Effects of midline laparotomy on cough strength: a prospective study measuring cough pressure.

BACKGROUND: Laparotomy is assumed to decrease cough strength due to three factors: abdominal muscle trauma, postoperative pain, and diaphragmatic dysfunction. However, the effect of trauma from laparotomy itself on strength (net of the other two factors) has not been measured to our knowledge. The aim of this study was to measure the effect of laparotomy on cough strength after first measuring the effect of epidural analgesia. METHODS: In 11 patients scheduled for open midline laparotomy, cough pressure (PCOUGH), a proxy for strength, was measured with a rectal balloon at three moments: before the procedure, at baseline; before surgery, under epidural bupivacaine to T6; and postoperatively, under epidural bupivacaine to the same analgesic level (T6). Continuous variables were compared using the Wilcoxon signed-rank test. The repeatability of PCOUGH measurements was confirmed with the intraclass correlation coefficient (ICC). Pain on coughing, hand grip strength, and the Ramsay and modified Bromage scores were also recorded. RESULTS: Median (interquartile range) PCOUGH decreased from a baseline of 103 (89-137) to 71 (56-116) cmH2O under presurgical epidural bupivacaine (P=0.003). Postoperative PCOUGH remained unchanged at 76 (46-85) cmH2O under epidural analgesia (P=0.131). The ICCs indicated excellent repeatability of the PCOUGH measurements (P<0.001). Pain on coughing was 0 to 1 in all subjects. Hand grip strength and the Ramsay and Bromage scores were unchanged. CONCLUSIONS: Although thoracic epidural bupivacaine reduces cough strength as measured by PCOUGH, midline laparotomy does not further reduce strength in the presence of adequate epidural analgesia.

A retrospective case-control study to evaluate the use of beta-lactam desensitization in the management of penicillin-allergic patients: a potential strategy for Antimicrobial Stewardship Programs.

Introduction: Penicillin allergy labels (PAL) are common in the hospital setting and are associated with worse clinical outcomes. Desensitization can be a useful strategy for allergic patients when alternative options are suboptimal or not available. The aim was to compare clinical outcomes of patients with PAL managed with antibiotic desensitization vs. those who received alternative non-beta-lactam antibiotic treatments. Methods: A retrospective 3:1 case-control study was performed between 2015-2022. Cases were adult PAL patients with infection who required antibiotic desensitization; controls were PAL patients with infection managed with an alternative antibiotic treatment. Cases and controls were adjusted for age, sex, infection source, and critical or non-critical medical services. Results: Fifty-six patients were included: 14 in the desensitization group, 42 in the control group. Compared to the control group, desensitized PAL patients had more comorbidities, with a higher Charlson index (7.4 vs. 5; p = 0.00) and more infections caused by multidrug-resistant (MDR) pathogens (57.1% vs. 28.6%; p = 0.05). Thirty-day mortality was 14.3% in the desensitized group, 28.6% in the control group (p = 0.24). Clinical cure occurred in 71.4% cases and 54.8% controls (p = 0.22). Four control patients selected for MDR strains after alternative treatment; selection of MDR strains did not occur in desensitized patients. Five controls had antibiotic-related adverse events, including Clostridioides difficile or nephrotoxicity. No antibiotic-related adverse events were found in the study group. In multivariate analysis, no differences between groups were observed for main variables. Conclusion: Desensitization was not associated with worse clinical outcomes, despite more severe patients in this group. Our study suggests that antibiotic desensitization may be a useful Antimicrobial Stewardship tool for the management of selected PAL patients.

Antibiotic desensitization as a potential tool in antimicrobial stewardship programs: retrospective data analysis and systematic literature review.

OBJECTIVES: Antibiotic allergy labels (AAL) are related to worse therapeutic results. Strategies to improve the management of these patients, such as the implementation of antibiotic desensitization, are essential for Antimicrobial Stewardship Programs (ASP). The aim of our study is to evaluate the efficacy and safety of antibiotic desensitization procedures for the management of patients with AAL. METHODS: A retrospective study from 2015 to 2022 was performed to describe all antibiotic desensitization conducted in our institution, within the framework of ASP. A systematic literature review using electronic databases, such as PubMed, was also done to identify studies describing antibiotic desensitization between 2000 and 2022. RESULTS: Sixteen antibiotic desensitization protocols were carried out in our institution. In fourteen cases, the desensitization was successfully completed, and the antibiotic could be used to treat the infection. In the systematic review, twenty-two studies were included, with a total of 202 desensitization episodes . In 97% of them, the desensitization was completed successfully. No desensitization-related mortality was observed neither in our cohort nor in literature review. CONCLUSIONS: Antibiotic desensitization strategies should be considered a safe and effective tool that can be included in ASP for patients with a high risk of or confirmed allergy to penicillin.

Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied.

BACKGROUND: In total knee arthroplasty surgery, a blood conservation program is applied as a normal clinical practice to avoid allogenic transfusions. The objective of this study was to assess the effectiveness of tranexamic acid to reduce transfusions in total knee replacement even when a blood conservation program is applied. STUDY DESIGN AND METHODS: In a double-blind prospective study the patients scheduled for total knee arthroplasty were included in a well-established blood conservation program and then randomly assigned into two groups: In tranexamic acid group, 10 mg per kg ev bolus followed by 1 mg per kg per hour perfusion was administered, while in the control group, saline was given matching the protocol. RESULTS: Ninety-five patients were included (tranexamic acid group, 46; control group, 49). Thirty-three patients (34.7%) underwent preoperative procedures to reduce transfusions: presurgical autologous blood donation (12), recombinant erythropoietin (6), and elementary iron (15); postoperative drain for reinfusion was allocated in all the cases. Total blood loss on the fourth postoperative day was [mean (+/-SD)] 1744 (+/-804) mL in controls compared with 1301 (+/-621) mL in the tranexamic acid group (p < 0.05). Eleven units of blood were transfused (6 patients) in the control group versus one in the tranexamic acid group (p < 0.05). Only 2 patients (4%) in the tranexamic acid group received reinfusion of blood recovered by drains compared with 36 (73%) in the control group (p < 0.0001). No thromboembolic complications were detected. CONCLUSION: Tranexamic acid reduces blood losses and transfusion requirements even when a blood conservation program was used and it questions the usefulness of the postoperative reinfusion drains.

[Anesthesia for diagnostic and nonsurgical procedures in Catalonia, Spain, in 2003]. / Anestesia para exploraciones y procedimientos no quirúrgicos en Cataluña el año 2003.

BACKGROUND AND OBJECTIVE: This arm of the ANESCAT survey sought to characterize and quantify nonsurgical anesthesia practice in Catalonia, Spain. PATIENTS AND METHOD: Information about anesthesia for nonsurgical procedures in 131 Catalan hospitals was gathered prospectively on 14 days in 2003. We analyzed patient characteristics, anesthetic techniques, procedures, duration, interventional context for the anesthetic procedure, type of hospital, and geographic distribution. RESULTS: Nonsurgical anesthesia accounted for 10.4% of all acts. Endoscopy of the digestive tract accounted for 70.4% of all nonsurgical procedures, electroconvulsive treatment for 11.7%, radiology for 11.5%, and electrical cardioversion for 1.5%. Anesthesia was provided outside an operating room in 73.7% of the cases. Most procedures were scheduled to be performed in outpatients under sedation or general anesthesia. The most commonly performed digestive tract endoscopic examinations were colonoscopy and gastroscopy, and most took place in private hospitals. CONCLUSIONS: Over 10% of anesthesia practice is for nonsurgical procedures and digestive tract endoscopy accounts for the largest proportion of such practice. As the trend is for such procedures to increase in number, their frequency should be studied so that organization and training can be planned.

[Anesthesias for the youngest and the oldest: pediatric and geriatric practice in Catalonia, Spain]. / Anestesias en Cataluña en las edades extremas: pediatría y geriatría.

BACKGROUND AND OBJECTIVE: The objective of this arm of the ANESCAT 2003 study was to analyze the characteristics of the youngest and oldest patients receiving anesthesia in Catalonia, Spain, and the procedures for which they require it. PATIENTS AND METHOD: We analyzed data from questionnaires pertaining to pediatric (under age 14 years) and geriatric patients (older than age 65 years). RESULTS: Pediatric patients underwent 6.3% of all anesthetic procedures and patients over 65 years old accounted for 32.9% of the sample population. Two of every 3 pediatric patients were males, whereas 55% of patients over age 65 years were females. The most frequently performed interventions requiring anesthesia in patients under 14 years of age were tonsillectomy and/or adenoidectomy (19.3%), nonsurgical procedures (11.5%), circumcision (10.6%), inguinal herniorrhaphy (8.3%), and appendectomy (4.2%). The most common procedures in elderly patients were cataract extraction (31.9%), nonsurgical procedures (9.5%), inguinal herniorrhaphy (4.4%), total knee replacement (3.6%), transurethral bladder surgery (3.2%), and repair of femoral neck fractures (2.6%). Because of the high incidence of appendectomy in patients between 8 and 14 years old and of femoral neck fractures in patients over 85 years old, the rate of emergency anesthesias in patients in those age brackets was around 30%. CONCLUSIONS: Pediatric and geriatric patients and the interventions for which they are administered anesthesia have particular features. Taking them into consideration in the short term would facilitate the development of new therapeutic strategies and the introduction of changes in health care organization.

Anestesia para exploraciones y procedimientos no quirúrgicos en Cataluña el año 2003 / Anesthesia for diagnostic and nonsurgical procedures in Catalonia, Spain, in 2003

Fundamento y objetivo: Conocer y cuantificar el peso de la actividad anestésica no quirúrgica en Cataluña (España) en el año 2003. Pacientes y método: Estudio prospectivo de las anestesias no quirúrgicas realizadas en 131 hospitales catalanes en 14 días del 2003. Se analizaron: características de los pacientes, técnicas anestésicas, procedimientos, duración, tipo de actividad, tipos de centros y distribución geográfica. Resultados: Las anestesias no quirúrgicas representaron el 10,4% del total de anestesias. De estos procedimientos, la endoscopia digestiva representó un 70,4%, el tratamiento electroconvulsivo el 11,7%, la radiología un 11,5% y las cardioversiones un 1,5%. El 73,7% de estos procedimientos se realizaron fuera de quirófano. Hubo un predominio de actividad programada realizada ambulatoriamente bajo sedación o anestesia general. Las endoscopias digestivas más representativas fueron la colonoscopia y la gastroscopia, realizadas mayoritariamente en centros privados. Conclusiones: La anestesia para procedimientos no quirúrgicos, especialmente endoscopias digestivas, fue superior al 10% de todas las anestesias. Estas técnicas tienden a aumentar y es necesario conocer su frecuencia para una correcta planificación y para adelantar las estrategias formativas y organizativas

Background and objective: This arm of the ANESCAT survey sought to characterize and quantify nonsurgical anesthesia practice in Catalonia, Spain. Patients and method: Information about anesthesia for nonsurgical procedures in 131 Catalan hospitals was gathered prospectively on 14 days in 2003. We analyzed patient characteristics, anesthetic techniques, procedures, duration, interventional context for the anesthetic procedure, type of hospital, and geographic distribution. Results: Nonsurgical anesthesia accounted for 10.4% of all acts. Endoscopy of the digestive tract accounted for 70.4% of all nonsurgical procedures, electroconvulsive treatment for 11.7%, radiology for 11.5%, and electrical cardioversion for 1.5%. Anesthesia was provided outside an operating room in 73.7% of the cases. Most procedures were scheduled to be performed in outpatients under sedation or general anesthesia. The most commonly performed digestive tract endoscopic examinations were colonoscopy and gastroscopy, and most took place in private hospitals. Conclusions: Over 10% of anesthesia practice is for nonsurgical procedures and digestive tract endoscopy accounts for the largest proportion of such practice. As the trend is for such procedures to increase in number, their frequency should be studied so that organization and training can be planned

Anestesias en Cataluña en las edades extremas: pediatría y geriatría / Anesthesias for the youngest and the oldest: pediatric and geriatric practice in Catalonia, Spain

Fundamento y objetivo: Analizar las características de los pacientes en los extremos de la edad y conocer el tipo y frecuencia de procedimientos para los que se administra anestesia. Pacientes y método: De los cuestionarios de la encuesta ANESCAT 2003 se analizaron los datos registrados en pacientes menores de 14 años (grupo pediatría) y mayores de 65 (grupo geriatría). Resultados: El porcentaje de anestesias en pacientes menores de 14 años fue el 6,3% del total y en mayores de 65, el 32,9%. Se administró anestesia a 2 niños por cada niña, mientras que el 55% de los mayores de 65 años fueron mujeres. Los procedimientos con anestesia más frecuentes en menores de 14 años fueron la amigdalectomía y/o la adenoidectomía (19,3%), los procedimientos no quirúrgicos (11,5%), la circuncisión (10,6%), la herniorrafia inguinal (8,3%) y la apendicectomía (4,2%); en la población geriátrica fueron la cirugía de cataratas (31,9%), los procedimientos no quirúrgicos (9,5%), la herniorrafia inguinal (4,4%), la sustitución total de rodilla (3,6%), la cirugía transuretral de vejiga (3,2%) y la reparación de la fractura del cuello de fémur (2,6%). Debido a la alta incidencia de apendicectomía entre los 8 y 14 años y de cirugía del cuello de fémur por encima de los 85 años, la proporción de urgencias en estas edades fue aproximadamente del 30%. Conclusiones: Los pacientes pediátricos y geriátricos y los procedimientos para los que se les administra anestesia presentan unas singularidades que deberán considerarse a corto plazo a fin de desarrollar nuevas estrategias terapéuticas e introducir cambios en la organización sanitaria

Background and objective: The objective of this arm of the ANESCAT 2003 study was to analyze the characteristics of the youngest and oldest patients receiving anesthesia in Catalonia, Spain, and the procedures for which they require it. Patients and method: We analyzed data from questionnaires pertaining to pediatric (under age 14 years) and geriatric patients (older than age 65 years). Results: Pediatric patients underwent 6.3% of all anesthetic procedures and patients over 65 years old accounted for 32.9% of the sample population. Two of every 3 pediatric patients were males, whereas 55% of patients over age 65 years were females. The most frequently performed interventions requiring anesthesia in patients under 14 years of age were tonsillectomy and/or adenoidectomy (19.3%), nonsurgical procedures (11.5%), circumcision (10.6%), inguinal herniorrhaphy (8.3%), and appendectomy (4.2%). The most common procedures in elderly patients were cataract extraction (31.9%), nonsurgical procedures (9.5%), inguinal herniorrhaphy (4.4%), total knee replacement (3.6%), transurethral bladder surgery (3.2%), and repair of femoral neck fractures (2.6%). Because of the high incidence of appendectomy in patients between 8 and 14 years old and of femoral neck fractures in patients over 85 years old, the rate of emergency anesthesias in patients in those age brackets was around 30%. Conclusions: Pediatric and geriatric patients and the interventions for which they are administered anesthesia have particular features. Taking them into consideration in the short term would facilitate the development of new therapeutic strategies and the introduction of changes in health care organization