Clinical utility of preoperative screening with STOP-Bang questionnaire in elective surgery

BACKGROUND

Obstructive sleep apnea (OSA) is a common disease which increases the risk of perioperative complications. The aim of this study is to assess the clinical utility of preoperative screening for OSA in determining the prevalence of patients at high risk of OSA in a surgical population, the incidence of difficult airway management and the incidence of perioperative complications.

METHODS

We conducted a multisite, prospective observational study on adult patients scheduled for elective surgery. All patients completed a STOP-Bang questionnaire as a part of their preoperative evaluation. Collected data included: demographic data, type of surgery, ASA class, postoperative course, complications within 48 hours, difficult intubation (DI) and difficult mask ventilation (DMV) rates.

RESULTS

A total of 3452 consecutive patients were recruited; 2997 (87%) were identified as low OSA risk patients and 455 (13%) were identified as high OSA risk patients; 113 (3%) postoperative complications, 315 (9%) cases of DMV and 375 (11%) of DI were observed. The percentage of postoperative complications in patients with HR-OSA was 9%, while the percentage of DI was 20% and the percentage of DMV was 23%. High risk for OSA and higher BMI (≥30 Kg m-2) were independently associated with risk for perioperative complications.

CONCLUSION

In conclusion, this study demonstrates that the prevalence of high OSA risk patients in the surgical population is high. The increase in the rates of perioperative complications justifies the implementation of perioperative strategies that use the STOP-Bang as a tool for triage.

The effect of anticoagulant therapy for idiopathic pulmonary fibrosis in real life practice

BACKGROUND

IPF is a common form of interstitial lung disease for which there is no effective therapy and usually results in death. Two previous contradictory studies showed anticoagulant therapy  to be associated with both improved and worsened survival, respectively.

OBJECTIVE

The objective of this retrospective cohort study was to evaluate the effect of anticoagulant therapy on the survival and disease progression of patients with idiopathic pulmonary fibrosis (IPF) in real clinical practice.

METHODS

We compared the clinical characteristics, time to disease progression, incidence of acute exacerbation, and survival of 25 (20%) IPF patients receiving anticoagulant therapy to the remaining 97 IPF patients not receiving anticoagulant therapy. In addition we conducted a sensitivity analysis using as comparator a group of 25 patients matched by age, sex, functional impairment, cardiac comorbidities and pulmonary hypertension.

RESULTS

Patients on anticoagulant therapy had a worse 1- and 3-year survival (84% and 53% versus 89% and 64% in the non-anticoagulant group, respectively), a difference that persisted after adjusting for age and comorbidities (hazard ratio 3.1 - 95% confidence interval, 1.4 to 7.0; p=0.006) and after comparison with the matched group (adjusted HR=4.8, 95% CI: 1.8-12.8; p=0.002). IPF patients on anticoagulant therapy had a shorter interval to disease progression ( 0.7 years versus 1.6 years, adjusted HR 2.2 -95% CI, 0.96 to 5.1; p=0.063) confirmed also in the analysis with matched subgroups (HR=2.7 (95% CI: 1.2-6.5); p=0.023). The incidence of acute exacerbations did not differ in the two groups (22% versus 23%). Two patients (8%) experienced anticoagulant treatment related complications and included an episode of hemorrhagic shock.

CONCLUSION

In this retrospective study patients treated with anticoagulants had a worse survival and a shorter interval to disease progression. This support the recent finding that warfarin worsen the respiratory status and survival of IPF patients.

Spinal anesthesia plus ketamine-midazolam sedation for pediatric orthopedic surgery in a developing country

INTRODUCTION

Spinal anesthesia produces a profound and uniformly distributed sensory block with rapid onset and muscle relaxation, and results in complete control of cardiovascular and stress responses. Ketamine is an anesthetic agent that is widely used for pediatric sedations in settings where safety and efficacy of the agents are mandatory because of limited healthcare resources. The authors report on their experience in a refugee hospital located in Bol-la (Saharawi, Algeria).

METHODS

Spinal anesthesia was performed for orthopedic surgery procedures in children. Before the spinal puncture, the patients were sedated with intramuscular ketamine followed by intravenous ketamine and midazolam. Boluses of midazolam were also administered throughout the surgery to keep the patients sedated; spinal anesthesia was performed with levobupivacaine 0.25 mg/kg.

RESULTS

There were no intraoperative adverse events; vital signs were within the normal pediatric ranges during the procedures and there was no need to switch to general anesthesia. In the postoperative period, no symptoms of dural puncture headache or postoperative delirium or nightmares were reported.

CONCLUSION

Based on the authors' experience, the combination of spinal anesthesia and sedation with midazolam and ketamine was found to be a safe approach for children undergoing orthopedic surgery in a low resources setting.

Catamenially recurring pneumothorax with partial liver herniation: a particular view

Few cases of catamenial pneumothorax with complete or partial diaphragmatic hernias are reported in the literature. We present herein the case of a 38-year-old woman affected by recurrent right-sided spontaneous pneumothorax during menstrual periods. CT scan revealed normal lung parenchyma and multiple diaphragmatic nodes suspected for endometrial implants. The patient underwent right thoracoscopy and the presence of multiple diaphragmatic perforations of the tendinous part was observed as well as partial hepatic hernia. Through a video-assisted procedure, pleural biopsies and diaphragmatic plication containing the tendinous part with total pleural abrasion and talc pleurodesis were performed. No endometrial implants were found on histologic examination of pleural biopsies. The surgical procedure was uneventful and totally successful. On the basis of the clinical data and endoscopic view, we consider our case as catamenially recurring pneumothorax.

The use of methylene blue in abdominal aortic surgery: a case report

The open abdominal aortic surgery includes a well-known phase in which arterial blood flow is stopped by occluding clamps, resulting in peculiar physiologic changes usually superimposed on advanced pathologic conditions. An anesthetic plan should aim at providing hemodynamic stability and preserving organ function. Clamp removal leads to an acute fall in blood pressure following a decrease in systemic vascular resistance, caused by reactive hyperemia due to opening of the previously minimally perfused vascular beds. Several different mediators, including the nitrous oxide (NO) pathway, have been thought to be responsible for this hemodynamic effect. The massive production of NO by the inducible isoform of NO synthase could be partially responsible for the profound vasodilatation and myocardial dysfunction. The dye methylene blue (MB) has been used as to prevent vasodilatation in other clinical situations like sepsis, cardiopulmonary bypass and liver transplantation. We describe its use in a patient with poor hemodynamic status, who was submitted to aortic aneurism repair with infrarenal cross clamp. The intervention was also associated with a severe bleeding. In this case MB allowed us to control hypotension with relatively low doses of vasopressors.

Left diaphragmatic hernia after pneumonectomy

Patients undergoing pneumonectomy can suffer by cardiovascular and respiratory postoperative complications that can affect patient's outcome by increasing morbidity and mortality. We describe a diaphragmatic hernia occurring after pneumonectomy. with late presentation and with epidural analgesia confusing the scenario suggesting that anesthesiologists should remain aware on this complication even in the late post operative period.

Pain relief and motor function during continuous interscalene analgesia after open shoulder surgery: a prospective, randomized, double-blind comparison between levobupivacaine 0.25%, and ropivacaine 0.25% or 0.4%

BACKGROUND AND OBJECTIVES

To compare pain relief and motor impairment of 0.25% levobupivacaine with either an equivalent (0.25%) or equipotent (0.4%) concentration of ropivacaine for continuous interscalene block after open shoulder surgery.

METHODS

Seventy-two adult patients scheduled for elective major shoulder surgery received an interscalene injection of mepivacaine 1.5% 30 mL followed by 24 h patient-controlled interscalene analgesia (basal infusion rate: 5 mL h-1; incremental bolus: 2 mL; lockout period: 10 min; maximum boluses per hour: 4) with either 0.25% levobupivacaine (n = 24), 0.25% ropivacaine (n = 24) or 0.4% ropivacaine (n = 24). A blinded observer recorded the evolution of pain relief and recovery of motor block during the first 24 h. Motor function was assessed as the maximum pressure developed while squeezing a sphygmomanometer cuff with the blocked hand. The reduction from preoperative values was considered as an index of motor impairment.

RESULTS

No differences were reported among the three groups in the quality of postoperative analgesia. The number of incremental patient-controlled interscalene analgesia doses, total volume of local anaesthetic infused during the 24-h patient-controlled interscalene analgesia, and number of rescue ketoprofen analgesia were higher in the ropivacaine 0.25% group than in the other two groups (P = 0.0005). The hand strength recovered to >or=90% of baseline values within the first 24 h of infusion in all groups, without differences among the three groups.

CONCLUSION

When providing patient-controlled interscalene analgesia after open shoulder surgery 0.25% levobupivacaine and 0.4% ropivacaine performed equally in terms of pain relief, motor block and number of patient-controlled boluses required, while patients receiving 0.25% ropivacaine needed significantly more boluses and rescue analgesia to control their pain.

[Patient controlled regional analgesia (PCRA) in surgery of stiff elbow: elastomeric vs electronic pump]

BACKGROUND

Aim of this study is to confront an elastomeric pump at regular infusion controlled by the patient with an electronic pump with self-administration for analgesia, by continuous infraclavicular brachial plexus block, as support for the intensive postoperative physiotherapy.

METHODS

With signed informed consent 10 patients undergoing corrective surgery for stiff elbow were included. All patients received ropivacaine 30 ml 0,50% for anaesthesia by infraclavicular block with bicipite twitch, after which a catheter was left in situ. In group 1 analgesia consisted of ropivacaina 0,4% by electronic pump (continuous infusion with self-administration of bolus) at day1 and day2, and by elastomeric pump at 5 ml/h, connected to a three way tap managed by the patient (open-closed) at day3 and day4. Group 2 received at day1 and day2 the elastomeric pump and then the electronic pump. All patients continued at home with the elastomeric pump. Flexion-extension capacity of the elbow, daily consumption of ropivacaine 0,4%, and patients comfort were all evaluated.

RESULTS

With the electronic pump, flexion-extension capacity is significantly better compared to elastomeric pump. During the use of the electronic pump, consumption of ropivacaina 0.4% was significantly higher in day2 compared to day1 (physiotherapy started day2); consumption in day3 and Day4 was significantly less compared to day2. All patients preferred the electronic pump for the first two days and then the elastomeric pump.

CONCLUSION

PCRA quality is higher with ropivacaine 0,4% during the first phase of recovery. The elastomeric pump instead, insufficient in the first phase, is useful for analgesia at home.