Postoperative Critical Care Admission Was Not Associated with Improved Postoperative Outcomes in Elective Colorectal Surgery: Secondary Analysis Of POWER Trial.

BACKGROUND: The efficacy of routine admission of high-risk patients to a critical care unit after surgery is not clear. The aim of our study was to investigate the association between critical care admission after scheduled colorectal surgery and postoperative complications, 30-day mortality, and length of stay in hospital. METHODS: A pre-defined secondary substudy of POWER study was performed. POWER study was a prospective multicenter observational study of patients undergoing elective primary colorectal surgery during a single period of two months of recruitment between September and December 2017. RESULTS: A total of 2084 patients from 80 Spanish hospitals were included, of which 722 (34.6%) were admitted to critical care unit (CCU) after elective surgery. After adjusting for confounding factors in the multivariate analysis, postoperative CCU admission was independently associated with a higher incidence of moderate-to-severe postoperative complications (adjusted OR 1.951, 95% CI 1.570, 2.425; p < 0.001). Regarding secondary outcomes, postoperative critical care admission was independently associated with higher 30-day mortality (adjusted OR 6.736; 95% CI 2.507, 18.101; p < 0.001) and independently associated with an increased hospital length of stay (adjusted OR 1.143, 95% CI 1.112, 1.175; p < 0.001). CONCLUSIONS: Direct admission to CCU after scheduled colorectal surgery was not associated with a reduction in moderate-to-severe postoperative complications.

Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2).

Importance: The Enhanced Recovery After Surgery (ERAS) care protocol has been shown to improve outcomes compared with traditional care in certain types of surgery. Objective: To assess the association of use of the ERAS protocols with complications in patients undergoing elective total hip arthroplasty (THA) and total knee arthroplasty (TKA). Design, Setting, and Participants: This multicenter, prospective cohort study included patients recruited from 131 centers in Spain from October 22 through December 22, 2018. All consecutive adults scheduled for elective THA or TKA were eligible for inclusion. Patients were stratified between those treated in a self-designated ERAS center (ERAS group) and those treated in a non-ERAS center (non-ERAS group). Data were analyzed from June 15 through September 15, 2019. Exposures: Total hip or knee arthroplasty and perioperative management. Sixteen individual ERAS items were assessed in all included patients, whether they were treated at a center that was part of an established ERAS protocol or not. Main Outcomes and Measures: The primary outcome was postoperative complications within 30 days after surgery. Secondary outcomes included length of stay and mortality. Results: During the 2-month recruitment period, 6146 patients were included (3580 women [58.2%]; median age, 71 [interquartile range (IQR), 63-76] years). Of these, 680 patients (11.1%) presented with postoperative complications. No differences were found in the number of patients with overall postoperative complications between ERAS and non-ERAS groups (163 [10.2%] vs 517 [11.4%]; odds ratio [OR], 0.89; 95% CI, 0.74-1.07; P = .22). Fewer patients in the ERAS group had moderate to severe complications (73 [4.6%] vs 279 [6.1%]; OR, 0.74; 95% CI, 0.56-0.96; P = .02). The median overall adherence rate with the ERAS protocol was 50.0% (IQR, 43.8%-62.5%), with the rate for ERAS facilities being 68.8% (IQR, 56.2%-81.2%) vs 50.0% (IQR, 37.5%-56.2%) at non-ERAS centers (P < .001). Among the patients with the highest and lowest quartiles of adherence to ERAS components, the patients with the highest adherence had fewer overall postoperative complications (144 [10.6%] vs 270 [13.0%]; OR, 0.80; 95% CI, 0.64-0.99; P < .001) and moderate to severe postoperative complications (59 [4.4%] vs 143 [6.9%]; OR, 0.62; 95% CI, 0.45-0.84; P < .001) and shorter median length of hospital stay (4 [IQR, 3-5] vs 5 [IQR, 4-6] days; OR, 0.97; 95% CI, 0.96-0.99; P < .001). Conclusions and Relevance: An increase in adherence to the ERAS program was associated with a decrease in postoperative complications, although only a few ERAS items were individually associated with improved outcomes.

Feocromocitoma-manejo anestésico perioperatorio en el adulto. De la pesadilla del anestesiólogo a la minimización de riesgos / No disponible

Los feocromocitomas son raros tumores neuroendocrinos con una presentación clínica muy variable, generalmente caracterizada por hipertensión arterial, cefalea y sudoración. Los pacientes con feocromocitoma pueden desarrollar complicaciones cardiovasculares potencialmente letales sin un adecuado manejo perioperatorio, incluidas miocardiopatía. Estas complicaciones son debidas a la secreción de catecolaminas. Durante el preoperatorio el enfermo debe ser preparado farmacológicamente para prevenir una crisis hipertensiva durante la cirugía. Tres periodos de tiempo intraoperatorio son los más críticos para el paciente: la intubación, la manipulación quirúrgica del tumor y la ligadura del drenaje venoso del tumor. Los dos primeros están relacionados con la liberación de catecolaminas, y el último a una deficiencia relativa de estas; esta etapa posterior a la resección del tumor se caracteriza por una hipotensión severa que requiere de cuidados anestesiológicos, ya que sus consecuencias pueden convertirse en complicaciones graves. El conocimiento de las alteraciones causadas por la secreción de catecolaminas así como de las opciones terapéuticas para el tratamiento resultan fundamentales para disminuir los riesgos en esta cirugía, la cual constituye un reto para el anestesiólogo (AU)

Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation usually includes high blood pressure, headache and sweating. Patients with pheochromocytoma may develop potentially lethal cardiovascular complications without adequate perioperative management, including cardiomyopathy. These complications are due to the secretion of catecholamines. During the preoperative period the patient should be prepared pharmacologically to prevent a hypertensive crisis during surgery. Three intraoperative periods are the most critical for the patient: intubation, surgical manipulation of the tumor and ligation of venous drainage of the tumor. The first two are associated with catecholamine release, and the latter to a relative deficiency of these; this stage after tumor resection is characterized by a severe hypotension requiring anesthesiologic care as their consequences can become serious complications. Knowledge of the alterations caused by the secretion of catecholamines and therapeutic options for treatment are essential to reduce the risk in this surgery, which is a challenge for the anesthesiologist (AU)