Long-Term Sedation with Isoflurane in Postoperative Intensive Care in Cardiac Surgery

Abstract: After cardiac surgery, patients often require prolonged mechanical ventilation. We studied the effectiveness and potential toxicity of isoflurane sedation in 40 patients undergoing mechanical ventilation after cardiovascular surgery. All patients who received isoflurane (0.5-1.0 minimum alveolar concentration [MAC]) were well sedated by it without significant adverse effects, such as renal, hepatic, or cardiovascular dysfunction. The highest serum inorganic fluoride concentration recorded was 45 |x molL after 98 MAC h. Patients on isoflurane recovered more rapidly and were weaned from mechanical ventilation sooner than those sedated with intravenous drugs including fentanyl/midazolam. Patients who received intravenous sedatives, but not those on isoflurane, often showed tachyphylaxis in the early stages, and some exhibited an abstinence syndrome involving nonpurposeful movements. Patients sedated with isoflurane did not show these two side effects. In conclusion, isoflurane can provide effective long-term sedation for patients after cardiovascular surgery without significant adverse effects.     

Utilization of Intensive Care Resources in Bariatric Surgery

Background: Obese patients occasionally require either elective or emergency critical care services following bariatric surgery. We describe this subgroup of patients. Methods: From July 1, 1991 to July 31, 2004, we performed 1,279 bariatric operations; 241 (19%) required admission to the surgical critical care service. We retrospectively reviewed medical records for gender, body mass index (BMI), age, whether the operation was initial or revisional, and whether critical care admission was elective or emergent. 3 complication clusters (thromboembolic, pulmonary, and anastomotic) were identified using discharge ICD-9 codes. The costs and length of stay of these subpopulations was calculated. Results: Patients were on average 46 ± 10 years old, with BMI 59 ± 13. Critical care admission was emergent in 52.7% (n=127) of cases. Revisional cases did not differ from the initial cases in BMI (56.4 vs 59.2, P=0.42) and they were no more likely to require emergent critical care admission than initial cases (P=0.16). Revisional cases were hospitalized longer (27.2 ± 25.6 vs 12.5 ± 18.7 days, P =0.003); had higher total hospital costs (US$ 60,631 ± 78,337 vs 27,697 ± 52,351, P=0.025); and were more likely to die from their complications (revisional surgery mortality 6.5% vs 1.9% for initial surgery [P=0.002]). Conclusions: An increasing number of surgical revisions will likely accompany the recent increase in popularity of bariatric surgery. In our experience, these patients require significant critical care services, and have longer, complicated, and more costly hospitalizations.     

Postoperative Medical Complications and Intermediate Care Unit/Intensive Care Unit Admission in Joint Replacement Surgery: A Prospective Risk Model

Background

Postoperative complications are the main consumers of technical, medical, and human resources. Especially in the field of elective joint replacement surgery, a specialized, easy-to-obtain, and cost-efficient preoperative stratification and risk-estimation model is missing.

Fast-track Surgery Improves Postoperative Recovery in Patients with Gastric Cancer: A Randomized Comparison with Conventional Postoperative Care

Background

Fast-track surgery is a new, promising comprehensive program for surgical patients and is beneficial to recovery. Prospective randomized, controlled clinical trials involving fast-track surgery for gastric cancer are lacking.

Patient and methods

Ninety-two patients with gastric cancer were randomly divided into a fast-track surgery group (n?=?45) and conventional surgery group (n?=?47). We compared outcomes (duration of postoperative stay in hospital, fever, and flatus, complications, and medical costs); postoperative serum levels of tumor necrosis factor-α, interleukin-6, and C-reactive protein; and resting energy expenditure between two groups.

Results

Compared with the conventional surgery group, the fast-track surgery group had no more complications (P?>?0.05) with a significantly shorter duration of fever, flatus, and hospital stay, and less medical costs as well as a higher quality of life score on hospital discharge (all P?<?0.05). With a significantly lower resting energy expenditure (days?1 and 3) postoperatively (P?<?0.05), the fast-track surgery group showed a lower serum level of tumor necrosis factor-α (days?1 and 3), interleukin-6 (days?1 and 3), and C-reactive protein (days?1, 3, and 7) than the conventional surgery group (all P?<?0.05).

Conclusions

Fast-track surgery can lessen postoperative stress reactions and accelerate rehabilitation for patients with gastric cancer.     

大型听神经瘤患者显微手术后护理

对38例大型听神经瘤患者行枕下乙状窦后入路开颅显微镜下肿瘤切除术.结果 术后患者面神经功能有不同程度恢复,8例饮水呛咳者术后明显缓解,但手术损伤颅神经,发生周围性面瘫3例,结膜炎15例,面部感觉异常8例,偏瘫3例,角膜炎2例.经精心治疗与护理,除1例因多器官衰竭死亡外,其余患者术后平均住院20 d,均康复出院.提出术后护理要点为,重视对神志和生命体征的观察,加强脑室引流管的护理,积极预防并发症及正确处理.     

Care of the Obesity Surgery Patient Requiring Immediate-Level Care or Intensive Care

Most bariatric surgery patients are triaged directly to the medical surgical floor postoperatively. However, patients at high risk due to comorbid factors, who have failed postoperative extubation or have suffered intraoperative complication, may require intensive care unit (ICU) or intermediate-level care (IMC). The special needs of the morbidly obese IMC/ICU patient include: triage, mobility, visiting, fluid resuscitation, management of sleep apnea, airway management, transporting for out of ICU procedures, and preventing pressure ulcers. Traditional approaches to nursing care require new thought when dealing with the massively obese. Our experiences with the special needs of these critically ill morbidly obese bariatric surgery patients are described.     

High Mortality Rate for Patients Requiring Intensive Care After Surgical Revision Following Bariatric Surgery

Background To report the prognosis and management of patients reoperated for severe intraabdominal sepsis (IAS) after bariatric surgery (S0) and admitted to the surgical intensive care unit (ICU) for organ failure. Methods A French observational study in a 12-bed adult surgical intensive care unit in a 1,200-bed teaching hospital with expertise in bariatric surgery. From January 2001 to August 2006, 27 morbidly obese patients (18 transferred from other institutions) developed severe postoperative IAS (within 45 days). Clinical signs, biochemical and radiologic findings, and treatment during the postoperative course after S0 were reviewed. Time to reoperation, characteristics of IAS, demographic data, and disease severity scores at ICU admission were recorded and their influence on prognosis was analyzed. Results The presence of respiratory signs after S0 led to an incorrect diagnosis in more than 50% of the patients. Preoperative weight (body mass index [BMI] > 50 kg/m²) and multiple reoperations were associated with a poorer prognosis in the ICU. The ICU mortality rate was 33% and increased with the number of organ failures at reoperation. Conclusion During the initial postoperative course after bariatric surgery, physical examination of the abdomen is unreliable to identify surgical complications. The presence of respiratory signs should prompt abdominal investigations before the onset of organ failure. An urgent laparoscopy, as soon as abnormal clinical events are detected, is a valuable tool for early diagnosis and could shorten the delay in treatment.