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BACKGROUND: Pulmonary complications are among the main causes of increased mortality, and morbidity, as well as prolonged ICU and hospital stay after cardiac surgery. Recently, a sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced. A higher risk of pulmonary injury could be anticipated due to the thoracic incision and the longer duration of surgery. Pulmonary complications in TCRAT were compared to standard coronary artery bypass grafting (CABG) via full median sternotomy (FS). METHODS: Records of 151 consecutive TCRAT (from 09/2021 to 11/2022) and 229 consecutive FS patients (from 01/2017-12/2018) patients, who underwent elective or urgent CABG, were analyzed. Preoperative baseline characteristics (age, sex, body mass index, diabetes, hypertension, COPD, smoking status, left ventricular ejection fraction, pulmonary hypertonus, EuroScore II) were comparable between groups. RESULTS: Differences between examined groups examined were found for the pulmonary parameters Horowitz index 6 hours after operation (TCRAT 270±72 vs. FS 293±73, p<0.05), pneumothorax (TCRAT 0% vs. FS 2.6%, p<0.05), bronchoscopies (TCRAT 5.9% vs. FS 1.7%, p<0.05), and pleural effusion (TCRAT 8.6% vs. FS 3.5%, p< 0.05). Moreover, there were differences between groups with regard to mean ICU-stay (TCRAT 2.4±3.0days vs. FS 1.8±1.8days, p<0.05), stroke (TCRAT 0% vs. FS 1.3%, p<0.05), and hospital stay (TCRAT 10.9±8.5days vs. FS 13.2±9.3days, p<0.05). There were no differences regarding atelectasis, re-intubations, tracheostomies, ventilation time, and mortality. CONCLUSION: Pulmonary complications in terms of pleural effusions were more common with TCRAT, however, without substantial impact on clinical outcome.
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COVID-19 has severely affected the delivery of surgical care worldwide. The aim of the present study was to evaluate its impact on adrenal surgery at our academic endocrine center. All primary adrenal surgeries performed at the University Hospital of Cologne, Germany between 01.01.2019 and 31.07.2022 were included. This time frame was divided into pre-Covid (before 02/20), acute Covid (until 05/21), and post acute period (after 05/2021). Demographics, clinic-pathologic characteristics and treatment of these patients were analyzed. One hundred adrenalectomies were included: 22 before, 30 during, and 48 after the acute phase. The percentage of Conn adenomas and pheochromocytomas decreased during the acute phase (from 45.4 to 26.6% and from 18 to 10%, respectively) in favor of Cushing adenomas and suspicious tumors (from 4.5 to 20% and from 31.8 to 36.6%). About 90.9% of tumors resected for suspicion of malignancy were confirmed malignant by final histopathology, as opposed to 71.4% and 52.6% before and after the acute phase. The operative technique was similar during the three phases (63% retroperitoneoscopic, 34% laparoscopic and 2% open resections), with a significantly shorter operative time for retroperitoneoscopy (p=0.04). ICU monitoring demand increased during the acute phase (from 13.6% to 43.3%), according to the increase in Cushing adenomas and malignant tumors. During the acute phase of COVID-19 pandemic adrenal surgery for Cushing and malignant tumors increased, while a delay in pheochromocytoma surgery to the post acute phase was observed. The suspicion of malignancy formulated by the endocrine tumor board was accurate in 90.9% of cases.
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Adenoma , Neoplasias de las Glándulas Suprarrenales , COVID-19 , Laparoscopía , Feocromocitoma , Humanos , Pandemias , COVID-19/epidemiología , Neoplasias de las Glándulas Suprarrenales/epidemiología , Neoplasias de las Glándulas Suprarrenales/cirugía , Neoplasias de las Glándulas Suprarrenales/patología , Adrenalectomía , Feocromocitoma/epidemiología , Feocromocitoma/cirugía , Feocromocitoma/patología , Adenoma/epidemiología , Adenoma/cirugía , Laparoscopía/métodosRESUMEN
INTRODUCTION: Application of tranexamic acid (TXA) in spine surgery is very frequent even without signs of hyperfibrinolysis, although its beneficial blood-saving effects are offset by harmful adverse events such as thromboembolic incidents. Thus, we investigated whether in relatively less invasive spinal procedures such as one-level posterior spinal fusion, omission of TXA affects the requirement for blood transfusions. METHODS: We conducted a retrospective propensity score-matched noninferiority study with 212 patients who underwent one-level posterior spine fusion and who were stratified according to whether they received TXA intraoperatively at our tertiary care center. The primary endpoint was the volume of transfused packed red cells. Testing for noninferiority or equivalence was performed by two one-sided testing procedure (TOST) with a priori defined noninferiority margins ([Formula: see text]). RESULTS: After propensity score matching a total of five patients (11.6%) treated with TXA were transfused compared with five patients (11.6%) who did not receive TXA. The majority of patients (51.2%) had a risk-increasing condition. The risk difference (no TXA-TXA) of intraoperative transfusion was - 4.7% (CI 90%â¯- 13.62â¯toâ¯4.32%), and omitting TXA was noninferior ([Formula: see text]â¯=â¯[Formula: see text] â¯10%). The mean intergroup difference in transfused volume (no TXA-TXA) was - 23.26 ml intraoperatively (CI 90%â¯- 69.34â¯toâ¯22.83 ml) and - 46.51 ml overall (CI 90%â¯- 181.12â¯toâ¯88.1 ml), respectively, suggesting equivalence of TXA omission ([Formula: see text]â¯=â¯[Formula: see text] 300 ml). The hemoglobin decline between both groups was also equivalent (with [Formula: see text]â¯=â¯[Formula: see text] 1 g/dl) both on the first postoperative day ([Formula: see text] Hb = 0.02 g/dl, CI 90%â¯- 0.53â¯toâ¯0.56 g/dl) and at discharge ([Formula: see text] Hb = - 0.29 g/dl, CI 90%â¯- 0.89â¯toâ¯0.31 g/dl). CONCLUSION: We demonstrated that requirement of transfusion is rare among one-level fusion surgery and the omission of TXA is noninferior with regard to blood transfusion in high-risk patients undergoing this procedure. Therefore, the prophylactic use of TXA cannot be recommended here, suggesting to focus on alternative blood conservation strategies, if necessary.
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Antifibrinolíticos , Fusión Vertebral , Ácido Tranexámico , Humanos , Antifibrinolíticos/uso terapéutico , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea , Puntaje de Propensión , Estudios Retrospectivos , Fusión Vertebral/efectos adversos , Ácido Tranexámico/uso terapéuticoRESUMEN
PURPOSE OF REVIEW: The purpose of this narrative review is to give an overview about the effects of multimodal prehabilitation and current existing and prospectively planned studies. The potential efficacy of exercise in the context of prehabilitation ranges from preoperatively improving patients' functional capacity to inducing cellular mechanisms that affect organ perfusion via endothelial regeneration, anti-inflammatory processes and tumour defense. RECENT FINDINGS: Current studies show that prehabilitation is capable of reducing certain postoperative complications and length of hospital stay in certain patient populations. These findings are based on small to mid-size trials with large heterogeneity, lacking generalizability and evidence that prehabilitation has positive effects on long term survival. SUMMARY: The concept of prehabilitation contains the features, namely preoperative exercise, nutritional intervention and psychological support. Preoperative exercise holds potential molecular effects that can be utilized in the perioperative period in order to improve patients' postoperative outcome. Future multimodal prehabilitation trials must specifically clarify the clinical impact of this concept on patients' quality of life after major cancer surgery and cancer-specific survival.
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Cuidados Preoperatorios , Ejercicio Preoperatorio , Humanos , Calidad de Vida , Periodo Posoperatorio , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & controlRESUMEN
BACKGROUND: In the recent years, an increasing number of patients with multiple comorbidities (e.g. coronary artery disease, diabetes, hypertension) presents to the operating room. The clinical risk factors are accompanied by underlying vascular-endothelial dysfunction, which impairs microcirculation and may predispose to end-organ dysfunction and impaired postoperative outcome. Whether preoperative endothelial dysfunction identifies patients at risk of postoperative complications remains unclear. In this prospective observational study, we tested the hypothesis that impaired flow-mediated dilation (FMD), a non-invasive surrogate marker of endothelial function, correlates with Days at Home within 30 days after surgery (DAH30). DAH30 is a patient-centric metric that captures postoperative complications and importantly also hospital re-admissions. METHODS: Seventy-one patients scheduled for major abdominal surgery were enrolled. FMD was performed pre-operatively prior to major abdominal surgery and patients were dichotomised at a threshold value of 10%. FMD was then correlated with DAH30 (primary endpoint) and postoperative complications (secondary endpoints). RESULTS: DAH30 did not differ between patients with reduced FMD and normal FMD (14 (4) (median (IQR)) vs. 15 (8), P = 0.8). Similary, no differences between both groups were found for CCI (normal FMD: 21 (30) (median (IQR)), reduced FMD: 26 (38), P = 0.4) or frequency of major complications (normal FMD: 7 (19%) (n (%)), reduced FMD: 12 (35%), P = 0.12). The regression analyses revealed that FMD in combination with ASA status and surgery duration had no additional significant predictive effect for DAH30, CCI or Clavien-Dindo score. CONCLUSION: FMD does not add predictive value with regards to DAH30, CCI or Clavien-Dindo score within our study cohort of patients undergoing abdominal surgery. TRIAL REGISTRATION: The study was registered in the German Clinical Trials Register ( DRKS00005472 ), prospectively registered on 25/11/2013.
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Abdomen/cirugía , Endotelio Vascular/patología , Complicaciones Posoperatorias/epidemiología , Vasodilatación/fisiología , Anciano , Estudios de Cohortes , Femenino , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Despite intensive research, cardiac arrest remains a leading cause of death. It is of paramount importance to undertake every possible effort to increase the overall quality of cardiopulmonary resuscitation (CPR) and improve patient outcome. CPR initiated by a bystander is one of the key factors in survival of such an incident. Telephone-assisted CPR (T-CPR) has proved to be an effective measure in improving layperson resuscitation. OBJECTIVE: We hypothesised that adding video-telephony to the emergency call (video-CPR, V-CPR) enhances the quality of layperson resuscitation. DESIGN: This randomised controlled simulation trial was performed from July to August 2018. Laypersons were randomly assigned to video-assisted (V-CPR), telephone-assisted (T-CPR) or control (unassisted CPR) groups. Participants were instructed to perform first aid on a mannequin during a simulated cardiac arrest. SETTING: This study was conducted in the Skills Lab of the University Hospital of Cologne. PARTICIPANTS: One hundred and fifty healthy adult volunteers. INTERVENTION: The participants received a smartphone to call emergency services, with Emergency Eye video-call in V-CPR group, and normal telephone functionality in the other groups. T-CPR and V-CPR groups received standardised CPR assistance via phone. MAIN OUTCOME MEASURES: Our primary endpoint was resuscitation quality, quantified by compression frequency and depth, and correct hand position. RESULTS: Mean compression frequency of V-CPR group was 106.4â±â11.7âmin, T-CPR group 98.9â±â12.3âmin (NS), unassisted group 71.6â±â32.3âmin (Pâ<â0.001). Mean compression depth was 55.4â±â12.3âmm in V-CPR, 52.1â±â13.3âmm in T-CPR (Pâ<â0.001) and 52.9â±â15.5âmm in unassisted (Pâ<â0.001). Total percentage of correct chest compressions was significantly higher (Pâ<â0.001) in V-CPR (82.6%), than T-CPR (75.4%) and unassisted (77.3%) groups. CONCLUSION: V-CPR was shown to be superior to unassisted CPR, and was comparable to T-CPR. However, V-CPR leads to a significantly better hand position compared with the other study groups. V-CPR assistance resulted in volunteers performing chest compressions with more accurate compression depth. Despite reaching statistical significance, this may be of little clinical relevance. TRIAL REGISTRATION: ClinicalTrials.gov (Identifier: NCT03527771).
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Reanimación Cardiopulmonar , Servicios Médicos de Urgencia , Paro Cardíaco Extrahospitalario , Adulto , Humanos , Maniquíes , Teléfono InteligenteRESUMEN
Positive effects of exercise on cancer prevention and progression have been proposed to be mediated by stimulating natural killer (NK) cells. Because NK cell receptors are regulated by epigenetic modifications, we investigated whether acute aerobic exercise and training change promoter DNA methylation and gene expression of the activating KIR2DS4 and the inhibiting KIR3DL1 gene. Sixteen healthy women (50-60 years) performed a graded exercise test (GXT) and were randomized into either a passive control group or an intervention group performing a four-week endurance exercise intervention. Blood samples (pre-, post-GXT and post-training) were used for isolation of DNA/RNA of NK cells to assess DNA promoter methylation by targeted deep-amplicon sequencing and gene expression by qRT-PCR. Potential changes in NK cell subsets were determined by flow cytometry. Acute and chronic exercise did not provoke significant alterations of NK cell proportions. Promoter methylation decreased and gene expression increased for KIR2DS4 after acute exercise. A high gene expression correlated with a low methylation of CpGs that were altered by acute exercise. Chronic exercise resulted in a minor decrease of DNA methylation and did not alter gene expression. Acute exercise provokes epigenetic modifications, affecting the balance between the activating KIR2DS4 and the inhibiting KIR3DL1, with potential benefits on NK cell function.
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Metilación de ADN , Ejercicio Físico/fisiología , Células Asesinas Naturales/metabolismo , Regiones Promotoras Genéticas , Receptores KIR/genética , Desmetilación , Epigénesis Genética , Prueba de Esfuerzo , Femenino , Expresión Génica , Humanos , Persona de Mediana EdadRESUMEN
OBJECTIVES: We evaluated end-tidal CO2 (etCO2), which has been proposed to assess acute hemodynamic changes, to guide percutaneous edge-to-edge mitral valve repair (PMVR) with the MitraClip system. METHODS: Thirty-nine patients (aged 78 ± 14 years) undergoing PMVR for moderate-to-severe mitral regurgitation (MR) of primary and secondary etiology were included. General anesthesia was maintained with sevoflurane and constant ventilation parameters to ensure stable etCO2 tension. MR grade was determined semiquantitatively by transesophageal echocardiography by 2 experienced operators blinded to etCO2 measurements. etCO2 levels were measured 3, 5, 10, and 15 min after final MitraClip placement. RESULTS: Overall, etCO2 increased from 32.2 ± 1.7 before to 35.4 ± 3.0, 34.6 ± 2.6, and 34.2 ± 2.4 mm Hg 3, 5, and 10 min after implantation. A significant correlation was noted between the echocardiographic reduction in MR grade and the increase in etCO2. ANOVA for repeated measures confirmed a significant increase in etCO2 after clip implantation (corrected F = 20.0; p < 0.001) and revealed a significantly greater increase in etCO2 in patients with MR reduction ≥2 grades as compared to lesser MR reductions (F = 6.47; p = 0.015). Blood pressure changes did not correlate with the degree of MR reduction. CONCLUSIONS: We observed a close correlation between the reduction in MR grade during PMVR and etCO2, which might evolve as a useful parameter to complement treatment guidance during PMVR.
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Dióxido de Carbono/sangre , Implantación de Prótesis de Válvulas Cardíacas/métodos , Insuficiencia de la Válvula Mitral/sangre , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Anciano de 80 o más Años , Ecocardiografía Transesofágica , Femenino , Hemodinámica , Humanos , Masculino , Persona de Mediana Edad , Curva ROC , Resultado del TratamientoRESUMEN
Hyper or hypoventilation may have serious clinical consequences in critically ill patients and should be generally avoided, especially in neurosurgical patients. Therefore, monitoring of carbon dioxide partial pressure by intermittent arterial blood gas analysis (PaCO2) has become standard in intensive care units (ICUs). However, several additional methods are available to determine PCO2 including end-tidal (PETCO2) and transcutaneous (PTCCO2) measurements. The aim of this study was to compare the accuracy and reliability of different methods to determine PCO2 in mechanically ventilated patients on ICU. After approval of the local ethics committee PCO2 was determined in n = 32 ICU consecutive patients requiring mechanical ventilation: (1) arterial PaCO2 blood gas analysis with Radiometer ABL 625 (ABL; gold standard), (2) arterial PaCO2 analysis with Immediate Response Mobile Analyzer (IRMA), (3) end-tidal PETCO2 by a Propaq 106 EL monitor and (4) transcutaneous PTCCO2 determination by a Tina TCM4. Bland-Altman method was used for statistical analysis; p < 0.05 was considered statistically significant. Statistical analysis revealed good correlation between PaCO2 by IRMA and ABL (R2 = 0.766; p < 0.01) as well as between PTCCO2 and ABL (R2 = 0.619; p < 0.01), whereas correlation between PETCO2 and ABL was weaker (R2 = 0.405; p < 0.01). Bland-Altman analysis revealed a bias and precision of 2.0 ± 3.7 mmHg for the IRMA, 2.2 ± 5.7 mmHg for transcutaneous, and -5.5 ± 5.6 mmHg for end-tidal measurement. Arterial CO2 partial pressure by IRMA (PaCO2) and PTCCO2 provided greater accuracy compared to the reference measurement (ABL) than the end-tidal CO2 measurements in critically ill in mechanically ventilated patients patients.
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Análisis de los Gases de la Sangre/métodos , Monitoreo de Gas Sanguíneo Transcutáneo/métodos , Unidades de Cuidados Intensivos , Monitoreo Fisiológico/métodos , Respiración Artificial/métodos , Adulto , Anciano , Dióxido de Carbono/sangre , Análisis Costo-Beneficio , Cuidados Críticos , Enfermedad Crítica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Presión Parcial , Pruebas en el Punto de Atención , Reproducibilidad de los Resultados , Tamaño de la Muestra , Factores de TiempoAsunto(s)
Enfermedades Cardiovasculares/etiología , Prueba de Esfuerzo/métodos , Tolerancia al Ejercicio/fisiología , Cuidados Preoperatorios/métodos , Ejercicio Preoperatorio/fisiología , Umbral Diferencial , Humanos , Aptitud Física , Valor Predictivo de las Pruebas , Pronóstico , Medición de Riesgo , Encuestas y CuestionariosRESUMEN
BACKGROUND: High-quality cardiopulmonary resuscitation (CPR) by laypersons is a key determinant of both outcome and survival for out-of-hospital cardiac arrest. Dispatcher-assisted CPR (telephone-CPR, T-CPR) increases the frequency and correctness of bystander-CPR but results in prolonged time to first chest compressions. However, it remains unclear whether instructions for rescue ventilation and/or chest compressions should be recommended for dispatcher-assisted CPR. OBJECTIVE: The aim of this study was to evaluate both principles of T-CPR with respect to CPR quality. DESIGN: Randomised controlled single-blinded manikin trial. SETTING: University Hospital of Cologne, Germany, 1 July 2012 to 30 September 2012. PARTICIPANTS: Sixty laypersons between 18 and 65 years. Medically educated individuals, medical professionals and pregnant women were excluded. Participants were asked to resuscitate a manikin and were randomised into three groups: not dispatcher-assisted (uninstructed) CPR (group 1; U-CPR; nâ=â20), dispatcher-assisted compression-only CPR (group 2; DACO-CPR; nâ=â19) and full dispatcher-assisted CPR with rescue ventilation (group 3; DAF-CPR; nâ=â19). MAIN OUTCOME MEASURES: Specific parameters of CPR quality [i.e. no-flow-time (NFT) as well as compression and ventilation parameters] were analysed. To compare different groups we used Student's t test and P less than 0.05 was considered significant. RESULTS: Initial NFT was lowest in the DACO-CPR group (mean 21.3â±â14.4%), followed by dispatcher-assisted full CPR (mean 49.1â±â8.5%) and by unassisted CPR (mean 55.0â±â12.9%). Initial NFT covering the time of instruction was lower in DACO-CPR (12.1â±â5.4%) as compared to dispatcher-assisted full CPR (20.7â±â8.1%). Compression depth was similar in all three groups: 40.6â±â13.0âmm (unassisted CPR), 41.0â±â12.2âmm (DACO-CPR) and 38.8â±â15.8âmm (dispatcher-assisted full CPR). Average compression frequency was highest in the DACO-CPR group (65.2â±â22.4âmin) compared with the unassisted CPR group (35.6â±â24.2âmin) and the dispatcher-assisted full CPR group (44.5â±â10.8âmin). Correct rescue ventilation was given in 3.1â±â11.1% (unassisted CPR) and 1.6â±â16.1% (dispatcher-assisted full CPR) of all ventilation attempts. CONCLUSION: Best quality of CPR was achieved by DACO-CPR because of superior compression frequencies and reduced NFT. In contrast, the full dispatcher-assisted CPR with a longer initial instructing phase (initial NFT) did not result in enhanced CPR quality or an optimised compression depth.
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Reanimación Cardiopulmonar/métodos , Servicios Médicos de Urgencia , Adolescente , Adulto , Anciano , Femenino , Primeros Auxilios , Humanos , Masculino , Maniquíes , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario , Estudios Prospectivos , Respiración , Método Simple Ciego , Teléfono , Volumen de Ventilación Pulmonar , Adulto JovenRESUMEN
OBJECTIVES: The authors hypothesized that, compared with conventional ultrasound (CUS), the use of a novel navigated ultrasound (NUS) technology would increase success rates and decrease performance times of vascular access procedures in a gel phantom model. DESIGN: A prospective, randomized, crossover study. SETTING: A university Hospital. PARTICIPANTS: Participants were 44 anesthesiologists with varying clinical experience. INTERVENTIONS: Anesthesiologists performed in-plane and out-of-plane vascular access procedures using both NUS and CUS for needle visualization in a gel phantom model. MEASUREMENTS AND MAIN RESULTS: Procedure time was measured from needle insertion to verbalization of final needle positioning by the participants, and successful needle placement into the simulated vessel was verified by aspiration of simulated blood. By employing ultrasound navigation capabilities in addition to real-time ultrasound imaging during in-plane/long-axis vascular access procedures, median procedure time showed a nonsignificant decrease (7.5 seconds v 13.0 seconds; p = 0.028), and the observed increase in procedure success rate (90.9% v 100%; p = 0.125) did not reach statistical significance. For out-of-plane/short-axis vascular access procedures, a significant reduction in median procedure time (5.0 seconds v 11.5 seconds; p<0.001) and a significant increase in procedure success rate (75% v 100%; p<0.001) were achieved by using navigation technology combined with real-time ultrasound. CONCLUSIONS: NUS technology improved the performance times and success rates of vascular access procedures conducted by anesthesiologists in a gel phantom model.
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Anestesiología/educación , Cateterismo Venoso Central/métodos , Competencia Clínica , Fantasmas de Imagen , Ultrasonografía/métodos , Estudios Cruzados , Geles , Humanos , Internado y Residencia , Estudios ProspectivosRESUMEN
BACKGROUND: Non-invasive measures of vascular reactivity have emerged to refine cardiovascular risk. However, limited data exists investigating vascular reactivity as a preoperative diagnostic tool for anesthesiologists. In this study, we compare the utility of two non-invasive techniques, Brachial Artery Reactivity Testing (BART) and Digital Thermal Monitoring (DTM), as surrogates for measuring vascular reactivity. METHODS: Following IRB approval, 26 patients scheduled for major thoracic surgery (e.g. esophagectomy and pneumonectomy) were studied prospectively. BART [Flow mediated dilation (FMD) and Peak flow velocity (PFV)] and DTM [Temperature rebound (TR%)] were performed preoperatively at baseline using 5 minute blood pressure cuff occlusion of the upper arm. Statistical summaries were provided for the comparison of BART and DTM with select patient characteristics, and correlations were used to investigate the strength of the relationship between BART and DTM measurements. RESULTS: Patients preoperatively diagnosed with hyperlipidemia were associated with lower FMD% values {Median (Range): 14.8 (2.3, 38.1) vs. 6.2 (0.0, 14.3); p = 0.006}. There were no significant associations between BART and DTM techniques in relation to cardiovascular risk factors or postoperative complications. CONCLUSION: Our study suggests that impaired vascular reactivity as measured by BART is associated with the incidence of hyperlipidemia. Also, using a novel technique such as DTM may provide a simpler and more accessible point of care testing for vascular reactivity in a perioperative setting. Both non-invasive techniques assessing vascular function warrant further refinement to better assist preoperative optimization strategies aimed at improving perioperative vascular function.
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Anestesia/métodos , Enfermedades Cardiovasculares/prevención & control , Complicaciones Posoperatorias/prevención & control , Cuidados Preoperatorios/métodos , Adulto , Anciano , Arteria Braquial/metabolismo , Enfermedades Cardiovasculares/etiología , Femenino , Humanos , Hiperemia/fisiopatología , Hiperlipidemias/epidemiología , Masculino , Persona de Mediana Edad , Sistemas de Atención de Punto , Estudios Prospectivos , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
CONTEXT: Tracheal intubation in nonstandardised positions is associated with a higher risk of tube misplacement and may have deleterious consequences for patients. Video laryngoscopes for tracheal intubation facilitate both glottic view and success rates. However, their use in the ice-pick position has not been evaluated. OBJECTIVE: To evaluate the role of video laryngoscopes for tracheal intubation in the ice-pick position. DESIGN: A randomised, controlled manikin trial. SETTING: A standardised airway manikin was placed in the corner of a room. Tracheal intubation was only possible from the lower right side of the manikin. In randomised order, participants used a standard Macintosh laryngoscope and GlideScope Ranger, Storz C-MAC, Pentax AWS, Airtraq and McGrath Series5 video laryngoscopes. Statistical analysis was performed using the Wilcoxon signed-rank and McNemar's tests; A P value of less than 0.05 was deemed statistically significant. PARTICIPANTS: Twenty anaesthesiologists, all emergency medicine board-certified. MAIN OUTCOME MEASURES: Time to first ventilation (primary); time to glottic view and confirmation of tube position (secondary). RESULTS: Successful ventilation was achieved most rapidly with the Macintosh laryngoscope (36.1â±â13.4âs; reference method), followed by the Airtraq (38.4â±â36.3âs; Pâ=ân.s.), Pentax AWS (51.6â±â43.3âs; Pâ=ân.s.) and Storz C-Mac (62.7â±â49.7âs; Pâ=ân.s.). The use of the GlideScope Ranger (79.8â±â61.9âs, Pâ=â0.01) and McGrath series5 (79.8â±â58.5âs, Pâ=â0.023) resulted in significantly longer times. When comparing overall intubation success, the rate of successful tracheal intubation was higher with the Airtraq than with the McGrath Series5 (Pâ=â0.031; all others n.s.). CONCLUSION: The use of video laryngoscopes did not result in higher success rates or faster tracheal intubation in the ice-pick position when compared with conventional laryngoscopy in this manikin study. TRIAL REGISTRATION: www.clinicaltrials.gov, NCT01210105.
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Intubación Intratraqueal/métodos , Laringoscopios , Maniquíes , Adulto , Femenino , Humanos , Masculino , Grabación en VideoRESUMEN
BACKGROUND: Cardiopulmonary exercise testing (CPET) objectively informs preoperative risk stratification prior to major surgery. CPET facilities are resource intensive and therefore more cost-effective triage methods are desirable for scalability. We tested two dynamic CPET parameters (end-tidal CO
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Dióxido de Carbono , Neoplasias Colorrectales , Humanos , Prueba de Esfuerzo/métodos , Estudios Retrospectivos , Consumo de Oxígeno/fisiología , Complicaciones Posoperatorias/epidemiología , Neoplasias Colorrectales/cirugíaRESUMEN
Background: Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods: We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings: Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation: Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding: There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Introduction: Prehabilitation is increasingly recognised as a therapeutic option to reduce postoperative complications. Investigating the beneficial effects of exercise on cellular mechanisms, we have previously shown that a single episode of exhaustive exercise effectively stimulates endothelial progenitor cells (a cell population associated with vascular maintenance, repair, angiogenesis, and neovascularization) in correlation with fewer postoperative complications, despite the ongoing debate about the appropriate cell surface marker profiles of these cells (common phenotypical definitions include CD45dim, CD133+, CD34+ and/or CD31+). In order to translate these findings into clinical application, a feasible prehabilitation programme achieving both functional and cellular benefits in a suitable timeframe to expedite surgery is necessary. Objective: The objective of this study was to test the hypothesis that a four-week prehabilitation programme of vigorous-intensity interval exercise training is feasible, increases physical capacity (primary outcome) and the circulatory number of endothelial progenitor cells within peripheral blood. Methods: In this unblinded, parallel-group, randomised controlled proof-of-concept clinical trial (German Clinical Trial Register number: DRKS00000527) conducted between 01st December 2014 and 30th November 2016, fifteen female adult patients scheduled for incontinence surgery with abdominal laparotomy at the University Hospital Cologne were allocated to either an exercise (n = 8, exclusion of 1 patient, analysed n = 7) or non-exercise group (n = 7, exclusion of 1 patient, analysed n = 6). The exercise group's intervention consisted of a vigorous-intensity interval training for four weeks preoperatively. Cardiopulmonary Exercise Testing accompanied by peripheral blood collection was performed before and after the (non-)training phase. Cellular investigations were conducted by flow cytometry and cluster-based analyses. Results: Vigorous-intensity interval training over four weeks was feasible in the exercise group (successful completion by 8 out of 8 patients without any harms), with significant improvements in patients' functional capacity (increased oxygen uptake at anaerobic threshold [intervention group mean + 1.71 ± 3.20 mL/min/kg vs. control group mean -1.83 ± 2.14 mL/min/kg; p = 0.042] and peak exercise [intervention group mean + 1.71 ± 1.60 mL/min/kg vs. control group mean -1.67 ± 1.37 mL/min/kg; p = 0.002]) and a significant increase in the circulatory number of endothelial progenitor cells (proportionate CD45dim/CD14dim/CD133+/CD309+/CD34+/CD31 + subpopulation within the circulating CD45-pool [p = 0.016]). Conclusions: We introduce a novel prehabilitation concept that shows effective stimulation of an endothelial progenitor cell subpopulation within four weeks of preoperative exercise, serving as a clinical cell-mediated intervention with the aim to reduce surgical complications. Funding: Institutional funding. DFG (German Research Foundation, 491454339) support for the Article Processing Charge.
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BACKGROUND: Preoperative risk stratification is used to derive an optimal treatment plan for patients requiring cancer surgery. Patients with reversible risk factors are candidates for prehabilitation programmes. This pilot study explores the impact of preoperative covariates of comorbid disease (Charlson Co-morbidity Index), preoperative serum biomarkers, and traditional cardiopulmonary exercise testing (CPET)-derived parameters of functional capacity on postoperative outcomes after major colorectal cancer surgery. METHODS: Consecutive patients who underwent CPET prior to colorectal cancer surgery over a 2-year period were identified and a minimum of 2-year postoperative follow-up was performed. Postoperative assessment included: Clavien-Dindo complication score, Comprehensive Complication Index, Days at Home within 90 days (DAH-90) after surgery, and overall survival. RESULTS: The Charlson Co-morbidity Index did not discriminate postoperative complications, or overall survival. In contrast, low preoperative haemoglobin, low albumin, or high neutrophil count were associated with postoperative complications and reduced overall survival. CPET-derived parameters predictive of postoperative complications, DAH-90, and reduced overall survival included measures of VCO2 kinetics at anaerobic threshold (AT), peakVO2 (corrected to body surface area), and VO2 kinetics during the post-exercise recovery phase. Inflammatory parameters and CO2 kinetics added significant predictive value to peakVO2 within bi-variable models for postoperative complications and overall survival (P < 0.0001). CONCLUSION: Consideration of modifiable 'triple low' preoperative risk (anaemia, malnutrition, deconditioning) factors and inflammation will improve surgical risk prediction and guide prehabilitation. Gas exchange parameters that focus on VCO2 kinetics at AT and correcting peakVO2 to body surface area (rather than absolute weight) may improve CPET-derived preoperative risk assessment.
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BACKGROUND: Increasing the cross-sectional area (CSA) of the right internal jugular vein facilitates cannulation and decreases complications. Maneuvers such as the Trendelenburg tilt position and ventilation with a positive end-expiratory pressure (PEEP) may increase the CSA of the right internal jugular vein. We determined the changes in the CSA in response to different maneuvers. METHODS: The CSA (cm(2)) of the right internal jugular vein was assessed in 50 anesthetized adult cardiothoracic surgery patients using 2-dimensional ultrasound. First, the CSA was measured in response to supine position with no PEEP (control condition, S0) and compared with 5 different randomly ordered maneuvers: (1) PEEP ventilation with 5 cm H(2)O (S5), (2) PEEP with 10 cm H(2)O (S10), (3) a 20 degrees Trendelenburg tilt position with a PEEP of 0 cm H(2)O (T0), (4) a 20 degrees Trendelenburg tilt position combined with a PEEP of 5 cm H(2)O (T5), and (5) a 20 degrees Trendelenburg tilt position combined with a PEEP of 10 cm H(2)O (T10). RESULTS: All maneuvers increased the CSA of the right internal jugular vein with respect to the control condition S0 (all P < 0.05). S5 increased the CSA on average by 15.9%, S10 by 22.3%, T0 by 39.4%, T5 by 38.7%, and T10 by 49.7%. CONCLUSION: In a comparison of the effectiveness of applying different PEEP levels and/or the Trendelenburg tilt position on the CSA of the right internal jugular vein, the Trendelenburg tilt position was most effective.