Emergence delirium in adults in the post-anaesthesia care unit

Background. Emergence delirium in the post-anaesthesia careunit (PACU) is poorly understood. The goal of this prospectivestudy was to determine frequency and risk factors of emergencedelirium in adults after general anaesthesia. Methods. In this prospective study, 1359 consecutive patientswere included. Contextual risk factors and occurrence of deliriumaccording to the Riker sedation scale were documented. Groupswere defined for the analysis according to the occurrence ornot of agitation, then after exclusion of patients with preoperativeanxiety and neuroleptics, or both, and antidepressants or benzodiazepinestreatments. Results. Sixty-four (4.7%) patients developed delirium in thePACU, which can go from thrashing to violent behaviour and removalof tubes and catheters. Preoperative anxiety was not found tobe a risk factor. Preoperative medication by benzodiazepines(OR=1.910, 95% CI=1.101–3.315, P=0.021), breast surgery(OR=5.190, 95% CI=1.422–18.947, P=0.013), abdominal surgery(OR=3.206, 95% CI=1.262–8.143, P=0.014), and long durationof surgery increased the risk of delirium (OR=1.005, 95% CI=1.002–1.008,P=0.001), while a previous history of illness and long-termtreatment by antidepressants decreased the risk (respectively,OR=0.544, 95% CI=0.315–0.939, P=0.029 and OR=0.245, 95%CI=0.084–0.710, P=0.010). Conclusions. Preoperative benzodiazepines, breast and abdominalsurgery and surgery of long duration are risk factors for emergencedelirium.     

Prevalence of postoperative bladder distension and urinary retention detected by ultrasound measurement

Background. Postoperative bladder distension and urinary retentionare commonly underestimated. Ultrasound enables accurate measurementof bladder volume and thus makes it possible to determine theprevalence of postoperative bladder distension. Methods. Using ultrasound, we measured the volume of the bladdercontents at the time of discharge from the recovery room in177 adult patients who had undergone thoracic, vascular, abdominal,orthopaedic or ENT surgery. Results. Forty-four per cent of the patients had a bladder volume>500 ml and 54% of the 44%, who had no symptoms of bladderdistension, were unable to void spontaneously within 30 min.The risk factors for urinary retention were age >60 yr (oddsratio (OR) 2.11, 95% confidence interval (CI) 1.01–4.38),spinal anaesthesia (OR 3.97, 95% CI 1.32–11.89) and durationof surgery >120 min (OR 3.03, 95% CI 1.39–6.61). Conclusion. Before discharge from the recovery room it seemsworthwhile to systematically check the bladder volume with aportable ultrasound device in patients with risk factors. Br J Anaesth 2004; 92: 544–6     

Assessment of preoperative fluid depletion using bioimpedance analysis

Background. Fluid depletion during the perioperative periodis associated with poorer outcome. Non-invasive measurementof total body water by bioimpedance may enable preoperativefluid depletion and its influence on perioperative outcome tobe assessed. Methods. Weight and foot bioimpedance were recorded under standardizedconditions in patients undergoing bowel preparation (n=43) orday surgery (n=44). Fifteen volunteers also followed standardnil-by-mouth instructions on two separate occasions to assessthe variabilities of weight and bioimpedance over time. Results. Body weight fell by 1.27 kg (95% CI 1.03–1.50kg; P<0.0001) and foot bioimpedance increased by 51 ohm afterbowel preparation (95% CI 36–66; P<0.0001). Weightchange after the nil-by-mouth period in day-surgery patients(mean –0.22 kg, 95% CI –0.05 to –0.47 kg;P=0.07) correlated (r=–0.46; P=0.005) with an increasein bioimpedance (16 ohms, 95% CI 5–27 ohms; P=0.01). Nodifference between two separate bioimpedance measurements wasseen in the volunteer group. Conclusions. Further work is warranted to determine if bioimpedancechanges may serve as a useful indicator of perioperative fluiddepletion. Br J Anaesth 2004; 92: 134–6     

Procalcitonin, interleukin 6 and systemic inflammatory response syndrome (SIRS): early markers of postoperative sepsis after major surgery

Background. Patients who undergo major surgery for cancer areat high risk of postoperative sepsis. Early markers of septiccomplications would be useful for diagnosis and therapeuticmanagement in patients with postoperative sepsis. The aim ofthis study was to investigate the association between early(first postoperative day) changes in interleukin 6 (IL-6), procalcitonin(PCT) and C-reactive protein (CRP) serum concentrations andthe occurrence of subsequent septic complications after majorsurgery. Methods. Serial blood samples were collected from 50 consecutivepatients for determination of IL-6, PCT and CRP serum levels.Blood samples were obtained on the morning of surgery and onthe morning of the first postoperative day. Results. Sixteen patients developed septic complications duringthe first five postoperative days (group 1), and 34 patientsdeveloped no septic complications (group 2). On day 1, PCT andIL-6 levels were significantly higher in group 1 (P-values of0.003 and 0.006, respectively) but CRP levels were similar.An IL-6 cut-off point set at 310 pg ml^–1 yielded a sensitivityof 90% and a specificity of 58% to differentiate group 1 patientsfrom group 2 patients. When associated with the occurrence ofSIRS on day 1 these values reached 100% and 79%, respectively.A PCT cut-off point set at 1.1 ng ml^–1 yielded a sensitivityof 81% and a specificity of 72%. When associated with the occurrenceof SIRS on day 1, these values reached 100% and 86%, respectively. Conclusions. PCT and IL-6 appear to be early markers of subsequentpostoperative sepsis in patients undergoing major surgery forcancer. These findings could allow identification of postoperativeseptic complications.     

Utility of B-type natriuretic peptide in predicting perioperative cardiac events in patients undergoing major non-cardiac surgery

Background: B-type natriuretic peptide (BNP) levels predict cardiovascularrisk in several settings. We hypothesized that they would identifyindividuals at increased risk of early cardiac complicationsafter major non-cardiac surgery. The current study tests thishypothesis. Methods: Two hundred and four patients undergoing major non-cardiac surgerywere studied. The primary end-point was the development of acutemyocardial injury [defined as cardiac troponin I (cTnI) level> 0.32 ng ml^–1] or death in the 3 days after surgery. Results: Preoperative BNP levels were raised in patients who died orsuffered perioperative myocardial injury (median 52.2 vs 22.2pg ml^–1, P = 0.01) and BNP predicted this outcome withan area under the receiver operating characteristic curve of0.72 [95% confidence interval (CI) 0.59–0.86, P = 0.01].A preoperative BNP value > 40 pg ml^–1 was associatedwith an increased risk of death or perioperative myocardialinjury [odds ratio (OR) 6.8, 95% CI 1.8–25.9, P = 0.003],and remained independently predictive after correction for theRevised Cardiac Risk Index. Preoperative BNP levels were higherin patients who exhibited new onset atrial fibrillation or ST/T-wavechanges on their postoperative ECG (median 50.5 vs 22.5 pg litre^–1,P = 0.01). They were also higher in patients who had eitherelevation of cTnI > 0.32 ng ml^–1 or postoperative ECGabnormalities (median 50.4 vs 21.5 pg ml^–1, P < 0.001). Conclusions: In the setting of major non-cardiac surgery, preoperative BNPlevels are higher in patients who experience perioperative deathand myocardial injury. Larger studies are required to confirmthese data and to clarify what BNP levels may add to existingmethods of risk stratification.     

Lactic acidosis in the rectal lumen of patients with septic shock measured by luminal equilibrium dialysis

Background. Gut ischaemia may contribute to morbidity in sepsis,but little is known about the metabolic state of the gut mucosain such patients. Methods. Nine patients with abdominal septic shock treated withnorepinephrine, and ten healthy subjects, were subjected toequilibrium dialysis with a rectal balloon. pH, PCO₂ and concentrationsof L-lactate were measured by auto-analyser. Results. In rectal dialysis fluid from patients with septicshock, acidosis was present (pH 7.23, 95% CI 7.11–7.36)and concentrations of L-lactate were approximately five timesgreater than controls (2.5–5.8 vs 0.5–1.2 mmollitre^–1). The lactate concentration was related to thedose of norepinephrine (P<0.001). In contrast, values ofdialysate PCO₂ did not differ significantly between patientsand controls (6.4–11.0 vs 8.9–13.8 kPa). Conclusions. The results suggest that, either lactic acidosisin rectal mucosa is related to shock severity, or that norepinephrinecauses mucosal ischaemia. In any case, metabolic dysfunctionis present in the rectal mucosa in patients with abdominal septicshock treated with norepinephrine. Br J Anaesth 2002; 89: 919–22     

Endotoxaemia during left ventricular assist device insertion: relationship between risk factors and outcome

Background. Endotoxaemia, caused by splanchnic ischaemia duringsurgery, is believed to trigger systemic inflammation and causepostoperative organ dysfunction. A relationship between theplasma concentration of endotoxin during surgery and known riskfactors for postoperative morbidity and mortality (e.g. age,abnormal gastric tonometric variables) and adverse outcome aftersurgery has not been demonstrated. Methods. In a prospective study, the plasma concentration ofendotoxin was measured in 12 patients undergoing implantationof a left ventricular assist device. Automated air gastric tonometrywas performed in all patients. The relationship between plasmaendotoxin concentration, risk factors, and postoperative outcomewas explored. Results. Carbon dioxide gap increased from 0.7 (0.3) to 3.6(1.6) kPa at the end of surgery. Endotoxin was detected in oneof 12 patients at baseline and in nine of 12 patients at theend of surgery (P=0.003). A high plasma concentration of endotoxinat the end of surgery was associated with a higher carbon dioxidegap (r=0.59, P<0.05), and a higher postoperative multipleorgan dysfunction score (r=0.7, P=0.01). Conclusions. The finding of an association between high intraoperativeplasma concentrations of endotoxin, abnormal gastric tonometricvariables and adverse outcome supports the view that endotoxaemiais caused by gut hypoperfusion during surgery and is associatedwith postoperative organ dysfunction. Br J Anaesth 2004; 92: 131–3     

Effect of preoperative beta-blockade on perioperative mortality in coronary surgery

Background. Many preoperative factors can influence perioperativemortality in cardiac surgery. Because the perioperative useof ß-blocking agents may reduce perioperative cardiaccomplications in non-cardiac surgery, we considered the possibilitythat ß-blocking agents could improve survival in coronarysurgery patients. Methods. In a retrospective study on 1586 patients undergoingcoronary bypass surgery, the relative risk of 30-day mortalitywas determined in relation to preoperative risk factors andmedication. Factors included patient characteristics, pre-existingillness, specific cardiovascular risk factors, cardiac statusand urgency of surgery. Treatment with ß-blockingagents, calcium antagonists, angiotensin-converting enzyme inhibitors,nitrates, anti-arrhythmic agents, diuretics and antithromboticagents was taken into account. Results. Sex, age, chronic obstructive pulmonary disease, urgencyand the preoperative use of diuretics and chronic ß-blockingtherapy were found to be linked to mortality (P<0.05). Backwardstepwise regression testing identified age, urgency and ß-blockingtherapy as independent factors that could predict mortality. Conclusions. Increasing age and urgency of surgery are associatedwith greater mortality, whereas preoperative ß-blockingtherapy is associated with less mortality. The characteristicsof patients who received chronic ß-blockade did notdiffer significantly from those of patients who did not. Theresults suggest that chronic preoperative ß-blockertherapy reduces 30-day mortality in coronary surgery. Br J Anaesth 2003; 90: 27–31     

Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study

BACKGROUND.: Sepsis is a major cause of acute renal failure in hospital patients,but its incidence and the associated prognostic factors haverarely been assessed prospectively by multivariate analysis. METHODS.: We conducted a prospective 6-month study in 20 multidisciplinaryintensive care units to assess the prognosis of patients hospitalizedwith acute renal failure due to sepsis. Sepsis syndrome andseptic shock were defined according to the criteria of the Societyof Critical Care Medicine Consensus Conference. Severity scoringindexes (SAPS, APACHE II, and organ system failure (OSF)) weremeasured on ICU admission and on inclusion. The end-point washospital mortality. RESULTS.: Acute renal failure had a septic origin in 157 patients (Group1), comprising 68 with septic shock and 89 with sepsis syndrome,and did not result from infection in 188 patients (Group 2).Patients with septic acute renal failure were older (mean age:62.2 versus 57.9 years, P<0.02) and had on inclusion a higherSAPS (19.3 versus 16.1, P<0.001), APACHE II (29.6 versus24.3, P<0.001), and OSF (2.07 versus 1.52, P<0.001) thanpatients with non-septic acute renal failure. They had a higherneed for mechanical ventilation (69.1% versus 47.3%, P<0.001),and acute renal failure was more often delayed during the ICUstay than was present on admission (47.7% versus 32.4% respectively,P<0.005). Hospital mortality was higher in patients withseptic acute renal failure (74.5%) than in those whose renalfailure did not result from sepsis (45.2%, P<0.001). Mortalitywas influenced by the presence of a septic shock (79.4%) orof a sepsis syndrome on inclusion (70.8%). Using a stepwiselogistic regression model, sepsis was an independent predictorof hospital mortality (OR, 2.51; 95% CI, 1.44–4.39) aswell as a delayed occurrence of acute renal failure, oliguria,an altered previous health status, hospitalization prior toICU, need for mechanical ventilation, age and severity scoringindexes on inclusion. In total patients, mortality was higherin dialyzed than in non-dialyzed patients (P<0.001), andin those treated by continuous compared to intermittent techniques(P<0.01). Patients dialysed with biocompatible membraneshad a lower mortality than those treated with cellulose membranes(P<0.005). CONCLUSIONS.: Patients with acute renal failure due to sepsis have a worseprognosis than those with non-septic acute renal failure. Sepsisand the above-defined predictive factors are to be consideredin studies on prognosis of ARF patients. Our results suggestthat the use of biocompatible membranes may reduce significantlymortality in these patients.     

Effects of hydroxyethyl starch administration on renal function in critically ill patients

BACKGROUND: The influence of hydroxyethyl starch (HES) solutions on renalfunction is controversial. We investigated the effect of HESadministration on renal function in critically ill patientsenrolled in a large multicentre observational European study. METHODS: All adult patients admitted to the 198 participating intensivecare units (ICUs) during a 15-day period were enrolled. Prospectivelycollected data included daily fluid administration, urine output,sequential organ failure assessment (SOFA) score, serum creatininelevels, and the need for renal replacement therapy (RRT) duringthe ICU stay. RESULTS: Of 3147 patients, 1075 (34%) received HES. Patients who receivedHES were older [mean (SD): 62 (SD 17) vs 60 (18) years,P = 0.022], more likely to be surgical admissions, had a higherincidence of haematological malignancy and heart failure, higherSAPS II [40.0 (17.0) vs 34.7 (16.9), P < 0.001] and SOFA[6.2 (3.7) vs 5.0 (3.9), P < 0.001] scores, and less likelyto be receiving RRT (2 vs 4%, P < 0.001) than those who didnot receive HES. The renal SOFA score increased significantlyover the ICU stay independent of the type of fluid administered.Although more patients who received HES needed RRT than non-HESpatients (11 vs 9%, P = 0.006), HES administration was not associatedwith an increased risk for subsequent RRT in a multivariableanalysis [odds ratio (OR): 0.417, 95% confidence interval (CI):0.05–3.27, P = 0.406]. Sepsis (OR: 2.03, 95% CI: 1.37–3.02,P < 0.001), cardiovascular failure (OR: 6.88, 95% CI: 4.49–10.56,P < 0.001), haematological cancer (OR: 2.83, 95% CI: 1.28–6.25,P = 0.01), and baseline renal SOFA scores > 1 (P < 0.01for renal SOFA 2, 3, and 4 with renal SOFA = 0 as a reference)were all associated with a higher need for RRT. CONCLUSIONS: In this observational study, haematological cancer, the presenceof sepsis, cardiovascular failure, and baseline renal functionas assessed by the SOFA score were independent risk factorsfor the subsequent need for RRT in the ICU. The administrationof HES had no influence on renal function or the need for RRTin the ICU.     

Loss to follow-up after laparoscopic gastric bypass surgery – a post hoc analysis of a randomized clinical trial

BackgroundFollow-up after bariatric surgery is important if we are to identify long-term complications at an early stage and thereby improve long-term outcome. Despite great efforts, many patients are lost to follow-up. Definition of characteristics of patients failing to attend follow-up could help in defining a specific group for whom extra resources may be applied to improve the situation.ObjectivesTo identify characteristics of patients failing to attend follow-up 2 years after laparoscopic gastric bypass surgery.SettingMulticenter study, Sweden.MethodsPost hoc analysis of a randomized clinical trial in which preoperative patient characteristics and postoperative outcome measures were compared between patients who attended or did not attend a 2-year follow-up visit after laparoscopic gastric bypass surgery.ResultsOf the 2495 patients included, 260 did not attend a 2-year follow-up visit. Factors associated with higher risk for failure to attend were younger age (adjusted odds ratio [OR] .96, 95% confidence interval [CI] .94–.98/yr, P < .001); male sex (adjusted OR 2.34, 95% CI 1.51–3.63, P < .001); depression (adjusted OR 1.61, 95% CI 1.05–2.47, P = .029); history of smoking (adjusted OR 1.78, 95% CI 1.26–2.51, P = .001); being single (adjusted OR 1.47, 95% CI 1.03–2.11, P = .036); and being first-generation immigrant (adjusted OR 1.74, 95% CI 1.05–2.88; P = .032). Elementary occupation (adjusted OR .42, 95% CI .18–.99, P = .047) was associated with lower risk.ConclusionThese findings indicate that there are preoperative characteristics that may help in identifying patients likely to fail to attend follow-up visits after laparoscopic gastric bypass surgery. Special effort should be made to inform these patients of the importance of follow-up and to encourage them to attend.     

妇科恶性肿瘤患者术后深静脉血栓危险因素的Meta分析

背景与目的:妇科恶性肿瘤患者术后发生深静脉血栓(DVT),可引起患者肺栓塞或猝死,严重威胁患者的生命,本研究通过Meta分析明确妇科恶性肿瘤患者术后发生DVT的危险因素,为预防和降低妇科恶性肿瘤患者术后DVT的发生提供循证依据.方法:计算机检索多个国内外数据库,搜集有关妇科恶性肿瘤患者术后DVT危险因素的队列研究或病例...     

Postoperative sepsis and septic shock after hip fracture surgery

IntroductionThere is a paucity of research in the rates for sepsis and septic shock in the hip fracture population specifically, despite marked clinical and prognostic differences between these conditions. The purpose of this study was to determine the incidence, risk factors, and mortality rates for sepsis and septic shock as well as evaluate potential infectious causes in the surgical hip fracture population.MethodsThe ACS-NSQIP (2015–2019) was queried for patients who underwent hip fracture surgery. A backward elimination multivariate regression model was used to identify risk factors for sepsis and septic shock. Multivariate regression that controlled for preoperative variables and comorbidities was used to calculate the odds of 30-day mortality.ResultsOf 86,438 patients included, 871 (1.0%) developed sepsis and 490 (0.6%) developed septic shock. Risk factors for both postoperative sepsis and septic shock were male gender, DM, COPD, dependent functional status, ASA class ≥3, anemia, and hypoalbuminemia. Unique risk factors for septic shock were CHF and ventilator dependence. The 30-day mortality rate was 4.8% in aseptic patients, 16.2% in patients with sepsis, and 40.8% in patients who developed septic shock (p < 0.001). Patients with sepsis (OR 2.87 [95% CI 2.37–3.48], p < 0.001) and septic shock (OR 11.27 [95% CI 9.26–13.72], p < 0.001) had increased odds of 30-day mortality compared to patients without postoperative septicemia. Infections that preceded a diagnosis of sepsis or septic shock included urinary tract infections (24.7%, 16.5%), pneumonia (17.6%, 30.8%), and surgical site infections (8.5%, 4.1%).ConclusionsThe incidence of sepsis and septic shock after hip fracture surgery was 1.0% and 0.6%, respectively. The 30-day mortality rate was 16.2% in patients with sepsis and 40.8% in patients with septic shock. Potentially modifiable risk factors for both sepsis and septic shock were anemia and hypoalbuminemia. Urinary tract infections, pneumonia, and surgical site infections preceded the majority of cases of sepsis and septic shock. Prevention, early identification, and successful treatment of sepsis and septic shock are paramount to lowering mortality after hip fracture surgery.     

Preoperative Patient Factors and Postoperative Complications as Risk Factors for New-Onset Depression Following Total Hip Arthroplasty

BackgroundDepression is known to be a risk factor for complication following primary total hip arthroplasty (THA), but little is known about new-onset depression (NOD) following THA. The purpose of this study is to determine the incidence of NOD and identify risk factors for its occurrence after THA.MethodsThis is a retrospective cohort study of the Truven MarketScan database. Patients undergoing primary THA were identified and separated into cohorts based on the presence or not of NOD. Patients with preoperative depression or a diagnosis of fracture were excluded. Patient demographic and comorbid data were queried, and postoperative complications were collected. Univariate and multivariate regression analysis was then performed to assess the association of NOD with patient-specific factors and postoperative complications.ResultsIn total, 111,838 patients undergoing THA were identified and 2517 (2.25%) patients had NOD in the first postoperative year. Multivariate analysis demonstrated that preoperative opioid use, female gender, higher Elixhauser comorbidity index, preoperative anxiety disorder, drug or alcohol use disorder, and preoperative smoking were associated with the occurrence of NOD (P ≤ .001). The following postoperative complications were associated with increased odds of NOD: prosthetic joint infection (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.42-2.34, P < .001), aseptic revision surgery (OR 1.47, 95% CI 1.06-2.04, P = .019), periprosthetic fracture (OR 1.72, 95% CI 1.13-2.61, P = .01), and non-home discharge (OR 1.59, 95% CI 1.42-1.77, P < .001).ConclusionsNOD is common following THA and there are multiple patient-specific factors and postoperative complications which increase the odds of its occurrence. Providers should use this information to identify at-risk patients so that pre-emptive prevention strategies may be employed.     

Fibromyalgia Increases the Risk of Surgical Complications Following Total Knee Arthroplasty: A Nationwide Database Study

BackgroundAlthough fibromyalgia is a common comorbidity with knee osteoarthritis, the orthopedic literature on this population is limited. Therefore, the purpose of this study is to assess if fibromyalgia patients have a higher likelihood of developing surgical complications after total knee arthroplasty (TKA) than a matched control cohort.MethodsThe Medicare Standard Analytical Files of the PearlDiver supercomputer was utilized to identify patients who underwent a TKA between 2005 and 2014. Patients were 1:1 propensity score matched based on the diagnosis of fibromyalgia, age, gender, and the Charlson Comorbidity Index, yielding a total of 305,510 patients. Odds ratios (ORs), 95% confidence intervals (95% CIs), and P-values (<.05) were calculated to examine the likelihood of developing any surgical complication, as well as specific surgical complications.ResultsCompared to a matched cohort, fibromyalgia patients had increased odds of developing any surgical complication (OR 1.55, 95% CI 1.51-1.60, P < .001), such as bearing wear (OR 2.11, 95% CI 1.48-3.01, P < .0001) and periprosthetic osteolysis (OR 1.71, 95% CI 1.10-2.66, P = .018). Furthermore, these patients had significantly greater odds of developing revision of tibial insert (OR 1.5, 95% CI 1.14-2.05, P = .046), mechanical loosening (OR 1.34, 95% CI 1.26-1.53, P < .0001), infection/inflammation (OR 1.33, 95% CI 1.26-1.14, P < .0001), dislocations (OR 1.33, 95% CI 1.21-1.47, P < .0001), as well as other complications (OR 1.74, 95% CI 1.68-1.80, P < .0001).ConclusionThis analysis of over 300,000 patients identified that fibromyalgia patients can have a greater risk of developing certain surgical complications after TKA. Therefore, fibromyalgia patients must be made aware of the increased postoperative risks and surgeons should consider enhanced preoperative medical and surgical optimization.     

Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery

Background. Occult hypovolaemia is a key factor in the aetiologyof postoperative morbidity and may not be detected by routineheart rate and arterial pressure measurements. Intraoperativegut hypoperfusion during major surgery is associated with increasedmorbidity and postoperative hospital stay. We assessed whetherusing intraoperative oesophageal Doppler guided fluid managementto minimize hypovolaemia would reduce postoperative hospitalstay and the time before return of gut function after colorectalsurgery. Methods. This single centre, blinded, prospective controlledtrial randomized 128 consecutive consenting patients undergoingcolorectal resection to oesophageal Doppler guided or centralvenous pressure (CVP)-based (conventional) intraoperative fluidmanagement. The intervention group patients followed a dynamicoesophageal Doppler guided fluid protocol whereas control patientswere managed using routine cardiovascular monitoring aimingfor a CVP between 12 and 15 mm Hg. Results. The median postoperative stay in the Doppler guidedfluid group was 10 vs 11.5 days in the control group P<0.05.The median time to resuming full diet in the Doppler guidedfluid group was 6 vs 7 for controls P<0.001. Doppler patientsachieved significantly higher cardiac output, stroke volume,and oxygen delivery. Twenty-nine (45.3%) control patients sufferedgastrointestinal morbidity compared with nine (14.1%) in theDoppler guided fluid group P<0.001, overall morbidity wasalso significantly higher in the control group P=0.05. Conclusions. Intraoperative oesophageal Doppler guided fluidmanagement was associated with a 1.5-day median reduction inpostoperative hospital stay. Patients recovered gut functionsignificantly faster and suffered significantly less gastrointestinaland overall morbidity.     

Drug absorption from the small intestine in immediate postoperative patients

Background. The effects of surgery on gastric emptying havebeen documented for a considerable time, but less is known aboutthe effects in the small intestine. It is thought that thereis minimal diminution in the absorptive capacity of the smallintestine after operation, although there is no literature ondrug absorption in the early period after surgery. This studyinvestigated drug absorption from the small bowel in patientsundergoing abdominal surgery. Methods. A prospective study of patients undergoing major abdominalsurgery in which patients acted as their own preoperative controlswas carried out. Patients were administered the test substances,acetaminophen and ^99mTcDTPA, before operation and 2 days afteroperation. Small intestine transit times, plasma concentrationsand other pharmacokinetic variables were compared using Student'spaired t-test. Two complementary studies were carried out toestablish pharmacokinetic parameters. Results. There were no significant differences in the pre- andpostoperative values of t_max, area under the curve, and areaunder the moment curve (AUMC) before and after operation (P>0.05).There were significant differences between the pre- and postoperativevalues of C_max [C_{max (preop)}>C_{max (postop)}; P<0.05] andthe pre- and postoperative values of mean residence time (MRT)[MRT_(preop)<MRT_(postop); P<0.01]. Conclusions. Drug absorption from the small bowel in the postoperativepatient does not differ significantly from its preoperativeabsorptive capacity.     

Influence of sepsis on sevoflurane minimum alveolar concentration in a porcine model

Sevoflurane is widely used in anaesthetic protocols for patientsundergoing surgical procedures. However, there are no reportson the influence of sepsis on minimum alveolar concentrationof sevoflurane (MAC_SEV) in animals or in humans. The aim ofthis study was to test the hypothesis that sepsis could alterthe MAC_SEV in a normotensive septic pig model. Twenty young,healthy pigs were used. After they had received 10 mg kg^–1of ketamine i.m. for premedication, anaesthesia was establishedwith propofol 3 mg kg^–1 and the trachea wasintubated. Sevoflurane was used as the sole anaesthetic agent.Baseline haemodynamic recording included electrocardiography,carotid artery blood pressure and a pulmonary thermodilutioncatheter. Baseline MAC_SEV in each pig was evaluated by pinchingwith a haemostat applied for 1 min to a rear dewclaw. MAC_SEVwas determined using incremental changes in sevoflurane concentrationuntil purposeful movement appeared. Pigs were assigned randomlyto two groups: the saline group (n=10) received a 1-h i.v. infusionof sterile saline solution while the sepsis group (n=10) receiveda 1-h i.v. infusion of live Pseudomonas aeruginosa. Epinephrineand hydroxyethylstarch were used to maintain normotensive andnormovolemic haemodynamic status. In both groups, MAC_SEV wasevaluated 5 h after infusion. Significant increases inmean artery pulmonary pressure, filling, epinephrine and vascularpulmonary resistances occurred in the sepsis group. MAC_SEV forthe saline group was 2.4% [95% confidence interval (CI) 2.1–2.55%]and the MAC_SEV for the sepsis group was 1.35% (95% CI 1.2–1.45%,P<0.05). These data indicate that MAC_SEV is significantlydecreased in this normotensive septic pig model. Br J Anaesth 2001; 86: 832–6     

The Potential Value of Performing Preoperative Urinalysis Prior to Total Knee Arthroplasty

BackgroundAlthough the practice of checking a urinalysis prior to elective total knee arthroplasty (TKA) is relatively common, very little has been reported on the association between a preoperative urinary tract infection (UTI) and adverse events in primary TKA. The goal of this study is to investigate the risk of postoperative complication following TKA as it relates to preoperative UTI.MethodsPatients undergoing TKA were queried in the National Surgical Quality Improvement Program. Morbid events were classified as minor (transfusion, pneumonia, wound dehiscence, UTI, and renal insufficiency) and serious (wound infection, thromboembolic event, renal failure, myocardial infarction, prolonged ventilation, unplanned intubation, sepsis, and death). Risk factors for adverse events were analyzed in both univariate and multivariate fashion.ResultsA total of 203,851 patients undergoing TKA met inclusion criteria and 507 patients had a UTI present at time of surgery (UTI PATOS). A propensity matched analysis controlling for age, gender, body mass index, operative year, and American Society of Anesthesiologists score identified 507 patients without a UTI PATOS to serve as the control group. Following adjustment for baseline characteristics, operative year, and American Society of Anesthesiologists score, UTI PATOS was associated with increased risk for serious adverse events (odds ratio [OR] 2.746, 95% confidence interval [CI] 1.546-4.878, P = .0006), occurrence of any morbid event (OR 1.894, 95% CI 1.299-2.761, P = .0009), and reoperation (OR 4, 95% CI 2.592-6.169, P < .0001).ConclusionThis study suggests that a UTI present at time of TKA increases the risk of multiple postoperative complications and reoperation.     

Risk factors for venous thromboembolism following surgical treatment of fractures: A systematic review and meta-analysis

This study aimed to determine the risk factors for postoperative venous thromboembolism (VTE) in patients treated surgically for fractures using a meta-analytic approach. Electronic searches were performed in PubMed, Embase, and the Cochrane library from inception until February 2022. The odds ratio (OR) and 95% confidence interval (CI) were applied to calculate the pooled effect estimate using the random-effects model. Sensitivity, subgroup, and publication bias tests were also performed. Forty-four studies involving 3 239 291 patients and reporting 11 768 VTE cases were selected for the meta-analysis. We found that elderly (OR: 1.72; 95% CI: 1.38-2.15; P < .001), American Society of Anesthesiologists (ASA) ≥ 3 (OR: 1.82; 95% CI: 1.46-2.29; P < .001), blood transfusion (OR: 1.82; 95% CI: 1.14-2.92; P = .013), cardiovascular disease (CVD) (OR: 1.40; 95% CI: 1.22-1.61; P < .001), elevated D-dimer (OR: 4.55; 95% CI: 2.08-9.98; P < .001), diabetes mellitus (DM) (OR: 1.36; 95% CI: 1.19-1.54; P < .001), hypertension (OR: 1.31; 95% CI: 1.09-1.56; P = .003), immobility (OR: 3.45; 95% CI: 2.23-5.32; P < .001), lung disease (LD) (OR: 2.40; 95% CI: 1.29-4.47; P = .006), obesity (OR: 1.52; 95% CI: 1.27-1.82; P < .001), peripheral artery disease (PAD) (OR: 2.13; 95% CI: 1.21-3.73; P = .008), prior thromboembolic event (PTE) (OR: 5.17; 95% CI: 3.14-8.50; P < .001), and steroid use (OR: 2.37; 95% CI: 1.73-3.24; P < .001) were associated with an increased risk of VTE. Additionally, regional anaesthesia (OR: 0.66; 95% CI: 0.45-0.96; P = .029) was associated with a reduced risk of VTE following surgical treatment of fractures. However, alcohol intake, cancer, current smoking, deep surgical site infection, fusion surgery, heart failure, hypercholesterolemia, liver and kidney disease, sex, open fracture, operative time, preoperative anticoagulant use, rheumatoid arthritis, and stroke were not associated with the risk of VTE. Post-surgical risk factors for VTE include elderly, ASA ≥ 3, blood transfusion, CVD, elevated D-dimer, DM, hypertension, immobility, LD, obesity, PAD, PTE, and steroid use.