Current Issue : April - June Volume : 2013 Issue Number : 2 Articles : 7 Articles
Patients with solid malignancies who were not candidates for tumor resections in the past are now presenting for extensive\r\noncological resections. Cancer patients are at risk for thromboembolic complications due to an underlying hypercoagulable state;\r\nhowever, some patients may have an increased risk for bleeding due to the effects of chemotherapy, the administration of anticoagulant\r\ndrugs, tumor-related fibrinolysis, tumor location, tumor vascularity, and extent of disease. A common potential complication\r\nof all complex oncological surgeries is massive intra- and postoperative hemorrhage and the subsequent risk for massive blood\r\ntransfusion. This can be anticipated or unexpected. Several surgical and anesthesia interventions including preoperative tumor\r\nembolization, major vessel occlusion, hemodynamic manipulation, and perioperative antifibrinolytic therapy have been used to\r\nprevent or control blood loss with varying success. The exact incidence of massive blood transfusion in oncological surgery is\r\nlargely unknown and/or underreported. The current literature mostly consists of purely descriptive observational studies. Thus,\r\nrecommendation regarding specific perioperative intervention cannot be made at this point, and more research is warranted....
Background: Improvement of surgical and anesthetic techniques, allowed total avoidance of blood transfusion\r\nduring liver transplantation (LT) in some cases. The last years showed much debate about prophylactic administration\r\nof rFVIIa with no guide for its rational use. Giving that it is off label, preoperative ROTEM assessed coagulation\r\nreserve may help its judicious use.\r\nPatients and methods: 3 groups retrospectively studied; (NRNB) n=38 not given rFVIIa and no blood\r\ntransfusion (BT), (RNB) n=43 given rFVIIa and no BT and (RAB) n=35 given rFVIIa and BT. 40 ug/kg rFVIIa were\r\ngiven. Comparison NRNB vs. RNB group answers need or not need rFVIIa to achieve bloodless surgery (decision\r\nof admission), while RNB vs. RAB group determine which patients rFVIIa can help to achieve bloodless surgery\r\n( responders and non responders). Data collected: Preoperative Extem, Fibtem, hemoglobin (HB), INR, platelet,\r\nfibrinogen, blood loss, and blood transfused in RAB group.\r\nResults: NRNB group had significantly higher HB, fibrinogen, platelets, and better ROTEM values vs. RNB.\r\nRAB had significantly lower HB, fibrinogen, platelets, and worse ROTEM values vs. RNB. Preoperative HB,\r\nfibrinogen level and ROTEM values are highly significant predictors to rFVIIa response. In RAB group, PRBCs\r\ntransfusion correlated with preoperative HB and Ex MCF, platelet transfusion correlated with Ex MCF, angle a and\r\nCFT, cryoprecipitate transfusion correlated with fibrinogen and Fibtem MCF, plasma transfusion correlated with\r\nExCT and ExCFT. Preoperative Rotem and HB cut values are sensitive and specific for admission and response to\r\nrFVIIa to achieve bloodless surgery.\r\nConclusion: ROTEM may help rational rFVIIa use, considering safety and cost, to achieve bloodless surgery.\r\nNon responders (RAB) may still require rFVIIa on risk benefit bases. Correction of HB and higher rFVIIa doses may\r\nimprove their response....
Background: The effect of peripheral nerve blocks on postoperative delirium in older patients has not been\r\nstudied. Peripheral nerve blocks may reduce the incidence of postoperative opioid use and its side effects such as\r\ndelirium via opioid-sparing effect.\r\nMethods: A prospective cohort study was conducted in patients who underwent total knee replacement. Baseline\r\ncognitive function was assessed using the Telephone Interview for Cognitive Status. Postoperative delirium was\r\nmeasured using the Confusion Assessment Method postoperatively. Incidence of postoperative delirium was\r\ncompared in two postoperative management groups: femoral nerve block �± patient-controlled analgesia and\r\npatient-controlled analgesia only. In addition, pain levels (using numeric rating scales) and opioid use were\r\ncompared in two groups.\r\nResults: 85 patients were studied. The overall incidence of postoperative delirium either on postoperative day one\r\nor day two was 48.1%. Incidence of postoperative delirium in the femoral nerve block group was lower than\r\npatient controlled analgesia only group (25% vs. 61%, P = 0.002). However, there was no significant difference\r\nbetween the groups with respect to postoperative pain level or the amount of intravenous opioid use.\r\nConclusions: Femoral nerve block reduces the incidence of postoperative delirium. These results suggest that a\r\nlarger randomized control trial is necessary to confirm these preliminary findings....
Background: Increasing numbers of elective surgical procedures are performed as day-cases. The impact of\r\nambulatory surgery on health-related quality of life in the recovery period has seldom been described.\r\nMethods: We assessed health-related quality of life in 143 adult outpatients scheduled for arthroscopic procedures of\r\nthe knee and shoulder joints, laparoscopic cholecystectomy and inguinal hernia repair using the RAND 36-Item Health\r\nSurvey preoperatively and one week after patients had returned to work or comparable normal daily routines.\r\nResults: Postoperatively all patient groups reported significant improvements in bodily pain and vitality. Physical\r\nfunctioning improved significantly in orthopedic and inguinal hernia patients. However, in the orthopedic groups,\r\npostoperative scores for physical health were still relatively lower compared to the general population reference values.\r\nConclusions: Ambulatory surgery has a positive impact on health-related quality of life. Assessment of the recovery\r\nprocess is necessary for recognition of potential areas of improvement in care and postoperative rehabilitation...
Objective: The objective of this study was to determine how intrathecal narcotic use impacts the postoperative\r\ncourse of patients undergoing major gynecologic oncologic procedures. The endpoints evaluated were toxicity and\r\npostoperative length of stay.\r\nMethods: This was a retrospective chart review of 598 patients who underwent major abdominal surgery and\r\nreceived intrathecal narcotics for post-operative pain control during a 49 month period at St. Vincent Hospital. Charts\r\nwere reviewed to determine the incidence of specific toxicities and postoperative length of stay.\r\nResults: The median length of stay for all patients was four days postoperatively, and 92.8% of patients fell\r\nwithin one standard deviation of the mean (mean of five days). Nausea occurred in 427 patients (71.4%). The total\r\nnumber of patients treated for pruritis was 280 (46.8%). Respiratory depression occurred in 14 patients (2.3%). Six\r\npatients (1.0%) were considered to have post-dural puncture headaches, and four (0.67%) required epidural blood\r\npatches. Hypotension was observed in 11 patients (1.8%) in the 30-minute period following intrathecal narcotic\r\nadministration, in 69 patients (11.5%) in the intraoperative period, and in 40 patients (6.7%) in the postoperative\r\nperiod. Twenty patients out of 535 (3.7%) experienced urinary retention, while 63 patients were inevaluable for\r\nurinary retention secondary to suprapubic catheter placement during radical hysterectomy (54) or discharge from\r\nhospital with a Foley catheter in place due to intraoperative cystotomy (9).\r\nConclusions: Intrathecal narcotics are a safe method of postoperative pain management with limited toxicity\r\nand do not appear to lengthen postoperative hospital stay....
Background: Mean arterial pressure above 65 mmHg is recommended for critically ill hypotensive patients\r\nwhereas they do not benefit from supranormal cardiac output values. In this study we investigated if the increase\r\nof mean arterial pressure after volume expansion could be predicted by cardiovascular and renal variables. This is a\r\nrelevant topic because unnecessary positive fluid balance increases mortality, organ dysfunction and Intensive Care\r\nUnit length of stay.\r\nMethods: Thirty-six hypotensive patients (mean arterial pressure < 65 mmH) received a fluid challenge with\r\nhydroxyethyl starch. Patients were excluded if they had active bleeding and/or required changes in vasoactive\r\nagents infusion rate in the previous 30 minutes. Responders were defined by the increase of mean arterial pressure\r\nvalue to over 65 mmHg or by more than 20% with respect to the value recorded before fluid challenge.\r\nMeasurements were performed before and at one hour after the end of fluid challenge.\r\nResults: Twenty-two patients (61%) increased arterial pressure after volume expansion. Baseline heart rate, arterial\r\npressure, central venous pressure, central venous saturation, central venous to arterial PCO2 difference, lactate,\r\nurinary output, fractional excretion of sodium and urinary sodium/potassium ratio were similar between responder\r\nand non-responder. Only 7 out of 36 patients had valuable dynamic indices and then we excluded them from\r\nanalysis. When the variables were tested as predictors of responders, they showed values of areas under the ROC\r\ncurve ranging between 0.502 and 0.604. Logistic regression did not reveal any association between variables and\r\nresponder definition.\r\nConclusions: Fluid challenge did not improve arterial pressure in about one third of hypotensive critically ill\r\npatients. Cardiovascular and renal variables did not enable us to predict the individual response to volume\r\nadministration....
We investigated the effects of reduced oxygen-carrying capacity on cardiac function during acute hemodilution, while the\r\nplasma viscosity was increased in anesthetized animals. Two levels of oxygen-carrying capacity were created by 1-step and 2-\r\nstep hemodilution in male golden Syrian hamsters. In the 1-step hemodilution (1-HD), 40% of the animals� blood volume (BV)\r\nwas exchanged with 6% dextran 70 kDa (Dx70) or dextran 2000 kDa (Dx2M). In the 2-step hemodilution (2-HD), 25% of the\r\nanimals� BV was exchanged with Dx70 followed by 40% BV exchanged with Dx70 or Dx2M after 30 minutes of first hemodilution.\r\nOxygen delivery in the 2-HD group consequently decreased by 17% and 38% compared to that in the 1-HD group hemodiluted\r\nwith Dx70 and Dx2M, respectively. End-systolic pressure and maximum rate of pressure change in the 2-HD group significantly\r\nlowered compared with that in the 1-HD group for both Dx70 and Dx2M. Cardiac output in the 2-HD group hemodiluted with\r\nDx2M was significantly higher compared with that hemodiluted with Dx70. In conclusion, increasing plasma viscosity associated\r\nwith lowering oxygen-carrying capacity should be considerably balanced to maintain the cardiac performance, especially in the\r\nstate of anesthesia....
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