重症监护病房非心脏手术患者术后新发房颤危险因素

目的调查重症监护病房(ICU)非心脏手术患者术后新发房颤(POAF)的发生情况,分析其危险因素及对近期预后的影响。方法采用回顾性、病例配对的方法。在2011年1月至2013年12月期间收住ICU的非心脏手术后成年患者2586例中,筛查术后住院期间新发房颤病例。按照1∶2的比例,选择年龄、性别和手术部位相同的病例作为对照组。采用SPSS 21.0统计软件对数据进行分析。多因素logistic回归分析筛选危险因素。比较2组患者的近期结局。结果 2.7%(71/2586)出现术后新发房颤。高龄(年龄≥75岁)及胸科手术患者术后新发房颤发生率高。在术后新发房颤患者中,77.5%(55/71)出现在术后3 d以内,仅33.8%(24/71)患者有不适主诉。在配对人群中,脓毒症(OR=11.81,95%CI 1.72~81.00,P=0.012)、低钾血症(OR=19.48,95%CI 2.31~164.09,P=0.006)、术后急性充血性心力衰竭(OR=9.91,95%CI1.92~51.22,P=0.006)及新发其他类型心律失常(OR=20.32,95%CI 3.51~117.55,P=0.001)是术后新发房颤的独立危险因素。术后新发房颤伴随机械通气时间及ICU停留时间延长及住院死亡率增高。结论非心脏手术入ICU的患者中术后新发房颤发生率为2.7%,多见于高龄(≥75岁)和胸科手术患者。在病例配对人群中,脓毒症、急性充血性心力衰竭、低钾血症和新发非房颤心律失常是术后新发房颤的危险因素。新发房颤伴随预后恶化。     

不同液体管理方案对ICU老年重症颅脑损伤术后患者组织氧合及肠功能的影响

【】目的 探讨不同液体管理方案对ICU老年重症颅脑损伤术后患者的组织氧合功能及肠功能的改善效果。方法 选取2012年1月至2015年12月期间本院收治的72例重度颅脑损伤术后患者作为研究对象,随机分为对照组和实验组各36例,对照组采用肠内营养和肠外营养支持的序贯疗法,研究组患者采用早期肠内营养支持疗法。对比治疗后两组患者的循环功能、组织氧合功能及肠功能指标。结果 观察组的HR、CVP 、MAP、PAWP、MPAP、CO、PVR、SVR及Lac较对照组均可见显著改善(P<0.05);观察组患者的各项氧代谢指标均较对照组有明显改善(P<0.05);观察组患者的平均肠鸣音恢复时间及肛门排气/排便时间均短于对照组,腹痛、腹泻、腹胀现象的发生率均低于对照组,差异具有统计学意义(P<0.05)。结论 早期肠内营养支持疗法可明显改善ICU老年重症颅脑损伤术后患者的循环功能及氧代谢障碍,恢复肠功能,降低术后并发症的发生。     

Dexamethasone and post-adenotonsillectomy pain in children: Double-blind,randomized controlled trial

Objective:To assess the impact of intraoperative intravenous dexamethasone on the reduction of postoperative morbidity in children undergoing adenotonsillectomy.Methods:A double blind randomized controlled trial conducted among children undergoing adenotonsillectomy at a tertiary hospital in Korea from November 2018 to June 2019. Children were randomly assigned to receive dexamethasone (0.5 mg/kg, maximum dose 24 mg) or placebo intravenously after induction of anesthesia. The primary endpoint was the reduction of postoperative pain and postoperative nausea and vomiting (PONV); secondary endpoints were adverse effects like postoperative hemorrhage.Results:The study included 105 children, and 67 were male. Their mean age was 6.2 ± 2.1 years. There was no significant difference between the groups in terms of demographic data or the operation time. The pain scores of the dexamethasone group were lower than those of the control group, but no significant difference was found (all P > .05). The average pain visual analog scale (VAS) during the study period (day 0–7) was 3.67 ± 1.59 and 4.40 ± 2.01 in the dexamethasone group and control group, respectively (P-value = .107). When we compared early pain VAS (day 0–2) and late pain VAS (day 5–7), the dexamethasone group showed significantly lower early mean VAS compared to the control group (4.55 ± 1.78 vs 5.40 ± 2.05, P-value = .046). The mean VAS for PONV was significantly lower in the dexamethasone group than in the control group (1.89 ± 2.22 vs 3.00 ± 2.37, P value = .044).Conclusion:In children undergoing adenotonsillectomy, dexamethasone decreased the early postoperative pain and PONV without increasing postoperative hemorrhage.     

Inspiratory training and immediate lung recovery after resective pulmonary surgery: a randomized clinical trial

BackgroundPrompt and uneventful recovery after resective pulmonary surgery benefits patients by decreasing length and total costs of hospital stay. Postoperative physiotherapy has been shown to be advantageous for patient recovery in several studies and lately inspiratory muscle training (IMT) physiotherapy has been used also in thoracic patients. This randomized controlled trial intended to evaluate whether IMT is an efficient and feasible method of physiotherapy compared to water bottle positive expiratory physiotherapy (PEP) immediately after lung resections.MethodsForty-two patients were randomly allocated into two intervention groups: water bottle PEP (n=20) and IMT group (n=22). Patients were given physiotherapeutic guidance once a day and patients were also instructed to do independent exercises. Measurements of pulmonary function were compared between the treatment groups according to intention to treat by using two-way repeated measures analysis of variances at three time points (preoperative, first postoperative day, and second postoperative day). Walking distance was measured at first and second postoperative day and similarly, evaluation of postoperative air leak during exercises was performed. Physiotherapy was modified or temporarily interrupted, if necessary, because of the air leak.ResultsPostoperative pulmonary function tests were equal between the intervention groups. Air leak was relatively common after lung resections: 31% of all patients had mild or moderate/severe air leak at first postoperative day and 14% of all patients had mild to severe air leak at second postoperative day respectively. There were no statistically significant differences in occurrence of air leak between intervention groups, but water resistance had to be reduced or physiotherapy discontinued significantly more often among the water bottle PEP group patients (P=0.01). Walking distance improved slightly faster in the IMT group between the first and the second postoperative day when compared to the water bottle PEP group, but the difference between the groups was not statistically significant.ConclusionsIMT physiotherapy is equally effective to water bottle PEP training in postoperative physiotherapy after lung resection surgery evaluated with pulmonary function tests and walking distance. In addition, IMT physiotherapy is safe and more feasible form of physiotherapy during postoperative air leak compared to water bottle PEP.     

Postoperative subdural hematoma as a rare complication of non-traumatic craniotomy: Two cases report

Rationale:Postoperative intracranial hemorrhage is a serious and even fatal complication after non-traumatic craniotomy, in which epidural hematoma and intracerebral hematoma are relatively common. Postoperative subdural hematoma is rare, and its pathogenic mechanism remains unclear.Patient concerns:In the present study, we report 2 cases with postoperative subdural hematoma after non-traumatic craniotomy.Diagnoses:The diagnosis of acute subdural hematoma (aSDH) was rendered according to the imaging features.Interventions:Hematoma evacuation was performed immediately.Outcomes:Two months later, the first patient continued to have impaired consciousness and sensorimotor deficiency in the right extremities. And the second one remained unconscious and continued to have sensorimotor disturbance in the right extremities after 6 weeks of rehabilitation.Lessons:Neurosurgeons should be aware of potential subdural hematoma after non-traumatic craniotomy, since this condition is usually latent and associated with poor prognosis. Early identification and surgical evacuation should be highlighted.     

Mortality of Tuberculosis in Very Old People

OBJECTIVES: To describe the clinical characteristics and outcomes of tuberculosis (TB) in elderly people.
DESIGN: Observational analysis of a prospective cohort of adults with TB (1995–2004). A case–control study to determine attributable mortality to TB in very old people was done.
RESULTS: Of 319 patients with TB, 109 (34.2%) were aged 65 and older. The older group was more likely to have comorbidities (1.4% vs 0.4%; P <.001), extrapulmonary and disseminated TB (50.4% vs 26.1%; P <.001), toxicity (22% vs 9.8%; P =.006), and 30-day mortality (18.3% vs 1.6%; P <.001). When patients aged 65 to 79 were compared with those aged 80 and older, only differences in TB-related mortality were detected (9.8% vs 44.4%; P =.01). In the attributable mortality analysis, 30-day and 6-month mortality were higher in very old patients with TB than in controls without TB (41.7% vs 11.1%, P =.005; 45.8% and 19.4%, P =.01, respectively). No differences in mortality were shown when excluding patients with postmortem TB diagnosis or those who died within the first 72 hours of diagnosis.
CONCLUSION: Older people with TB had a higher frequency of atypical features, more adverse drug reactions, and greater TB-related mortality than younger people. Data suggest that very old patients with TB have higher mortality, but if diagnosed early and adequately treated, very old patients with TB do not have greater mortality than those without.     

Dexmedetomidine as an adjuvant for patients undergoing breast cancer surgery: A meta-analysis

Background:The goal of this study was to comprehensively evaluate the analgesic and antiemetic effects of adjuvant dexmedetomidine (DEX) for breast cancer surgery using a meta-analysis.Methods:Electronic databases were searched to collect the studies that performed randomized controlled trials. The effect size was estimated by odd ratio (OR) or standardized mean difference (SMD). Statistical analysis was performed using the STATA 13.0 software.Results:Twelve published studies involving 396 DEX treatment patients and 395 patients with control treatment were included. Pooled analysis showed that the use of DEX significantly prolonged the time to first request of analgesia (SMD = 1.67), decreased the postoperative requirement for tramadol (SMD = −0.65) and morphine (total: SMD = −2.23; patient-controlled analgesia: SMD = −1.45) as well as intraoperative requirement for fentanyl (SMD = −1.60), and lower the pain score at 1 (SMD = −0.30), 2 (SMD = −1.45), 4 (SMD = −2.36), 6 (SMD = −0.63), 8 (SMD = −2.47), 12 (SMD = −0.81), 24 (SMD = −1.78), 36 (SMD = −0.92), and 48 (SMD = −0.80) hours postoperatively compared with the control group. Furthermore, the risks to develop postoperative nausea/vomiting (PONV) (OR = 0.38) and vomiting (OR = 0.54) were significantly decreased in the DEX group compared with the control group. The pain relief at early time point (2, 6, 12, 24 hours postoperatively) and the decrease in the incidence of PONV were especially obvious for the general anesthesia subgroup (P < .05) relative to local anesthesia subgroup (P >.05).Conclusion:DEX may be a favorable anesthetic adjuvant in breast cancer surgery, which could lower postoperative pain and the risk to develop PONV. DEX should be combined especially for the patients undergoing general anesthesia.     

Mortality and refusal in the longitudinal 90+ project

Attrition is one of the most important threats for longitudinal studies on aging mainly due to refusal and mortality. This study deals with those individuals who were assessed in the base line of 90+ project but died, dropped out or were examined in the follow-up. Participants of the 90+ project baseline consist of a sample of 188 older than 90 years, independent individuals (mean age = 92.9; 67 men and 121 women) living in the community (n = 76) or in residences (n = 112). They were assessed through the European Survey on Aging Protocol (ESAP) by collecting anthropometric, health and life styles, bio-behavioral, psychological and social data. After 6-14 months from the baseline, 55% individuals were re-assessed, 11% died and 34% dropped out for several reasons. Comparisons between the individuals deceased, interviewed and those who dropped out yielded significant differences mainly due to contextual variables. The mortality rate of participants living in residences is three times greater than those of participants living in the community. Trying to determine the differences between these three groups due to bio-psycho-social variables, we found that regular physical activity, mental status, leisure activities, fitness, perceived control and openness assessed at the baseline differentiate our three groups. Finally, 90% of those individuals who died were identified at the baseline as “non successful agers”, while more than a half of those who participated and a third of the non-participants were identified as “successful agers”. It can be concluded that among those independent but very old people, mortality is less important than willing to participate and contextual, behavioral and psychological factors are relevant for distinguishing mortality, survival and participation.     

The effect of formalizing enhanced recovery after esophagectomy with a protocol

Enhanced recovery after surgery (ERAS) pathways aim to accelerate functional return and discharge from hospital. They have proven effective in many forms of surgery, most notably colorectal. However, experience in esophagectomy has been limited. A recent study reported significant reductions in pulmonary complications, mortality, and length of stay following the introduction of an ERAS protocol alone, without the introduction of any clinical changes. We instituted a similar change 16 months ago, introducing a protocol to provide a formal framework, for our existing postoperative care. This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change. Data were collected from prospectively maintained secure web‐based multidisciplinary databases. Complication severity was classified using the Clavien‐Dindo scale. Operative mortality was defined as death within 30 days of surgery, or at any point during the same hospital admission. Lower respiratory tract infection was defined as clinical evidence of infection, with or without radiological signs. Respiratory complications included lower respiratory tract infection, pleural effusion (irrespective of drainage), pulmonary collapse, and pneumothorax. Statistical analysis was performed using SPSS v21. One hundred thirty‐two patients underwent esophagectomy (55 protocol group; 77 before). All were performed open. There were no differences between the two groups in terms of age, gender, operation, use of neoadjuvant therapy, cell type, stage, tumor site, or American Society of Anesthesiologists grade. Median length of stay was 14.0 days (protocol) compared with 12.0 before (interquartile range 9–19 and 9.5–15.5, respectively; P = 0.073, Mann–Whitney U‐test). Readmission within 30 days of discharge occurred in five (9.26%) and six (8.19%; P = 1.000, Fisher's exact test). There were four in‐hospital deaths (3.03%): one (1.82%) and three (3.90%), respectively (P = 0.641). There were no differences in the severity of complications (P = non‐significant; Pearson's chi‐squared). There were no differences in the type of complications occurring in either group. The protocol was completed successfully by 26 (47.3%). No baseline factors were predictive of this. In contrast to previous studies, we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol. Consequently, improvements in short‐term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care. Consequently, we would recommend that centers introducing new (or reviewing existing) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such standardized pathways.     

Operative Stress Response Is Reduced After Laparoscopic Compared toOpen Cholecystectomy

Our objective was to determine the least invasive surgical procedure; to do this we compared postoperative pain, duration of ileus, and level of neurohormonal stress response after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC). Postoperative recovery of patients was faster after LC than OC but comparison of the neurohormonal stress response after laparoscopic and open surgical procedures revealed conflicting results. Forty-one consecutive patients with noncomplicated gallstones were randomized for LC (N = 25) and OC (N = 16). The stress level was evaluated in patients before surgery by the Hamilton anxiety scale. Postoperative pain was assessed by a visual analogic scale (VAS) pain score and by the amount of analgesic drugs (propacetamol) administered, while the duration of ileus was determined by the delay between surgery and the time to first passage of flatus as well by the colonic transit time (CTT) measured by radiopaque markers. Plasma concentrations of anti-diuretic hormone (ADH), adrenocorticotropic hormone (ACTH), -endorphin (BE), neurotensin (NT), and aldosterone (Ald) were measured before and during surgery as well as 2 and 5 hr after the surgery (D0) and on the day following surgery (D1). Urinary cortisol (uCOR) and urinary catecholamine metabolites were assessed before surgery, during D0, and on D1. Patient characteristics, the duration of surgery, and the doses of anesthetic drugs were not different in LC and OC. In LC patients the VAS pain score and the doses of postoperative antalgics were lower (P < 0.05), the time to first passage of flatus was shorter (P < 0.001), and the CTT tended to be shorter (54 ± 12 hr vs 81 ± 17) compared to OC patients. Patients who required the highest doses of postoperative antalgics had the longest delay to first passage of flatus (P < 0.01). During surgery, all neurohormonal parameters increased compared to the preoperative period (P < 0.05), and only plasma NT concentrations were lower during LC than OC (P < 0.05). During the postoperative period, ACTH, BE, Ald, catecholamines, and uCOR concentrations were lower in LC than in OC (P < 0.05). Concentrations of hormonal parameters were higher when the duration of surgery increased (P < 0.05). A greater need for propacetamol to relieve pain was associated with a greater increase in BE, ACTH, and urinary catecholamine levels (P < 0.05–P < 0.005). When the time to first passage of flatus was delayed, levels of BE, ACTH, and catecholamines and NT concentrations were increased (P < 0.05–P < 0.005). In conclusion, LC is less invasive because this surgical procedure induces a shorter neurohormonal stress response than OC, even if the peroperative response is not different. Postoperative pain levels and the duration of ileus are associated with BE, ACTH, and catecholamine levels and NT concentrations, suggesting the importance of hormones in postoperative functional recovery.     

Determining optimal fluid and air leak cut off values for chest drain management in general thoracic surgery

Background

Chest drain duration is one of the most important influencing aspects of hospital stay but the management is perhaps one of the most variable aspects of thoracic surgical care. The aim of our study is to report outcomes associated with increasing fluid and air leak criteria of protocol based management.

Methods

A 6-year retrospective analysis of protocolised chest drain management starting in 2007 with a fluid criteria of 3 mL/kg increasing to 7 mL/kg in 2011 to no fluid criteria in 2012, and an air leak criteria of 24 hours without leak till 2012 when digital air leak monitoring was introduced with a criteria of <20 mL/min of air leak for more than 6 hours. Patient data were obtained from electronic hospital records and digital chest films were reviewed to determine the duration of chest tube drainage and post-drain removal complications.

Results

From 2009 to 2012, 626 consecutive patients underwent thoracic surgery procedures under a single consultant. A total of 160 did not require a chest drain and data was missing in 22, leaving 444 for analysis. The mean age [standard deviation (SD)] was 57±19 years and 272 (61%) were men. There were no differences in the incidence of pneumothoraces (P=0.191), effusion (P=0.344) or re-interventions (P=0.431) for drain re-insertions as progressively permissive criteria were applied. The median drain duration dropped from 1-3 days (P<0.001) and accordingly hospital stay reduced from 4-6 days (P<0.001).

Conclusions

Our results show that chest drains can be safely removed without fluid criteria and air leak of less than 20 mL/min with median drain duration of 1 day, associated with a reduced length of hospital stay.     

Effect of Octreotide on Postoperative Intraperitoneal Adhesions in Rats

Background: Octreotide, a long-acting somatostatin analogue that can inhibit glycosaminoglycan synthesis by fibroblasts in skin, may be a potent inhibitor of postoperative intraperitoneal adhesions. An animal model was developed to evaluate the effect of octreotide. Methods: Twenty-four male Wistar rats were divided into four groups. Laparotomy with a 15-cm intestinal resection and reanastomosis was performed on each group of rats. The intestinal serosa was also scratched to induce adhesion formation. No medication was given to group-1 rats (C). Group-2 rats received peritoneal irrigation with 6 ml normal saline intraoperatively (NS). Group-3 rats received irrigation with 6 ml octreotide solution (5 μg/ml) intraperitoneally (Oc). Group-4 rats received irrigation with 6 ml octreotide solution intraoperatively and 10 μg/kg of octreotide injection intramuscularly twice a day for 14 days (Oc + IM). All rats were killed 2 weeks later. The number of fibrous bands at and away from the anastomotic site was recorded. The strength and extent of the fibrous bands were also measured. Results: The total scores of intraperitoneal adhesion bands were significantly reduced in group Oc and group Oc + IM rats when compared with group C (p < 0.05). When the fibrous bands at the anastomotic site and away from it were distinguished, the results were the same. As to the strength and extent of intestinal adhesions, the data showed no significant difference among all four groups. Conclusions: These data supported the suggestion that octreotide can reduce the incidence of postoperative intraperitoneal adhesions in rats.     

人工心脏起搏术后并发症的临床分析

我院自１９７３～１９９５年８月共植入永久性心脏起搏器８００例，术后各种并发症１４９例，发生率为１８．６％。并发症的发生与起搏方式、术中操作、起搏系统质量及起搏器使用不当有关。与起搏方式有关的并发症８２例，占并发症发生率的５５．０％；与手术有关的并发症３０例，占２０．１％；起搏系统并发症３７例，占２４．８％。对患者危害较大的并发症有ＶＶＩ起搏后心力衰竭、起搏器综合征及术后皮囊感染。并发症处理不当会影响起搏功能，重者可能危及到患者生命。本组并发症经及时处理绝大部分对患者预后无影响。并发症防止的重点应放在“预防”上，即合理选用起搏器及严把手术操作关。     

Wirsungostomy as a salvage procedure after pancreaticoduodenectomy

Background

Mortality rates associated with postoperative peritonitis or haemorrhage secondary to pancreatic fistula (PF) after pancreaticoduodenectomy (PD) remain high. This study analysed the results of an alternative management strategy for these life-threatening complications.

Methods

All patients undergoing PD between January 2004 and April 2011 were identified. Patients who underwent further laparotomy for failure of the pancreatico-digestive anastomosis were identified. Since 2004, this problem has been managed by dismantling the pancreatico-digestive anastomosis and canulating the pancreatic duct remnant with a thin polyethylene tube (Escat tube), which is then passed through the abdominal wall. Main outcome measures were mortality, morbidity and longterm outcome.

Results

From January 2004 to April 2011, 244 patients underwent a PD. Postoperatively, 21 (8.6%) patients required re-laparotomy to facilitate a wirsungostomy. Two patients were transferred from another hospital with life-threatening PF after PD. Causes of re-laparotomy were haemorrhage (n = 12), peritonitis (n = 4), septic shock (n = 4) and mesenteric ischaemia (n = 1). Of the 21 patients who underwent wirsungostomy, six patients subsequently died of liver failure (n = 3), refractory septic shock (n = 2) or mesenteric ischaemia (n = 1) and nine patients suffered complications. The median length of hospital stay was 42 days (range: 34–60 days). The polyethylene tube at the pancreatic duct was removed at a median of 4 months (range: 2–11 months). Three patients developed diabetes mellitus during follow-up.

Conclusions

These data suggest that preservation of the pancreatic remnant with wirsungostomy has a role in the management of patients with uncontrolled haemorrhage or peritonitis after PF.