: a prospective observational study. J Clin Monit Comput 2018; 32:1033-1040. [PMID: 29404892 DOI: 10.1007/s10877-018-0107-6] [Citation(s) in RCA: 10] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 01/28/2018] [Indexed: 01/30/2023]
Abstract
This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO2), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO2 was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO2 was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO2 values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO2 was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO2 nadir values were also significant lower (p = 0.047). Low ScO2 during initial resuscitation (defined as ScO2 < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO2 was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.
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Affiliation(s)
- C G Clemmesen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark.
| | - L M Pedersen
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - S Hougaard
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
| | - M L Andersson
- Department of Anaesthesiology, Copenhagen University Hospital, Herlev & Gentofte, Denmark
| | - V Rosenkvist
- Department of Respiratory Medicine, Copenhagen University Hospital, Herlev & Gentofte, Denmark
| | - H B Nielsen
- Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | - H Palm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology, Copenhagen University Hospital Hvidovre, Kettegaard Alle 30, 2650, Hvidovre, Denmark
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Wied C, Tengberg PT, Kristensen MT, Holm G, Kallemose T, Troelsen A, Foss NB. Total Blood Loss After Transfemoral Amputations Is Twice the Intraoperative Loss: An Observational Cohort Study of 81 Nontraumatic Amputations. Geriatr Orthop Surg Rehabil 2017; 8:123-127. [PMID: 28835867 PMCID: PMC5557193 DOI: 10.1177/2151458517706595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 02/15/2017] [Accepted: 02/16/2017] [Indexed: 12/14/2022] Open
Abstract
Introduction: Underestimation of the actual blood loss in patients undergoing nontraumatic transfemoral amputation (TFA) can impact negatively on outcome in these often frail patients, with very limited physiological reserves. The primary aim of this study is to estimate the total blood loss (TBL) after TFA, and second, to evaluate the impact of blood loss on 30-day mortality and medical complications. Methods: A single-center retrospective cohort study conducted from 2013 to 2015. The TBL was calculated on the fourth postoperative day. It was based on the hemoglobin levels, transfusions, and the estimated blood volume. Results: Eighty-one patients undergoing TFA were included for final analysis. The median TBL was 964 mL (interquartile range [IQR]: 443-1558). The intraoperative blood loss (OBL) was 400 mL (IQR: 200-500). The median difference between TBL and OBL was 688 mL (IQR: 124-1075). The patient received red blood cell (RBC) transfusion of a median amount of 2 units. Higher number of transfusions (>2) did not impact the outcome. From multivariable analysis, it was evident that the TBL increased significantly in patients with renal disease prior to surgery, (P = .034). The TBL itself was not independently associated with increased 30-day mortality or medical complications. Conclusion: The TBL after TFAs is significantly greater than the volume estimated intraoperatively and increases significantly in the presence of renal disease prior to surgery. An increased TBL and requirement for RBC transfusion is not directly associated with 30-day mortality or medical complications. A high vigilance for anemia seems advisable when planning for TFA surgery. Research on optimum blood conservation and transfusion strategies during TFA is warranted.
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Affiliation(s)
- Christian Wied
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Peter T Tengberg
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Morten T Kristensen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Gitte Holm
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Thomas Kallemose
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Clinical Research Centre, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Anders Troelsen
- Department of Orthopaedic Surgery, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Nicolai B Foss
- Department of Anesthesiology and Intensive Care, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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Münter KH, Clemmesen CG, Foss NB, Palm H, Kristensen MT. Fatigue and pain limit independent mobility and physiotherapy after hip fracture surgery. Disabil Rehabil 2017; 40:1808-1816. [DOI: 10.1080/09638288.2017.1314556] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kristine H. Münter
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | | | - Nicolai B. Foss
- Department of Anaesthesiology, Hvidovre University Hospital, Hvidovre, Denmark
| | - Henrik Palm
- Hip Fracture Unit, Department of Orthopaedic Surgery, Hvidovre University Hospital, Hvidovre, Denmark
| | - Morten T. Kristensen
- Hip Fracture Unit, Department of Orthopaedic Surgery, Hvidovre University Hospital, Hvidovre, Denmark
- Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C), Department of Physiotherapy, Copenhagen University Hospital, Hvidovre, Denmark
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Tengberg PT, Foss NB, Palm H, Kallemose T, Troelsen A. Tranexamic acid reduces blood loss in patients with extracapsular fractures of the hip: results of a randomised controlled trial. Bone Joint J 2017; 98-B:747-53. [PMID: 27235515 DOI: 10.1302/0301-620x.98b6.36645] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [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] [Received: 06/05/2015] [Accepted: 01/21/2016] [Indexed: 01/21/2023]
Abstract
AIMS We chose unstable extra-capsular hip fractures as our study group because these types of fractures suffer the largest blood loss. We hypothesised that tranexamic acid (TXA) would reduce total blood loss (TBL) in extra-capsular fractures of the hip. PATIENTS AND METHODS A single-centre placebo-controlled double-blinded randomised clinical trial was performed to test the hypothesis on patients undergoing surgery for extra-capsular hip fractures. For reasons outside the control of the investigators, the trial was stopped before reaching the 120 included patients as planned in the protocol. RESULTS In all 72 patients (51 women, 21 men; 33 patients in the TXA group, 39 in the placebo group) were included in the final analysis, with a significant mean reduction of 570.8 ml (p = 0.029) in TBL from 2100.4 ml (standard deviation (sd) = 1152.6) in the placebo group to 1529.6 ml (sd = 1012.7) in the TXA group. The 90-day mortality was 27.2% (n = 9) in the TXA group and 10.2% (n = 4) in the placebo group (p = 0.07). We were not able to ascertain a reliable cause of death in these patients. DISCUSSION TXA significantly reduced TBL in extra-capsular hip fractures, but concerns regarding its safety in this patient group must be investigated further before the use of TXA can be recommended. TAKE HOME MESSAGE We present a randomised clinical trial that is unique in the literature. We evaluate the effect of TXA in very homogenous population - extra-capsular fractures operated with short intramedullary nails. Cite this article: Bone Joint J 2016;98-B:747-53.
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Affiliation(s)
- P T Tengberg
- Copenhagen University Hospital , Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital , Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - H Palm
- Copenhagen University Hospital , Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - T Kallemose
- Copenhagen University Hospital , Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
| | - A Troelsen
- Copenhagen University Hospital , Hvidovre, Kettegaard Alle 30, 2650 Hvidovre, Denmark
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Tengberg LT, Bay-Nielsen M, Bisgaard T, Cihoric M, Lauritsen ML, Foss NB, Orbæk J, Veyhe L, Jørgen Nielsen H, Lindgaard L. Multidisciplinary perioperative protocol in patients undergoing acute high-risk abdominal surgery. Br J Surg 2017; 104:463-471. [DOI: 10.1002/bjs.10427] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/30/2016] [Accepted: 10/07/2016] [Indexed: 12/23/2022]
Abstract
Abstract
Background
Acute high-risk abdominal (AHA) surgery carries a very high risk of morbidity and mortality and represents a massive healthcare burden. The aim of the present study was to evaluate the effect of a standardized multidisciplinary perioperative protocol in patients undergoing AHA surgery.
Methods
The AHA study was a prospective single-centre controlled study in consecutive patients undergoing AHA surgery, defined as major abdominal pathology requiring emergency laparotomy or laparoscopy including reoperations after elective gastrointestinal surgery. Consecutive patients were included after initiation of the AHA protocol as standard care. The intervention cohort was compared with a predefined, consecutive historical cohort of patients from the same department. The protocol involved continuous staff education, consultant-led attention and care, early resuscitation and high-dose antibiotics, surgery within 6 h, perioperative stroke volume-guided haemodynamic optimization, intermediate level of care for the first 24 h after surgery, standardized analgesic treatment, early postoperative ambulation and early enteral nutrition. The primary outcome was 30-day mortality.
Results
Six hundred patients were included in the study and compared with 600 historical controls. The unadjusted 30-day mortality rate was 21·8 per cent in the control cohort compared with 15·5 per cent in the intervention cohort (P = 0·005). The 180-day mortality rates were 29·5 and 22·2 per cent respectively (P = 0·004).
Conclusion
The introduction of a multidisciplinary perioperative protocol was associated with a significant reduction in postoperative mortality in patients undergoing AHA surgery. NCT01899885 (http://www.clinicaltrials.gov).
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Affiliation(s)
- L T Tengberg
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Bay-Nielsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - T Bisgaard
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - M L Lauritsen
- Gastro Unit Surgical Division, Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital, Hvidovre, Denmark
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Wied C, Tengberg PT, Holm G, Kallemose T, Foss NB, Troelsen A, Kristensen MT. Tourniquets do not increase the total blood loss or re-amputation risk in transtibial amputations. World J Orthop 2017; 8:62-67. [PMID: 28144581 PMCID: PMC5241547 DOI: 10.5312/wjo.v8.i1.62] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 10/11/2016] [Accepted: 12/09/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the total blood loss (TBL) and the safety with respect to the re-amputation rate after transtibial amputation (TTA) conducted with and without a tourniquet.
METHODS The study was a single-centre retrospective cohort study of patients with a primary TTA admitted between January 2013 and April 2015. All patients with a primary TTA were assessed for inclusion if the amputation was performed because of arteriosclerosis or diabetic complications. All patients underwent a standardized TTA procedure that was performed approximately 10 cm below the knee joint and performed with sagittal flaps. The pneumatic tourniquet, when used, was inflated around the femur to a pressure of 100 mmHg above the systolic blood pressure. The number of blood transfusions within the first four postoperative days was recorded. The intraoperative blood loss (OBL), which is defined as the volume of blood lost during surgery, was determined from the suction volume and by the weight difference of the surgical dressings. The trigger for a blood transfusion was set at a decrease in the Hgb level < 9.67 g/dL (6 mmol/L). Transfusions were performed with pooled red blood cells containing 245 mL per portion, which equals 55 g/L of haemoglobin. The TBL during the first four postoperative days was calculated based on the haemoglobin level and the estimated blood volume. The re-amputation rate was evaluated within 30 d.
RESULTS Seventy-four out of 86 consecutive patients who underwent TTA within the two-year study period were included in the analysis. Of these, 38 were operated on using a tourniquet and 36 were operated on without using a tourniquet. There were no significant preoperative differences between the groups. The patients in both groups had a postoperative decrease in their Hgb level compared with preoperative baseline values. The patients operated on using a tourniquet received approximately three millilitres less blood transfusion per kilogram body weight compared with patients operated on without a tourniquet. The duration of surgery was shorter and the OBL was less for the tourniquet group than the non-tourniquet group, whereas no significant difference was observed for the TBL. The TBL median was 859 mL (IQR: 383-1315) in the non-tourniquet group vs 737 mL (IQR: 331-1218) in the tourniquet group (P = 0.754). Within the 30-d follow-up period, 9 patients in the tourniquet group and 11 in the non-tourniquet group underwent a re-amputation at the trans-femoral level. The use of a tourniquet showed no statistically significant association with the 30-d re-amputation at the femur level in the multiple logistic regression model (P = 0.78). The only variable with a significant association with re-amputation was age (OR = 1.07; P = 0.02).
CONCLUSION The results indicate that tourniquets do not cause severe vascular damage with an increased postoperative bleeding or failure rate as the result.
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Wied C, Foss NB, Kristensen MT, Holm G, Kallemose T, Troelsen A. Surgical apgar score predicts early complication in transfemoral amputees: Retrospective study of 170 major amputations. World J Orthop 2016; 7:832-838. [PMID: 28032037 PMCID: PMC5155260 DOI: 10.5312/wjo.v7.i12.832] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 08/25/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess whether the surgical apgar score (SAS) is a prognostic tool capable of identifying patients at risk of major complications following lower extremity amputations surgery.
METHODS This was a single-center, retrospective observational cohort study conducted between January 2013 and April 2015. All patients who had either a primary transtibial amputation (TTA) or transfemoral amputation (TFA) conducted at our institution during the study period were assessed for inclusion. All TTA patients underwent a standardized one-stage operative procedure (ad modum Persson amputation) performed approximately 10 cm below the knee joint. All TTA procedures were performed with sagittal flaps. TFA procedures were performed in one stage with amputation approximately 10 cm above the knee joint, performed with anterior/posterior flaps. Trained residents or senior consultants performed the surgical procedures. The SAS is based on intraoperative heart rate, blood pressure and blood loss. Intraoperative parameters of interest were collected by revising electronic health records. The first author of this study calculated the SAS. Data regarding major complications were not revealed to the author until after the calculation of SAS. The SAS results were arranged into four groups (SAS 0-4, SAS 5-6, SAS 7-8 and SAS 9-10). The cohort was then divided into two groups representing low-risk (SAS ≥ 7) and high-risk patients (SAS < 7) using a previously established threshold. The outcome of interest was the occurrence of major complications and death within 30-d of surgery.
RESULTS A logistic regression model with SAS 9-10 as a reference showed a significant linear association between lower SAS and more postoperative complications [all patients: OR = 2.00 (1.33-3.03), P = 0.001]. This effect was pronounced for TFA [OR = 2.61 (1.52-4.47), P < 0.001]. A significant increase was observed for the high-risk group compared to the low-risk group for all patients [OR = 2.80 (1.40-5.61), P = 0.004] and for the TFA sub-group [OR = 3.82 (1.5-9.42), P = 0.004]. The AUC from the models were estimated as follows: All patients = [0.648 (0.562-0.733), P = 0.001], for TFA patients = [0.710 (0.606-0.813), P < 0.001] and for TTA patients = [0.472 (0.383-0.672), P = 0.528]. This indicates moderate discriminatory power of the SAS in predicting postoperative complications among TFA patients.
CONCLUSION SAS provides information regarding the potential development of complications following TFA. The SAS is especially useful when patients are divided into high- and low-risk groups.
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Tengberg LT, Cihoric M, Foss NB, Bay-Nielsen M, Gögenur I, Henriksen R, Jensen TK, Tolstrup MB, Nielsen LBJ. Complications after emergency laparotomy beyond the immediate postoperative period - a retrospective, observational cohort study of 1139 patients. Anaesthesia 2016; 72:309-316. [PMID: 27809332 DOI: 10.1111/anae.13721] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 12/25/2022]
Abstract
Mortality and morbidity occur commonly following emergency laparotomy, and incur a considerable clinical and financial healthcare burden. Limited data have been published describing the postoperative course and temporal pattern of complications after emergency laparotomy. We undertook a retrospective, observational, multicentre study of complications in 1139 patients after emergency laparotomy. A major complication occurred in 537/1139 (47%) of all patients within 30 days of surgery. Unadjusted 30-day mortality was 20.2% and 1-year mortality was 34%. One hundred and thirty-seven of 230 (60%) deaths occurred between 72 h and 30 days after surgery; all of these patients had complications, indicating that there is a prolonged period with a high frequency of complications and mortality after emergency laparotomy. We conclude that peri-operative, enhanced recovery care bundles for preventing complications should extend their focus on continuous complication detection and rescue beyond the first few postoperative days.
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Affiliation(s)
- L T Tengberg
- Copenhagen University Hospital, Hvidovre, Denmark
| | - M Cihoric
- Copenhagen University Hospital, Hvidovre, Denmark
| | - N B Foss
- Copenhagen University Hospital, Hvidovre, Denmark
| | | | - I Gögenur
- Copenhagen University Hospital, Køge, Denmark
| | - R Henriksen
- Copenhagen University Hospital, Hillerød, Denmark
| | - T K Jensen
- Copenhagen University Hospital, Herlev, Denmark
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Duch P, Haahr C, Møller MH, Rosenstock SJ, Foss NB, Lundstrøm LH, Lohse N. Anaesthesia care for emergency endoscopy for peptic ulcer bleeding. A nationwide population-based cohort study. Scand J Gastroenterol 2016; 51:1000-6. [PMID: 27152958 DOI: 10.3109/00365521.2016.1164237] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Currently, no standard approach exists to the level of monitoring or presence of staff with anaesthetic expertise required during emergency esophago-gastro-duodenoscopy (EGD) for peptic ulcer bleeding (PUB). We assess the association between anaesthesia care and mortality. We further describe the prevalence and inter-hospital variation of anaesthesia care in Denmark and identify clinical predictors for choosing anaesthesia care. MATERIAL AND METHODS This population-based cohort study included all emergency EGDs for PUB in adults during 2012-2013. About 90-day all-cause mortality after EGD was estimated by crude and adjusted logistic regression. Clinical predictors of anaesthesia care were identified in another logistic regression model. RESULTS Some 3.056 EGDs performed at 21 hospitals were included; 2074 (68%) received anaesthesia care and 982 (32%) were managed under supervison of the endoscopist. Some 16.7% of the patients undergoing EGD with anaesthesia care died within 90 days after the procedure, compared to 9.8% of the patients who had no anaesthesia care, adjusted OR = 1.51 (95% CI = 1.25-1.83). Comparing the two hospitals with the most frequent (98.6% of al EGDs) and least frequent (6.9%) use of anaesthesia care, mortality was 13.7% and 11.7%, respectively, adjusted OR = 1.22 (95% CI = 0.55-2.71). The prevalence of anaesthesia care varied between the hospitals, median = 78.9% (range 6.9-98.6%). Predictors of choosing anaesthesia care were shock at admission, high ASA score, and no pre-existing comorbidity. CONCLUSIONS Use of anaesthesia care for emergency EGD was associated with increased mortality, most likely because of confounding by indication. The use of anaesthesia care varied greatly between hospitals, but was unrelated to mortality at hospital level.
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Affiliation(s)
- Patricia Duch
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Camilla Haahr
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Morten Hylander Møller
- b Department of Intensive Care , Copenhagen University Hospital Rigshospitalet , Copenhagen , Denmark
| | - Steffen J Rosenstock
- c Department of Gastroenterology, Surgical Unit , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Nicolai B Foss
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
| | - Lars Hyldborg Lundstrøm
- d Department of Anaesthesiology and Intensive Care Medicine , Nordsjællands Hospital, Copenhagen University Hospital , Hillerød , Denmark
| | - Nicolai Lohse
- a Department of Anaesthesiology and Intensive Care Medicine , Copenhagen University Hospital Hvidovre , Hvidovre , Denmark
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Røjskjaer JO, Gade E, Kiel LB, Lind MN, Pedersen LM, Kristensen BB, Rasmussen YH, Foss NB. Analgesic effect of ultrasound-guided transversus abdominis plane block after total abdominal hysterectomy: a randomized, double-blind, placebo-controlled trial. Acta Obstet Gynecol Scand 2015; 94:274-8. [DOI: 10.1111/aogs.12567] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 12/11/2014] [Indexed: 11/29/2022]
Affiliation(s)
| | - Erik Gade
- Department of Anesthesia; Hvidovre University Hospital; Hvidovre Denmark
| | - Louise B. Kiel
- Department of Anesthesia; Hvidovre University Hospital; Hvidovre Denmark
| | - Morten N. Lind
- Department of Anesthesia; Hvidovre University Hospital; Hvidovre Denmark
| | - Lars M. Pedersen
- Department of Anesthesia; Hvidovre University Hospital; Hvidovre Denmark
| | | | | | - Nicolai B. Foss
- Department of Anesthesia; Hvidovre University Hospital; Hvidovre Denmark
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Svenningsen P, Manoharan T, Foss NB, Lauritsen ML, Bay-Nielsen M. Increased mortality in the elderly after emergency abdominal surgery. Dan Med J 2014; 61:A4876. [PMID: 25123123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION The purpose of this study was to evaluate the relation between preoperative delay and mortality in surgical patients undergoing primary emergency laparotomy (PEL) in an unselected, well-described patient cohort in a university hospital setting. MATERIAL AND METHODS This study was a retrospective analysis of patient charts and perioperative documentation in an unselected consecutive cohort of 131 patients. Covariates for survival outcomes were evaluated in a multivariate analysis. No external funding and no competing interests were declared. The study was approved by The Danish Data Protection Agency; and in pursuance of national Danish research guidelines concerning retrospective studies, approval from ethics committee was not relevant. RESULTS PEL was performed in 131 patients in the observation period. The median age of the patients was 68 years. The median time from admission to start of operation for all patients was 9.5 hours. No association between a time to operation exceeding six hours and post-operative mortality was found (adjusted odds ratio (95% confidence interval) = 0.67 (0.25-1.78)). Patients over 75 years of age had a very high mortality (47.8%). Most patients died within 30 days post-operatively. CONCLUSION Acute admission and emergency laparotomy is associated with a very high mortality, especially in elderly patients. However, delay in the surgical treatment exceeding six hours is not associated with a higher mortality. There may be a considerable potential for improving care and management in these patients through a more systematic approach.
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Affiliation(s)
- Peter Svenningsen
- Gastroenheden, Hvidovre Hospital, Kettegård Alle 30, 2650 Hvidovre, Denmark.
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Jørgensen CC, Foss NB. [Age as risk factor in elective and emergent surgery]. Ugeskr Laeger 2013; 175:2402-2405. [PMID: 24630193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This paper focuses on the current evidence regarding age as an independent predictor of impaired post-operative outcome and on the possibilities of perioperative interventions in elective and emergent surgery. Co-morbidity and functional parameters, i.e. frailty, are better predictors than age and can be combined with intraoperative data to help identifying patients who might benefit from increased level of care and observation. Most elderly patients go through surgery without impaired outcome, however, further studies are needed to identify who might benefit from increased level of care.
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Affiliation(s)
- Christoffer C Jørgensen
- Enhed for Kirurgisk Patofysiologi, Afdeling 4074, Rigshospitalet, Blegdamsvej 9, 2100 København Ø.
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Abstract
BACKGROUND AND PURPOSE Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture. PATIENTS AND METHODS We studied 280 patients with a median age of 81 (interquartile range 72-86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status. RESULTS Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases. INTERPRETATION The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.
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Affiliation(s)
| | - Nicolai B Foss
- Anesthesiology, Hvidovre Hospital, Copenhagen University
| | - Charlotte Ekdahl
- Division of Physical Therapy, Health Sciences Center, Lund UniversitySweden
| | - Henrik Kehlet
- Section of Surgical Pathophysiology, Rigshospitalet, Copenhagen UniversityDenmark
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Foss NB, Kristensen MT, Jensen PS, Palm H, Krasheninnikoff M, Kehlet H. The effects of liberal versus restrictive transfusion thresholds on ambulation after hip fracture surgery. Transfusion 2009; 49:227-34. [DOI: 10.1111/j.1537-2995.2008.01967.x] [Citation(s) in RCA: 140] [Impact Index Per Article: 9.3] [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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Abstract
BACKGROUND Hip fracture patients experience high pain levels during postoperative rehabilitation. The role of surgical technique on postoperative pain has not been evaluated previously. METHODS One hundred and seventeen hip fracture patients were included in a descriptive prospective study. All patients received continuous epidural analgesia and were treated according to a standardized perioperative rehabilitation programme. Resting pain, pain on hip flexion, and walking were measured during daily physiotherapy sessions on a verbal five-point rating scale during the first four postoperative days. Patients were stratified into four groups according to surgical procedure: screws or pins, arthroplasty, dynamic hip screw (DHS), and intra-medullary hip screw (IMHS). RESULTS Cumulated pain levels were significantly different between surgical procedures both for hip flexion (P=0.002) and for walking (P=0.02) with highest dynamic pain levels for patients who had either DHSs or IMHSs compared with arthroplasty or parallel implants. There were significant negative correlations between ambulatory capacity assessed by the cumulated ambulation score and both the dynamic cumulated pain scores on hip flexion (r=-0.43, P<0.001) and walking (r=-0.36, P=0.004). CONCLUSIONS Postoperative pain levels after surgery for hip fracture are dependent on the surgical procedure, which should be taken into account in future studies of analgesia and rehabilitation.
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Affiliation(s)
- N B Foss
- Department of Anesthesiology, Rigshospitalet Copenhagen University, Copenhagen DK-2100, Denmark.
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Abstract
BACKGROUND the impact of anaemia on the outcome after a hip fracture surgery is controversial, but anaemia can potentially decrease the physical performance and thereby impede post-operative rehabilitation. We therefore conducted a prospective study to establish whether anaemia affected functional mobility in the early post-operative phase after a hip fracture surgery. PATIENTS AND METHODS four hundred and eighty seven consecutive hip fracture patients, treated according to a well-defined multimodal rehabilitation programme with a uniform, liberal transfusion threshold, were studied. Hb was measured on each of the first three post-operative days, and anaemia defined as Hb <100 g/l. Functional mobility was measured with the Cumulated Ambulation Score (CAS). RESULTS the results were obtained from 170, 132 and 116 patients who were found anaemic on the first, second and third post-operative day, respectively. A significant association between anaemia and the ability to walk independently before the correction of anaemia was present on each of the 3 days separately (P<0.05). A significant correlation was also found on each day between the functional score and the Hb level. A multivariate analysis integrating the type of surgery, medical complications and prefracture function showed that anaemia at the time of the physiotherapy session was an independent risk factor for not being able to walk on the third post-operative day [OR 0.41 (0.14-0.73) P = 0.002]. CONCLUSION anaemia impedes functional mobility in the early post-operative phase after a hip fracture surgery and is an independent risk factor for patients not being able to walk post-operatively. The potential for a liberal transfusion policy to improve the rehabilitation potential in hip fracture patients with anaemia should be investigated.
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Affiliation(s)
- Nicolai B Foss
- Department of Anaesthesia, Hvidovre University Hospital, Hvidovre, Denmark.
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Foss NB, Jensen PS, Kehlet H. Risk factors for insufficient perioperative oral nutrition after hip fracture surgery within a multi-modal rehabilitation programme. Age Ageing 2007; 36:538-43. [PMID: 17660529 DOI: 10.1093/ageing/afm079] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [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: 11/12/2022] Open
Abstract
OBJECTIVE To examine oral nutritional intake in the perioperative phase in elderly hip fracture patients treated according to a well-defined multi-modal rehabilitation program, including unselected oral nutritional supplementation, and to identify independent risk factors for insufficient nutritional intake. DESIGN Prospective, descriptive. SETTING A specialised hip fracture unit at the department of orthopaedic surgery in a university hospital. SUBJECTS Two hundred and sixty-two consecutive, unselected elderly hip fracture patients. INTERVENTION Patients were treated according to a well-defined multi-modal care and nutrition plan comprising early surgery, short fasting period, supplementary protein drinks, epidural anaesthesia and analgesia, standardised fluid and transfusion protocols and aggressive mobilisation and physiotherapy. All nutritional intake during the first three post-operative days was recorded, as well as post-operative morbidity and mortality. RESULTS Nutritional energy intake during the first three post-operative days was median 90% of BMR and 86% of recommended protein intake. The independent risk factors for an insufficient energy intake were perioperative medical complications, and no association between low nutritional intake in the perioperative phase and the commonly used predictors of low BMI or albumin on admission was found. CONCLUSION Perioperative medical complications and dementia restricted nutritional intake in the perioperative phase. These factors help identify hip fracture patients in whom increased nutritional support is necessary.
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Affiliation(s)
- Nicolai B Foss
- Department of Anaesthesia, Hvidovre University Hospital, Denmark.
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Holte K, Foss NB, Andersen J, Valentiner L, Lund C, Bie P, Kehlet H. Liberal or restrictive fluid administration in fast-track colonic surgery: a randomized, double-blind study. Br J Anaesth 2007; 99:500-8. [PMID: 17681972 DOI: 10.1093/bja/aem211] [Citation(s) in RCA: 198] [Impact Index Per Article: 11.6] [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: 12/30/2022] Open
Abstract
BACKGROUND Evidence-based guidelines on optimal perioperative fluid management have not been established, and recent randomized trials in major abdominal surgery suggest that large amounts of fluid may increase morbidity and hospital stay. However, no information is available on detailed functional outcomes or with fast-track surgery. Therefore, we investigated the effects of two regimens of intraoperative fluids with physiological recovery as the primary outcome measure after fast-track colonic surgery. METHODS In a double-blind study, 32 ASA I-III patients undergoing elective colonic surgery were randomized to 'restrictive' (Group 1) or 'liberal' (Group 2) perioperative fluid administration. Fluid algorithms were based on fixed rates of crystalloid infusions and a standardized volume of colloid. Pulmonary function (spirometry) was the primary outcome measure, with secondary outcomes of exercise capacity (submaximal exercise test), orthostatic tolerance, cardiovascular hormonal responses, postoperative ileus (transit of radio-opaque markers), postoperative nocturnal hypoxaemia, and overall recovery within a well-defined multimodal, fast-track recovery programme. Hospital stay and complications were also noted. RESULTS 'Restrictive' (median 1640 ml, range 935-2250 ml) compared with 'liberal' fluid administration (median 5050 ml, range 3563-8050 ml) led to significant improvement in pulmonary function and postoperative hypoxaemia. In contrast, we found significantly reduced concentrations of cardiovascularly active hormones (renin, aldosterone, and angiotensin II) in Group 2. The number of patients with complications was not significantly different between the groups [1 ('liberal' group) [corrected] vs 6 ('restrictive' group) [corrected] patients, P = 0.08]. CONCLUSIONS A 'restrictive' [corrected] fluid regimen led to a transient improvement in pulmonary function and postoperative hypoxaemia but no other differences in all-over physiological recovery compared with a 'liberal' [corrected] fluid regimen after fast-track colonic surgery. Since morbidity tended to be increased with the 'restrictive' fluid regimen, future studies should focus on the effect of individualized 'goal-directed' fluid administration strategies rather than fixed fluid amounts on postoperative outcome.
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Affiliation(s)
- K Holte
- Department of Surgical Gastroenterology, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark.
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