ASAI-II Patients Research Articles

Adenotonsillektomi ve Tonsillektomi operasyonlarında preemptif analjezinin derlenme deliryumu üzerine etkisi

Amaç: Derlenme deliryumu etiyolojisi tam olarak bilinmeyen, çoğunlukla küçük çocuklarda görülen, agresif davranışlar, göz teması eksikliği ve çevrenin farkında olmamakla karakterize bir fenomendir. Birçok sebepten kaynaklanabileceği gösterilmiş ancak en çok baş-boyun cerrahisi, inhaler ajanlar ve postoperatif ağrı suçlanmaktadır. Değerlendirmek için bazı skalalar kullanılır. Duyarlılığı en yüksek olan Pediyatrik Anestezi Deliryum Skalası olan "PAED" (Pediatric Anesthesia Delirium Scale)'dir. Preemptif analjezi, ağrı yolaklarının henüz ağrılı uyaran oluşmadan kesilerek engellenmesidir ve postoperatif analjezi için etkinliği birçok çalışma ile doğrulanmıştır. Bu çalışma: preemptif analjezi yöntemi ile azaltılan postoperatif ağrının derlenme deliryumunu azaltacağı hipotez edilerek planlanmıştır.
 Gereç ve Yöntemler: Etik kurul onayı alındıktan sonra adenotonsillektomi ve tonsillektomi operasyonu geçirecek, 2-7 yaş arası 96 hasta iki gruba randomize edildi. Analjezikler preemptif gruba indüksiyondan önce, intraoperatif gruba ise operasyonun başlamasından 15 dakika sonra uygulandı. Derlenme ünitesinde derlenme deliryumu PAED skalası ile, ağrı skorları çocuğun yüz ifadesi, bacakların pozisyonu, hareketleri, ağlaması ve avutulabilmesi değerlendirilerek yapılan “FLACC” (Face, Legs, Activity, Cry, Consolability) ağrı değerlendirme skalası ile değerlendirildi. FLACC>7 ağrı ve PAED> 10 derlenme deliryumu kabul edildi.
 Bulgular: Preemptif grupta PAED ve FLACC skorları istatistiksel olarak anlamlı düşük bulundu ancak derlenme deliryum gelişme insidansı açısından iki grup arasında sadece 5.dakikada anlamlı fark saptandı (p

Outcomes of liver surgery: A decade of mandatory nationwide auditing in the Netherlands

BackgroundIn 2013, the nationwide Dutch Hepato Biliary Audit (DHBA) was initiated. The aim of this study was to evaluate changes in indications for and outcomes of liver surgery in the last decade. MethodsThis nationwide study included all patients who underwent liver surgery for four indications, including colorectal liver metastases (CRLM), hepatocellular carcinoma (HCC), and intrahepatic– and perihilar cholangiocarcinoma (iCCA – pCCA) between 2014 and 2022. Trends in postoperative outcomes were evaluated separately for each indication using multilevel multivariable logistic regression analyses. ResultsThis study included 8057 procedures for CRLM, 838 for HCC, 290 for iCCA, and 300 for pCCA. Over time, these patients had higher risk profiles (more ASA-III patients and more comorbidities). Adjusted mortality decreased over time for CRLM, HCC and iCCA, respectively aOR 0.83, 95%CI 0.75–0.92, P < 0.001; aOR 0.86, 95%CI 0.75–0.99, P = 0.045; aOR 0.40, 95%CI 0.20–0.73, P < 0.001. Failure to rescue (FTR) also decreased for these groups, respectively aOR 0.84, 95%CI 0.76–0.93, P = 0.001; aOR 0.81, 95%CI 0.68–0.97, P = 0.024; aOR 0.29, 95%CI 0.08–0.84, P = 0.021). For iCCA severe complications (aOR 0.65 95%CI 0.43–0.99, P = 0.043) also decreased. No significant outcome differences were observed in pCCA. The number of centres performing liver resections decreased from 26 to 22 between 2014 and 2022, while median annual volumes did not change (40–49, P = 0.66). ConclusionOver time, postoperative mortality and FTR decreased after liver surgery, despite treating higher-risk patients. The DHBA continues its focus on providing feedback and benchmark results to further enhance outcomes.

A comparison of perioperative safety for breast augmentation in cis- vs. trans patients.

Gender-affirming surgery provides a psychosocial benefit to transgender women. However, increased medical complexity within the transgender population has limited access for some transgender women. This study compared patient population comorbidities and 30-day peri-operative safety following primary augmentation mammoplasty between cis- and transgender women. Data were extracted from the National Surgical Quality Improvement Program (NSQIP) database between 2007 and 2016. Transgender patients were identified using ICD-9 &10 codes for gender dysphoria. Categorical variables were compared using chi-squared and Fisher's exact tests while independent t-tests were used for continuous variables. Statistical significance was set at P<0.05. There were 4,234 breast augmentations identified in cisgender women and 137 in transgender women. Transgender women had a higher frequency of ASA-II and ASA-III patients (P<0.001), diabetes (P<0.001), hypertension (P=0.006), and active smoking status (P<0.001). Despite the higher comorbidity burden and routine use of hormonal therapy, there were no significant differences between populations in major or minor peri-operative complication rates. Top surgery improves quality of life in transgender women. Despite the more complex pre-operative risk profile in the transgender population, there is no difference in peri-operative safety profiles. Plastic surgeons treating this patient population should consider more liberal surgical indications for reconstructive top surgery compared with cosmetic breast augmentation.

Efficacy of continuous positive airway pressure and incentive spirometry on respiratory functions during the postoperative period following supratentorial craniotomy: A prospective randomized controlled study

Study objectiveVolume controlled ventilation with low PEEP is used in neuro-anesthesia to provide constant PaCO2 levels and prevent raised intracranial pressure. Therefore, neurosurgery patients prone to atelectasis formation, however, we could not find any study that evaluates prevention of postoperative pulmonary complications in neurosurgery. DesignA prospective, randomized controlled study. SettingIntensive care unit in a university hospital in Istanbul. PatientsSeventy-nine ASAI-II patients aged between 18 and 70years scheduled for elective supratentorial craniotomy were included in the study. InterventionsPatients randomized into 3 groups after surgery. The Group IS (n=20) was treated with incentive spirometry 5 times in 1min and 5min per hour, the Group CPAP (n=20) with continuous positive airway pressure 10 cmH2O pressure and 0.4 FiO2 via an oronasal mask 5min per hour, and the Group Control (n=20) 4L·min−1O2 via mask; all during the first 6h postoperatively. Respiratory functions tests and arterial blood gases analysis were performed before the induction of anesthesia (Baseline), 30min, 6h, 24h postoperatively. Main resultsThe IS and CPAP applications have similar effects with respect to FVC values. The postoperative 30min FEV1 values were statistically significantly reduced compared to the Baseline in all groups (p<0.0001). FEV1 values were statistically significantly increased at the postoperative 24h compared to the postoperative 30min in the Groups IS and CPAP (p<0.0001). This increase, however, was not observed in the Group Control, and the postoperative 24h FEV1 values were statistically significantly lower in the Group Control compared to the Group IS (p=0.015). ConclusionAlthough this study is underpowered to detect differences in FEV1 values, the postoperative 24h FEV1 values were significantly higher in the IS group than the Control group and this difference was not observed between the CPAP and Control groups. It might be evaluate a favorable effect of IS in neurosurgery patients. But larger studies are needed to make a certain conclusion.

Feasibility of percutaneous cryoablation of vertebral metastases under local anaesthesia in ASAIII patients

Purposespine metastases are common concern from several primary neoplasms, modern management include percutaneous techniques such as ablation and cementoplasty. This research aims to evaluate the treatment under local anaesthesia in high-risk patients (ASA III). Methods and materialfrom January 2013 up to September 2016 we treated via percutaneous cryoablation 11 advanced oncological patients classified as ASA III, then retrospectively a review of their clinical history has been performed. Interventions were managed under local anaesthesia, injecting low doses of bupivacaine 2,5mg/ml (from10 to 30ml). Cryoprobes of 17G were introduced under CT guidance. VAS scores were evaluated pre, intra and post operative up to the 3rd month and further, statistical analyses were obtained using T student test. Resultsthirteen spinal metastases were cryoablated in 11 patients (6W, 5M; mean age of 53 years, range 52–81). Tumour location was: sacrum (n=6), lumbar spine (n=3), thoracic spine (n=2). The average VAS value during the procedure was 5,27 (standard deviation 0,90). There were statistically significant decreases in the median numeric VAS scale score at 1-week, 1-month, and 3-month time points (P<.001 for all). Technical success was achieved in all cases. Among patients with neurological deficit, some clinical improvement was assessed. Conclusioncryoablation with or without subsequent cement injection can be safely performed with local anaesthesia for pain relief also in patients with high ASA score with higher risk of complications, in the absence of any other suitable treatment.

Inducción con propofol: infusión controlada por objetivo o manual. Un estudio observacional

BackgroundTarget-controlled infusion (TCI) systems allow the administration of drug to achieve a target blood or site-effect concentration. We determine induction and recovery times and the amount of drug used with TCI systems vs. manual induction. ObjectiveTo determine whether the induction of propofol TCI and manual infusion are two comparable techniques. MethodsA retrospective observational study was conducted in which 62 ASAI-II patients scheduled for elective surgery received induction using TCI or manually. Anaesthetic induction was achieved with remifentanil (0.25μg/kg/min) and propofol (manual bolus injection: 2mg/kg, or target blood concentration: 5μg/ml with the TCI system [Marsh model]) with maintenance doses of remifentanil (0.15μg/kg/min) and propofol (manually 0.10mg/kg/min or 2.5-4μg/ml using the TCI system). In both groups, rocuronium bromide was used (induction and maintenance doses: 0.6 and 0.3mg/kg, respectively) as was morphine (0.1mg/kg) 45min before the end of the surgery.We measured: induction, operative and recovery mean times; bispectral index, heart rate, blood pressure, costs, haemodynamic instability, and intraoperative awareness. A telephone questionnaire was administered 1 month later. ResultsThe mean induction time was longer in the TCI than the manual group (1.76±0.94 vs. 0.9±0.4min; P<.001), but the total dose of propofol (TCI: 112.4±60.9 vs. manual: 133.8±80.3ml, P=.241) tended to be smaller and the recovery time was significantly shorter (TCI: 7.48±3.1 vs. manual: 10.3±4.9min) (P=.008). ConclusionsInduction with propofol using TCI is similar to manually delivered propofol.

Comparison of the Effects of Intravenous Phenylephrine and Ephedrine in Treatment of Hypotension after Spinal Anesthesia in Orthopedic Surgery

BACKGROUND AND OBJECTIVE: Hypotension after spinal anesthesia is a common and potentially dangerous complication, prompt and accurate prevention and treatment of which are of paramount importance. In the recent studies there have been conflicting results regarding the efficacy of phenylephrine and ephedrine in the prevention and treatment of hypotension after spinal anesthesia. Thus, in this study, we purport to compare the effects of phenylephrine and ephedrine in the treatment of hypotension after spinal anesthesia for lower limb orthopedic surgery. METHODS: This double-blind clinical trial was conducted on 110 ASAI-II patients aged 40-65 years, who were candidates for orthopedic surgery of lower limbs under spinal anesthesia with 3 mL of bupivacaine 0.5%. The subjects were randomly divided into two groups of 55. After observing 20% fall in blood pressure or blood pressure less than 90/60 mm/Hg, the first group received 50 µg of phenylephrine and the second group was administered 5 mg of intravenous ephedrine. Information concerning the hemodynamic status of the patients was collected and compared. FINDINGS: Phenylephrine was more effective in the treatment of systolic and diastolic hypotension following spinal anesthesia compared to ephedrine (systolic blood pressure: 119±10.6 vs. 112.35±10.34 nc and diastolic blood pressure: 73.42±6.67 vs. 70.05±6.15 nc). However, it should be noted that except for 2 and 4 minutes after administration of vasopressor, there was no statistically significant difference between the two groups. In both groups, heart rate elevated simultaneously with decrease in blood pressure. CONCLUSION: The results revealed that phenylephrine was more effective in the treatment of hypotension following spinal anesthesia compared to ephedrine in lower limb orthopedic surgery.

Clinical research on the use of flexible laryngeal mask, classic laryngeal mask and supreme laryngeal mask in breast surgery under general anesthesia

Objective Randomized controlled research on the safety of the use of flexible laryngeal mask,classic laryngeal mask and Supreme laryngeal mask in breast surgeries under general anesthesia.Methods Sixty ASA Ⅰ-Ⅱpatients aged 27 y-77 y weighing 51 kg-82 kg scheduled for breast surgery under general anesthesia were randomly divided into 3 groups (n=20),according to random number table:flexible laryngeal mask group (group A),classic laryngeal mask group (group B) and Supreme laryngeal mask group (group C).After induction of anesthesia,laryngeal mask insertion was performed,respectively.Noninvasive blood pressure (BP),heart rate (HR) and bispectral index(BIS) were recorded at the time before induction,the time before and just the time of laryngeal mask insertion,at 1,2,3,5,10 min after laryngeal mask insertion was complete.Observe the hemodynamic response and complications of laryngeal mask insertion.Results Patients of three groups had high one-time success rate above 90％,and short intubation time(＜1 min).BIS of three groups all decreased significantly[group A (93±5) vs (39±7),group B (96±3) vs (39±9),group C (95±5) vs (39±9),P＜0.05].In group A,BP was significantly decreased after induction [systolic blood pressure (SBP)(134±13) mmHg vs (109±12) mmHg (1 mmHg=0.133 kPa),diastolic blood pressure (DBP) (77±10) mmHg vs (64±9) mmHg,mean artery pressure (MAP) (90±11) mmHg vs (74±9) mmHg,P＜0.05].In group B,there was no significant change in BP and HR.While in group C,there was significant change in HR and BP [HR (77±10) bpm vs (68±9) bpm,SBP (127±28) mmHg vs (107±15) mmHg,DBP(72±14) mmHg vs (58±11) mmHg,MAP (85 ±15) mmHg vs (70±10) mmHg,P＜0.05].Insertion and extubation of laryngeal mask didn't cause violent hemodynamic responses.There were no significant differences among the hemodynamic responses of three groups,during the period of induction of anesthesia and laryngeal mask insertion.And the intubation time,recovery time and extubation time were not different among three groups.There were less complications of intubation and extubation observed in group A,compared with other two groups.Conclusions Flexible laryngeal mask,classic laryngeal mask and Supreme laryngeal mask can all prevent hemodynamic responses to intubation,and flexible laryngeal mask has advantage in reducing complications produced by intubation than other two kinds of laryngeal mask. Key words: General anesthesia; Breast surgery; Laryngeal mask ; Hemodynamic response ; Complications

Functional capacity as a significant independent predictor of postoperative mortality for octogenarian ASA-III patients.

The American Society of Anesthesiology's (ASA) 6-point physical status classification remains one of the most significant predictors of perioperative morbidity and mortality and is the most widely used risk stratification tool worldwide. Its utility is significantly limited for octogenarians, however, as the majority of these patients are classified as ASA-III. Thus, for patients aged 80 or older, we hypothesized that incorporating patients' functional status, defined by the ability to perform activities of daily living independently, would improve perioperative risk stratification. All data were extracted from the Veterans Affairs Surgical Quality Improvement Program, a perioperative prospectively maintained computerized database. ASA-III patients were reclassified into subgroups IIIA or IIIB, with IIIA representing functionally independent patients and IIIB representing partially or fully dependent patients. Functional status was self-reported during preoperative assessments. In this database, mortality data (primary outcome) was reliably available for all patients for the duration of the 96-month follow-up period, as were other perioperative patient data. Seven hundred and fifty-nine (72.4%) patients were classified as ASA-IIIA, and 290 (27.6%) patients were ASA-IIIB. Thirty-day and long-term survival was significantly better in the ASA-IIIA group, irrespective of type of surgery (hazard ratio 1.87, confidence interval 1.55-2.25, p < .001). ASA-IIIB hazard ratios for mortality were greatest for orthopedic and vascular surgery patients, but a significant divergence in survival between ASA-IIIA and IIIB patients was observed in all surgical specialties. As evidenced by Kaplan-Meier and multivariate analyses, functional capacity was a significant independent predictor of mortality for ASA-III patients older than 80 years of age.

The concentration changes during two low initial fresh gas flow and 2% sevoflurane wash tn semiclosed-circuit anesthesia

Objective To investigate the concentration changes of sevoflurane during semiclosedcircuit anesthesia with two low initial fresh gas flow. Methods Forty ASAⅠ-Ⅱ patients undergoing operation were randomly allocated to one of two equal groups （ n = 20）, The vaporize setting of both group were fixed at 2% sevoflurane,group A and group B receive either 2.0 or 1.0 L/rain fresh gas flow. The inspired （F1） ,end-tidal （FA ）, and ratio FA/F1 sevoflurane concentrations were estimated. Results After 120 minutes of sevoflurane anesthesia the inspired and end-tidal sevoflurane concentration were （ 1.47 ± 0.12） % versus （1.69 ±0.09）% （P〈0.01） in the group A and （1.23 ±0.13）% versus（1.46 ±0.11）% （P〈 0.01 ） in the group B. The ratio end-tidal and inspired concentrations/vaporizer setting was 0.73 ± 0.07 and 0.85 ± 0.08 in the group A versus 0.62 ± 0.06 and 0.73 ± 0.07 in the group B. For the ratio inspired and end-tidaL/vaporizer setting there were significant difference between the groups （ P 〈 0.01 ）. The estimated ratio end-tidal/inspired was 0.87 ± 0.08 in the group A versus 0.85 ± 0.09 in the group B （ P 〉 0. 05 ）. Conclusion After 120 minutes of sevotlurane anesthesia at a vaporizer setting of 2% there is a significant difference between tow groups for inspired and end-tidal concentrations, but not for the ratio FA/F1. Key words: Low-flow anesthesia ; Inhalation ; Semiclosed-circuit ; Sevoflurane

Effects of patient-controlled analgesia with small dose ketamine combined with morphine and the influence thereof on plasma beta-endorphin level in patients after radical operation for esophageal carcinoma

To evaluate the effects of patient-controlled analgesia (PCA) with small dose ketamine combined with morphine on analgesia and influence thereof on the plasma beta-endorphin (EP) level in the patients after radical operation for esophageal carcinoma. Thirty ASAI-II patients, aged 35-65, weighing 42-75 kg, with visual analogue score>or=3, undergoing elective radical operation for esophageal carcinoma under general anesthesia received intravenous morphine 2 - 3 mg were randomly divided into 2 equal groups: group m receiving morphine 0.02 mg.kg(-1).h(-1), and with group mk receiving morphine 0.02 mg.kg(-1).h(-1) combined with ketamine 0.08 mg.kg(-1).h(-1) for 50 h. In the course of treatment the patients received intravenous injection of morphine 2-3 mg when the VAS was >or=3. VAS was recorded 4, 8, 20, 24, and 48 h after operation. The amount of morphine used after operation, PCA button pressing times (effective/active), side effects, and vital signs including pulse, saturation of blood oxygen, respiratory rate, heart rate, and average arterial pressure were recorded. Central venous blood samples were collected when entering the operation room (T0), by the end of operation (T1), and 6 h (T2), 24 h (T3), and 48 h (T4) after operation respectively to examine the beta-endorphin level. During the period 4-48 h after operation the VAS scores of the group mk were significantly lower than those of the group m in activity state (all P<0.05) and were not significantly different those of the group m at resting state (all P>0.05). The total amount of morphine consumed and the actual PCA button pressing times were significantly less in the group mk than in the group m (both P<0.05). The incidence rates of nausea, vomiting, and pruritus of the group mk were all significantly lower than those of the group m (all P<0.05). There were not significant differences in the incidence rates of dreaming and pseudoesthesia between these 2 groups. All the vital signs were stable in the 2 groups. The plasma beta-EP levels at the time point T1 of these 2 groups were both significantly higher than those at T0 (both P<0.05). The plasma beta-endorphin levels at T2-4 of the group mk decreased gradually from the level at T1 to the level at T0, and the plasma beta-endorphin levels of the group m rapidly decreased from the level at T0 to the T0 level and remained at this level to the 48 h after operation. The combination of small dose of ketamine with morphine provides optimal analgesia with low side-effect rate and little effect on the plasma beta-EP level.

Lansoprazole in the prophylaxis of acid aspiration during elective surgery

We have assessed the efficacy of a single dose of lansoprazole in increasing the pH and decreasing the volume of gastric residue at induction of anaesthesia in adult patients undergoing elective orthopaedic surgery. We studied 66 ASAI-II patients, allocated to one of three groups to receive either placebo (group 1), lansoprazole 30 mg (group 2) or lansoprazole 60 mg (group 3), 8-12 h before induction of anaesthesia. Volume and pH of gastric contents were measured after induction of anaesthesia by aspiration via a 16-French gauge gastric tube. Patients who received lansoprazole had a significantly higher pH than the placebo group (P < 0.01) but there was no difference between the two lansoprazole groups. The volume of gastric residue was significantly smaller (P < 0.01) in both lansoprazole groups compared with the placebo group: 28% of those in group 3 had a pH of gastric residue < 2.5 and volume > 25 ml compared with 30% in group 2 and 63% in group 1, respectively.