Can postoperative nausea and vomiting be predicted?

BACKGROUND: Iletrospective studies fail to identify predictors of postoperative nausea and vomiting (PONV). The authors prospectively studied 17,638 consecutive outpatients who had surgery to identify predictors. METHODS: Data on medical conditions, anesthesia, surgery, and PONV were collected in the post-anesthesia care unit, in the ambulatory surgical unit, and in telephone interviews conducted 24 h after surgery. Multiple logistic regression with backward stepwise elimination was used to develop a predictive model An independent set of patients was used to validate the model RESULTS: Age (younger or older), sex (female or male), smoking status (nonsmokers or smokers), previous PONV, type of anesthesia (general or other), duration of anesthesia (longer or shorter), and type of surgery (plastic, orthopedic shoulder, or other) were independent predictors of PONV. A 10-yr increase in age decreased the likelihood of PONV by 13%. The risk for men was one third that for women. A 30-min increase in the duration of anesthesia increased the likelihood of PONV by 59%. General anesthesia increased the likelihood of PONV 11 times compared with other types of anesthesia. Patients with plastic and orthopedic shoulder surgery had a sixfold increase in the risk for PONV. The model predicted PONV accurately and yielded an area under the receiver operating characteristic curve of 0.785+/-0.011 using an independent validation set. CONCLUSIONS: A validated mathematical model is provided to calculate the risk of PONV in outpatients having surgery. Knowing the factors that predict PONV will help anesthesiologists determine which patients will need antiemetic therapy.     

Can haemodialysis-induced hypotension be predicted?

BACKGROUND: During haemodialysis (HD) ultrafiltration may affect the central blood volume to an extent that blood pressure decreases. Thoracic electrical impedance (TI) is applied to monitor the central blood volume and we evaluated if it can be used to predict HD-induced hypotension. METHODS: In 12 hypotensive prone (H) and 13 non-hypotensive prone (N) patients, blood pressure and heart rate were recorded during one dialysis session every 30 min, while TI, thoracic intracellular water (Th(ICW)) and total body impedance (TBI) were followed every 10 min. Hypotension was defined as a decrease in systolic blood pressure (SAP) >/=30 mm Hg or a SAP < 90 mm Hg. RESULTS: All 12 H patients developed hypotension after 190 +/- 10 min (mean +/- SE) as SAP decreased 35 +/- 5 mm Hg, while the 13 N patients maintained blood pressure. TBI increased in all patients and the increase was similar (60 +/- 5 and 56 +/- 6 Omega in H and N patients, respectively). In N patients TI did not change significantly for the first 2 h of HD, while it became elevated by 2.8 +/- 0.6 Omega (1.5 kHz) and 2.3 +/- 0.7 Omega (100 kHz) by the end of the dialysis. In H patients, the increase in TI took place at the onset of HD to reach higher values (by 7.0 +/- 0.5 Omega at 1.5 kHz and 5.9 +/- 0.5 Omega at 100 kHz). Th(ICW) was changed only in H patients (decreased by 7.9 +/- 2.1 Siemens (S) 10(-4), p < 0.05), while HR increased (9 +/- 2 beats/min) in 8 of 12 H patients, while it decreased in 1 patient (by 9 beats/min). CONCLUSIONS: The results suggest that in HD patients hypotension is elicited by a reduction in the central blood volume that affects heart rate and the distribution of red cells within the body. To prevent HD-induced hypotention, the ultrafiltration rate could be reduced when an increase in thoracic impedance approaches 5 Omega, or when an index of intracellular water decreases by 6 10(-4).     

Can parathyroid hyperplasia be predicted preoperatively?

Introduction

The purpose of this study was to determine if there are clinical features that raise suspicion for parathyroid hyperplasia.

Can progression of valvar aortic stenosis be predicted accurately?

BACKGROUND: It was the aim of the present study to elaborate criteria for the assessment of rapid hemodynamic progression of valvar aortic stenosis. These criteria are of special importance when cardiac surgery is indicated for other reasons but the established criteria for aortic valve replacement are not yet fulfilled. Such aspects of therapeutic planing were mostly disregarded in the past so that patients had to undergo cardiac reoperation within a few years. METHODS: Hemodynamic, echocardiographic, and clinical data of 169 men and 88 women with aortic stenosis, aged 55.2 +/- 15.7 years at their first and 63.4 +/- 15.6 years at their second cardiac catheterization, were analyzed. RESULTS: The progression rate of aortic valve obstruction was found to be dependent on the degree of valvar calcification ([VC] scoring 0 to III) and to be exponentially correlated with the aortic valve opening area (AVA) at initial catheterization. Neither age nor sex of the patient nor etiology of the valvar obstruction significantly influence the progression of aortic stenosis. If AVA decreases below 0.75 cm(2) with a present degree of VC = 0, or AVA of 0.8 with VC of I, AVA of 0.9 with VC of II, or AVA of 1.0 with VC of III, it is probable that aortic stenosis will have to be operated upon in the following years. CONCLUSIONS: The present data indicate that for clinical purposes and planning of valvar surgery the progression of asymptomatic aortic stenosis can be sufficiently predicted by the present aortic valve opening area and the degree of valvar calcification.     

Can the outcome of carpal tunnel release be predicted?

Between 1994 and 1996 we performed a prospective study on the effect of carpal tunnel release on the health status of 96 patients. The Nottingham Health Profile, a validated global scoring system, was used to assess quality of life before, and at 4 months after surgery. Carpal tunnel syndrome had a significant impact on the health status of our patients. There were significant improvements in the scores for pain, energy and sleep. Patients who were dissatisfied following surgery had significantly higher pre-operative scores, indicating poor perceived health status. Our findings show that outcome assessment tools have predictive value in identifying patients who may not benefit from surgery, or in whom a poor result might be anticipated.     

Can I improve postoperative outcome after abdominal surgery?

Most of the textbooks of anesthesia do not devote any chapter to anesthesia for abdominal surgery. Whereas the choice of anesthetics has minimal impact on postoperative outcome of the patient scheduled for these procedures global perioperative anesthetic management however affects postoperative recovery, convalescence, or even morbidity. This presentation highlights practical measures susceptible of reducing postoperative complications and of shortening patient convalescence.     

Can acute renal failure be prevented?

Correction of salt and volume depletion is paramount in the prevention of renal damage. Measures which stimulate intense filtration of glomeruli in acute renal failure, such as the use of atrial natriuretic peptide analogues, theophylline, dopamine, or growth factors should be regarded with caution, since they all increase metabolic workload in the outer medulla and hence aggravate medullary hypoxia. Neither frusemide, dopamine nor dopexamine have been shown to be better than aggressive saline loading in preventing acute renal failure in at risk patients. Until new clinical studies emerge, avoidance of nephrotoxic insults where possible, monitoring of circulating concentrations of potentially nephrotoxic drug levels and volume loading coupled with supportive measures is recommended. When volume depletion persists, usual blood pressure cannot be restored and patients remain oliguric, early referral to the intensive care unit is paramount. The mortality rate in patients with acute renal failure is high; therefore, measures which reduce the incidence and progression of renal dysfunction will be of benefit.     

Puncture-drainage sanation of abdominal abscesses: is it sufficient treatment?

Some anatomical grounds of postoperative extravisceral abscess formation, methods and results of their treatment, therapeutic policy in abscesses of parenchymatous organs are presented. 681 patients with abdominal abscess of various location were examined. Detailed analysis of ultrasonic and computed tomographic semiotics of postoperative extravisceral suppurative focus was carried out in 164 patients. The risk zones of extravisceral abscess formation in the conditions of changed visceral syntopy and destroyed ligamentic structures were determined. The efficiency of puncture-drainage treatment in different variants of subdiaphragmatic abscess was 89.4%, in abscess of omental bursa--83.3%. Intracavital prolonged proteolysis by immobilized proteinases (imosimase) was applied. The injection of imosimase in abscess cavity led to its content lysis, including the thick products of inflammation, improving their secretion through the drainage. In the majority of the patients, the puncture-drainage treatment of abscesses of various etiology and pathogenesis is an adequate method of sanation.     

Can pT0 stage of prostate cancer be predicted before radical prostatectomy?

OBJECTIVES: To report our experience with biopsy-proven pT0 prostate cancer over the last 10 yr. METHODS: We retrospectively analysed a series of 1950 consecutive patients treated with radical prostatectomy (RP) for clinically localized prostate cancer between 1996 and 2005 at our institution. The patients without residual tumour on RP specimen were defined as pT0 patients. The group of pT0 patients was compared with a control group of 295 patients operated consecutively during the same period. RESULTS: Overall, 11 (0.5%) patients were classified as pT0 on pathologic examination of the RP specimen. There was no pT0 tumour in the control group. Among the pT0 patients, five characteristics were particularly frequent: T1c clinical stage (90.9%), prostate-specific antigen (PSA) or=60 g (100%). All these characteristics were present in 8 of the 11 (72.7%) pT0 patients, while they were present in only 12 of the 295 (4.1%) controls. These parameters, when combined together, had a sensitivity of 72%, a specificity of 96%, and an accuracy of 99% for the prediction of pT0 stage. With a mean follow-up of 30 months after RP, no pT0 patient had clinical or biologic evidence of prostate cancer. CONCLUSIONS: In our experience, the rate of pT0 tumours after RP is 0.5%. The combination of clinical stage, preoperative PSA, number of positive biopsy cores, Gleason score, and prostate weight could help to predict pT0 stage after RP.     

Can we predict the failure of thoracostomy tube drainage in the treatment of pediatric parapneumonic collections?

Background/Purpose

Tube thoracostomy is a standard method of treating pediatric parapneumonic collections. Despite recent work denoting thoracoscopy as a superior method of treatment, few studies have looked at factors predictive of tube thoracostomy failure. We reviewed parapneumonic collections initially treated with tube thoracostomy to identify such factors.

Methods

Nontuberculous parapneumonic collections treated initially with tube thoracostomy over a 10-year period were reviewed. A “failed primary tube thoracostomy” was defined as the presence of worsening clinicoradiological signs requiring a further chest procedure (ie, thoracoscopy, thoracotomy, or second thoracostomy).

Results

Fifty-eight patients were identified. Forty-three percent failed primary tube thoracostomy. Within group F (failure group), 32% of patients had a concomitant medical condition (P < .001). Sixty percent of group F patients had duration of symptoms for more than 1 week compared with only 24% of group S (successful group) (P < .001).

Conclusions

Our results suggest that primary treatment of parapneumonic collections with tube thoracostomy is likely to be unsuccessful in patients who are symptomatic for more than a week or who have a concomitant medical condition.A more aggressive primary surgical intervention is suggested for this group.