Synbiotics reduce postoperative infectious complications: a randomized controlled trial in biliary cancer patients undergoing hepatectomy

Background and aims The clinical value of synbiotics in surgical patients remains unclear. The aim of this study was to investigate the effect of synbiotics on intestinal integrity and microflora, as well as on surgical outcome, in patients undergoing high-risk hepatectomy.Methods Fifty-four patients with biliary cancer were randomly allocated to two groups before hepatectomy. One group received postoperative enteral feeding that included synbiotics; the other received enteral feeding only. Lactulose/mannitol (L/M) ratio, serum diamine oxidase (DAO) activity, and fecal microflora and organic acid concentrations were determined. Postoperative infectious complications were recorded.Results Of the 54 patients, 44 completed the trial (21 receiving synbiotics and 23 others as controls). Postoperative changes in L/M ratios and serum DAO activities were identical between the two groups. Numbers of beneficial bacteria increased in the synbiotics group after surgery but decreased in controls. Numbers of harmful microorganisms decreased in the synbiotics group but increased in controls. Total organic acid concentrations increased in the synbiotics group but decreased in controls. Incidence of infectious complications was 19% (4/21) in the synbiotics group and 52% (12/23) in controls (P<0.05). All study patients tolerated surgery (mortality 0%).Conclusions Synbiotics, combined with early enteral nutrition, can reduce postoperative infections. This beneficial effect presumably involves correction of an intestinal microbial imbalance induced by surgical stress.     

前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后镇痛效果的比较

目的比较前锯肌平面阻滞与胸椎旁神经阻滞用于胸腔镜手术患者术后的镇痛效果。方法选择择期行胸腔镜手术患者60例,男38例,女22例,年龄18～65岁,BMI 18～25kg/m2,ASAⅠ或Ⅱ级,采用随机数字表法分为前锯肌平面阻滞组(S组)和胸椎旁阻滞组(T组),每组30例。两组患者均采用支气管插管静脉全身麻醉,术后采用PCIA。S组于麻醉诱导前行超声引导下前锯肌平面阻滞,T组则行超声引导下胸椎旁阻滞,两组均使用0.4%罗哌卡因30ml,阻滞完成后30min使用针刺法测定并记录感觉阻滞平面;记录阻滞操作时间、起效时间、持续时间;记录术后2、4、8、12、24、48h的静息和咳嗽VAS评分;记录首次按压镇痛泵时间、术后48h内镇痛泵有效按压次数、舒芬太尼使用总量和哌替啶补救性镇痛例数;记录阻滞相关并发症、镇痛不良反应发生情况。结果与T组比较,S组阻滞操作时间明显缩短,阻滞持续时间明显延长(P0.01);S组术后12h静息时和咳嗽时VAS评分明显降低(P0.01),S组PCIA首次按压时间明显延长,S组PCIA 48h内按压次数、舒芬太尼使用量明显减少(P0.01),两组气胸、恶心呕吐发生率差异无统计学意义。结论超声引导下前锯肌平面阻滞或胸椎旁阻滞均可为胸腔镜手术患者提供良好术后镇痛,但前锯肌平面阻滞较胸椎旁阻滞作用更持久、操作时间更短、并发症更少,且能有效减少患者术后对阿片类药物的需求量。     

胸椎旁阻滞对开胸患者开胸前心功能及术后情况的影响

目的 观察胸椎旁阻滞对开胸患者开胸前心功能的影响、术后镇痛及不良反应发生情况.方法 开胸手术患者90例,随机均分为全麻组(I组)、硬膜外阻滞复合全麻组(Ⅱ组)和胸椎旁阻滞复合全麻组(Ⅲ组).Ⅱ、Ⅲ组根据手术切口部位在全麻前20 min行相应的硬膜外或胸椎旁间隙给药.采用血流动力学监护仪分别于进入手术室后安静状态(T0)、硬膜外或胸椎旁间隙阻滞20 min(T1)、全麻诱导后插管前(T2)、气管插管后(T3)4个时段监测三组HR、无创MAP、心排血量(CO)、心脏指数(CI)、加速度指数(ACI)、外周血管阻力(SVR)和收缩时间比率(STR),同时记录ECG和SpO2;并观察术后镇痛情况及不良反应.结果 T2时I和Ⅱ组HR、MAP、CI、CO、SVR、ACI较T0和Ⅲ组明显下降(PcC0.05);STR较Ⅲ组明显上升(P＜0.05).Ⅲ组心电图ST段下移的发生率明显低于I组和Ⅱ组(P＜0.05).三组患者对术后镇痛满意率相似.Ⅲ组患者术后并发症明显少于I组和Ⅱ组(P＜0.05).结论 全麻及硬膜外阻滞复合全麻对开胸患者心功能影响大,术后并发症较多;而椎旁阻滞系单侧脊神经阻滞,复合全麻对心功能和呼吸功能影响相对较轻,适宜于单侧开胸手术及术后镇痛治疗.     

胸椎旁神经阻滞对开胸手术患者静脉镇痛效果的影响

目的 研究胸椎旁神经阻滞对开胸于术后静脉镇痛效果的影响.方法 择期全麻下肺叶切除术的患者102例,随机分成二三组:Ⅰ组,32例,单纯全麻;Ⅱ组,36例,于全麻诱导后行胸椎旁神经阻滞;Ⅲ组,34例.于全麻诱导前行硬膜外阻滞.三组均于术毕缝皮时启动患者静脉自控镇痛(PCIA)泵行芬太尼、氟比洛芬酯静脉镇痛,分别于患者清醒拔除气管导管后即刻(T1)、术后24 h(T2)、48 h(T3)进行视觉模拟评分(VAS),记录启动自控按钮次数及背景输注总量.结果 三组24、48 h PCIA泵的背景输注总晕差异无统计学意义.Ⅱ、Ⅲ组在T1、T2时的VAS均低于Ⅰ组(P＜0.05),术后48 h内启动自控按钮次数明显少于Ⅰ组(P＜0.05).结论 在开胸手术前行胸椎旁神经阻滞或硬膜外阻滞可以增强芬太尼、氟比洛芬酯的静脉镇痛效果.     

胸科手术后舒芬太尼静脉镇痛的剂量探讨

目的探讨普胸外科手术后舒芬太尼静脉镇痛的合理剂量和效果。方法80例普胸外科手术后的病人均分为四组,A组（芬太尼30μg／h）,B组（舒芬太尼3μg／h）,C组（舒芬太尼4μg／h）,D组（舒芬太尼5μg／h）。观察术后4、8、16、24、48h的疼痛、镇静、情绪、睡眠质量评分,并记录有无恶心、呕吐、呼吸抑制、皮肤瘙痒等不良反应,记录镇痛泵输注情况、（实际／有效）按压次数,计算单位时间实际用药量。结果四组间镇静、睡眠质量评分以及不良反应差异无统计学意义,D组疼痛评分显著低于其他三组（P〈0．05）,PCA泵按压次数最少,B、C、D组单位时间实际药量大致相近。结论普胸外科手术后舒芬太尼静脉镇痛的最佳剂量为5μg／h,且恒速背景输注比反复追加给药更容易为病人所接受。     

Aprotinin reduces postoperative bleeding and the need for blood products in thoracic surgery: results of a randomized double-blind study

Objective: Bleeding complications have been a major concern in certain thoracic surgery operations, especially decortication and pulmonary resection for inflammatory pulmonary infection. Prevention of plasminogen activation and fibrinolysis by aprotinin administration has been shown to reduce perioperative bleeding during operations associated with high blood consumption. Methods: Use of blood products (packed red cells, whole blood), chest tube drainage, analgesic requirement, chest tube duration for the patients undergoing major thoracic operations were recorded. In a double blind randomized fashion, patients were assigned to two groups receiving aprotinin (n=51) at a loading dose of 10⁶ kallikrein inhibitory units (KIU) followed by an infusion of the same dose during chest closure or receiving placebo (n=52). On a daily basis, red-cell percentages of total fluid from drainage bottles were recorded and using the blood hematocrit level of the patient of the day before, the corrected value for the patient's blood volume equivalent of daily drainage was calculated. Results: There was a significant reduction in perioperative use of donor blood (0.98±0.92 vs. 0.45±0.32 unit; P=0.0026), and total chest tube drainage (corrected value for the corresponding blood volume) (28.2±36.9 vs. 76.9±53.3 ml, P=0.0004) (mean±standard deviation) in the aprotinin group. However, aprotinin did not reduce postoperative transfusion or decrease in hematocrit level due to thoracic operations. In high transfusion-risk thoracic surgery patients (patients who underwent decortication, pulmonary resection for inflammatory lung disease and chest wall resection), the perioperative transfusion was only 0.50±1.08 units in aprotinin group, compared with 1.94±0.52 units in control group (P=0.003). Postoperative transfusion was also reduced in aprotinin administrated group (0.53±0.56 vs. 1.38±0.97 units; P=0.02). The mean total blood loss was decreased to nearly one third of the blood loss of the control group (41±28 ml vs. 121±68 ml; P=0.001). Conclusion: Aprotinin significantly reduced perioperative transfusion requirement and postoperative bleeding during major thoracic operations. Aprotinin decreased perioperative transfusion needs. Moreover, patients who were at risk of greater blood loss during and after certain thoracic operations had a greater potential to benefit from prophylactic perioperative aprotinin treatment.     

Effects of methylprednisolone on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery: A randomized controlled trial

Study objectiveEvidence from previous studies indicates that glucocorticoids offer effective postoperative analgesia and improve the quality of recovery (QoR). The aim of this study was to evaluate the efficacy of preoperative methylprednisolone on early postoperative pain and QoR following thoracoscopic lung surgery.DesignA prospective, single-center, three-arm, double-blinded, randomized trial.SettingTertiary university hospital.PatientsAdult patients aged ≥18 years undergoing thoracoscopic lung surgery were eligible for participation.InterventionsPatients enrolled in this study were randomized to receive preoperative methylprednisolone (40 mg or 120 mg) or identical volumes of 0.9% saline.MeasurementsThe primary outcome was the proportion of moderate-to-severe pain (numerical rating scale [NRS] ≥ 4 when coughing during pulmonary rehabilitation exercises) on the first day postoperatively. The postoperative pain scores, QoR-15 scores and other secondary outcomes were also recorded.Main resultsOf the 180 enrolled patients, 173 patients were included in the primary analysis. The results showed that the proportion of moderate-to-severe pain was not significantly different between the combined methylprednisolone group and the placebo group (51.7% vs. 64.9%; absolute difference, 13.2%; 95% CI, −2.1% to 29.3%; P = 0.10). Patients who received methylprednisolone treatment had lower pain scores at rest and coughing on the first day after surgery than those who received placebo treatment, with mean differences of 0.5 and 0.7, respectively (P < 0.01). QoR-15 scores were higher in patients treated with methylprednisolone at day 1 (mean difference, 6.9; P < 0.001) and day 2 (mean difference, 7.2; P < 0.001) than in patients who received placebo treatment. No side-effects associated with methylprednisolone treatment were observed.ConclusionsOur findings suggested that preoperative methylprednisolone (either high or low dose) has limited impact on early postoperative pain and recovery in patients undergoing thoracoscopic lung surgery, with no clinically relevant benefits detected when compared with placebo.Trial registrationChinese Clinical Trail Register (identifier: ChiCTR1900021020).     

The efficacy of paravertebral block using a catheter technique for postoperative analgesia in thoracoscopic surgery: a randomized trial

Objective: The analgesic scheme combining paravertebral block (PVB) and intravenous non-steroidal anti-inflammatory drug (NSAID) has proven to be effective for postoperative pain control after thoracotomy. The hypothesis tested in this study was that this policy was also suitable to improve pain control after video-assisted thoracic surgery (VATS). Methods: This was a prospective randomized study on 40 patients submitted to three-ports’ VATS for pneumothorax or solitary pulmonary nodule. The sample size was calculated to detect one point of minimum pain score difference with 80% statistical power. Patients were randomly assigned to two groups: (1) paravertebral block group (PVB) (n = 20) – At the end of surgery, a catheter was placed in patients in the thoracic paravertebral space under camera control; they received a bolus of 15 ml of local anesthetic (ropivacaine 0.2%) every 6 h, combined with endovenous metamizol (1 g); and (2) alternate NSAIDs group (AN) (n = 20) – They were treated with paracetamol (1 g) combined with metamizol (1 g) every 6 h. Subcutaneous meperidine (synthetic opioid) was employed as rescue drug. Both groups were comparable in terms of age, sex, pathology, and co-morbidity. Pain level was measured with the visual analog scale (VAS) at 1, 6, 24, and 48 h. Results: No side effects related to any of the two analgesic techniques were noted. Two patients needed rescue meperidine in the AN group, and none in the PVB group. VAS scores were the following: PVB group, VAS 1 h: 1.4 ± 0.8, VAS 6 h: 3.4 ± 1.2, VAS 24 h: 2.6 ± 1.0, VAS 48 h: 2.2 ± 0.9, and mean VAS: 2.4 ± 1.3; AN group, VAS 1 h: 2.8 ± 1.0, VAS 6 h: 4.9 ± 1.3, VAS 24 h: 3.9 ± 1.4, VAS 48 h: 3.3 ± 1.0, and mean VAS: 3.8 ± 1.4. VAS scores were significantly lower at any time in the PVB patients (p < 0.01). Conclusions: The analgesic regimen combining PVB and NSAID provided an excellent level of pain control. Thoracoscopy assisted positioning of the paravertebral catheter is simple and effective, and allows direct visualization of correct delivery of local anesthetic. It represents a valuable addition to any VATS procedure.     

昂丹司琼预防妇科腹腔镜手术恶心呕吐的Meta分析

目的 系统评价昂丹司琼预防妇科腹腔镜全麻术后恶心呕吐(postoperative nausea and vomiting,PONV)的有效性和安全性. 方法 电子检索中国学术期刊全文数据库(CNKI)、中国生物医学文献数据库(CBM)、重庆维普中文科技期刊全文数据库、万方数据库、Pubmed、Springer、Embase、Web of knowledge数据库,并查阅所获文献的参考文献,收集1995～2012年发表的有关昂丹斯琼预防妇科腹腔镜全麻PONV的随机对照试验(randomized controlled trials,RCTs).按Cochrane Handbook5.0.1对纳入文献进行质量评价和资料提取,统计学分析采用Stata11.0软件. 结果共纳入18个RCT,包括1 597例患者.Meta分析结果显示:①有效性:昂丹司琼单次静脉注射能降低妇科腹腔镜全麻PONV的发生率[(RR=0.210,95％CI=0.164～0.268)];昂丹司琼4 mg与8 mg单次静脉注射对预防妇科腹腔镜全麻术后患者24 h PONV效果相当[(RR=0.948,95％CI=0.433～2.075)];手术前期应用昂丹司琼较术毕应用患者PONV发生率更低[(RR=0.450,95％CI=0.290～0.698)];昂丹斯琼4 mg或氟哌利多1.25 mg～2 mg静脉注射患者术后24 h PONV发生率相同[(RR=1.36,95％CI=0.74～2.51)];昂丹司琼联合氟哌利多静脉注射预防术后PONV发生较单独使用昂丹司琼效果更好[(RR=3.56,95％CI=1.74～7.29)].②安全性:昂丹司琼静脉注射不增加头痛、低热的发生率. 结论 昂丹司琼4 mg术前静脉注射能明显降低妇科腹腔镜全麻PONV的发生率,但并不能降低头痛、低热等副作用的发生率.昂丹司琼联合小剂量氟哌利多静脉注射较单独使用昂丹司琼对预防妇科腹腔镜全麻PONV的发生效果更好.     

胸椎旁神经阻滞和竖脊肌平面阻滞用于胸腔镜肺叶切除术术后镇痛效果的Meta分析

目的:通过Meta分析方法评价超声引导下胸椎旁神经阻滞（thoracic paravertebral nerve block, TPVB）和竖脊肌平面阻滞（erector spinae plane block, ESPB）用于胸腔镜肺叶切除术术后镇痛的效果。方法:计算机检索PubMed、Web of Science、C...     

硬膜外阻滞对胸科手术患者血液流变学及凝血功能的影响

目的观察硬膜外阻滞及硬膜外镇痛对胸科手术患者血液流变学和凝血功能的影响.方法胸科手术(肺叶切除或食管中下段切除)患者22例,随机分全麻复合硬膜外阻滞组(GEA组)和全麻组(GA组),每组11例.分别测定全麻诱导前(基础值)、术中1、3 h、术后1、3 d的血栓弹性描记图(TEG)、血液粘度、红细胞变形聚集指数、血小板计数(PLT)、血小板聚集指数(PAG)、活化部分凝血活酶时间(APTT)、凝血酶原时间(PT)、纤维蛋白原(FIB)、组织纤溶酶原激活物(t-PA)、组织纤溶酶原抑制物(PAI-A)的水平.结果GEA组PT、APTT显著性高于GA组(P＜0.01);GEA组红细胞聚集指数较GA组显著性降低(P＜0.05);GEA组血液粘度较GA组显著性降低(P＜0.05);GEA组血小板聚集功能显著性增强(P＜0.05),GA组无改变;GEA组t-PA无显著性变化,而GA组术后1 d显著性升高(P＜0.05);两组PAI-A均无显著性变化;TEG参数R、K在GA组显著性缩短(P＜0.05),而GEA组无显著性变化;两组ANG均在术后3 d时显著性增大(P＜0.05);GEA组MA术后3 d显著性高于GA组(P＜0.01);GA组CL30、CL60术后1 d升高,并显著性高于GEA组(P＜0.05).GEA组TPI术后3 d显著性高于GA组(P＜0.05).结论胸段硬膜外阻滞及术后镇痛能够抑制胸科手术应激反应引起的凝血功能增强,可降低红细胞的聚集、降低血液粘度、改善术后纤溶抑制,对血小板聚集有促进作用.     

超声引导下横突-胸膜中点阻滞与胸椎旁神经阻滞用于单孔胸腔镜手术后镇痛效果的比较

目的 比较超声引导下横突-胸膜中点阻滞(MTPB)与胸椎旁神经阻滞(TPVB)用于单孔胸腔镜手术术后镇痛的效果。
方法 选择择期行单孔胸腔镜手术患者80例,男36例,女44例,年龄18～65岁,BMI 19～28 kg/m²,ASA Ⅰ―Ⅲ级。采用随机数字表法分为MTPB组（M组）和TPVB组（P组）,每组40例。手术结束后M组行超声引导下MTPB,P组行TPVB,两组均注射0.5%罗哌卡因15 ml。两组患者术后均采用PCIA。记录神经阻滞操作时间、穿刺深度,记录术后2、6、12、24、48 h安静和咳嗽时VAS疼痛评分,记录镇痛泵首次按压时间、总按压次数、舒芬太尼使用量和补救镇痛例数,记录穿刺相关并发症、镇痛不良反应发生情况。
结果 与P组比较,M组神经阻滞操作时间明显缩短（P<0.05）,进针深度明显变浅（P<0.05）。术后2、6、12、24、48 h两组安静和咳嗽时VAS疼痛评分差异无统计学意义。两组患者术后镇痛泵首次按压时间、总按压次数、舒芬太尼用量和补救镇痛率差异无统计学意义。两组患者术后恶心、呕吐等不良反应差异无统计学意义。
结论 MTPB或TPVB联合术后PCIA应用于单孔胸腔镜手术患者,术后均可取得良好的镇痛效果,但MTPB操作简单、安全,可作为单孔胸腔镜手术患者术后镇痛方案的选择。     

胸科手术患者围术期右心功能影响因素的研究进展

胸科手术患者围术期会因不同原因出现不同程度的右心功能下降,可持续至术后数周。围术期右心功能下降与术后右心功能不全的发展紧密相关。避免围术期右心功能下降,降低术后心血管事件的发生率,已成为目前围术期医学的研究热点。围术期多种因素会影响患者右心功能,主要包括单肺通气、手术方式、镇痛模式、液体管理等。全文对胸科手术患者围术期右心功能影响因素的研究进行简要综述,旨在更好地践行加速康复外科理念,有效保护胸科手术患者围术期右心功能,为改善患者预后提供参考。     

骨科手术中自体血液回输对血清前炎性细胞因子浓度的影响

目的 测定下肢骨科手术术野回收血经自体血回收机处理前后及患者自血回输前后血清前炎性细胞因子浓度,观察骨科手术中自体血回输对患者细胞免疫的影响.方法 30例择期行下肢骨科手术患者,分别采集自体血回收机处理前后的术野回收血,并于自体血回输前10min、回输后1 h采集患者动脉血,采用放射酶联免疫吸附测量法测定血样中3种前炎性细胞因子白细胞介素(IL)-1β、IL-6、肿瘤坏死因子(TNF)浓度,并观察相关并发症.结果　术野回收血经自体血回收机处理前后3种前炎性细胞因子IL-1β、IL-6、TNF浓度分别为(0.54 ±0.22)、(0.71±0.16)、(16.23±5.68)μg/L和(0.26±0.12)、(0.29±0.09)、(6.32±2.57)μg/L,与处理前比较,处理后3种细胞因子浓度显著降低(P＜0.05);自血回输前后患者血清中3种细胞因子IL-1β、IL-6、TNF浓度分别为(0.35±0.17)、(0.47±0.15)、(8.44±3.56)μg/L和(0.39±0.19)、(0.52±0.18)、(9.48±3.45)μg/L,与回输前比较,回输后患者血清中3种细胞因子浓度增高(P＜0.05);30例患者自体血回输后12 h内均未观察到低血压、心动过速、血红蛋白尿、凝血功能紊乱、脓毒血症、空气栓塞、心肺问题等并发症.结论　骨科手术患者术中可适量自体血回输,回收血液经自体血回收机处理后前炎性细胞因子浓度显著降低,回输后未观察到严重并发症.

Abstract：

Objective To investigate the effects of autologous blood transfusion on serum cytokine levels in patients undergoing lower limb orthopedic surgery. Methods A total of 30 cases scheduled for undergoing lower limb orthopedic surgery were enrolled in this study. Each patient had four blood samples taken (pre-transfusion, one h post-transfusion, cell saver container, and post-filtration from the blood bag). An enzyme linked immunosorbent assay (ELISA) measurement of radiation was conducted to determine levels of the cytokines interleukin (IL)-1β, IL-6 and tumor necrosis factor (TNF). Serious complications and sequelae associated with autotransfusion were recorded. Results In comparison to cell saver container, levels of IL-1β, IL-6 and TNF in the blood bag were decreased significantly (P＜0. 05 ). In comparison to pre-transfusion, levels of IL-1β, IL-6 and TNF were increased significantly (P ＜ 0. 05 ). No serious complications and sequelae associated with autotransfusion were observed. Conclusion The use of cell saver container appears to be safe in patients undergoing orthopedic surgery and the levels of the cytokines in post-filtration blood are decreased.     

The evaluation of clopidogrel use in perioperative general surgery patients: a prospective randomized controlled trial

Background

The perioperative safety profile of clopidogrel, a potent antiplatelet agent used in the management of cardiovascular disease, is unknown, and there are no evidence-based guidelines recommending for either its interruption or continuation at this time. The aim of this study was to determine whether patients who are maintained on clopidogrel before general surgical procedures are at increased risk of perioperative bleeding complications.

Methods

Patients receiving clopidogrel at the time of elective general surgery were randomized to either discontinue clopidogrel 1 week before surgery (group A) or continue clopidogrel into surgery (group B). All other antiplatelet and anticoagulant agents were discontinued before surgery. The primary end points were perioperative bleeding requiring intraoperative or postoperative transfusion of blood or blood components and bleeding-related readmission, reoperation, or mortality within 90 days of surgery. The secondary end points were perioperative myocardial infarction or cerebrovascular accidents within 90 days of surgery.

Results

Thirty-nine patients were enrolled and underwent 43 general surgical operations. Twenty-one procedures were randomized to group A and 22 to group B. The most commonly performed individual procedures were open inguinal hernia repair (23%), laparoscopic cholecystectomy (21%), open ventral hernia repair (15%), laparoscopic ventral hernia repair (11%), and laparoscopic inguinal hernia repair (9%). No perioperative mortalities, bleeding events requiring blood transfusion, or reoperations occurred. One readmission for intra-abdominal hematoma requiring percutaneous drainage occurred in each group (group A: 4.8% vs group B: 4.5%; P = 1.0). No myocardial infarctions or cerebrovascular accidents were observed or reported.

Conclusions

The outcomes from this prospective study suggest that, patients undergoing commonly performed elective general surgical procedures can be safely maintained on clopidogrel without increased perioperative bleeding risk.     

The influence of preoperative carbohydrate loading on postoperative outcomes in bariatric surgery patients: a randomized,controlled trial

BackgroundPreoperative carbohydrate loading is a component of Enhanced Recovery After Surgery (ERAS) protocols, but there is limited literature in bariatric surgery patients.ObjectivesThe objective of this study was to characterize the impact of preoperative carbohydrate loading on postoperative bariatric surgery outcomes.SettingUniversity Hospital.MethodsPatients undergoing a primary minimally invasive Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between 2018 and 2020 were randomized to standard management or intervention. Standard management patients were nothing by mouth (NPO) after midnight prior to surgery. Intervention patients consumed 2 carbohydrate drinks: 1 the night before and another 3 hours prior to surgery. Primary outcomes analyzed included postoperative nausea and vomiting (PONV), length of stay, and overall complications.ResultsIn total, 134 patients were analyzed: 64 intervention (47.8%) and 70 (52.2%) standard. In the end, 7% and 15% of patients were lost to follow-up at 6-weeks and 3-months, respectively. There was no statistically significant difference in length of stay (2.0 ± 1.2 vs 2.1 ± .9 d; P = .65) or postoperative outcomes between the 2 groups. There were no episodes of aspiration among the intervention group. Among RYGB patients, intervention patients had a shorter duration of nausea compared with standard patients. There was no significant difference in glycemic control among patients with and without diabetes.ConclusionsPreoperative carbohydrate drinks can be administered to bariatric surgery patients without significant risks. Carbohydrate loading preoperatively can decrease the duration of PONV in RYGB patients. Carbohydrate drinks can be safely included in bariatric ERAS protocols for patients with and without diabetes, although the benefits remain unknown.     

A randomized, controlled trial of aprotinin in neonates undergoing open-heart surgery

Background:  Neonates undergoing open-heart surgery are especially at risk for massive bleeding and pronounced inflammation. The efficacy of aprotinin, a serine protease inhibitor, at ameliorating these adverse effects of cardiopulmonary bypass has not been clearly demonstrated in neonates.
Methods:  Term neonates were enrolled and randomly assigned in a blinded fashion to receive saline (group P, placebo) or high-dose aprotinin (group A). Intraoperative management was standardized: surgeon, anesthesia, cardiopulmonary bypass and hemostasis therapy. Patients were admitted postoperatively to a pediatric cardiac intensive care unit. Primary outcome measure of efficacy was duration of the postoperative mechanical ventilation. Secondary outcome measures were total volume and units of blood products transfused intraoperatively and for 24 h after surgery, duration of chest tube in situ , and intensive care and hospital stays after surgery.
Results:  Twenty-six neonates were enrolled; 13 received aprotinin and 13 received placebo. The study was halted prematurely because of US Food and Drug Administation's concerns about aprotinin's safety. Baseline patient, surgery and cardiopulmonary bypass characteristics were similar between groups. No outcome variables differed between groups ( P  > 0.05). Duration of postoperative ventilation was 115 ± 139 h (group A); 126 ± 82 h (group P); P  = 0.29, and total blood product exposure was 8.2 ± 2.6 U (group A); 8.8 ± 1.4 U (group P); P  = 0.1. Postoperative blood creatinine values did not differ between groups. In-hospital mortality rate was 4%.
Conclusions:  Aprotinin was not shown to be efficacious in neonates undergoing open-heart surgery. It is unclear whether adult aprotinin safety data are relevant to neonates undergoing open-heart surgery.     

胸段硬膜外镇痛对开胸手术病人血糖、胰岛素和皮质醇水平的影响

目的　观察胸段硬膜外镇痛 (TEA)对开胸手术病人血糖、胰岛素和皮质醇水平的影响。方法　 2 0例在地氟醚麻醉下行开胸手术病人 ,随机分为TEA组和对照组。于麻醉前、术中 90分钟、术毕 6 0分钟和术后第 1、2、3天测定血糖、胰岛素及皮质醇浓度 ,计算胰岛素敏感性指数。结果　两组病人血糖均自术中 90分钟时明显升高 ,术毕 6 0分钟达峰值 ,术后第 1、2天仍居高不下 (P<0 0 5或P <0 0 1)。TEA组术中及术后胰岛素水平无明显改变 ;对照组术后第 1、2天胰岛素水平升高明显 (P <0 0 5或P <0 0 1)。TEA组病人皮质醇仅术毕 6 0分钟时明显升高 (P <0 0 5 ) ,而对照组于手术中 90分钟明显升高 ,并持续到术后第 1、2天 (P <0 0 5 )。两组胰岛素敏感性指数均明显下降 (P <0 0 5 ) ,于术后第 3天TEA组恢复接近麻醉前水平 (P >0 0 5 ) ;而对照组至术后第 3天仍低于麻醉前值 (P <0 0 5 )。结论　TEA可缓解开胸手术应激反应 ,减轻术后糖代谢紊乱。     

Avoidance of nitrous oxide for patients undergoing major surgery: a randomized controlled trial

BACKGROUND: Nitrous oxide is widely used in anesthesia, often administered at an inspired concentration around 70%. Although nitrous oxide interferes with vitamin B12, folate metabolism, and deoxyribonucleic acid synthesis and prevents the use of high inspired oxygen concentrations, the consequences of these effects are unclear. METHODS: Patients having major surgery expected to last at least 2 h were randomly assigned to nitrous oxide-free (80% oxygen, 20% nitrogen) or nitrous oxide-based (70% N2O, 30% oxygen) anesthesia. Patients and observers were blind to group identity. The primary endpoint was duration of hospital stay. Secondary endpoints included duration of intensive care stay and postoperative complications; the latter included severe nausea and vomiting, and the following major complications: pneumonia, pneumothorax, pulmonary embolism, wound infection, myocardial infarction, venous thromboembolism, stroke, awareness, and death within 30 days of surgery. RESULTS: Of 3,187 eligible patients, 2,050 consenting patients were recruited. Patients in the nitrous oxide-free group had significantly lower rates of major complications (odds ratio, 0.71; 95% confidence interval, 0.56-0.89; P = 0.003) and severe nausea and vomiting (odds ratio, 0.40; 95% confidence interval, 0.31-0.51; P < 0.001), but median duration of hospital stay did not differ substantially between groups (7.0 vs. 7.1 days; P = 0.06). Among patients admitted to the intensive care unit postoperatively, those in the nitrous oxide-free group were more likely to be discharged from the unit on any given day than those in the nitrous oxide group (hazard ratio, 1.35; 95% confidence interval, 1.05-1.73; P = 0.02). CONCLUSIONS: Avoidance of nitrous oxide and the concomitant increase in inspired oxygen concentration decreases the incidence of complications after major surgery, but does not significantly affect the duration of hospital stay. The routine use of nitrous oxide in patients undergoing major surgery should be questioned.