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1.
BMJ ; 368: m540, 2020 Mar 11.
Artículo en Inglés | MEDLINE | ID: mdl-32161042

RESUMEN

OBJECTIVE: To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA: Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS: Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS: 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS: Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions. STUDY REGISTRATION: Prospero CRD42016035662.


Asunto(s)
Vías Clínicas , Complicaciones Posoperatorias/prevención & control , Enfermedades Respiratorias/prevención & control , Analgesia Epidural , Expectorantes/uso terapéutico , Fluidoterapia , Hemodinámica , Humanos , Cuidados Intraoperatorios , Modalidades de Fisioterapia , Terapia Respiratoria , Vasoconstrictores/uso terapéutico
2.
Med Sci Monit ; 26: e921350, 2020 Mar 22.
Artículo en Inglés | MEDLINE | ID: mdl-32200388

RESUMEN

BACKGROUND To facilitate early treatment, we constructed a nomogram to predict risk of postoperative fever before prostate biopsy in patients with high risk of fever. MATERIAL AND METHODS We collected information on patients undergoing prostate biopsy from January 2015 to December 2018 from their medical records, including clinical characteristics and laboratory test results. Finally, after strict screening, the prediction model was established in 440 patients who underwent a transrectal prostate biopsy (TRPB). We divided these patients into a training group and validation group at a ratio of 7: 3, respectively. Univariate analysis and multivariate logistic regression analysis were used to select the predictors and to develop the model. Calibration curve and C-index were used to evaluate the accuracy of the nomogram, while DCA was used to assess the clinical value. RESULTS The individualized predictive nomogram contained 3 clinical features - Biopsy-positive rate (BPR), Hematuria, and Urine WBC - significantly associated with post-biopsy fever. The nomogram had good discriminating ability in both the training group and validation group - the C-index was 0.774 (95% CI=0.717-0.832) in the training group and 0.808 (95% CI=0.706-0.909) in the validation group. Hosmer-Lemeshow test proved a good calibration curve fit. The DCA curve suggested that the nomogram would have good clinical utility. CONCLUSIONS This is the first study to develop a nomogram to predict fever after prostate biopsy via Biopsy-positive rate (BPR), Hematuria, and Urine WBC. Use of this nomogram might help prevent fever and infection, and could facilitate individualized medical treatment after prostate biopsy.


Asunto(s)
Biopsia con Aguja/efectos adversos , Fiebre/epidemiología , Nomogramas , Neoplasias de la Próstata/diagnóstico , Anciano , Anciano de 80 o más Años , Biopsia con Aguja/métodos , Hematuria , Humanos , Recuento de Leucocitos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/prevención & control , Valor Predictivo de las Pruebas , Próstata/patología , Enfermedades de la Próstata/diagnóstico , Enfermedades de la Próstata/patología , Neoplasias de la Próstata/patología , Estudios Retrospectivos , Ultrasonografía Intervencional , Orina/citología
4.
Medicine (Baltimore) ; 99(5): e18999, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-32000439

RESUMEN

The intraoperative lung protective ventilation with low tidal volume, positive end expiratory pressure (PEEP) and intermittent lungs recruitment was found to decrease postoperative pulmonary complications. In this retrospective medical records study, we investigated the effects of lung protective ventilation on postoperative pulmonary outcomes among the patients received prolonged oral cancer combined with free flap surgery.We collected the medical records of the patients received oral cancer surgery with the operation time more than 12 hours from January 2011 to December 2015. We recordedFifty nine cases were included. Thirty cases received the lung protective ventilation and 29 cases received conventional ventilation. Compared to the patients received conventional ventilation, the patients received intraoperative lung protective ventilation showedIn conclusion, for the prolonged oral cancer combined with free flap surgery, the intraoperative lung protective ventilation improves postoperative pulmonary outcomes and decreases the duration of ICU stay.


Asunto(s)
Colgajos Tisulares Libres , Neoplasias de la Boca/cirugía , Complicaciones Posoperatorias/prevención & control , Respiración Artificial/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Respiración con Presión Positiva , Estudios Retrospectivos , Volumen de Ventilación Pulmonar
6.
Br J Anaesth ; 124(3): 251-260, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32007241

RESUMEN

Immunotherapy has revolutionised the treatment of oncologic malignancies. Immune checkpoint inhibitors represent a new class of immunotherapy drugs. Although these drugs show promise, they are associated with immune-related adverse reactions. An increasing number of patients who undergo surgery will have had treatment with immune checkpoint inhibitors. In this narrative review article, we discuss their mechanism of action, therapeutic effects, pertinent toxicities, and address specific perioperative considerations for patients treated with immune checkpoint inhibitors.


Asunto(s)
Anestesiólogos , Antineoplásicos Inmunológicos/efectos adversos , Inmunoterapia/efectos adversos , Neoplasias/tratamiento farmacológico , Atención Perioperativa/métodos , Rol del Médico , Anticuerpos Monoclonales/efectos adversos , Anticuerpos Monoclonales/uso terapéutico , Antineoplásicos Inmunológicos/uso terapéutico , Antígeno CTLA-4/antagonistas & inhibidores , Humanos , Inmunoterapia/métodos , Complicaciones Intraoperatorias/inducido químicamente , Complicaciones Intraoperatorias/prevención & control , Neoplasias/inmunología , Complicaciones Posoperatorias/inducido químicamente , Complicaciones Posoperatorias/prevención & control
9.
Lancet ; 395(10222): 417-426, 2020 02 08.
Artículo en Inglés | MEDLINE | ID: mdl-32035551

RESUMEN

BACKGROUND: Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. METHODS: In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964. FINDINGS: Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43-0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26-0·69; p<0·001). There was also a reduction in symptomatic hernia (16%, 52 of 329 vs 19%, 64 of 331; adjusted relative risk 0·83, 0·60-1·16; p=0·29) and surgical reintervention (12%, 42 of 344 vs 16%, 54 of 346: adjusted relative risk 0·78, 0·54-1·13; p=0·19) at 2 years, but this result did not reach statistical significance. No significant differences were seen in wound infection rate, seroma rate, quality of life, pain scores, or serious adverse events. INTERPRETATION: Reinforcement of the abdominal wall with a biological mesh at the time of stoma closure reduced clinically detectable incisional hernia within 24 months of surgery and with an acceptable safety profile. The results of this study support the use of biological mesh in stoma closure site reinforcement to reduce the early formation of incisional hernias. FUNDING: National Institute for Health Research Research for Patient Benefit and Allergan.


Asunto(s)
Técnicas de Cierre de Herida Abdominal/instrumentación , Hernia/epidemiología , Complicaciones Posoperatorias/epidemiología , Mallas Quirúrgicas , Estomas Quirúrgicos , Adulto , Anciano , Colágeno , Colon/cirugía , Método Doble Ciego , Femenino , Hernia/etiología , Hernia/prevención & control , Humanos , Ileus/cirugía , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Estudios Prospectivos
10.
Am Surg ; 86(1): 42-48, 2020 Jan 01.
Artículo en Inglés | MEDLINE | ID: mdl-32077415

RESUMEN

The goal of this pilot study was to track patient outcomes after an expedited discharge after enhanced recovery after surgery (ERAS) pathway for pancreaticoduodenectomy (PD). A quantitative content analysis approach was used. All PD patients in a single academic medical center between February 2017 and June 2018 were called twice by specialized physician extenders after discharge. A semi-structured interview approach was used to identify patient's symptoms or concerns, proactively educate them, and provide outpatient management when indicated. A detailed narrative of the conversation was documented. Ninety patients (mean age 66.3; 58.1% males) were included in the study. Of all, 88.9 per cent of the patients received follow-up phone calls in accordance with our PD ERAS protocol. Among the 80 patients called, 71 (88.8%) reported at least one symptom, issue, or self-care need. The most common issues involved bowel movements and nutrition. A total of 147 interventions were performed to address patient needs including medication management, local care coordination, and outpatient referral to a healthcare provider. The intervention led to the identification of 15 patients for earlier evaluation. This identification was associated with the total number of reported symptoms (X² = 15.6, P = 0.004). Most patients require additional care after discharge after traditional ERAS pathways. ERAS transitional care protocols uncovered an unmet need for additional patient support after PD.


Asunto(s)
/normas , Pancreaticoduodenectomía , Alta del Paciente , Teléfono , Anciano , Protocolos Clínicos , Femenino , Humanos , Tiempo de Internación , Masculino , Educación del Paciente como Asunto , Proyectos Piloto , Complicaciones Posoperatorias/prevención & control
11.
Chirurg ; 91(2): 121-127, 2020 Feb.
Artículo en Alemán | MEDLINE | ID: mdl-32025774

RESUMEN

An appropriate perioperative infusion management is pivotal for the perioperative outcome of the patient. Optimization of the perioperative fluid treatment often results in enhanced postoperative outcome, reduced perioperative complications and shortened hospitalization. Hypovolemia as well as hypervolemia can lead to an increased rate of perioperative complications. The main goal is to maintain perioperative euvolemia by goal-directed therapy (GDT), a combination of fluid management and inotropic medication, to optimize perfusion conditions in the perioperative period; however, perioperative fluid management should also include the preoperative and postoperative periods. This encompasses the preoperative administration of carbohydrate-rich drinks up to 2 h before surgery. In the postoperative period, patients should be encouraged to start per os hydration early and excessive i.v. fluid administration should be avoided. Implementation of a comprehensive multimodal, goal-directed fluid management within an enhanced recovery after surgery (ERAS) protocol is efficient but the exact status of indovodual items remains unclear at present.


Asunto(s)
Fluidoterapia , Atención Perioperativa , Humanos , Periodo Perioperatorio , Complicaciones Posoperatorias/prevención & control , Periodo Posoperatorio
12.
Br J Anaesth ; 124(3): 314-323, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32000978

RESUMEN

BACKGROUND: In surgical patients undergoing general anaesthesia, coughing at the time of extubation is common and can result in potentially dangerous complications. We performed a systematic review and meta-analysis to assess the efficacy and safety of i.v. lidocaine administration during the perioperative period to prevent cough and other airway complications. METHODS: We searched Medical Literature Analysis and Retrieval System, Excerpta Medica database, and Cochrane Central Register of Controlled Trials for RCTs comparing the perioperative use of i.v. lidocaine with a control group in adult patients undergoing surgery under general anaesthesia. The RCTs were assessed using risk-of-bias assessment, and the quality of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). RESULTS: In 16 trials (n=1516), the administration of i.v. lidocaine compared with placebo or no treatment led to large reductions in post-extubation cough (risk ratio [RR]: 0.64; 95% confidence interval [CI]: 0.48-0.86) and in postoperative sore throat at 1 h (RR: 0.46; 95% CI: 0.32-0.67). There was no difference in incidence of laryngospasm (risk difference [RD]: 0.02; 95% CI: -0.07 to 0.03) or incidence of adverse events related to the use of lidocaine. CONCLUSIONS: The use of i.v. lidocaine perioperatively decreased airway complications, including coughing and sore throat. There was no associated increased risk of harm.


Asunto(s)
Anestesia General/efectos adversos , Anestésicos Locales/administración & dosificación , Tos/prevención & control , Lidocaína/administración & dosificación , Complicaciones Posoperatorias/prevención & control , Anestésicos Locales/uso terapéutico , Tos/etiología , Remoción de Dispositivos/efectos adversos , Humanos , Inyecciones Intravenosas , Intubación Intratraqueal/efectos adversos , Lidocaína/uso terapéutico , Atención Perioperativa/métodos , Faringitis/etiología , Faringitis/prevención & control
13.
Br J Anaesth ; 124(3): 324-335, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-32007240

RESUMEN

BACKGROUND: The debate on lung-protective ventilation strategies for surgical patients is ongoing. Evidence suggests that the use of low tidal volume VT improves clinical outcomes. However, the optimal levels of PEEP and recruitment manoeuvre (RM) strategies incorporated into low VT ventilation remain unclear. METHODS: Several electronic databases were searched to identify RCTs that focused on comparison between low VT strategy and conventional mechanical ventilation (CMV), or between two different low VT strategies in surgical patients. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes were atelectasis, pneumonia, acute respiratory distress syndrome, and short-term mortality. Bayesian network meta-analyses were performed using WinBUGS. The odds ratios (ORs) and corresponding 95% credible intervals (CrIs) were estimated. RESULTS: Compared with CMV, low VT ventilation with moderate-to-high PEEP reduced the risk of PPCs (moderate PEEP [5-8 cm H2O]: OR 0.50 [95% CrI: 0.28, 0.89]; moderate PEEP+RMs: 0.39 [0.19, 0.78]; and high PEEP [≥9 cm H2O]+RMs: 0.34 [0.14, 0.79]). Low VT ventilation with moderate-to-high PEEP and RMs also specifically reduced the risk of atelectasis compared with CMV (moderate PEEP+RMs: OR 0.36 [95% CrI: 0.16, 0.87]; and high PEEP+RMs: 0.41 [0.15, 0.97]), whilst low VT ventilation with moderate PEEP was superior to CMV in reducing the risk of pneumonia (OR 0.46 [95% CrI: 0.15, 0.94]). CONCLUSIONS: The combination of low VT ventilation and moderate-to-high PEEP (≥5 cm H2O) seems to confer lung protection in surgical patients undergoing general anaesthesia. CLINICAL TRIAL REGISTRATION: PROSPERO (CRD42019144561).


Asunto(s)
Enfermedades Pulmonares/prevención & control , Complicaciones Posoperatorias/prevención & control , Respiración Artificial/métodos , Teorema de Bayes , Humanos , Enfermedades Pulmonares/etiología , Neumonía/etiología , Neumonía/prevención & control , Respiración con Presión Positiva/métodos , Atelectasia Pulmonar/etiología , Atelectasia Pulmonar/prevención & control , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Respiración Artificial/efectos adversos , Síndrome de Dificultad Respiratoria del Adulto/etiología , Síndrome de Dificultad Respiratoria del Adulto/prevención & control , Volumen de Ventilación Pulmonar
14.
Br J Anaesth ; 124(3): 271-280, 2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-31902588

RESUMEN

BACKGROUND: Preclinical data suggest suppression of cancer proliferation by propofol, and retrospective studies suggest improved survival after cancer surgery with propofol-based anaesthesia. METHODS: To determine whether propofol dose administered for anaesthesia is associated with 1-yr mortality in patients with and without a diagnosis of solid cancer, we analysed adult patients undergoing monitored anaesthesia care or general anaesthesia at two academic medical centres in Boston, MA, USA. Logistic regression with interaction term analysis was applied with propofol dose (mg kg-1) as primary and diagnosis of solid cancer as co-primary exposure, and 1-yr mortality as the primary outcome. RESULTS: Of 280 081 patient cases, 10 744 (3.8%) died within 1 yr. Increasing propofol dose was associated with reduced odds of 1-yr mortality (adjusted odds ratio [aOR] 0.93 per 10 mg kg-1; 95% confidence interval [CI]: 0.89-0.98; absolute risk reduction fifth vs first quintile 0.5%; 95% CI: 0.2-0.7). This association was modified by a diagnosis of solid cancer (P<0.001 for interaction). Increasing propofol dose was associated with reduced odds of 1-yr mortality in patients without solid cancer (aOR: 0.78; 95% CI: 0.71-0.85), but not in patients with solid cancer (0.99; 0.94-1.04), a finding that was replicated when examining 5-yr mortality. CONCLUSIONS: Increasing propofol dose is associated with lower 1-yr mortality in patients without, but not in patients with, a diagnosis of solid cancer. We found evidence for competing effects, modifying the association between propofol dose and mortality.


Asunto(s)
Anestesia General/métodos , Anestésicos Intravenosos/administración & dosificación , Neoplasias/mortalidad , Complicaciones Posoperatorias/prevención & control , Propofol/administración & dosificación , Adulto , Anciano , Relación Dosis-Respuesta a Droga , Femenino , Estudios de Seguimiento , Humanos , Masculino , Massachusetts/epidemiología , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Estudios Retrospectivos , Análisis de Supervivencia
15.
Plast Reconstr Surg ; 145(2): 330-332, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-31985615

RESUMEN

Dual-plane breast augmentation offers the advantages of a subpectoral implant location with the ability to expand its use to glandular ptotic and constricted lower pole breasts. Alas, high implant position or very loose breast tissue can lead to a notorious breast shape known as the "waterfall deformity." To prevent many of these undesired deformities, the authors introduce a novel pectoralis major median myotomy they call the "median cut." From all of the dual-plane breast augmentations that were performed by the two authors between the years 2011 and 2017, a total of 605 included a median cut to resolve an apparent waterfall deformity. Without this procedure, a shift to subglandular augmentation would have been performed. The authors strongly believe that the median cut is a powerful and effective way to avoid intraoperative waterfall deformities and to have more women benefit from a submuscular approach. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.


Asunto(s)
Mamoplastia/métodos , Músculos Pectorales/trasplante , Adulto , Implantación de Mama/métodos , Implantes de Mama , Femenino , Humanos , Miotomía/métodos , Complicaciones Posoperatorias/prevención & control , Estudios Retrospectivos , Resultado del Tratamiento
16.
JAMA ; 323(3): 225-236, 2020 01 21.
Artículo en Inglés | MEDLINE | ID: mdl-31961418

RESUMEN

Importance: It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective: To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants: Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions: Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59 am the following day. Main Outcomes and Measures: The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results: Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, -3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34]; P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL]; P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, -0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94]; P = .17). Conclusions and Relevance: Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02502773.


Asunto(s)
Abdomen/cirugía , Fluidoterapia/métodos , Derivados de Hidroxietil Almidón/uso terapéutico , Complicaciones Posoperatorias/prevención & control , Solución Salina/uso terapéutico , Procedimientos Quirúrgicos Operativos/efectos adversos , Lesión Renal Aguda/prevención & control , Anciano , Método Doble Ciego , Femenino , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Cuidados Posoperatorios , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidad , Estadísticas no Paramétricas
17.
Anaesthesia ; 75 Suppl 1: e83-e89, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31903571

RESUMEN

Standardised peri-operative care pathways for patients undergoing emergency laparotomy or laparoscopy for non-traumatic pathologies have been shown to be inadequate and associated with high morbidity and mortality. Recent research has highlighted this problem and showed that simple pathways with 'rescue' interventions have been associated with reduced mortality when implemented successfully. These rescue pathways have focused on early diagnosis and surgery, specialist surgeon and anaesthetist involvement, goal-directed therapy and intensive or intermediary postoperative care for high-risk patients. In elective surgery, enhanced recovery has resulted in reduced length of stay and morbidity by the application of procedure-specific, evidence-based interventions inside rigorously implemented patient pathways based on multidisciplinary co-operation. The focus has been on attenuation of peri-operative stress and pain management to facilitate early recovery. Patients undergoing emergency laparotomy are a heterogeneous group consisting mostly of patients with intestinal perforations and/or obstruction with varying levels of comorbidity and frailty. However, present knowledge of the different pathophysiology and peri-operative trajectory of complications in these patient groups is limited. In order to move beyond rescue pathways and to establish enhanced recovery for emergency laparotomy, it is essential that research on both the peri-operative pathophysiology of the different main patient groups - intestinal obstruction and perforation - and the potentially differentiated impact of interventions is carried out. Procedure- and pathology-specific knowledge is lacking on key elements of peri-operative care, such as: multimodal analgesia; haemodynamic optimisation and fluid management; attenuation of surgical stress; nutritional optimisation; facilitation of mobilisation; and the optimal use and organisation of specialised wards and improved interdisciplinary collaboration. As such, the future challenges in improving peri-operative patient care in emergency laparotomy are moving from simple rescue pathways to establish research that can form a basis for morbidity- and procedure-specific enhanced recovery protocols as seen in elective surgery.


Asunto(s)
Abdomen/cirugía , Laparoscopía/métodos , Complicaciones Posoperatorias/prevención & control , Recuperación de la Función , Urgencias Médicas , Fluidoterapia , Humanos , Modalidades de Fisioterapia
18.
Anaesthesia ; 75 Suppl 1: e75-e82, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31903572

RESUMEN

Patients undergoing emergency laparotomy are a heterogeneous group with regard to comorbidity, pre-operative physiological state and surgical pathology. There are many factors to consider in the peri-operative period for these patients. Surgical duration should be as short as possible for adequate completion of the procedure. This is of particular importance in the elderly and comorbid population. To date, there are limited data addressing the role of damage control surgery in emergency general surgery. Dual consultant-led care in all stages of emergency laparotomy care is increasing, with increased presence out of hours and also for high-risk patients. The role of the stoma care team should be actively encouraged in all patients who may require a stoma. Due to the emergent and unpredictable nature of surgical emergencies, healthcare teams may need to employ novel strategies to ensure early input from the stoma care team. It is important for all members of the medical teams to ensure that patients have given consent for both anaesthesia and surgery before emergency laparotomy. Small studies suggest that patients and their families are not aware of the high risk of morbidity and mortality following emergency laparotomy before operative intervention. Elderly patients should have early involvement from geriatric specialists and careful attention paid to assessment of frailty due to its association with mortality and morbidity. Additionally, the use of enhanced recovery programmes in emergency general surgery has been shown to have some impact in reducing length of stay in emergency surgical patients. However, the emergent nature of this surgery has been shown to be a detrimental factor in full implementation of enhanced recovery programmes. The use of a national database to collect data on patients undergoing emergency laparotomy and their processes of care has led to reduced mortality and length of stay in the UK. However, internationally, fewer data are available to draw conclusions.


Asunto(s)
Abdomen/cirugía , Laparoscopía/métodos , Atención Perioperativa/métodos , Complicaciones Posoperatorias/prevención & control , Urgencias Médicas , Humanos
19.
Anaesthesia ; 75 Suppl 1: e158-e164, 2020 01.
Artículo en Inglés | MEDLINE | ID: mdl-31903575

RESUMEN

An ageing population and rising healthcare costs are challenging cost-efficient hospital systems wanting to adapt, employing novel organisational structures designed to merge diverse skill sets. This needs not only physician and nursing leadership but also new models of care. Anaesthetists have expanded their role into the broader multidisciplinary field of peri-operative medicine, emphasising collaboration and safety in health teams. A greater focus on patient-centred care and shared decision making, along with validated metrics to quantify quality improvement activities, have emphasised the importance of comfort, patient satisfaction and quality of life after surgery. Shared decision-making is more likely to be manifest in a flat hierarchy in which each member of the team brings their own experience and skills to optimise patient care. Successful surgery is best achieved by a coordinated, multidisciplinary team, embedded in a culture of collaboration and safety.


Asunto(s)
Grupo de Atención al Paciente , Atención Dirigida al Paciente/métodos , Complicaciones Posoperatorias/prevención & control , Recuperación de la Función , Humanos , Periodo Posoperatorio
20.
Anaesthesia ; 75 Suppl 1: e54-e61, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31903577

RESUMEN

Enhanced postoperative recovery programmes (ERAS) were developed about 20 years ago based on improved understanding of the pathophysiology of postoperative recovery within an integrated multidisciplinary approach. The results across surgical procedures have been extremely positive with a reduction in hospitalisation and medical complications, without increased re-admission rates. However, several challenges lie ahead including improved implementation of existing scientific evidence, increased focus on post-discharge recovery problems and a need for improved design of future ERAS studies. However, the most important challenges lie within a better understanding and control of undesirable peri-operative pathophysiological responses with subsequent risk of organ dysfunction. These efforts should focus on: the inflammatory and neurohumoral surgical stress responses; fluid management; pain management; blood management; mechanisms of orthostatic intolerance; postoperative cognitive dysfunction; risk factors for thrombo-embolic complications; and mechanisms and prevention of postoperative ileus. Finally, more focus should be made on the different barriers to post-discharge functional recovery and the choice of (pre- and postoperative) rehabilitation. These efforts should be made on a procedure-specific as well as on a patient-specific basis.


Asunto(s)
Complicaciones Posoperatorias/prevención & control , Recuperación de la Función , Humanos , Periodo Posoperatorio
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