Acute Postoperative Phase Research Articles

Change in choroidal blood flow and choroidal morphology due to segmental scleral buckling in eyes with rhegmatogenous retinal detachment

Although scleral buckling is a well-established surgical treatment for rhegmatogenous retinal detachment (RRD), the procedure can reportedly cause problems in the ocular circulation. Segmental scleral bucking without a concomitant encircling procedure was performed on 46 eyes with successfully reattached macula-on RRD. Choroidal blood flow was assessed using laser speckle flowgraphy. Spectral-domain optical coherence tomography was used to image macular regions, to measure the subfoveal choroidal thickness (SFCT), and to calculate the luminal and the stromal areas by the binarization method preoperatively and 1, 4, 8 and 12 weeks postoperatively. Choroidal mean blur rate at the macula did not significantly change, while that at the buckle and unbuckle side significantly reduced at 8 weeks postoperatively in the operated eye (P = 0.007 and P = 0.017, respectively). The SFCT and the luminal area increased temporarily 1 week following surgery in the operated eye (P < 0.001). The trend of SFCT with time coincided with that of the luminal area (P < 0.001). Venous drainage obstruction induced by compression force of scleral buckling leads to SFCT thickening in the acute postoperative phase. The macular choroidal blood flow might be less susceptible because the blood flow at the macula, in contrast to the other areas, does not change following segmental scleral buckling.

Surgical stress response and the potential role of preoperative glucocorticoids on post-anesthesia care unit recovery.

The immediate postoperative course in the post-anesthesia care unit (PACU) remains a challenge across surgical procedures. Postoperative pain, sedation/cognitive dysfunction, nausea and vomiting (PONV), circulatory and respiratory problems and orthostatic intolerance constitute the bulk of the difficulties that may delay the postoperative recovery. A common feature in the observed organ dysfunctions is the inflammatory response to surgery during the acute postoperative recovery phase, suggesting that control of inflammation may improve outcomes and reduce complications. This narrative review focuses on our understanding of the inflammatory responses in the acute PACU setting in relation to organ dysfunction and suggests where further research is warranted. The main finding is that current evidence suggests inflammation to potentially impair on almost all organ dysfunctions observed in the post-anesthesia care unit (PACU), but with a scarcity of intervention studies using glucocorticoids to control inflammation. We, therefore, suggest a future research focus on the role of inflammation and effect of glucocorticoids in the PACU setting to improve patient recovery.

Treatment Strategies for Paradoxical Hypertension Following Surgical Correction of Coarctation of the Aorta in Children.

Background:Paradoxical hypertension after repair of coarctation of the aorta is a well-known phenomenon. The pathogenesis involves the activation of the sympathetic nervous system (first phase) and renin–angiotensin system (second phase). Only a limited number of different treatment strategies have been published in the literature, without any comparative studies.Methods:Our aim was to describe the current international practice variation surrounding pharmacological treatment currently being employed to treat paradoxical hypertension following the repair of coarctation of the aorta in children. We performed an online survey among 197 members of the Pediatric Cardiac Intensive Care Society. We also conducted a systematic review of the literature regarding the treatment of paradoxical hypertension.Results:Eighty-eight people (45%), from 62 different centers, responded and answered the questions regarding blood pressure control. Nitroprusside is the first drug of choice for initial blood pressure control in 66% of respondents, esmolol in 11%, labetalol in 11%, and angiotensin-converting enzyme inhibitors (ACEIs) are used by 3% of respondents. For oral blood pressure control after discharge from the pediatric intensive care unit, 75% of respondents use ACEIs, 18% use labetalol, and 12% use other beta-blockers (propranolol, carvedilol, atenolol, metoprolol). The systematic review identified 14 articles reporting pharmacological treatment of direct postoperative hypertension following coarctation repair.Conclusion:There is wide practice variability, due to the lack of sufficient compelling evidence. The majority (66%) of caregivers use nitroprusside to control blood pressure in the acute postoperative phase. The ACEIs are the drug of choice for chronic blood pressure control.

Synergistic Interactions Between Direct and Indirect Bypasses in Combined Procedures: The Significance of Indirect Bypasses in Moyamoya Disease.

Whether additional indirect bypasses effectively contribute to revascularization in combined procedures remains unclear in patients with moyamoya disease. To evaluate the longitudinal changes associated with combined procedures while following up pediatric and adult patients long term and to assess whether any other clinical factors or hemodynamic parameters affected these changes to determine an optimal surgical strategy. We studied 58 hemispheres in 43 adults and 39 hemispheres in 26 children who underwent combined revascularization for moyamoya disease. To evaluate bypass development, we assessed the sizes of the superficial temporal artery and middle meningeal artery using magnetic resonance angiography. Multivariate analysis determined the effects of multiple variables on bypass development. Indirect bypass (middle meningeal artery) development occurred in 95% and 78% of the pediatric and adult hemispheres, respectively. Of these, dual development of direct and indirect bypasses occurred in 54% of the pediatric hemispheres and in 47% of the adult hemispheres. Reciprocal superficial temporal artery regression occurred in 28% of the hemispheres during the transition from the postoperative acute phase to the chronic phase during indirect bypass development. Good indirect bypass development was associated with adult hemispheres at Suzuki stage 4 or greater (odds ratio, 7.4; 95% confidence interval, 1.4-39.4; P = .02). Disease onset type and preoperative hemodynamic parameters were not considered predictors for the development of surgical revascularization. Simultaneous direct and indirect bypass development was most frequently observed, regardless of patient age and hemodynamic status. Applying indirect bypass as an adjunct to direct bypass could maximize revascularization in adults and children.

Abdominal Gossypiboma: A Diagnostic Dilemma in Late Postoperative Period

Abstract: We reported a case of gossypiboma in 59-year old woman who presented with vague abdominal pain since her cesarean section and described her plain radiograph and abdominal CT scan. Keywords: Gossypiboma Introduction: 59-year old woman was admitted in our emergency department because of long lasting vague abdominal pain. She had occasionally nausea and vomiting however with no weight loss. Her past medical history was unremarkable except for cesarean section performed 15 years ago. On physical examination mild periumbilical tenderness was found and routine lab data showed no abnormality. Plain abdominal radiograph was performed which showed linear metallic density in the midpart of abdomen (Figure 1). Abdominal CT scan showed a well-defined mass like structure in RT sided abdominal cavity with no peripheral fat stranding with metallic artifact within it (Figure 2). Diagnosis of gossypiboma was made preoperatively. Surgery was done which revealed surgical sponge within abdominal cavity. The patient’s symptom resolved after surgery. Gossypiboma is a term used for description of any surgical substance remained within the body with retained surgical cotton or sponge as the commonest reported intra-abdominal foreign body. For many years they can be unnoticed until they lead to complications [1]. Gossypiboma is an avoidable condition should be considered in any postoperative patient who presents with unusual manifestation as it can be misdiagnosed and unnecessary procedure may be done [2]. In spite of its rarity in clinical practice in any patient with previous history of laparotomy should be considered as one of differential diagnosis [3]. It can cause significant morbidity or even mortality for patients and most patients with gossypiboma of abdomen are symptomatic and present with nonspecific abdominal pain [4]. Retained surgical sponge or gossypiboma is a serious unusual condition with medicolegal effect that its frequency is difficult to estimate however seems to be 1 in 1000 to 1500 intra-abdominal operations. The gossypiboma even if aseptic can induce foreign body reaction and mimic a soft tissue neoplasm and usually misinterpreted preoperatively due to low clinical and even radiological suspicious [5]. It can be anywhere in the body with intra-abdominal location as the most common site but unusual location such as paraspinal muscle, shoulder and intrathoracic region also have been reported. They usually diagnosed with radiological examination as radio-opaque density within surgical sponge help diagnosis easily however radiolucent density cause dilemma for correct diagnosis. CT scan may be needed especially in chronic presentation as they can present like a soft tissue neoplasm which revealed hypodense structure with peripheral thick rim [6]. Various imaging appearances present depending on time of retention and surgical site. They can be seen as sponge-like appearance due to bacterial overgrowth within surgical sponge and whirl like structure. In MRI, in T2 weighted sequence, folded fabric structure demonstrated. Negative uptake in scintigraphy study help in differentiation of same appearance soft tissue tumors from gossypiboma in equivocal cases [7,8]. Other radiologic characteristics in acute post-operative phase may mimic hematoma, abscess or seroma formation but in chronic phase they may be confused with chronic granulomatous reaction or soft tissue tumors[7]. Sarcoma may arise from gossypiboma in rare frequency when retention time is more than 20 years so it is necessary for careful examination of gossypiboma resected specimen for rule out of coexisting sarcoma [8]. It is preventable event with staff change avoidance during surgery and strict swab count. Minimally invasive procedures also help in decreasing its incidence [9]. Conclusion: Gossypiboma is an avoidable condition that should be considered in differential diagnosis of any patient with previous history of operation with unusual presentation in acute or chronic states.

Single-incision Laparoscopic Gastrectomy for Gastric Cancer.

The implementation of national cancer screening has increased the detection rates of early gastric cancer (EGC) in Korea. Since the successful introduction of laparoscopic gastrectomy for gastric cancer in the early 1990s, this technique has demonstrated improved short-term outcomes without compromising long-term oncologic results. It is associated with reduced pain, shorter hospitalization, reduced morbidity rates, better cosmetic outcomes, and equivalent mortality rates as those for open surgery. Laparoscopic gastrectomy improves patients' quality of life (QOL) and provides favorable prognosis. Single-incision laparoscopic gastrectomy (SILG) is one extremely minimally invasive method, theoretically offering improved cosmetic results, less postoperative pain, and earlier recovery after surgery than conventional multiport laparoscopic gastrectomy. In this context, SILG is thought to be an optimal method to promote and maximize patients' QOL in the acute postoperative phase. However, the technical difficulties of this procedure have limited its use. Since the first report describing single-incision distal gastrectomy in 2011, only 16 studies to date have evaluated SILG. Most of these studies have focused on the technical feasibility and safety of SILG because its long-term outcomes have not been reported. This article reviews the advantages and limitations of SILG.

Factors Associated with Knee Stiffness following Surgical Management of Multiligament Knee Injuries.

Postoperative knee stiffness can influence outcomes following operative treatment of multiligament knee injuries (MLKIs). The purpose of this study was to evaluate patient and surgical factors that may potentially contribute to stiffness following surgery for MLKIs. All surgically managed MLKIs involving two or more ligaments over a 10-year period at a single level one trauma center were included in this study. A retrospective review was performed to gather objective data related to the development of knee stiffness after surgery. Patients were classified as "stiff" postoperatively if they (1) had a flexion contracture greater than 10 degrees, (2) failed to reach 120 degrees of flexion at final follow-up, or (3) underwent a manipulation under anesthesia with or without arthroscopic lysis of adhesions to improve range of motion. Patient and surgical factors were evaluated systematically to determine factors associated with stiffness. The mean age of the cohort was 27.6 years at the time of surgery and mean follow-up was 50 weeks. Overall, 26/121 (21.5%) knees were diagnosed with postoperative stiffness. In the acute postoperative phase, 17 patients underwent manipulation under anesthesia. There were no significant differences in age, body mass index, associated injuries, mechanism, external fixation use or surgical timing (acute vs. chronic) between stiff and normal knees. Factors associated with the development of postoperative stiffness included knee dislocation (p = 0.04) and surgical intervention on three or more ligaments (p = 0.04). Careful attention to postoperative rehabilitation regimens should be given to patients with knee dislocations and/or those undergoing reconstruction or repair of three or more injured ligaments. Surgeons may utilize spanning external fixation if necessary without increasing the rate of long-term stiffness. Further, acute surgery does not appear to influence rates of postoperative stiffness or the need for manipulation.

Kinesio taping as a treatment method in the acute phase of ACL reconstruction: A double-blind, placebo-controlled study

ObjectiveIn this study, we aimed on investigating the effects of Kinesio taping (KT) in acute postoperative rehabilitation phase of anterior cruciate ligament (ACL) reconstruction. MethodsThirty male patients (mean age: 28.1 years) with ACL reconstruction were randomly assigned to two groups: (1) an experimental group to receive a KT treatment through the muscle and lymphatic correction techniques; or (2) a control group for sham KT. Both interventions were applied twice during a 10-day period from the fourth postoperative day. All patients received the same rehabilitation program for three months. The groups were compared according to range of motion (ROM), pain, swelling and muscle strength before treatment and on the fifth and tenth treatment days. Subjective evaluations were made with the Lysholm, modified Cincinnati and Tegner scores on the first and third postoperative months. ResultsIntragroup comparisons showed significant improvements in both groups on the fifth and tenth day and first and third month evaluations (p < 0.05). In comparison to the control group, the experimental group showed significant improvements in swelling around the patella, all pain measurements and hamstring muscle strength on the fifth KT day and knee flexion range of motion (ROM), night pain, all swelling measurements and hamstring muscle strength on the tenth KT day (p < 0.05). ConclusionOur results revealed that KT techniques applied in addition to the acute rehabilitation program of ACL reconstruction are beneficial in treatment of pain, swelling, knee flexion ROM, and hamstring muscle strength. Level of evidenceLevel I, Therapeutic study.

Efficacy of video-assisted thoracoscopic surgery in the treatment of lung cancer

Objective To compare the efficacy of video-assisted thoracoscopic surgery and open-thoracotomy in the treatment of lung cancer. Methods 77 patients with lung cancer were chose as study objects, all the patients were divided into two groups, 43 cases of video-assisted thoracoscopic surgery group (VATS) and 34 cases of open-thoracotomy group (OT) The operative time, blood loss, postoperative chest tube indwelling time and hospital stay and postoperative complication rate were compared.The VAS postoperative 1d, 3d, 5d after operation were calculated, and the serum CRP preoperative and postoperative 1d, postoperative 5d were detected. Results The operative time, postoperative chest tube indwelling time, hospital stay, the blood loss, the complication rate in VATS group and OT group were (134±52)min and (167±45)min, (2.50±0.30)d and (4.68±0.66)d, (4.77±0.54)d and (7.20±0.68)d, 103±26)mL and (248±43)mL, 11.63% and 38.24%, the differences were statistically significant (t=3.563, 3.725, 9.621, 3.402 and χ2=7.504, all P<0.05). The VAS postoperative 1d, 3d in VATS group and OT group were (6.22±0.82)score and (8.13±0.72)score, (4.46±0.48)score and (6.31±0.54)score, the differences were statistically significant, t=3.927, 3.742, all P<0.05; the serum CRP after 1d, 5d postoperative in VATS group and OT group were (38.32±9.59)μg/L and (58.43±10.62)μg/L, (17.71±5.42)μg/L and (36.65±8.25)μg/L, which were all higher than those of before surgery, but the serum CRP after 1d, 5d postoperative in VATS group were lower than those of OT group, the differences were statistically significant(t=5.541, 6.662, all P<0.05). Conclusion VATS lobectomy is a trauma, quicker recovery, less postoperative pain surgical methods, and can reduce postoperative acute phase reaction, which should be recommended as a treatment for lung cancer. Key words: Lung cancer; Lobectomy; Video-assisted thoracoscopic surgery; Open-thoracotomy

Perioperative Pain Management Strategies for Amputation: A Topical Review.

To review acute pain management strategies in patients undergoing amputation with consideration of preoperative patient factors, pharmacologic/interventional modalities, and multidisciplinary care models to alleviate suffering in the immediate post-amputation setting. Regardless of surgical indication, patients undergoing amputation suffer from significant residual limb pain and phantom limb pain in the acute postoperative phase. Most studies have primarily focused on strategies to prevent persistent pain with inclusion of immediate postoperative outcomes as secondary measures. Pharmacologic agents, including gabapentin, ketamine, and calcitonin, and interventional modalities such as neuraxial and perineural catheters, have been examined in the perioperative period. Focused Literature Review. Pharmacologic agents (gabapentin, ketamine, calcitonin) have not shown consistent efficacy. Neuraxial analgesia has demonstrated both an opioid sparing and analgesic benefit while results have been mixed regarding perineural catheters in the immediate post-amputation setting. However, several early studies of perineural catheters employed sub-optimal techniques (distal surgical placement), and prolonged use of perineural catheters may provide a sustained benefit. Regardless of analgesic technique, a multidisciplinary approach is necessary for optimal care. Patient-tailored analgesic regimens utilizing catheter-based techniques are essential in the acute post-amputation phase and should be implemented in all patients undergoing amputation. Future research should focus on improved measurement of acute pain and comparisons of effective analgesic regimens instead of single techniques.

Preoperative cognitive-behavioural intervention improves in-hospital mobilisation and analgesic use for lumbar spinal fusion patients.

BackgroundCatastrophic thinking and fear-avoidance belief are negatively influencing severe acute pain following surgery causing delayed ambulation and discharge. We aimed to examine if a preoperative intervention of cognitive-behavioural therapy (CBT) could influence the early postsurgical outcome following lumbar spinal fusion surgery (LSF).MethodsNinety patients undergoing LSF due to degenerative spinal disorders were randomly allocated to either the CBT group or the control group. Both groups received surgery and postoperative rehabilitation. In addition, the CBT group received a preoperative intervention focussed on pain coping using a CBT approach. Primary outcome was back pain during the first week (0–10 scale). Secondary outcomes were mobility, analgesic consumption, and length of hospitalisation. Data were retrieved using self-report questionnaires, assessments made by physical therapists and from medical records.ResultsNo difference between the groups’ self-reported back pain (p = 0.76) was detected. Independent mobility was reached by a significantly larger number of patients in the CBT group than the control group during the first three postoperative days. Analgesic consumption tended to be lower in the CBT group, whereas length of hospitalisation was unaffected by the CBT intervention.ConclusionParticipation in a preoperative CBT intervention appeared to facilitate mobility in the acute postoperative phase, despite equally high levels of self-reported acute postsurgical pain in the two groups, and a slightly lower intake of rescue analgesics in the CBT group. This may reflect an overall improved ability to cope with pain following participation in the preoperative CBT intervention.Trial registrationThe study was approved by the Danish Protection Agency (2011-41-5899) and the Ethics Committee of the Central Denmark Region (M-20110047). The trial was registered in Current Controlled Trials (ISRCTN42281022).

Force-plate analyses of balance following a balance exercise program during acute post-operative phase in individuals with total hip and knee arthroplasty: A randomized clinical trial.

Objectives:Typical rehabilitation programs following total hip arthroplasty and total knee arthroplasty include joint range of motion and muscle-strengthening exercises. Balance and balance exercises following total hip arthroplasty and total knee arthroplasty have not received much attention. The purpose of this study was to determine whether an intervention of balance exercises added to a typical rehabilitation program positively affects patients’ balance.Methods:A total of 63 patients were provided with outpatient physical therapy at their home. Patients were randomly assigned to either typical (n = 33) or balance (n = 30) exercise group. The typical group completed seven typical surgery-specific joint range of motion and muscle-strengthening exercises, while the balance group completed the typical exercises plus three balance exercises. After 5 weeks of administering the rehabilitation program, patients’ balance was assessed on a force plate using 95% ellipse area of the center of pressure amplitude.Results:Patients in the balance group demonstrated significant reduction in the 95% ellipse area for the anterior and posterior lean standing conditions (p < 0.01).Conclusion:Balance exercises added to the typical outpatient physical therapy program resulted in significantly greater improvements in balance for participants with total hip arthroplasty or total knee arthroplasty, compared to the typical exercise program alone. Physical therapists might consider the use of balance exercises to improve balance in individuals in the acute post-operative phase following total hip arthroplasty or total knee arthroplasty.

心臓血管外科領域における術後急性期リハビリテーション

心臓血管外科領域における術後急性期リハビリテーション

Hand-assisted laparoscopic surgery (HALS) is associated with less-restrictive ventilatory impairment and less risk for pulmonary complication than open laparotomy in thoracoscopic esophagectomy

Esophagectomy with extended lymphadenectomy improves prognosis but it is associated with high morbidity and mortality. The thoracoscopic approach is associated with fewer pulmonary complications. Abdominal wall injury greatly affects pulmonary function and complication rates during the acute postoperative phase. In this study we aimed to compare the incidence of pulmonary complications and respiratory recovery after thoracoscopic esophagectomy in the prone position with hand-assisted laparoscopic surgery (HALS) versus open laparotomy (OL). This was a case-matched control study of patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position. Thirty-two patients in the HALS group and 32 patients in the OL group were selected by the use of propensity score matching. Operative outcomes and perioperative changes in respiratory function were compared. There was no operative mortality in either group. Estimated blood loss was less in the HALS group (P<.001). The incidence of postoperative pneumonia was 6.2% (4/64) overall; it was less in the HALS group (0%) than in the OL group (12.5%) (P=.016). There were no differences in preoperative vital capacity (VC) and percent predicted vital capacity (%VC). Each parameter, including the ratio of the postoperative to preoperative %VC (%VC ratio), reached its nadir on postoperative day 7 in both groups but was greater in the HALS group (VC, 2.91±0.68L vs 2.53±0.53L, P=.018; %VC, 90.62±16.92% vs 78.91±16.65%, P=.007; %VC ratio, 80.90±9.87% vs 72.09±11.95%, P=.002). At 1 and 3months, respiratory recovery was seen in both groups but more so in the HALS group. At 6months, further respiratory recovery was seen in both groups, without any significant intergroup differences. During the acute phase after thoracoscopic esophagectomy in the prone position, HALS is associated with less-restrictive ventilatory impairment, fewer subsequent pulmonary complications, and less blood loss than OL. The combination of HALS and thoracoscopic esophagectomy in the prone position is less invasive on respiratory function.

The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review.

A number of insulin infusion algorithms, with varying methods and effects, have been developed to guide the management of postoperative hyperglycemia in critically ill patients. The objective of this study was to investigate the effect of insulin therapy algorithms on blood glucose levels in patients in critical care environments following cardiac surgery. Types of participants: Adult patients aged 18 or older who were admitted to a critical care environment after cardiac surgery and who received insulin therapy for glycemic control during the acute postoperative phase of their admission. Types of intervention: The intervention of interest was continuous intravenous insulin therapy. Types of studies: Experimental study designs including randomized controlled trials, non-randomized controlled trials and controlled before and after studies published in the English language were included in this review. Types of outcomes: Primary outcomes of interest included objective measures of glycemic control and secondary outcomes of interest included the incidence of adverse events. The search aimed to find both published and unpublished studies through electronic databases, reference lists, key reports and the World Wide Web. An extensive search was undertaken for the following databases: Medline, CINAHL, PubMed, Embase, Scopus, the Cochrane Library, Dare, Social Science Index, ProQuest, and MedNar. Databases were searched up to March 2014. All studies selected were assessed by two reviewers independently for methodological quality prior to inclusion in the review using the standardized Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument critical appraisal tool. Any disagreements that arose between the reviewers were resolved through discussion. Quantitative data was extracted from papers included in the review using the standardized data extraction tool from Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument. All results were subject to double data entry. Statistical pooling of the data in meta-analysis was carried out using Review Manager meta-analysis software where possible. Odds Ratios, Relative Risks, Weighted Means Differences and their 95% Confidence Interval were calculated where appropriate. Where statistical pooling was not possible due to the heterogeneity of the studies the findings are presented in narrative form including tables and figures. Thirteen studies were included in the final review. Pooled data demonstrated significantly improved mean blood glucose levels (Weighted Means Differences -27.24, 95% Confidence Interval: -27.77 - -26.72), p < 0.00001 and achievement of target blood glucose levels range (Relative Risks 1.43, 95% Confidence Interval: 1.18 - 1.72), p = 0.0002, among participants who received the paper nomogram continuous intravenous insulin method of glucose control compared to the bolus regime group. Studies that investigated paper nomogram directed continuous intravenous insulin compared to computer calculator directed continuous intravenous insulin demonstrated a statistically significant improved mean blood glucose levels (Weighted Means Differences -23.74, 95% Confidence Interval: -24.45 - -23.02), p <0.00001 and higher percentage of time in which glucose levels were within the target range in the computer calculator group. A significantly lower incidence (p < 0.05) of hyperglycemia was observed in the computerized calculator directed CII group (1.3 ± 1.2%) compared to the paper nomogram CII (6.5 ± 2%). There is evidence of a benefit of continuous insulin infusions for patients following cardiac surgery with the computer calculator CII method achieving optimal glycemic control. The implementation of a computer calculator CII algorithm allows for individualized patient treatment. However, given the limited availability of the computer based algorithm, the implementation of a paper based algorithm would be justified. Future studies to compare the methods of computer calculator directed CII to paper nomogram directed CII should be undertaken using more rigorous research designs such as randomized controlled trials with sufficiently powered sample sizes. Definitions for both hypoglycemia and hyperglycemia should be standardized.

Effectiveness of balance exercises in the acute post-operative phase following total hip and knee arthroplasty: A randomized clinical trial.

Objectives:To determine the effectiveness of balance exercises in the acute post-operative phase following total hip arthroplasty or total knee arthroplasty.Methods:Patients who had total hip arthroplasty (n = 30) or total knee arthroplasty (n = 33) were seen in their residence 1–2 times per week for 5 weeks. At the first post-operative home visit, patients were randomly assigned to either typical (TE, n = 33) or typical plus balance (TE + B, n = 30) exercise groups. The TE group completed seven typical surgery-specific joint range-of-motion and muscle strengthening exercises, while the TE + B group completed the typical exercises plus three balance exercises. Patients were assessed before and 5 weeks after administering the rehabilitation program using four outcome measures: (1) the Berg Balance Scale, (2) the Timed Up and Go test, (3) the Western Ontario McMaster Universities Osteoarthritis Index, and (4) the Activities-specific Balance Confidence Scale.Results:Post-intervention scores for all four outcome measures were significantly improved (p < 0.01) over baseline scores. Patients who participated in the TE + B group demonstrated significantly greater improvement on the Berg Balance Scale and the Timed Up and Go tests (p < 0.01).Conclusion:Balance exercises added to a typical rehabilitation program resulted in significantly greater improvements in balance and functional mobility compared to typical exercises alone.

Sleeve Gastrectomy With or Without a Multimodal Perioperative Care. A Randomized Pilot Study.

Multimodal protocols may enhance postoperative recovery. The aim of this study was to evaluate the influence of a multimodal protocol in the clinical results, insulin resistance, and inflammatory response to trauma in morbidly obese patients undergoing sleeve gastrectomy. The population of the study consisted of morbidly obese patients, who were operated using sleeve gastrectomy, from Cuiaba, MT, Brazil, between April and October 2012. Twenty patients were divided into two groups whom received either traditional preoperative care or treatment following the Acerto (accelerating the total recovery of patients in the postoperative period) protocol. The study examined inflammatory response and insulin resistance by measuring levels of glucose, insulin, Homa-IR, reactive C protein, albumin, prealbumin, alpha 1 acid glycoprotein, interleukin 6, and glycosylated hemoglobin. In addition, the study investigated hydration levels, nausea and vomiting, hypertension, and length of hospital stay. Patients who followed the Acerto protocol showed no postoperative hypertensive crises (p = 0.03), and 30 % less vomiting (p = 0.35), and showed significant reductions in length of hospital stay, on average of 3 days versus 2 days (p = 0.02). There were not significant statistical differences between the two groups with respect to inflammatory response and insulin resistance (p > 0.05). This pilot study suggests that the prescription of the Acerto multimodal protocol for morbidly obese patients undergoing sleeve gastrectomy was safe, reduced the rate hypertensive complications, and the length of both ICU and hospital postoperative stay. However, there was no improvement in postoperative insulin resistance or inflammatory acute phase response.

Functional reorganization of the attentional networks in low-grade glioma patients: A longitudinal study

Right brain damage often provokes deficits of visuospatial attention. Although the spatial attention networks have been widely investigated in stroke patients as well as in the healthy brain, little is known about the impact of slow growing lesions in the right hemisphere. We here present a longitudinal study of 20 patients who have been undergoing awake brain surgery with per-operative line bisection testing. Our aim was to investigate the impact of tumour presence and of tumour resection on the functional (re)organization of the attention networks. We assessed patients' performance on lateralized target detection, visual exploration and line bisection before surgery, and in the acute and post-acute operative phases after surgery. Clear evidence for transient neglect signs was observed in the acute post-operative phase, although full recovery had invariably occurred in all patients. The resection of the right angular gyrus was associated with transient neglect-like symptoms in all tasks, whereas resection of more anterior regions correlated with transient deficits only in visual exploration or detection (but not in line bisection). The attentional networks showed substantial functional recovery. This impressive pattern of recovery is discussed in terms of involvement of the contralateral left hemisphere and of preservation of long-range white matter pathways within the right hemisphere.

Coagulation and transfusion in the postoperative bleeding patient.

Bleeding can be minimal, severe, life-threatening, or organ-threatening. Depending on the compensatory capacity of the patient, most bleeding events going beyond 20% blood volume may represent an emergency as well as a risk factor for anemia, transfusion, coagulopathy, and tissue hypoperfusion. All these factors are independent predictors for survival in postoperative critical care and are drivers for resource use and costs. A systematic literature search behind the guidelines from the European Society of Anesthesiology on the management of severe perioperative bleeding gives an up-to-date evidence-based summary of strategies intended to correct hemostasis, control bleeding, and increase patient safety. The current review discusses information, recommendations, and suggestions in the European Society of Anesthesiology guidelines, which appear applicable to the bleeding patient after the end of surgery. Individualized coagulation management guided by viscoelastic tests and restrictive transfusion behavior are encouraged in clinical practice of critical care. Potential fields of research are multifold, for example, thromboembolic adverse effects of hemostatic interventions in the isochronic postoperative acute-phase response, transfusion restrictions by increasing postoperative tolerance to anemia and erythropoiesis, and implementation of guidelines and institutional algorithms.

The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: A systematic review protocol

Review question/objective The objective of this review is to determine the best available evidence related to the effect of insulin therapy algorithms on blood glucose levels in patients in critical care environments following cardiac surgery. More specifically, the review question to be answered is: Among adults within critical care environments who are in the acute postoperative phase (5 days) following cardiac surgery, what is the effect of insulin therapy algorithms for the control of blood glucose levels? Inclusion criteria Types of participants This review will consider studies that include adult patients aged 18 years and over admitted to a critical care unit following cardiac surgery and who received insulin therapy for glycemic control during the acute postoperative phase (five days) of admission. In this review studies that include participants with a known diagnosis of Diabetic Ketoacidosis will be excluded. Types of intervention(s)/phenomena of interest This review will consider studies that evaluate the use of intravenous insulin therapy algorithms to control blood glucose levels in acute postoperative phase patients in critical care environments following cardiac surgery. In this review, studies will be included if they make one of the following comparisons: 1. Intravenous insulin therapy algorithm compared to another insulin therapy algorithm. 2. Intravenous insulin therapy algorithm compared to no treatment. 3. Intravenous insulin therapy algorithm compared to a placebo. In this review, studies that include a Glucose-Insulin-Potassium (GIK) infusion as an intervention or a comparator will be excluded. Types of outcomes This review will consider studies that include the following outcome measures: Primary outcome: •Overall control of blood glucose levels as measured by time to target BGL range, time spent in BGL target range and time above or below target BGL range. Secondary outcome: •Incidence of adverse events, including: - Hypo/hyper glycemia, measured by standard point of care glucometers, arterial blood analysis, or venous blood analysis, with hypoglycemia defined as a BGL reading 7.8mmol/L(140mg/dL).13 - Sternal wound infection, identified by a positive wound culture or a positive wound exudate culture.14 - Mortality rate measured by in-hospital mortality (from day of operation to day of discharge) and/or 30 day mortality.15