A clinical trial of volume- versus pressure-controlled intraoperative ventilation during laparoscopic bariatric surgeries.

BACKGROUND: Intra-operative ventilation is often challenging in patients with morbid obesity undergoing bariatric surgery. OBJECTIVES: To test the noninferiority of pressure-controlled ventilation (PCV) to volume-controlled ventilation (VCV) in respiratory mechanics. SETTING: Bariatric Surgery Center, Iran. METHODS: In a randomized open-labeled clinical trial, 66 individuals with morbid obesity undergoing laparoscopic bariatric surgeries underwent intraoperative ventilation with either PCV or VCV. The measurements taken were peak and mean airway pressures (H2O), partial pressure of arterial oxygen (PaO2), partial pressure of arterial carbon dioxide (PaCO2) and end-tidal carbon dioxide (CO2). We additionally collected pulse-oximetric oxygen saturation, inspiratory concentration of oxygen (FiO2), and hemodynamic variables. Data were analyzed with repeated measures over the time of intubation, after peritoneal insufflation, and every 15 minutes, thereafter up to one hour. RESULTS: PCV mode was successful to sustain adequate ventilation in 97% of the patients, which was similar to the 94% success rate of the VCV mode. Peak airway pressure increased 6 cmH2O and end-tidal CO2 rose by 5 mm Hg after abdominal insufflation in both groups (P = .850 and .376). Alveolar-arterial oxygen gradient similarly increased within 30 minutes after tracheal intubation both in PCV and VCV groups, with small trend of being higher in the VCV group. The ratio of dead space to tidal volumes (VD/VT) did not have a meaningful change (P = .724). CONCLUSION: PCV was noninferior to VCV during laparoscopic bariatric surgery. Either mode of ventilation could be alternatively used during the anesthesia care of these patients.

The utilization spectrum of cardiac output monitoring devices among anesthesiology programs across Veterans Health Administration in the United States.

Background: Electronic monitoring of physiologic variables has gained widespread support over the past decade for critical patients in the intensive care setting. Specifically, anesthesiologists have increased the emphasis and practice of hemodynamic control through monitoring cardiac output (CO). However, these physicians are presented with several options in terms of how they wish to study the trend of this physiologic parameter. Materials and Methods: A survey was distributed to 250 general and subspecialty-trained anesthesiologists. A series of questions were presented in terms of preference of patient monitoring methods requiring yes or no answers. Anesthesiologists were asked about subspecialty training, years since residency graduation, and preferences toward specific hemodynamic monitoring tools. Nonparametric statistical analysis and Chi-squared tests were used to analyze both normal and nonnormally distributed data. Results: CO monitoring devices were implemented by 106 out of 133 anesthesiologists, with 98 of these physicians utilizing CO monitoring for fluid and vasopressors response. Of the physicians implementing a monitoring device, 48 out of 107 physicians preferred pulmonary artery catheter, while pulse contour analysis was preferred by 17 anesthesiologists. An echocardiography unit was available to the department for 90 anesthesiologists, and 77 anesthesiologists were trained to use this technology for monitoring cardiac function. Conclusion: Many anesthesiologists have placed emphasis on the importance of CO monitoring within the intensive care setting. However, physicians are still faced with multiple options in terms of how they wish to specifically monitor this hemodynamic variable. Factors that influence such decisions include the time of physician's residency training along with patient and clinical case characteristics.

Acute kidney injury after non-cardiovascular surgery: risk factors and impact on development of chronic kidney disease and long-term mortality.

OBJECTIVE: To identify factors associated with acute kidney injury (AKI) and its progression to chronic kidney disease (CKD) in a non-cardiac/non-vascular surgery setting. METHODS: This study examined the Veterans Affairs Surgical Quality database for surgical entries between 2000-2014. Demographics, comorbidities, laboratory findings and hospital outcomes were assessed. The primary end-point was the occurrence of AKI, defined as an increase of ≥0.3 mg/dL, 48 h post-operatively. Major adverse cardiac event (MACE) was defined as the composite first occurrence of myocardial infarction, cardiac arrest, and death in 30 days (secondary end-point) and was compared between two groups. Rates of progression to CKD in 1 year and long-term survival were examined. MAIN OUTCOME MEASURES: Occurrence of AKI 48 h post-operatively. RESULTS: AKI was documented in 8.5% of patients. Age, diabetes, and chronic obstructive pulmonary disease, chronic kidney disease, platelet count, serum albumin level, and duration of surgery were identified as independent predictors of AKI. In total, 6.4% patients developed MACE, which was more frequent in patients with AKI (p < .001). Age and pre-operative hematocrit <30% were independent predictors of progression to CKD. Pre-operative hematocrit with a cut-off value of 30% was the only modifiable factor to predict the long-term survival. CONCLUSION: Development of AKI is associated with increased odds of various post-operative complications and long-term renal insufficiency and mortality.

A pilot trial of l-carnitine in patients with traumatic brain injury: Effects on biomarkers of injury.

OBJECTIVE: To investigate the effects of l-Carnitine on neuron specific enolase (NSE) as a marker of inflammation in patients with traumatic brain injury (TBI). METHODS: Forty patients with severe TBI were randomized into 2 groups. The (LCA-) group received standard treatment with placebo while the (LCA+) group received l-Carnitine 2g/day for one week. NSE was measured on days 1, 3 and 7 after the initiation of the study. Neurocognitive and neurobehavioral disorders were recorded on the first and third months. RESULTS: Neurocognitive function and NSE significantly improved within one week in both groups. Patient mortality was similar in LCA+ and LCA- groups (P value: 0.76). Brain edema was present in 7 patients in LCA+ group and 13 patients in LCA-group (P value: 0.044). While there was no difference in NSE levels between the two groups. Neurological function was preserved in the LCA+ group with an exception of attention deficit, which was frequent in the LCA+ group. CONCLUSION: We concluded that despite improvements in neurobehavioral function and the degree of cerebral edema, 7-days of treatment with l-Carnitine failed to reduce serum NSE levels or improve mortality rate at 90days in patients with TBI.

Novel therapies for perioperative respiratory complications.

Postoperative respiratory complications are of paramount clinical importance as they prolong the hospitalization, increase the costs of treatment and contribute to the perioperative mortality. Obesity, preexisting pulmonary disease and advanced age are known risk factors for developing postoperative respiratory complications, which affect exceeding number of patients. Hereby, we present a review on the pathogenesis of post-operative respiratory complications particularly in obese and older patients. We further focus on the standard management and emerging therapies for the post-operative respiratory complications.

Crystalloid versus colloid fluids for reduction of postoperative ileus after abdominal operation under combined general and epidural anesthesia.

BACKGROUND: The main objective of this study was to compare the effect of perioperative administration of crystalloid versus colloid solutions and its impact on reversal of ileus after resection with primary anastomosis of intestine. We hypothesized that inclusion of colloids will improve the return of intestinal motility. METHODS: In a double-blinded clinical trial, 91 the American Society of Anesthesiologists I to III patients undergoing abdominal operation for resection with anastomosis of small or large intestine were randomized to receive either lactated Ringer solution crystalloid group or 6% hydroxyethyl starch colloid group to replace intraoperative fluid loss (blood loss + third space). The time to resume normal intestinal motility was the primary end point and the prevalence of composite postoperative complications was the secondary end point. RESULTS: Average duration of ileus was 86.7 ± 23.6 hours in crystalloid group and it lasted 73.4 ± 20.8 hours in colloid group (P = .006). While there was no difference in the frequency of postoperative nausea and vomiting between the 2 groups (P = .3), the actual vomiting occurred less frequently in colloid group (P = .02). Serum concentrations of potassium ion decreased significantly in both groups, whereas the degree of potassium changes was more remarkable in colloid group compared with crystalloid group (P = .03). Postoperative ileus did not correlate with sex, age, and the duration of operation. Duration of hospital stay was similar between the 2 groups. CONCLUSION: We concluded that administration of colloids as a part of perioperative fluid management improves intestinal motility and shortens the duration of ileus after gastrointestinal operations. This may improve the tolerance for enteral feeding and reduce ileus-related symptoms.

Development of a curriculum and training program in Woman Veterans Health for Internal Medical Residents.

INTRODUCTION: Internal Medicine residents must develop competency as Primary Care Providers, but a gap exists in their curriculum and training with regard to women's reproductive health. With increasing need in VA due to new influx of women veterans it poses problems in recruitment of competent physicians trained in Women's health. METHODS: An intensive, one-month women's reproductive health curriculum with hands on experience for Internal Medicine residents was provided. Curriculum was taught to the residents who rotated at the Women's Health Clinic for one month. Pre-test and post-test exams were administered. Increase in knowledge of residents in providing gender specific evaluations and management was objectively assessed by changes in post-test scores. Data were analyzed for statistically significant improvement in written tests scores. RESULTS: Total of 47 Internal Medicine residents rotated through Women's Health Center during the evaluation period. All residents completed both pre-test and post-test exams. The average time to complete the pre-test was 20.5 ± 5.4 min and 19.5 ± 4.8 min for post-test. There was no correlation between the time to complete the pre-test exam and the post-test exam. The total score was significantly improved from 8.5 ± 1.6 to 13.2 ± 1.8 (p < 0.0001). CONCLUSION: This study shows how to equip physicians in training with information on women's health that enables them to provide safe and gender appropriate care in primary care settings. This practice will reduce the need for frequent referrals for specialized care and thus provide cost saving for patient and health care on the whole.

Preoperative serum potassium predicts the clinical outcome after non-cardiac surgery.

BACKGROUND: Potassium disorders have been linked to adverse outcomes in various medical conditions. However, the association of preoperative serum potassium with postoperative outcome is not well established. We aimed to examine the association between preoperative potassium with a 30-day mortality and adverse cardiovascular event (MACE). METHODS: We conducted a cohort study using a prospectively collected database of patients, undergoing surgical procedures from 1998 to 2013 in the VA Western New York Healthcare System, which are reported to the Veterans Affairs Surgical Quality Improvement Program (VASQIP). The patients were categorized into three groups based on their documented preoperative potassium concentrations. Hypokalemia was defined as serum potassium concentration <4 mmol/L and hyperkalemia was defined as serum potassium concentrations >5.5 mmol/L. The values within the range of 4.0-5.5 mmol/L were considered as normokalemia and used as the control group. Statistical analyses included Chi-square test, analysis of variance and multivariate logistic regression to estimate the risk of MACE within 30 days of surgery. RESULTS: Study included 5959 veterans who underwent surgery between 1998 and 2013. The patients in the hyperkalemics group had lower kidney function compared to the other two groups. The frequency of MACE was 13.6% in hypokalemics and 21.9% in hyperkalemics that were both significantly higher than 4.9% in controls. In multivariate logistic regression the hazard risk (HR) ratios of MACE were (2.17, 95% CI 1.75-2.70) for hypokalemics and (3.23, 95% CI 2.10-4.95) for hyperkalemics when compared to normokalemic controls. CONCLUSIONS: Preoperative hypokalemia and hyperkalemia are both independent predictors of MACE within 30 days.

Hyperlipidemia sink for anesthetic agents.

We present a case that involves anesthetic resistance during anesthesia for electroconvulsive therapy. Despite adequate dosing of both intravenous and inhalation anesthetics, our patient was resistant to induction of the state of general anesthesia. Subsequently, we noticed extreme hyperlipidemia. We hypothesized that the patient's extreme hyperlipidemia served as an anesthetic "sink" and prevented the full dose of intravenous agents from quickly reaching their intended site of action.

Postanesthesia emergence in patients with post-traumatic stress disorder.

STUDY OBJECTIVE: Recovery from anesthesia may be complicated with development of severe panic symptoms and anxiety. Preexisting anxiety disorder has been reported as a risk factor for development of these symptoms. We aimed to examine the frequency of emergence delirium (EDL) among veterans diagnosed with posttraumatic stress disorders (PTSDs). DESIGN: Retrospective cohort. SETTING: Postoperative recovery area. PATIENTS: Perioperative information of 1763 consecutive patients who underwent a surgical procedure requiring general anesthesia were collected. The patients were grouped on the basis of previous diagnosis of PTSD. A total of 317 patients were identified with a positive history of PTSD and were compared to 1446 patients without such a history for the occurrence of EDL in the postanesthesia care unit (PACU) as the primary endpoint. MEASUREMENTS: Duration of stay in PACU in minutes and the frequency of hospital admission were the secondary endpoints. Multivariate binary logistic regression analysis was performed to identify the predictors of EDL among the veteran population. MAIN RESULTS: Emergence delirium was reported in 37 cases (2.1%) after general anesthesia. Fifteen (4.7%) of 317 patients with PTSD and 22 (1.5%) of 1446 patients without history of PTSD demonstrated symptoms related to EDL in the PACU (P=.002). After propensity matching, there were 8 patients with EDL in the PTSD group whereas there were only 2 patients with EDL among controls. Posttraumatic stress disorder was also an independent predictor of EDL in multivariate analysis with an odds ratio of 6.66 and a 95% confidence interval of 2.04 to 21.72 (P=.002). CONCLUSIONS: Posttraumatic stress disorder independently predicted the frequency of EDL even after correcting for preexisting depression and anxiety disorders. A relatively longer duration of PACU stay in PTSD patients may reflect raised awareness of the health care workers about this debilitating mental disorder.

Pain Intensity and Opioid Utilization in Response to CPAP Therapy in Veterans with Obstructive Sleep Apnea on Chronic Opioid Treatment.

STUDY OBJECTIVES: Sleep fragmentation has been linked to poor pain tolerance and lowered pain threshold. Little evidence exists on whether continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA) who are taking opioids for non-malignant pain would ameliorate pain and reduce consumption of opioids. METHODS: A retrospective case-control study was performed at a VA sleep center. Pain intensity was assessed using the Numerical Categorical Scale prior to CPAP treatment and 12-mo follow-up. Opioids intake was assessed using the morphine equivalent daily dose (MEDD). Adherence to CPAP was evaluated with the built-in meter. RESULTS: We reviewed 113 patients with OSA (apnea-hypopnea index [AHI] 35.9 ± 29.5) using a MEDD of 61.6 mg (range 5-980 mg) and a control group of 113 veterans with OSA (AHI 33.4 ± 27.3) on no opioids treatment. CPAP adherence was significantly lower at 12 mo in opioid-treated patients compared to controls (37% versus 55%; p = 0.01). Greater pain intensity was the only independent variable associated with CPAP non-adherence at 12-mo follow-up (p = 0.03). Compared to baseline, no significant difference was observed in pain intensity or consumption of opioids in CPAP adherent patients. CONCLUSIONS: CPAP treatment did not reduce pain intensity or consumption of opioids in veterans with chronic pain who have coexisting OSA. CPAP adherence was lower in opioid-treated veterans with OSA compared to opioid-free veterans with OSA. Pain intensity was the only determinant of CPAP adherence. Future studies are needed to evaluate pain management program on adherence to CPAP.

Applications of Nasal High-Flow Oxygen Therapy in Critically ill Adult Patients.

The use of nasal high-flow oxygen therapy (NHFOT) has become increasingly common in hospitals across Europe, Asia, and North America. These high utility devices provide an efficient and comfortable access points for providing supplemental oxygen to patients with variety of respiratory disorders. They are relatively easy to set up, and clinicians and patients alike give very positive feedback about their ease of use and comfort for patients in the hospital setting. However, it remains uncertain whether NHFOT improves patient survival or even reduces respiratory complications. Outcome data in adult populations are few and frequently underpowered to guide physicians for their widespread use in hospital setting. In this article, we present a review of the current technology and available studies pertinent to NHFOT.

Impact of Sedation on Cognitive Function in Mechanically Ventilated Patients.

The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function.

A systematic review of GLP-1 agonists on the metabolic syndrome in women with polycystic ovaries.

PURPOSE: Glucagon-like peptides receptor agonists are currently approved as anti-obesity agents, yet the experience with their use in polycystic ovarian syndromes (PCOS)-related obesity and insulin resistance is still limited. METHODS: We examined the effects of liraglutide on obesity, insulin resistance, and androgen levels in PCOS through a meta-analysis. RESULTS: Seven RCTs where women with PCOS were treated with liraglutide were identified. The variables that were examined before and after a 90-day treatment included waist circumference, body mass index (BMI), fasting insulin concentrations, insulin resistance using homeostatic model (HOMA-IR), serum testosterone, and sex hormone-binding globulin (SHBG). The analysis included 178 women. Only 172 patients had post-treatment measurements. While BMI significantly dropped by -1.65 (0.72-2.58) Kg/m(2) after 3 months treatment with liraglutide, waist circumference did not change significantly. Similarly, fasting insulin levels, insulin sensitivity, and SHBG did not change significantly. However, serum testosterone decreased by 0.29 nmol/L in 88 women (P = 0.0003). CONCLUSION: In a limited number of the women with PCOS, BMI and serum testosterone are only variables that significantly decrease after 3 months of treatment with GLP-1 receptor agonists. Larger sample size studies with longer durations of treatment may be required to examine potential benefits of these medications in improving insulin sensitivity.