Analgesia with continuous wound infusion of local anesthetic versus saline: Double-blind randomized, controlled trial in hepatectomy.

BACKGROUND: Surgical wound is source of pain in hepatectomy with laparotomy. Continuous wound infusion of ropivacaine may provide effective analgesia. METHODS: This prospective, randomized trial, patients scheduled for hepatectomy received a 48-h preperitoneal continuous wound infusion of either 0.23% ropivacaine or 0.9% saline at 5 ml/h. Primary endpoint was 48 h morphine consumption. RESULTS: 53 patients included in the ropivacaine group and 46 in the saline group. Morphine consumption was 24.63 mg in the ropivacaine group, and 26.78 mg (p = 0.669) in the saline group. Pain was comparable between groups and there were no differences in solid food intake, ambulation, or length of hospital stay. No local or systemic complications were recorded. CONCLUSIONS: Continuous wound infusion with ropivacaine is safe, but it neither reduced morphine consumption nor enhanced recovery in patients undergoing hepatectomy. Success of enhanced recovery in hepatectomy is not influenced by the analgesic regimen if pain is well controlled.

Protocolized hyperventilation enhances electroconvulsive therapy.

BACKGROUND: Hyperventilation is recommended in electroconvulsive therapy (ECT) to enhance seizures and to increase patients' safety. However, more evidence is needed regarding its effects and the optimum method of application. METHODS: This prospective study involving 21 subjects compared two procedures, protocolized hyperventilation (PHV) and hyperventilation as usual (HVau), applied to the same patient in two consecutive sessions. Transcutaneous partial pressure of carbon dioxide (TcPCO2) was measured throughout all sessions. Ventilation parameters, hemodynamic measures, seizure characteristics, and side effects were also explored. RESULTS: PHV resulted in lower TcPCO2 after hyperventilation (p=.008) and over the whole session (p=.035). The lowest TcPCO2 was achieved after voluntary hyperventilation. Changes in TcPCO2 from baseline showed differences between HVau and PHV at each session time-point (all p<.05). Between- and within-subjects factors were statistically significant in a general linear model. Seizure duration was greater in PHV sessions (p=.028), without differences in other seizure quality parameters or adverse effects. Correlations were found between hypocapnia induction and seizure quality indexes. LIMITATIONS: Secondary outcomes could be underpowered. CONCLUSIONS: PHV produces hypocapnia before the stimulus, modifies patients' TcPCO2 values throughout the ECT session and lengthens seizure duration. Voluntary hyperventilation is the most important part of the PHV procedure with respect to achieving hypocapnia. A specific ventilation approach, CO2 quantification and monitoring may be advisable in ECT. PHV is easy to apply in daily clinical practice and does not imply added costs. Ventilation management has promising effects in terms of optimizing ECT technique.

Hypocapnia and hyperoxia induction using a hyperventilation protocol in electroconvulsive therapy. / Inducción de hipocapnia e hiperoxia con maniobras de hiperventilación reglada en la terapia electroconvulsiva.

INTRODUCTION: Hyperventilation in electroconvulsive therapy sessions has been associated with seizure threshold, seizure characteristics, and cognitive effects. There is no consensus on the optimal procedure of applying hyperventilation manoeuvres during electroconvulsive therapy. MATERIAL AND METHODS: Prospective evaluation of the effects of systematic use of hyperventilation manoeuvres with facial mask and capnography (protocolized hyperventilation [pHV]), on ventilation parameters and on seizures. The study included a sample of 130 sessions (65 performed according to hyperventilation standard practice and 65 successive sessions, with pHV) of 35 patients over a period of 10 weeks. RESULTS: The pHV manoeuvres reduced exhaled CO2 and increased O2 saturation significantly (P<.001). The average CO2 reduction achieved was 6.52±4.75mmHg (95% CI -7.7 to -5.3). The CO2 values after pHV correlated significantly with seizure duration and O2 values, with other electroencephalographic quality indices. In pHV sessions, compared with sessions performed according to hyperventilation standard practice, the average lengthening of the motor and electroencephalographic seizure was 3.86±14.62 and 4.73±13.95s, respectively. No differences were identified in other ictal quality parameters. CONCLUSIONS: The proposed pHV manoeuvres significantly modify ventilation parameters. The hypocapnia and hyperoxia obtained by applying these manoeuvres lengthen the duration of seizures without worsening the quality of the electroencephalographic trace. The use of pHV is generalisable and might improve electroconvulsive therapy procedure without adding costs.

Risk factors and mortality after elective and emergent laparatomies for oncological procedures in 899 patients in the intensive care unit: a retrospective observational cohort study.

BACKGROUND: Abdominal surgeries for cancer are associated with postoperative complications and mortality. A view of the success of anaesthetic, surgical and critical care can be gained by analyzing factors associated with mortality in patients admitted to intensive care units (ICUs). The objective of this study was to identify the postoperative mortality rate and the causes of perioperative death in high-risk patients after abdominal surgery for cancer. A secondary objective was to explore possible risk factors for death in scheduled and emergency surgeries, with a view to finding guidance on preventable risk factors. METHODS: An observational study, in a 12-bed surgical ICU of a tertiary hospital. Patients admitted after abdominal surgery for cancer to the ICU for more than 24 hours' care were included from January 1, 2008-December 31, 2009. Data were extracted from the minimum basic dataset. The main outcome considered was 90-day mortality. RESULTS: Of 899 patients included, 80 (8.9%) died. Seven died within 48 hours of surgery, 18 died between 2 and 7 days, and 55 died after 7 days. Non-survivors were older and had more respiratory comorbidity, chronic liver disease, metastasis, and underwent more palliative procedures. 112 patients underwent emergency surgery; mortality in these patients for resection surgery was 32.5%; in the 787 patients who underwent scheduled surgery, mortality was 4.7% for resection procedures. The estimated odds ratios (95% confidence interval) of preoperative patient factors in emergency surgery confirmed a negative association between survival and older age 0.96 (0.91-1), the presence of respiratory comorbidity 0.14 (0.02-0.77) and metastasis 0.18 (0.05-0.6). After scheduled surgery, survival was negatively associated with age 0.93 (0.90-0.96) and chronic liver disease 0.40 (0.17-0.91). Analysis of complications after emergency surgery also indicated a negative association with sepsis 0.03 (0.003-0.32), respiratory events 0.043 (0.011-0.17) and cardiac events 0.11 (0.027-0.45); after scheduled surgery, respiratory 0.03 (0.01-0.08) and cardiac 0.11 (0.02-0.45) events, renal failure 0.02 (0.006-0.14) and neurological events 0.06 (0.007-0.5). CONCLUSIONS: As most deaths occurred after discharge from the ICU, postoperative sepsis, respiratory and cardiac events should be watched carefully on the ward.

[Incidence of surgical wound infection in elective colorectal surgery and its relationship with preoperative factors]. / Incidencia de la infección de la herida quirúrgica en cirugía colorrectal electiva y su relación con factores perioperatorios.

INTRODUCTION: Surgical wound infection in colorectal surgery has incidence rate of up to 26%. Peri-operative factors and those of the patients themselves play a part in these infections. The correct administration of the antibiotic, a normal temperature, and hyperoxygenation are a commonly applied triad. The primary aim of the study was to evaluate the incidence of surgical wound infection in patients subjective to colorectal surgery where a surgical infection prevention protocol was applied. The second objective was the relationship between surgical infection and peri-operative factors. MATERIAL AND METHODS: An observational study was conducted on 100 patients who had undergone elective colorectal surgery. Demographic data and related surgical and post-surgical data were recorded. A surgical wound infection was defined using the criteria of Disease Control and Prevention Hospital Infection Centres. RESULTS: The median age of the patients was 68 years (range 25-88), 65% were male, and 59% were ASA 3-4. There was more than 80% compliance to the protocol in its different sections. There was laparoscopic access in 31% of the cases. The incidence of superficial and deep surgical wound infection was 25%. The patients with an infection had a higher prevalence of diabetes (48% vs 24%), transfusion (56% vs 28%), paralytic ileum (48% vs 18.7%), and intra-abdominal abscess (16% vs 3%). The multivariate analysis associated, preoperative haemoglobin and blood glucose, and the duration of the surgery, with incisional infection. CONCLUSIONS: The prevention protocol did not have an impact on the incidence of surgical wound infection.

Hemostasis and coagulation monitoring and management during liver transplantation.

PURPOSE OF REVIEW: The objective of this review is to evaluate the present state of nonpharmacological measures, pharmacological measures applied to reduce bleeding and perioperative blood products management during orthotopic liver transplantation. RECENT FINDINGS: Recent studies improve the knowledge in the hemostatic response in cirrhotic patients such as thrombin generation and platelet adhesion due to elevated levels of von Willebrand factor. Restrictive fluid therapy is an important measure to avoid hemodilution and so bleeding. Prophylaxis with antifibrinolytics is being questioned for the risk of thrombosis. Correction of coagulation defects with fresh frozen plasma has not reduced blood loss, and it has been related to worse outcome. Also, platelets administration has a negative effect in the outcome. SUMMARY: In order to maintain hemostatic system in compensated cirrhotic patient, every effort we do to improve it must consider not to imbalance it resulting in thrombi-hemorrhagic events. Pharmacological measures must be based on their clinical evidence. Identification of high risk bleeding patients would help in developing coagulation guidelines.

Hemodynamic profile and tissular oxygenation in orthotopic liver transplantation: Influence of hepatic artery or portal vein revascularization of the graft.

We performed a prospective, randomized study of adult patients undergoing orthotopic liver transplantation, comparing hemodynamic and tissular oxygenation during reperfusion of the graft. In 30 patients, revascularization was started through the hepatic artery (i.e., initial arterial revascularization) and 10 minutes later the portal vein was unclamped; in 30 others, revascularization was started through the portal vein (i.e., initial portal revascularization) and 10 minutes later the hepatic artery was unclamped. The primary endpoints of the study were mean systemic arterial pressure and the gastric-end-tidal carbon dioxide partial pressure (PCO(2)) difference. The secondary endpoints were other hemodynamic and metabolic data. The pattern of the hemodynamic parameters and tissue oxygenation values during the dissection and anhepatic stages were similar in both groups At the first unclamping, initial portal revascularization produced higher values of mean pulmonary pressure (25 +/- 7 mm of Hg vs. 17 +/- 4 mm of Hg; P < 0.05) and wedge and central venous pressures. At the second unclamping, initial portal revascularization produced higher values of cardiac output and mean arterial pressure (87 +/- 15 mm of Hg vs. 79 +/- 15 mm of Hg; P < 0.05) and pulmonary blood pressure. Postreperfusion syndrome was present in 13 patients (42.5%) in the arterial group and in 11 patients (36%) in the portal group. During revascularization, the values of gastric and arterial pH decreased in both groups and recovered at the end of the procedure, but were more accentuated in the initial arterial revascularization group. In conclusion, we found that initial arterial revascularization of the graft increases pulmonary pressure less markedly, so it may be indicated for those patients with poor pulmonary and cardiac reserve. Nevertheless, for the remaining patients, initial portal revascularization offers more favorable hemodynamic and metabolic behavior, less inotropic drug use, and earlier normalization of lactate and pH values.

The prophylactic use of tranexamic acid and aprotinin in orthotopic liver transplantation: a comparative study.

The efficacy of tranexamic acid (TA) and aprotinin (AP) in reducing blood product requirements in orthotopic liver transplantation (OLT) was compared in a prospective, randomized and double-blind study. One hundred and twenty seven consecutive patients undergoing OLT were enrolled; TA was administered to 64 OLT patients at a dose of 10mg /kg/h and aprotinin was administered to 63 OLT patients at a loading dose of 2 x 10(6) KIU followed by an infusion of 500,000 KIU/h. The portocaval shunt could not be performed in 14 OLT patients in the TA group and in 13 OLT patients in the AP group. However, all OLT patients that received either drug were included in the analysis. Perioperative management was standardized. Hemogram, coagulation tests, and blood product requirements were recorded during OLT and during the first 24 hours. No differences in diagnosis, Child score, preoperative coagulation tests, and intraoperative data were found between groups. No significant differences were observed in hemogram and intraoperative coagulation tests with the exception of activated partial thromboplastin time (aPTT). Similarly, there were no intergroup differences in transfusion requirements. Thromboembolic events, reoperations and mortality were similar in both groups. In conclusion, administration of regular doses of TA and AP during OLT did not result in large differences between the two groups.

Intraoperative red blood cell transfusion in liver transplantation: influence on patient outcome, prediction of requirements, and measures to reduce them.

Objectives of this study are to quantify the need for blood transfusion during liver transplantation (LT) and confirm the importance of intraoperative blood transfusion as an independent prognostic factor for postoperative outcome. Furthermore, we try to detect useful variables for the preoperative identification of patients likely to require transfusion of packed red blood cell units (PRCUs) and identify measures to reduce transfusion needs. Data were collected prospectively between September 1998 and November 2000. One hundred twenty-two LTs were included in the study. Forty-two patients (34%) did not require transfusion of PRCUs. In multivariate analysis, transfusion of more than three PRCUs was found to be the only significant variable associated with prolonged hospital stay. In addition, excluding perioperative deaths, PRCU transfusion, using a cutoff value of six units, was the only variable to reach statistical significance (P =.008; risk ratio, 4.93; 95% confidence interval, 15 to 15.9) to predict survival in a multivariate analysis that also included Child's class and United Network for Organ Sharing (UNOS) classification. Moreover, only preoperative hemoglobin (Hb) level was found to significantly predict the need for transfusion of one or more PCRUs. Finally, only UNOS classification and placement of an intraoperative portacaval shunt were found to be statistically significant to predict the need to transfuse more than six PRCUs. We found the requirement of even a moderate number of blood transfusions is associated with longer hospital stay, and transfusion of more than six PRCUs is associated with diminished survival. Preoperative normalization of Hb levels and placement of an intraoperative portacaval shunt can diminish the number of blood transfusions during LT.

Sevoflurane requirements during coloproctologic surgery: difference between two different epidural regimens.

STUDY OBJECTIVE: To examine the influence of epidural morphine on the end-tidal sevoflurane concentration titrated to maintain bispectral index (BIS) values between 40 and 50. DESIGN: Prospective, double-blinded clinical trial. SETTINGS: Anesthesia department of a university hospital. PATIENTS: 40 ASA physical status I, II, and III patients scheduled for elective coloproctological surgery. INTERVENTIONS: Patients were randomized to receive via a thoracic epidural catheter either a) bupivacaine 0.25% (10 mL) and saline 0.9% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% (5 mL/hr) or b) bupivacaine 0.25% (10 mL) and morphine 0.1% (2 mL) as a bolus followed by an infusion of bupivacaine 0.25% plus morphine 0.025% (5 mL/hr). Anesthesia was induced with propofol, fentanyl 2 microg kg(-1) and atracurium and maintained with sevoflurane and nitrous oxide in oxygen. Sevoflurane level was titrated to maintain a BIS value between 40 and 50. After extubation, patients were asked about the presence of pain. MAIN RESULTS: There was no significant difference between groups of end-tidal sevoflurane concentrations at identical BIS values and hemodynamic values at any time in the study. However, the morphine group had a lower pain score level at extubation than did the plain bupivacaine group (no pain on movement, 79% vs. 31.5%, p < 0.01). CONCLUSIONS: Adding morphine to the bupivacaine epidural solution did not reduce sevoflurane requirements but did provide high-quality postoperative analgesia, mainly just after tracheal extubation.

Influence of endothelin-1 on hemodynamics during liver transplantation with and without temporary portocaval shunt: results of a clinical randomized study.

Aims of this study are to analyze the influence of endothelin-1 (ET-1) on hemodynamic evolution during liver transplantation (LT) and study the role of a temporary portacaval shunt in ET-1 synthesis. Forty LTs in patients with cirrhosis were studied. Two groups were analyzed: the first group had a temporary portacaval shunt during the anhepatic phase, and the second group did not. Portal and systemic ET-1 levels were measured at several times. At the end of the anhepatic phase, systemic (16.1 +/- 6.5 pg/mL) and portal (19.2 +/- 7 pg/mL) ET-1 levels increased, whereas they decreased after reperfusion (systemic, 11.8 +/- 7.1 pg/mL; portal, 13.2 +/- 6.8 pg/mL). Portal flow at the beginning of LT correlated with systemic ET-1 levels (R2 = 0.3; P =.004). A temporary portacaval shunt reduced portal pressure during the anhepatic phase, but did not modify ET-1 levels. Patients with reperfusion syndrome had greater systemic ET-1 levels in the anhepatic phase (19.1 +/- 6.9 v 15.1 +/- 6.1 pg/mL; P =.07). Although there is a relationship between ET-1 levels and portal flow and reperfusion syndrome, no clear clinical effect on hemodynamics could be shown. Creation of a portacaval shunt made no change in ET-1 levels.