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INTRODUCTION: The geriatric nutritional risk index (GNRI) can easily identify malnutrition-associated morbidity and mortality. We investigated the association between preoperative GNRI and 30-d mortality in geriatric burn patients who underwent surgery. METHODS: The study involved geriatric burn patients (aged ≥ 65 y) who underwent burn surgery between 2012 and 2022. The GNRI was computed using the following formula: 1.489 × serum albumin concentration (mg/L) + 41.7 × patient body weight/ideal body weight. Patients were dichotomized into the high GNRI (≥ 82) and low GNRI (< 82) groups. GNRI was evaluated as an independent predictor of 30-d postoperative mortality. The study also evaluated the association between GNRI and sepsis, the need for continuous renal replacement therapy (CRRT), major adverse cardiac events (MACE), and pneumonia. RESULTS: Out of 270 patients, 128 (47.4%) had low GNRI (< 82). Multivariate Cox regression analysis revealed that low GNRI was significantly associated with 30-d postoperative mortality (hazard ratio: 1.874, 95% confidence interval [CI]: 1.146-3.066, P = 0.001). Kaplan-Meier analysis revealed that the 30-day mortality rate differed significantly between the low and high GNRI groups (log-rank test, P < 0.001). The 30-d postoperative mortality (hazard ratio: 2.677, 95% CI: 1.536-4.667, P < 0.001) and the incidence of sepsis (odds ratio [OR]: 2.137, 95% CI: 1.307-3.494, P = 0.004), need for CRRT (OR: 1.919, 95% CI: 1.101-3.344, P = 0.025), MACE (OR: 1.680, 95% CI: 1.018-2.773, P = 0.043), and pneumonia (OR: 1.678, 95% CI: 1.019-2.764, P = 0.044), were significantly higher in the low GNRI group than in the high GNRI group. CONCLUSIONS: Preoperative low GNRI was associated with increased 30-d postoperative mortality, sepsis, need for CRRT, MACE, and pneumonia in geriatric burn patients.
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BACKGROUND: Catheter-related bladder discomfort (CRBD) is problematic in patients with a urinary catheter. Transcutaneous electrical nerve stimulation (TENS) is a non-invasive analgesic modality used to relieve various types of pain. OBJECTIVES: We evaluated the effect of TENS on CRBD after transurethral resection of bladder tumours (TURBT). DESIGN: A randomised controlled trial. SETTING: A large university tertiary hospital, from October 2022 to March 2023. PATIENTS: Patients requiring urinary catheterisation after TURBT. INTERVENTION: In this randomised controlled trial, patients were randomly allocated to the TENS (nâ =â56) or control (nâ =â56) groups. CRBD manifests as a burning sensation with an urge to void or discomfort in the suprapubic area. Moderate to severe CRBD was defined as patients self-reporting CRBD symptoms with or without behavioural response, including attempts to remove the urinary catheter, intense verbal reactions, and flailing limbs. TENS was performed from the end of surgery to 1âh postoperatively. MAIN OUTCOME MEASURE: The primary endpoint was considered moderate to severe CRBD immediately postoperatively. Secondary endpoints included moderate to severe CRBD at 1, 2 and 6âh postoperatively. Additionally, postoperative pain, patient satisfaction, and TENS-related adverse effects were evaluated. RESULTS: Moderate to severe CRBD immediately postoperatively was significantly less frequent in the TENS group than in the control group: 10 (17.9%) vs. 34 (60.7%); Pâ<â0.001; relative risk (95% CI)â=â0.294 (0.161 to 0.536); absolute risk reductionâ=â0.43; number needed to treatâ=â2.3. Moderate to severe CRBD differed between the two groups at 1âh postoperatively: 1 (1.8%) vs. 16 (28.6%); Pâ<â0.001; relative risk = 0.06 (95% CI 0.01 to 0.46); absolute risk reductionâ=â0.27; number needed to treatâ=â3.7. The TENS group exhibited a significantly lower score for postoperative pain at 1âh (1.8â±â0.6 vs. 2.2â±â0.4; Pâ<â0.001, mean difference (95% CI)â=â0.4 (0.2 to 0.6) and a higher score for patient satisfaction, 5.0 (4.0 to 6.0) vs. 3.0 (3.0 to 4.0); Pâ<â0.001; median difference (95% CI)â=â2.0 (1.0 to 2.0). CONCLUSIONS: TENS reduced moderate to severe CRBD, decreased postoperative pain, and increased patient satisfaction after TURBT. CLINICAL TRIAL REGISTRY: Clinical Research Information Service (KCT0007450). VISUAL ABSTRACT: http://links.lww.com/EJA/B12.
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Ácido Ascórbico , Neoplasias de la Vejiga Urinaria , Humanos , Neoplasias de la Vejiga Urinaria/cirugía , Ácido Ascórbico/administración & dosificación , Cateterismo Urinario/efectos adversos , Cistectomía/efectos adversos , Catéteres Urinarios/efectos adversos , Vejiga Urinaria/cirugía , Dolor Postoperatorio/etiología , Dolor Postoperatorio/prevención & control , Resección Transuretral de la VejigaRESUMEN
BACKGROUND: Intraocular pressure (IOP) can increase with postural changes, which can cause ocular complications. Neck extension is commonly used during palatoplasty to improve surgical angulation. This study evaluates whether neck extension affects IOP during palatoplasty. METHODS: In this prospective observational study, IOP was measured using a rebound tonometer at four specific time points: T1, 10â¯min after anaesthesia while in the supine position; T2, 5â¯min after neck extension; T3, at completion of palatoplasty with neck extended; and T4, 5â¯min after returning to the supine position. The primary outcome was the IOP at T2, and the secondary outcomes were the IOPs at T3 and T4. Haemodynamic and respiratory variables were also measured at each time point. RESULTS: Thirty-seven patients were included. IOP at T2 was significantly higher than at T1 (15.8⯱â¯3.4â¯mmHg vs 10.5⯱â¯2.8â¯mmHg, Pâ¯<â¯0.001), and IOPs at T3 and T4 were also significantly higher than at T1 (T3 vs T1: 18.9⯱â¯3.6â¯mmHg vs 10.5⯱â¯2.8â¯mmHg, Pâ¯<â¯0.001; T4 vs T1: 13.3⯱â¯3.7â¯mmHg vs 10.5⯱â¯2.8â¯mmHg, Pâ¯<â¯0.001). However, no significant differences were observed for the haemodynamic and respiratory variables at any time point. CONCLUSION: Our findings indicate that the intraoperative neck extension position during palatoplasty significantly increases IOP in paediatric cleft palate patients undergoing a palatoplasty.
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Fisura del Paladar , Presión Intraocular , Humanos , Niño , Fisura del Paladar/cirugía , Tonometría Ocular , Hemodinámica , OjoRESUMEN
BACKGROUND: A high fresh gas flow of >5 L/minute is commonly used for emergence from inhalation anesthesia. In addition, a high fresh gas flow may have detrimental effects on climate change. However, no study has determined the optimal fresh gas flow for emergence from inhalation anesthesia. Therefore, we compared the effect of fresh gas flows of 5 L/minute and 10 L/minute on emergence time from sevoflurane anesthesia. METHODS: Patients who were scheduled for transurethral resection of bladder tumor were randomly assigned to receive fresh gas flows of 5 L/minute (group 5) or 10 L/minute (group 10) during emergence. Emergence time was defined as the time from discontinuation of sevoflurane to tracheal extubation. The primary outcome was the emergence time, and the secondary outcomes were the time to self-movement and the time to eye-opening. RESULTS: A total of 54 patients were included. In groups 5 and 10, emergence time (12.1 ± 2.9 minutes vs 11.1 ± 2.7 minutes, respectively; P = .232), time to self-movement (9.4 ± 3.8 minutes vs 8.5 ± 4.6 minutes, respectively; P = .435), and time to eye-opening (11.5 ± 3.1 minute vs 10.6 ± 3.0 minutes, respectively; P = .252) were not significantly different. CONCLUSIONS: Emergence time, time to self-movement, and time to eye opening were not significantly different between fresh gas flow rates of 5 L/minute and 10 L/minute in transurethral resection of bladder tumor, thus suggesting that fresh gas flow of 5 L/minute is sufficient for emergence from sevoflurane anesthesia. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05376631).
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Anestesiología , Anestésicos por Inhalación , Éteres Metílicos , Neoplasias , Humanos , Sevoflurano , Anestésicos por Inhalación/farmacología , Anestesia por InhalaciónRESUMEN
STUDY OBJECTIVE: We evaluated the effect of vitamin C administration on postoperative catheter-related bladder discomfort (CRBD). DESIGN: A double-blind, randomized controlled trial. SETTING: University tertiary hospital. PATIENTS: The participants were patients undergoing transurethral resection of bladder tumor. INTERVENTION: Patients were randomly assigned to either vitamin C (n = 59) or control (n = 59). The vitamin C group received 1 g of vitamin C intravenously and the control group received normal saline, administered after the induction of anesthesia. MEASUREMENTS: The primary endpoint was moderate or greater CRBD immediately postoperatively. Secondary outcomes included the incidence of moderate or greater CRBD at 1, 2, and 6 h postoperatively. The symptom of CRBD is either a burning sensation with an urge to void or discomfort in the suprapubic area. Moderate CRBD was defined as spontaneously reported by the patient without any behavioral responses, such as attempts to remove the urinary catheter, intense verbal reactions, and flailing limbs. Severe CRBD was spontaneously reported by the patient with behavioral responses. Patient satisfaction scores were also evaluated. MAIN RESULTS: The group that received vitamin C exhibited a significantly lower incidence of moderate or greater CRBD immediately postoperatively compared with the control group (17 [28.8%] vs. 40 [67.8%], p < 0.001, relative risk [95% confidence interval] = 0.426 [0.274-0.656]). The vitamin C group also showed a significantly lower incidence of moderate or greater CRBD at 1 and 2 h postoperatively compared with the control group (10 [16.9%] vs. 25 [42.4%], p = 0.003; and 5 [8.5%] vs. 16 [27.1%], p = 0.008, respectively). However, there was no significant difference in the incidence of moderate or greater CRBD 6 h postoperatively. Patient satisfaction scores were significantly higher in the vitamin C group than in the control group (5.0 ± 1.3 vs. 4.4 ± 1.4, p = 0.009). CONCLUSIONS: Patients who received vitamin C had decreased CRBD and improved patient satisfaction following transurethral resection of bladder tumor.
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Neoplasias de la Vejiga Urinaria , Catéteres Urinarios , Humanos , Catéteres Urinarios/efectos adversos , Vejiga Urinaria/cirugía , Ácido Ascórbico/uso terapéutico , Resección Transuretral de la Vejiga , Dolor Postoperatorio/etiología , Neoplasias de la Vejiga Urinaria/cirugía , Método Doble CiegoRESUMEN
BACKGROUND: Radical cystectomy is a major urological procedure with high morbidity and mortality. The chart-derived frailty index (CFI), a measure of preoperative frailty, can be calculated by using demographic and routine laboratory variables. We assessed the impact of CFI on 1-year mortality after radical cystectomy. METHODS: This retrospective study included patients with bladder cancer who underwent radical cystectomy between 2007 and 2021. The CFI was calculated as the sum of the presence of the following parameters: age > 70 years, body mass index < 18.5 kg/m2, hematocrit < 35%, albumin < 3.4 g/dL, and creatinine > 2.0 mg/dL. Patients were divided into those with low (0-2) and high (3-5) CFI. The 1-year, all-cause and cancer-specific mortalities after radical cystectomy were evaluated. RESULTS: Of the 1004 patients, 914 (91.0%) had a low CFI and 90 (9.0%) had a high CFI. The 1-year, all-cause mortality in the low and high CFI groups was 12.0% and 27.8%, respectively (P < 0.001). Multivariate Cox regression analysis revealed that high CFI (P < 0.001), tumor stage (P = 0.003), and red blood cell transfusion amount (P < 0.001) were significantly associated with 1-year, all-cause mortality after radical cystectomy. Kaplan-Meier survival analysis demonstrated significantly different 1-year, all-cause and cancer-specific mortalities after radical cystectomy between patients with a high CFI and those with a low CFI (log-rank test, both P < 0.001). CONCLUSIONS: High CFI is associated with higher 1-year mortality after radical cystectomy, suggesting that the CFI can effectively predict mortality after radical cystectomy.
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Fragilidad , Neoplasias de la Vejiga Urinaria , Humanos , Anciano , Cistectomía , Estudios Retrospectivos , Fragilidad/complicaciones , Tasa de Supervivencia , Neoplasias de la Vejiga Urinaria/patologíaRESUMEN
Patau syndrome (trisomy 13) is a severe disorder associated with multiple systemic defects. Patau syndrome is commonly associated with ocular abnormalities but rarely associated with congenital glaucoma. To obtain a better surgical view, palatoplasty requires neck extension during surgery. The intraocular pressure (IOP) of patients with Patau syndrome can increase owing to the neck extension position while undergoing palatoplasty, particularly in those with congenital glaucoma. Here, we describe a case with increased IOP measured using a rebound tonometer during palatoplasty in a pediatric patient with Patau syndrome and congenital glaucoma. This case shows that it may be important to reduce the degree of neck extension and shorten the operation time to minimize any increase in the IOP during palatoplasty in pediatric patients with Patau syndrome accompanied by congenital glaucoma.
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Fisura del Paladar , Glaucoma , Humanos , Niño , Presión Intraocular , Síndrome de la Trisomía 13 , Tonometría Ocular , Glaucoma/cirugía , Glaucoma/congénito , Fisura del Paladar/cirugíaRESUMEN
PURPOSE: Robotic prostatectomy is the most common surgical approach for treating prostate cancer. Patients undergoing robotic prostatectomy may have bullae, which may rupture leading to pneumothorax. We evaluated the incidence of pneumothorax due to preoperative bullae rupture in robotic prostatectomy. METHODS: A large retrospective study of patients who underwent robotic prostatectomy between 2009 and 2021 was conducted. Bullae were detected using chest computed tomography. Pneumothorax was detected using a chest X-ray. The primary outcome was the incidence of pneumothorax due to bullae rupture. Secondary outcomes were the prevalence of preoperative bullae and the evaluation of postoperative outcomes, including length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay (> 2 days). RESULTS: A total of 6605 patients were included. The prevalence of preoperative bullae was 3.0% (196/6,605). There was no incidence of pneumothorax due to bullae rupture. No significant difference in the incidences of pneumothorax between patients with and without bullae (0/196 vs. 2/6,409, P > 0.999) was observed. In addition, length of hospital stay, intensive care unit admission rate, and prolonged intensive care unit stay were not significantly different between the two groups. Kaplan-Meier analysis showed that there was no significant difference in lengths of hospital stay between the two groups (log-rank test, P > 0.999). CONCLUSION: In our cohort, there was no incidence of pneumothorax following robotic prostatectomy in patients with preoperative bullae. This result could help in the management of patients with prostate cancer with bullae.
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Neumotórax , Neoplasias de la Próstata , Procedimientos Quirúrgicos Robotizados , Masculino , Humanos , Neumotórax/epidemiología , Neumotórax/etiología , Vesícula/etiología , Vesícula/complicaciones , Estudios Retrospectivos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Prostatectomía/efectos adversos , Neoplasias de la Próstata/complicaciones , Neoplasias de la Próstata/cirugíaRESUMEN
INTRODUCTION: Burns can cause multiple organ systemic derangements, particularly in respiratory systems. The prognostic nutritional index (PNI) can predict postoperative outcomes. We evaluated the incidence and risk factors, including PNI, for postoperative pulmonary complications (PPCs) in patients with major burns. METHODS: PNI was calculated as 10 × (serum albumin level) + 0.005 × (total lymphocyte count). Major burn patients admitted to the ICU without burn-induced lung injuries were retrospectively included. The incidence of PPCs was measured within 1 wk of burn surgery. A multivariable logistic regression analysis was performed to evaluate the risk factors for PPCs. Receiver operating characteristic curve analysis and propensity-score matched analysis were conducted to estimate the influence of PNI on PPCs. Outcomes after burn surgery were also assessed. RESULTS: Of 444 major burn patients, 138 (31.1%) showed PPCs. Risk factors for PPCs were PNI, gender, total body surface area burned, interval between burn and surgery, and red blood cell transfusion rate. The area under the curve of PNI for predicting PPCs was 0.709 (cutoff value = 31.5). The incidence of PPCs was significantly higher in the PNI ≤ 31.5 group than in the PNI > 31.5 group (55.7% versus 22.8%, P < 0.001) after propensity-score matching. The intensive care unit stay duration was longer and 90-d mortality was higher in patients who developed PPCs (19 [9-27] d versus 8 [4-17] d, P < 0.001; 11.6% versus 0.3%, P < 0.001). CONCLUSIONS: The prevalence of PPCs in patients with major burns was 31.1% and preoperative PNI was a predictor of PPCs in these patients. PNI ≤ 31.5 was significantly related to a higher incidence of PPCs.
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Quemaduras , Evaluación Nutricional , Quemaduras/complicaciones , Quemaduras/cirugía , Humanos , Estado Nutricional , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Albúmina SéricaRESUMEN
BACKGROUND: During robot-assisted partial nephrectomy (RAPN), renal artery clamping is necessary to optimize the surgical field. However, renal artery clamping can induce renal blood flow reduction and postoperative renal dysfunction. Papaverine is used as a potent vasodilator agent. We determined if periarterial administration of papaverine after renal artery clamping improved intraoperative renal artery blood flow and early postoperative glomerular filtration rate (GFR) compared with placebo in RAPN. PATIENTS AND METHODS: In this randomized controlled trial, 96 patients who underwent RAPN were enrolled between November 2019 and December 2020. Patients were administered periarterial normal saline as a placebo (placebo group) or papaverine (papaverine group) just after renal artery declamping. The primary outcome was renal artery blood flow by Doppler ultrasound 2 min after periarterial administration of papaverine or placebo after renal artery declamping. The secondary outcome was GFR estimated by renal scan 3 months after RAPN. RESULTS: Renal artery blood flow and GFR were significantly higher in the papaverine group than in the placebo group (538.0 [376.6-760.0] mL/min versus 338.8 [205.8-603.4] mL/min, P = 0.002 and 93.5 ± 17.1 mL/min/1.73 m2 versus 85.9 ± 15.8 mL/min/1.73 m2, P = 0.033, respectively). CONCLUSIONS: Periarterial papaverine administration increased intraoperative renal artery blood flow and early postoperative GFR in RAPN, suggesting that papaverine administration has beneficial effects on renal perfusion after renal artery clamping and could be a valuable option for improving renal function after RAPN.
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Neoplasias Renales , Procedimientos Quirúrgicos Robotizados , Robótica , Humanos , Neoplasias Renales/tratamiento farmacológico , Neoplasias Renales/cirugía , Nefrectomía , Papaverina/farmacología , Arteria Renal/cirugía , Circulación Renal , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Myocardial infarction (MI) is the leading cause of death from coronary heart disease and requires immediate reperfusion therapy with thrombolysis, primary percutaneous coronary intervention, or coronary artery bypass grafting. However, myocardial reperfusion therapy is often accompanied by cardiac ischemia/reperfusion (I/R) injury, which leads to myocardial injury with detrimental consequences. The causes of I/R injury are unclear, but are multifactorial, including free radicals, reactive oxygen species, calcium overload, mitochondria dysfunction, inflammation, and neutrophil-mediated vascular injury. Mild hypothermia has been introduced as one of the potential inhibitors of myocardial I/R injury. Although animal studies have demonstrated that mild hypothermia significantly reduces or delays I/R myocardium damage, human trials have not shown clinical benefits in acute MI (AMI). In addition, the practice of hypothermia treatment is increasing in various fields such as surgical anesthesia and intensive care units. Adequate sedation for anesthetic procedures and protection from body shivering has become essential during therapeutic hypothermia. Therefore, anesthesiologists should be aware of the effects of therapeutic hypothermia on the metabolism of anesthetic drugs. In this paper, we review the existing data on the use of therapeutic hypothermia for AMI in animal models and human clinical trials to better understand the discrepancy between perceived benefits in preclinical animal models and the absence thereof in clinical trials thus far.
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Hipotermia Inducida , Hipotermia , Infarto del Miocardio , Daño por Reperfusión Miocárdica , Intervención Coronaria Percutánea , Animales , Humanos , Hipotermia Inducida/efectos adversos , Hipotermia Inducida/métodos , Infarto del Miocardio/complicaciones , Infarto del Miocardio/terapia , Daño por Reperfusión Miocárdica/prevención & control , Intervención Coronaria Percutánea/efectos adversosRESUMEN
INTRODUCTION: Robotic prostatectomy requires pneumoperitoneum and a steep Trendelenburg position; however, this condition may compromise cerebral blood flow. Here, we evaluated the effect of pneumoperitoneum and the steep Trendelenburg position on internal carotid artery (ICA) blood flow measured by Doppler ultrasound during robotic prostatectomy. METHODS: Patients who underwent robotic prostatectomy were prospectively recruited. The ICA blood flow was measured at the following five time-points: with the patient awake and in the supine position (Ta), 10 min after anaesthetic induction in the supine position (T1), 10 (T2) and 30 (T3) min after pneumoperitoneum in the steep Trendelenburg position, and at the end of surgery in the supine position after desufflation of the pneumoperitoneum (T4). Hemodynamic and cerebrovascular variables were measured at each time-point. RESULTS: A total of 28 patients were evaluated. The ICA blood flows were significantly lower at T2 and T3 than at T1 (162.3 ± 44.7 [T2] vs. 188.0 ± 49.6 ml/min [T1]; p = .002, 163.1 ± 39.9 [T3] vs. 188.0 ± 49.6 ml/min [T1]; p = .009). The ICA blood flow also differed significantly between Ta and T1 (236.8 ± 58.3 vs. 188.0 ± 49.6 ml/min; p < .001). Heart rates, cardiac indexes, peak systolic velocity, and end-diastolic velocity were significantly lower at T2 and T3 than at T1. However, ICA diameter, mean blood pressure, and end-tidal carbon dioxide partial pressure did not differ significantly at all time-points. CONCLUSION: Pneumoperitoneum and the steep Trendelenburg position caused decreased ICA blood flow, suggesting that they should be carefully performed during robotic prostatectomy, especially in patients at risk of postoperative cerebrovascular accident.
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Laparoscopía , Neumoperitoneo , Procedimientos Quirúrgicos Robotizados , Arteria Carótida Interna/diagnóstico por imagen , Arteria Carótida Interna/cirugía , Inclinación de Cabeza , Hemodinámica , Humanos , Masculino , Neumoperitoneo Artificial , ProstatectomíaRESUMEN
BACKGROUND: Red cell distribution width (RDW) and serum albumin concentration are associated with postoperative outcomes. However, the usefulness of the RDW/albumin ratio in burn surgery remains unclear. Therefore, we evaluated the association between RDW/albumin ratio and 90-day mortality after burn surgery. METHODS: Between 2013 and 2020, a retrospective review of patients in a burn intensive care unit (ICU) was performed. Receiver operating characteristic curve, multivariate Cox logistic regression, multivariate logistic regression and Kaplan-Meier analyses were conducted to evaluate the association between RDW/albumin ratio and 90-day mortality after burn surgery. Additionally, prolonged ICU stay rate (>60 days) and ICU stay were assessed. RESULTS: Ninety-day mortality was 22.5% (210/934) in burn patients. Risk factors for 90-day mortality were RDW/albumin ratio at postoperative day 1, age, American Society of Anesthesiologists physical status, diabetes mellitus, inhalation injury, total body surface area burned, hypotensive event and red blood cell transfusion volume. The area under the curve of the RDW/albumin ratio at postoperative day 1 to predict 90-day mortality, after adjusting for age and total body surface area burned, was 0.875 (cut-off value, 6.8). The 90-day mortality was significantly higher in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (49.2% vs 12.3%, p < 0.001). Prolonged ICU stay rate and ICU stay were significantly higher and longer in patients with RDW/albumin ratio >6.8 than in those with RDW/albumin ratio ≤6.8 (34.5% vs 26.5%; 21 [11-38] vs 18 [7-32] days). CONCLUSION: RDW/albumin ratio >6.8 on postoperative day 1 was associated with higher 90-day mortality, higher prolonged ICU stay rate and longer ICU stay after burn surgery.
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BACKGROUND: One of the critical factors for free flap survival is to maintain adequate perfusion. The authors evaluated the effect of epidural anesthesia on arterial maximal flow velocity of the free flap in microvascular lower extremity reconstruction. METHODS: This is a prospective randomized study where patients were allocated to receive either combined general-epidural anesthesia (epidural group, n = 26) or general anesthesia alone (control group, n = 26). After injecting epidural ropivacaine 10 ml in the epidural group, the effect on arterial maximal flow velocity of the free flap was analyzed using ultrasonography. The primary outcome measurement was the arterial maximal flow velocity 30 minutes after establishing the baseline. Intraoperative hemodynamics and postoperative outcomes such as postoperative pain, opioid requirements, surgical complications, intensive care unit admission, and hospital length of stay were also assessed. RESULTS: The arterial maximal flow velocity 30 minutes after the baseline measurement was significantly higher in the epidural group (35.3 ± 13.9 cm/second versus 23.5 ± 8.4 cm/second; p = 0.001). The pain score at 1 hour postoperatively and opioid requirements at 1 and 6 hours postoperatively were significantly lower in the epidural group [3.0 (interquartile range, 2.0 to 5.0) versus 5.0 (interquartile range, 3.0 to 6.0), p = 0.019; 0.0 µg (interquartile range, 0.0 to 50.0 µg) versus 50.0 µg (interquartile range, 0.0 to 100.0 µg), p = 0.005; and 46.9 µg (interquartile range, 0.0 to 66.5 µg) versus 96.9 µg (interquartile range, 41.7 to 100.0 µg), p = 0.014, respectively]. There were no significant differences in intraoperative hemodynamics or other postoperative outcomes between the two groups. CONCLUSION: Epidural anesthesia increased the arterial maximal flow velocity of the free flap and decreased postoperative pain and opioid requirements in microvascular lower extremity reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.
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Anestesia Epidural , Anestesia General , Colgajos Tisulares Libres/irrigación sanguínea , Extremidad Inferior/cirugía , Adulto , Anciano , Analgésicos Opioides/uso terapéutico , Velocidad del Flujo Sanguíneo , Femenino , Humanos , Masculino , Microvasos , Persona de Mediana Edad , Dolor Postoperatorio/tratamiento farmacológico , Estudios Prospectivos , Procedimientos de Cirugía Plástica/métodosRESUMEN
Burn injuries can cause significant malnutrition, leading to cardiovascular impairments. The prognostic nutritional index (PNI) predicts postoperative complications. We evaluated the impact of preoperative PNI on major adverse cardiac events (MACE) after burn surgery. PNI was calculated using the equation, 10×(serum albumin level)+0.005×(total lymphocyte count). Multivariable logistic regression analysis was conducted to evaluate the predictors for MACE at 6 months after burn surgery. Receiver operating characteristic curve and propensity score matching analyses were conducted. Additionally, Kaplan-Meier analysis was conducted to compare postoperative 1-year mortality between MACE and non-MACE groups. MACE after burn surgery occurred in 184 (17.5%) of 1049 patients. PNI, age, American Society of Anesthesiologists physical status, and TBSA burned were significantly related to MACE. The area under the receiver operating characteristic curve of PNI was 0.729 (optimal cutoff value = 35). After propensity score matching, the incidence of MACE in the PNI <35 group was higher than that in the PNI ≥35 group (20.1% vs 9.6%, P < .001). PNI <35 was related to an increased incidence of MACE (odds ratio = 2.373, 95% confidence interval = 1.499-3.757, P < .001). The postoperative 1-year mortality was higher in the MACE group than in the non-MACE group (54.9% vs 9.1%, P < .001). Preoperative PNI was a predictor for MACE after burn surgery. PNI <35 was significantly related to an increased incidence of MACE. Moreover, MACE was related to higher postoperative 1-year mortality.