Adequate Perioperative Management Research Articles

How to teach regional anesthesia

The demand for peripheral nerve blocks and neuroaxial blocks from both patients and surgeons has increased over the last few years. This change in attitude towards regional anesthesia is prompted by the insight that adequate perioperative pain management leads to earlier ambulation, shorter hospital stay, reduced cost and increased patient satisfaction. To avoid serious complications of these techniques structured residency programs need to be available. Until 2004, the Residency Review Committee for Anesthesiology in the United States required a minimum of 50 epidurals, 40 spinals and 40 peripheral nerve blocks during residency. Similarly, the German Society for Anesthesia and Intensive Care required 100 neuroaxial blocks and 50 peripheral nerve blocks. In 2004 the American Society of Regional Anesthesia and Pain Medicine endorsed standardized guidelines for regional anesthesia fellowships which regulate the administrative, equipment and educational demands. This review introduces the reader to the different teaching methods available, including cadaver workshops, three-dimensional videoclips, video filming, ultrasound guidance and acoustic assist devices as well as demonstrating their advantages and disadvantages. Moreover, an overview is given of future residency training programs, which integrate administrative, material and educative demands as well as the teaching means into the daily clinical routine.

Perioperative Cardiac Risk Stratification and Modification in Abdominal Aortic Aneurysm Repair

Cardiovascular complications are important causes of morbidity and mortality following vascular surgery. Adequate preoperative risk assessment and perioperative management may modify postoperative mortality and morbidity and improve long-term prognosis. The objective of this review is to examine the present day knowledge regarding the preoperative evaluation and perioperative management of patients undergoing noncardiac surgery, focusing specifically on abdominal aortic aneurysm (AAA) repair.Clinical markers combined with ECG and surgical risk assessment can effectively divide patients in a truly low-risk, intermediate and high-risk population. Low-risk patients can probably be operated on without additional cardiac testing. Notably, due to the surgical risk, AAA patients are never low-risk patients. Intermediate-risk and high-risk patients are referred for cardiac testing to exclude extensive stress induced myocardial ischemia, as beta-blockers provide insufficient myocardial protection in this case and preoperative coronary revascularization might be considered. Whether patients at intermediate risk without ischemic heart disease should be treated with statins and/or beta-blockers is still controversial. In high-risk patients, it is strongly advised to administer beta-blockers with heart rate determined dose adjustment, while the effects of preoperative revascularization remain subject to debate.

Cochlear implantation in children with chronic suppurative otitis media

Chronic otitis media was previously a contraindication to cochlear implantation. In recent years, potential benefits of implantation in deaf children with chronic suppurative otitis media has fueled new approaches to this treatment dilemma. We review the current and historical literature, analyze the risk and benefits, and perioperative treatments and operative techniques to improve outcomes and minimize complications of cochlear implantation in children with chronic suppurative otitis media. We conclude that cochlear implantation in children with chronic suppurative otitis media is a viable therapy if adequate and meticulous preoperative and perioperative management is undertaken.

Surgical treatment of Pancoast tumours.

Due to its localisation in the apex of the lung with invasion of the lower part of the brachial plexus, first ribs, vertebrae, subclavian vessels or stellate ganglion, a superior sulcus tumour causes characteristic symptoms, like arm or shoulder pain or Horner's syndrome. If rib invasion is the only feature, lysis of the rib must be evident on the chest radiograph; otherwise the tumour cannot be defined as a Pancoast tumour. It is important to adequately stage the tumour, because staging significantly influences survival. Survival is better for T3 than T4 tumours and mediastinal lymph node involvement has been found to be a negative prognostic factor. Also Horner's syndrome and incompleteness of resection worsen survival. The management of superior sulcus tumours has evolved over the past 50 years. Before 1950 it was considered to be inoperable and uniformly fatal. Shaw and Paulson introduced combined modality treatment and for many years, this combination of radiotherapy and surgery was the treatment of choice with a mean 5-year survival of approximately 30%. Postoperative radiotherapy or brachytherapy does not improve survival in patients with complete or incomplete resection. The tumour can be resected through the classic posterior Shaw-Paulson approach or the newer anterior transcervical approach, introduced by Dartevelle. This method facilitates better exposure of the extreme apex of the lung, brachial plexus and subclavian vessels. Regarding the extent of pulmonary resection, en bloc resection of the involved ribs with a lobectomy is recommended. Recent multimodality studies, involving chemoradiotherapy and surgical resection, show promising results regarding completeness of resection, local recurrence and survival, provided that appropriate staging has been carried out. However, careful patient selection and adequate perioperative management with protection of the bronchial stump or anastomosis are important to achieve reasonable rates of morbidity and mortality. As brain metastases remain one of the most common forms of relapse, further studies are needed to examine the role of prophylactic cranial irradiation in patients with complete resection. Also the addition of other chemotherapy agents or biologic agents such as angiogenesis inhibitors or tyrosine kinase inhibitors gives a new perspective in the treatment of Pancoast tumours.

Transperineal approach for the treatment of posterior urethral stricture

目的 评价经会阴途径手术治疗后尿道狭窄的临床效果.方法经会阴途径手术治疗14例后尿道狭窄病人,对手术时期、手术方式及术后并发症进行了讨论.结果手术成功率86%,12例术后排尿良好,1例需尿道扩张.结论经会阴途径手术是治疗后尿道狭窄特别是尿道闭锁的有效方法,正确的术前诊断及手术操作、合理的围手术期处理是确保手术效果的关键。

Reoperations in adults with congenital heart disease: analysis of early outcome

Background: Grown-ups with congenital heart disease (GUCH) are an increasingly important group of patients, with many requiring reoperations because of late complications or residual defects, correction after palliation, further palliation or heart transplantation. Methods: In order to identify perioperative risk factors, we have retrospectively analysed perioperative mortality and morbidity of 66 consecutive GUCH patients needing reoperations between July 1987 and December 2000 with a mean age of 28±12 (14.2–63.5) years and preoperative ejection fraction of 57±21%. Primary cardiac defects were LVOT pathology (17 patients), coarctation (10), Tetralogy of Fallot (TOF) (9), VSD (9), transposition of the great arteries (TGA) (7), Marfan syndrome (6), ASD (5) and others (3). Results: Reoperations included various aortic valve procedures (28), aortic replacements (16), ASD/VSD closures (16), conduits (11), RVOT procedures (8), coarctation repair (5), cardiac transplantation (3) or others (8). Early mortality was 7.6%. Serious postoperative complications occurred in 24%. Presence of cyanosis, heart failure, VSD, TGA, pulmonary atresia, correction after palliative surgery and number of previous operations were preoperative risk factors and duration of operation, cardiopulmonary bypass and aortic cross-clamp, core temperature, low output syndrome, use of epinephrine, pneumonia and ARDS, renal failure, dialysis and stroke perioperative risk factors for fatal outcome. Conclusions: Reoperations in GUCH patients are mostly due to outflow tract lesions, coarctations and TOF. Perioperative risks remain important especially with cyanosis, TGA, pulmonary atresia and poor ventricular function. Therefore, close follow-up, timely referral for re-intervention and adequate perioperative management are mandatory to reduce perioperative risks and improve results.

Pain, nausea, vomiting and ocular complications delay discharge following ambulatory microdiscectomy.

Nowadays, microsurgical discectomy is being performed as an outpatient procedure. A retrospective chart review was done to document factors that delayed discharge or led to unanticipated admission. After Institutional Review Board approval, the hospital medical records of 106 patients who underwent microsurgical discectomy on an ambulatory basis were reviewed. All patients were operated upon by a single surgeon at the Toronto Western Hospital. Perioperative data were collected on specifically designed data sheets. All anesthetic and surgical factors that affected discharge were noted. Of the 106 patients reviewed, only six required unanticipated admission. Two patients were admitted due to nausea and vomiting, one due to severe pain, one due to urinary retention and two were surgical causes (dural tear). Eight patients had delayed discharge. Anesthesia causes were severe nausea, severe pain, low oxygen saturation, sore throat and dry eyes. Two patients had surgical causes. The incidence of postoperative nausea was 61% and postoperative vomiting was 9.4%. Eighty patients (75.4%) complained of pain in the postanesthesia care unit. Of these, 33.9% had visual analogue pain scale scores more than 6. Ambulatory lumbar microdiscectomy can be carried out as an ambulatory procedure with an acceptably low unanticipated admission rate (5.7%). The percentage of patients with severe nausea (16%) and pain (33.9%) is high. Adequate perioperative pain management and effective control of nausea and vomiting may further improve the patients' experience after anesthesia for ambulatory microdiscectomy.

Peripartum cardiomyopathy. Perioperative anaesthesiological management of a rare complication of pregnancy

Peripartum cardiomyopathy is a rare disorder with an incidence from 1:3,000 to 1:15,000 live births and thus not often described in the anaesthesiology literature. The etiology of this disease is still not known but the symptoms are similar to idiopathic dilated cardiomyopathy. Echocardiographic findings show a dilatation of the left ventricle in addition to abnormal wall motion with a severe reduction of the cardiac function. Despite the rarity of this disorder, the anaesthesiologist or ICU physician should consider peripartal cardiomyopathy as a differential diagnosis to ensure an adequate perioperative management. There seems to be an increased incidence in pregnant women who are elderly (age >30 years),who have a history of gestosis/hypertension,have a gemini pregnancy or are of black origin. The prognosis depends on the recovery of the left ventricular contractility within the first 6 months after onset of the disease. The mortality rate is reported to vary between 25% and 50%. Heart transplantation is regarded as the last resort which has successfully been performed with several patients. This case describes the perioperative management of a 32-year-old women with peripartum cardiomyopathy.

Perioperative pain management in patients undergoing thoracic surgery

Adequate perioperative pain management has become an important part of thoracic anaesthesia. In the past few years, many trials have been performed to evaluate the efficacy of various analgesic regimens. This review summarizes the most frequently used analgesic techniques, with a particular emphasis on the results of studies and innovative ideas published between August 1999 and August 2000.

Perioperative considerations in chronic alcoholics

The prevalence of alcoholism exceeds 20% in surgical disciplines. Chronic alcoholics are endangered by an increased postoperative morbidity and mortality. Due to an elaborated preoperative alcoholism-related diagnostic evaluation (alcoholism-related questionnaire and laboratory markers) and an adequate perioperative management (prophylactic treatment of alcohol withdrawal symptoms and symptom-orientated therapy of infections, cardiac complications and bleeding disorders), intercurrent complications may be reduced and postoperative outcome improved.

Open Biliary Tract Surgery: Multivariate Analysis of Factors Affecting Mortality

Background/Aim: The overall mortality rate in patients undergoing supraduodenal choledochotomy for benign biliary tract disease is around 3%. The aim of this study is to identify and quantify factors affecting the mortality in a group of patients undergoing open common bile duct exploration for benign biliary disease. Methods: Patients (n = 158) who underwent common bile duct exploration during a 5-year period in a teaching hospital were retrospectively reviewed. Results: Univariate and multivariate statistical analyses were performed. The former identified four statistically significant variables: age (p < 0.001), acute cholangitis on admission (p < 0.001), heart disease (p < 0.05), and a dilated common bile duct on preoperative ultrasound scan (p < 0.05). Multivariate analysis identified three variables which independently increased operative mortality: age (p = 0.05), heart disease (p = 0.03), and cholangitis (p = 0.008). The latter was associated with the greatest operative mortality, since it increased almost eight times the risk to die after surgical intervention. Conclusion: We conclude that an adequate perioperative cardiovascular management may be important in order to improve surgical outcome. Appropriate antibiotic prophylaxis and subsequent treatment after routine operative bile cultures may reduce septic complications and mortality. Finally, an alternative procedure, such as endoscopic sphincterotomy, may be indicated in high-risk patients in order to drain the common bile duct preoperatively and to decrease the risk of unresponsive biliary sepsis.

Treatment of ascites and renal failure in cirrhosis

Ascites is a frequent complication in patients with liver cirrhosis. The accumulation of fluid in the abdominal cavity is associated with disturbances of systemic and splanchnic haemodynamics and of kidney function, which contribute to the poor prognosis of these patients. Classically, the treatment of ascites in patients with cirrhosis has been based on the combination of a sodium-restricted diet and the administration of diuretics. However, this treatment is not entirely satisfactory, since it is associated with a relatively high incidence of side-effects, and about 20% of patients hospitalized for the treatment of an episode of ascites do not respond to such therapy. In the last two decades, alternative therapies to diuretics have been introduced. PVS is an effective method of treating ascites. The high incidence of complications observed in early studies may be reduced by adequate perioperative management and careful selection of patients. The role of the PVS in the treatment of cirrhotics with ascites, however, still remains to be established. Recently, paracentesis has emerged as an alternative method of treating ascites in patients with cirrhosis. Several studies have shown that therapeutic paracentesis plus i.v. albumin infusion is more effective than conventional diuretic therapy and is associated with a lower incidence of complications. It has also been demonstrated that therapeutic paracentesis without the i.v. administration of albumin is associated with a marked increase in plasma renin activity, suggesting an impairment of effective blood volume, and with the development of hyponatraemia and/or renal failure in 20% of cases. Therefore, the i.v. administration of albumin is an essential measure in preventing the impairment of systemic haemodynamics and renal function that frequently follows the mobilization of ascites by paracentesis.