Recovery Room Cortisol Predicts Long-Term Glucocorticoid Need After Transsphenoidal Surgery for Pituitary Tumors.

BACKGROUND: Accurate assessment of the need for glucocorticoid therapy is essential after transsphenoidal surgery (TSS) for pituitary tumors. Agreement on the best test to use in the early postoperative setting is lacking. OBJECTIVE: To examine recovery room (RR) cortisol as a predictor of long-term need for glucocorticoids. METHODS: We conducted a retrospective cohort study of 149 patients who underwent TSS for pituitary tumors between January 2007 and December 2014. Pathological tumor diagnoses were confirmed. Endocrinologists assessed the need for glucocorticoid supplementation within 6 to 8 wk after TSS. We extracted data on preoperative, RR, and day 1 to 3 post-TSS morning serum cortisol (MSC). We reported areas under the receiver operating characteristic curve (AUC) and diagnostic measures for different cortisol measures. We also conducted a logistic regression to identify the most predictive variables. RESULTS: Eighteen patients required glucocorticoid supplementation at follow-up. RR cortisol was the most accurate measurement in the early postoperative period (AUC [95% confidence interval (CI)], .92 [.85-.99]; P < .001), followed by day 1, 2, and 3 post-TSS MSC, respectively. A threshold RR cortisol of 744.0 nmol/L (26.97 µg/dL) had 90.9% sensitivity and 73.7% specificity for detecting patients in the hypocortisolism group, while 757.5 nmol/L (27.46 µg/dL) had 100% and 70.0%, respectively. The logistic regression identified RR cortisol as the sole significant predictor (odds ratio [CI], .36[.18-.71] for every 100 nmol/L increase; P = .0033). CONCLUSION: The RR cortisol is accurate in predicting long-term glucocorticoid supplementation and may be the best early postoperative measure. Future larger studies should validate these findings and derive optimal RR cortisol threshold values.

Mínimo flujo de oxígeno necesario para soporte vital durante la simulación de reanimación post parada cardiorrespiratoria / Minimum oxygen flow needed for vital support during simulated post-cardiorespiratory arrest resuscitation

De acuerdo con las guías de la AHA y la ERC, la FiO2 a administrarse debería ser aquella con la que se obtuviera una SatO2 ≥ 94%. El objetivo de este estudio es determinar el mínimo flujo de oxígeno y tiempo necesarios para alcanzar una FiO2 de 0,32 y de 0,80 durante el manejo posparada cardiaca. Se emplearon diferentes reanimadores, que fueron conectados a un pulmón artificial: Mark IV, SPUR II, Revivator Res-Q, O-TWO. Los flujos de oxígeno probados fueron 2, 5, 10 y 15 lpm. Los test estadísticos aplicados fueron Bonferroni y U de Mann-Whitney. Se obtuvo una FiO2 ≥ 0,32 con cualquiera de los flujos de oxígeno y reanimadores. Tras un mínimo de 75 s ventilando con 2 o 5 lpm, solo se consiguió una FiO2 de 0,80 con Mark IV. Se hallaron diferencias clínica y estadísticamente significativas (p < 0,05): con 15 lpm se necesitaron 35 s para alcanzar una FiO2 ≥ 0,80 con Mark IV (85,6 [0,3]) y Revivator (84,3 [1,5]) comparado con los 50 s que precisó SPUR II (87,1 [6,4]); con 2 lpm, todos los resucitadores alcanzaron una FiO2 ≥ 0,32 en 30 s(Mark IV (34,8 [1,3]), Revivator (35,7 [1,5]) y SPUR II (34,4 [2,1]), excepto O-TWO, que necesitó 35 s (36,3 [4,3]). Para alcanzar una FiO2 de 0,32 se podría emplear cualquiera de los resucitadores usando 2 lpm, aunque quizá el menos recomendable sería O-TWO. Si el objetivo fuera una FiO2 de 0,80, debería bastar con 10 lpm, usando preferiblemente Mark IV o Revivator Res-Q. En conclusión, atendiendo a los resultados de nuestro estudio, ante cualquier situación potencial, sería preferible emplear Revivator Res-Q o Mark IV que O-TWO o SPUR II (AU)

According to the ERC and the AHA guidelines, FiO2 should be titrated to achieve an O2Sat ≥ 94%. The aim of this study was to determine the minimum oxygen flow and time needed to reach an FiO2 of 0.32 and 0.80 during post-cardiac arrest care. An experimental analysis was performed that consisted of a simulated post-cardiac arrest situation. Different resuscitators were tested and connected to an artificial lung: Mark IV, SPUR II, Revivator Res-Q, O-TWO. The oxygen flow levels tested were 2, 5, 10 and 15 lpm. Bonferroni and Mann-Whitney U tests were used. An FiO2 of 0.32 or more was obtained using any of the oxygen flow and resuscitators. Only the Mark IV achieved an FiO2 of 0.80 after a minimum of 75 s ventilating with 2 or 5 lpm. Clinical and statistical differences (P < .05) were found: at 15 lpm it took 35 s to reach an FiO2 of 0.80 or more for Mark IV (85.6 [0.3]) and Revivator (84.3 [1.5]) compared to 50 s for SPUR II (87.1 [6.4]); at 2 lpm, all of the devices reached an FiO2 of ≥ 0.32 at 30 s(Mark IV (34.8 [1.3]), Revivator (35.7 [1.5]) and SPUR II (34.4 [2.1]), except for O-TWO, which took 35 s (36.3 [4.3]). Patients could be ventilated with any of the resuscitators using 2 lpm to obtain an FiO2 of 0.32, although possibly O-TWO would be the last option during the first 60 s. In order to reach an FiO2 of 0.80, ventilating with 10 lpm should be sufficient, and preferably using Mark IV or Revivator Res-Q. In conclusion, on observing the results of our study, in any possible scenario, it would be advisable to use Revivator Res-Q or Mark IV rather than O-TWO or SPUR II (AU)

Cardiac surgery fast-track treatment in a postanesthetic care unit: six-month results of the Leipzig fast-track concept.

BACKGROUND: The authors compared the safety and efficacy of a newly developed fast-track concept at their center, including implementation of a direct admission postanesthetic care unit, to standard perioperative management. METHODS: All fast-track patients treated within the first 6 months of implementation of our direct admission postanesthetic care unit were matched via propensity scores and compared with a historical control group of patients who underwent cardiac surgery prior to fast-track implementation. RESULTS: A total of 421 fast-track patients were matched successfully to 421 control patients. The two groups of patients had a similar age (64 +/- 13 vs. 64 +/- 12 yr for fast-track vs. control, P = 0.45) and European System for Cardiac Operative Risk Evaluation-predicted risk of mortality (4.8 +/- 6.1% vs. 4.6 +/- 5.1%, P = 0.97). Fast-track patients had significantly shorter times to extubation (75 min [45-110] vs. 900 min [600-1140]), as well as shorter lengths of stay in the postanesthetic or intensive care unit (4 h [3.0-5] vs. 20 h [16-25]), intermediate care unit (21 h [17-39] vs. 26 h [19-49]), and hospital (10 days [8-12] vs. 11 days [9-14]) (expressed as median and interquartile range, all P < 0.01). Fast-track patients also had a lower risk of postoperative low cardiac output syndrome (0.5% vs. 2.9%, P < 0.05) and mortality (0.5% vs. 3.3%, P < 0.01). CONCLUSION: The Leipzig fast-track protocol is a safe and effective method to manage cardiac surgery patients after a variety of operations.

[Future perspectives for anesthesia induction and recovery]. / Zukunftsperspektiven für die Narkoseein- und -ausleitung.

The provision of separate rooms for the induction of anesthesia and the recovery phase is said to allow for a higher frequency of surgical procedures. However, the use of special rooms for the recovery phase is unnecessary from a practical and economic point of view. The availability of separate rooms for the induction of anesthesia may be important whenever the frequency of regional anesthesia is high. The induction of general anesthesia in low-risk patients can be performed in the operating room (OR) without too much delay between cases. Anesthesia in high-risk patients should be induced and reversed in the OR while problems of monitoring during transport remain unsolved.