The Impact of Enhanced Recovery after Surgery Protocol Implementation on Postoperative Pain Management in the Era of Opioid Crisis: The Postchemotherapy Open RPLND Experience.

AIM: Enhanced Recovery After Surgery (ERAS) protocols have been proven to optimize postoperative outcomes; however, misuse of opioid analgesics can still hinder postoperative recovery due to related side effects and potential complications. INTRODUCTION: To determine if the implementation of ERAS protocol in post-chemotherapy retroperitoneal lymph node dissection (PC-RPLND) patients could help with reducing postoperative pain and opioid use. METHODS: A case-control study of consecutive testicular cancer patients with indications for PCRLPND, who were offered Conventional Post-operative Management (CPM) or ERAS protocol. Outcomes of interest included Visual Analogue Scale (VAS)-assessed pain level at postoperative days 3, 7, and 30, and Morphine-Equivalent Doses (MEDs)/postoperative day. Intraoperative parameters and postoperative complications were recorded. Parametric and non-parametric tests were used for statistical analysis. RESULTS: In total, 100 opioid-naïve PC-RPLND patients were studied. CPM and ERAS groups (36 and 64 patients, respectively) had similar demographic and baseline clinical characteristics). ERAS group patients had significantly lower blood loss (p = 0.005), blood transfusion rate (p < 0.001), and duration of the procedure (p < 0.001). Post-operative complications were comparable between groups. Nausea and bowel disorders were numerically but not statistically more frequent in the CPM group. ERAS patients had shorter mean hospital stay (5.3 ± 1.4 vs. 7.4 ± 1.6 days, p < 0.001), lower daily MEDs (4.73 ± 2.63 vs. 7.04 ± 2.29, p < 0.001), and lower VAS scores on post-operative day 7 (3.89 ± 1.07 vs. 4.67 ± 1.17, p = 0.001). Post-operative pain was similar between groups on post-operative days 3 and 30. CONCLUSION: Systematic implementation of ERAS protocol after PC-RPLND improves pain management, optimizes patient recovery, and prevents over-prescription of opioid analgesics.

Corrigendum to "Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery".

[This corrects the article DOI: 10.1155/2017/2753962.].

Do Difficult Airway Techniques Predispose Obese Patients to Bronchospasm?

OBJECTIVE: The existing evidence separately correlates morbid obesity with difficult intubation and bronchospasm. However, there is a lack of data on whether anaesthesia provider manipulations during difficult intubation contribute to an increased ratio of bronchospasm in these patients. METHODS: This is a retrospective analysis of data prospectively taken from 50 morbidly obese patients involved in a previously published study. A possible difficult intubation was preoperatively investigated by recording the following specific physical examination indices: Mallampati and Cormack-Lehane (CL) classifications, cervical spine mobility (CSM), thyromental distance (Td) and patients' ability to open their mouth (mouth opening). Bronchospasm was clinically detected by auscultation and confirmed by measuring peak airway pressures during mechanical ventilation. The Kruskal-Wallis H test was used for data analysis, followed by the Mann-Whitney U test as applicable. RESULTS: Different physical examination prognostic indices, including Mallampati and CL scales (p<0.001; the CSM excluded -p=0.790), showed that they are related to difficult intubation. Bronchospasm not attributable to difficult intubation was observed in six obese patients. CONCLUSION: Patients with morbid obesity constitute an increased relative risk group as far as difficult intubation is concerned, particularly if preoperative findings support a relationship between the two variables examined. In our study, difficult intubation and the concomitant use of special equipment and manipulations did not contribute to an increased rate of bronchospasm in obese patients, but in view of the lack of data, a large number of more sophisticated studies are required to elucidate such an assumption.

Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery.

Introduction. Pain after cardiac surgery affects long-term patient wellness. This study investigated the effect of preoperative pregabalin on acute and chronic pain after elective cardiac surgery with median sternotomy. Methods. Prospective double blind study. 93 cardiac surgery patients were randomly assigned into three groups: Group 1 received placebo, Group 2 received oral pregabalin 75 mg, and Group 3 received oral pregabalin 150 mg. Data were collected 8 hours, 24 hours, and 3 months postoperatively. Results. Patients receiving pregabalin required fewer morphine boluses (10 in controls versus 6 in Group 1 versus 4 in Group 2, p = 0.000) and had lower pain scores at 8 hours (4 versus 3 versus 3, p = 0.001) and 3 months (3 versus 2 versus 2, p = 0.000) and lower morphine consumption at 8 hours (14 versus 13 versus 12 mg, p = 0.000) and 24 hours (19.5 versus 16 versus 15 mg, p = 0.000). Percentage of patients with sleep disturbances or requiring analgesics was lower in the pregabalin group and even lower with higher pregabalin dose (16/31 versus 5/31 versus 3/31, p = 0.000, and 26/31 versus 16/31 versus 10/31, p = 0.000, resp.) 3 months after surgery. Conclusion. Preoperative oral pregabalin 75 or 150 mg reduces postoperative morphine requirements and acute and chronic pain after cardiac surgery.

Ultrasound-guided radiofrequency ablation for cT1a renal masses in poor surgical candidates: mid-term, single-center outcomes.

OBJECTIVES: Surgical management of small renal masses can be challenging in frail patients and thus modalities such as radiofrequency ablation (RFA) have emerged as valid alternative options. The aim of the current study was to present mid-term oncological and functional results on a series of patients with cT1a renal cell carcinomas (RCCs) who were unfit for surgery and underwent RFA using ultrasound guidance under local anesthesia. METHODS: Data from patients fulfilling the study selection criteria were retrospectively collected. RENAL nephrometry score was used for tumor description. Parametric tests were used for data analysis and survival curves were estimated using the Kaplan-Meier method. RESULTS: Overall, 32 patients (mean±standard deviation age, 72.4 ± 7.6 years) with biopsy-proven RCCs (tumor size, 23.75 ± 10.44 mm and RENAL score, 5.28 ± 1.33) underwent 32 RFA sessions. Twenty-seven patients (84.4%) had low complexity masses and five patients had masses of intermediate complexity (15.6%) according to RENAL score categorization. Over a follow-up period of 22.1 ± 13.7 months, one case of primary treatment failure was recognized (primary technical success 97.0%), and overall, three patients were diagnosed with residual disease (primary technique effectiveness 90.6%). No major complications occurred during the postprocedure 90-day follow up, while no difference was found in serum creatinine and estimated glomerular filtration rate pre and post procedure. Patients with intermediate-complexity renal lesions had shorter time to recurrence in comparison to low-complexity masses (p = 0.002). All patients were alive at the time of study data analysis without diagnosed metastases. CONCLUSIONS: Percutaneous RFA of small RCCs using ultrasound-based guidance under local anesthesia can be an effective alternative method for managing patients who are unfit for surgery.

Bronchospasm in obese patients undergoing elective laparoscopic surgery under general anesthesia.

BACKGROUND: Existing data suggest that obesity correlates with airway hyper-reactivity. However, the incidence of bronchospasm during bariatric surgery in obese patients has not been well studied. METHODS: This was a prospective observational study comparing 50 obese versus 50 non obese patients undergoing elective laparoscopic surgery over a 2 year period. Bronchospasm was detected clinically by auscultation and was confirmed by measuring peak airway pressure during mechanical ventilation. Blood gases were measured at predetermined time intervals intraoperatively. Categorical variables were analyzed using Fisher's exact test, while numerical variables within and between groups were compared using repeated measures general linear model. RESULTS: The incidence of bronchospasm was significantly higher in obese compared to non obese patients (P = 0.027). Peak airway pressures and blood gases differed significantly when comparing non obese patients versus obese patients without bronchospasm versus obese patients with bronchospasm. Hypoventilation resulting in gradual increase of arterial PaCO2 was noted in all groups during surgery. CONCLUSION: The incidence of bronchospasm is higher in obese patients compared to non obese patients undergoing elective laparoscopic surgery. Airway pressures and blood gas values in obese patients are somewhere between values in non obese patients and values in patients with bronchospasm, thereby implying that obesity is associated with a state where bronchial smooth muscles are not fully relaxed. Consideration of increased airway reactivity in obese patients undergoing laparoscopic surgery is important for improved patient care and uneventful anesthetic course.

Depth of Anesthesia as a Risk Factor for Perioperative Morbidity.

Introduction. The prognostic value of age, physical status, and duration of surgery on perioperative course has been extensively studied. However, the impact of deep hypnotic time (time when Bispectral Index values are less than 40) has not been well evaluated. Methods. We designed an observational study to clarify the relative influence of deep hypnotic time (DHT) on outcome. Eligible participants were mentally stable patients over 18 years old scheduled for elective major abdominal surgery. In total, 248 patients enrolled. Data were analyzed using Fisher's exact test and multiple logistic regression. Results. Five variables (DHT, hypotension, age, comorbidity, and duration of surgery) showed statistically significant association with complications, when examined independently. However, when all variables were examined together in a multiple logistic regression model, age and comorbidity were no longer associated with outcome. DHT, hypotension, and duration of surgery were significant predictors of "complications," and "hypotension" was a significant predictor of prolonged hospital stay (P < 0.001). Conclusion. Deep hypnotic time emerged as a new factor associated with outcome, and its impact compared to other factors such as age, surgery duration, hypotension, and comorbidity is redefined. Monitoring and managing depth of anesthesia during surgery are important and should be part of careful operation planning.

Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial.

BACKGROUND: Blood transfusions are common in cardiac surgery, but have been associated with increased morbidity and long-term mortality. Efforts to reduce blood product use during cardiac surgery include fluid restriction to minimize hemodilution, and protocols to guide transfusion decisions. INVOS is a modality that monitors brain tissue oxygen saturation, and could be useful in guiding decisions to transfuse. However, the role of INVOS (brain tissue oxygen saturation) as part of an algorithm to direct blood transfusions during cardiac surgery has not been evaluated. This study was conducted to investigate the value of INVOS as part of a protocol for blood transfusions during cardiac surgery. METHODS: Prospective, randomized, blinded clinical trial, on 150 (75 per group) elective cardiac surgery patients. The study was approved by the Institution Ethics committee and all patients gave written informed consent. Data were initially analyzed based on "intention to treat", but subsequently were also analyzed "per protocol". RESULTS: When protocol was strictly followed ("per protocol analysis"), compared to the control group, significantly fewer patients monitored with INVOS received any blood transfusions (46 of 70 patients in INVOS group vs. 55 of 67 patients in the control group, p = 0.029). Similarly, patients monitored with INVOS received significantly fewer units of red blood cell transfusions intraoperatively (0.20 ± 0.50 vs. 0.52 ± 0.88, p = 0.008) and overall during hospital stay (1.31 ± 1.20 vs. 1.82 ± 1.46, p = 0.024). When data from all patients (including patient with protocol violation) were analyzed together ("intention to treat analysis"), the observed reduction of blood transfusions in the INVOS group was still significant (51 of 75 patients transfused in the INVOS group vs. 63 of 75 patients transfused in the control group, p = 0.021), but the overall number of units transfused per patient did not differ significantly between the groups (1.55 ± 1.97 vs. 1.84 ± 1.41, p = 0.288). CONCLUSIONS: Our data suggest that INVOS could be a useful tool as part of an algorithm to guide decisions for blood transfusion in cardiac surgery. Additional data from rigorous, well designed studies are needed to further evaluate the role of INVOS in guiding blood transfusions in cardiac surgery, and circumvent the limitations of this study.

Impact of intraoperative hypotension on hospital stay in major abdominal surgery.

PURPOSE: Although the relationship between preoperative risk factors and outcomes has been extensively studied, the effect of intraoperative hemodynamic changes in a patient's postoperative course has been less well defined. METHODS: We designed a prospective observational study to assess the impact of several variables, and especially hypotension, on postoperative outcome. Patients considered eligible for the study, all more than 18 years old, were mentally stable patients scheduled for major abdominal surgery with an expected duration of more than 2 h. Total hypotension time (THT), with other variables that possibly influence the outcome, was analyzed using multivariate logistic regression analysis in 100 consecutive patients. RESULTS: Total hypotension time was isolated as a factor significantly associated with morbidity [odds ratio, 5.1 (1.95-13.35)] and significantly prolonged hospital stay [odds ratio, 4.56 (1.85-10.96)]. Patients who had prolonged THT presented more complications (50 vs. 30), especially of the cardiovascular, pulmonary, and gastrointestinal systems. These complications led to delayed hospital discharge in a significant number of patients (36 with THT vs. 17 others). Finally, duration of surgery was associated with postoperative complications [odds ratio, 3.1 (1.2-8.0)]. CONCLUSION: Persistent hypotension during elective major abdominal surgery is a significant risk factor for postoperative complications and may prolong hospitalization and affect patient outcomes. Anesthetic management for the avoidance of hypotension, as much as possible, during major abdominal surgery may positively affect outcomes.