Elective Major Abdominal Surgery Research Articles

Activities of daily living associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery: An observational cohort study.

Elderly patients who undergo major abdominal surgery are being in increasing numbers. Intensive care unit (ICU) survival is critical for surgical decision-making process. Activities of daily living (ADL) are associated with clinical outcomes in the elderly. We aimed to investigate the relationship between ADL and postoperative ICU survival in elderly patients following elective major abdominal surgery.We conducted a retrospective cohort study involving patients aged ≥65 years admitted to the surgical intensive care unit (SICU) following elective major abdominal surgery. Data from all patients were extracted from the electronic medical records. The Barthel Index (BI) was used to assess the level of dependency in ADL at the time of hospital admission.ICU survivors group had higher Barthel Index (BI) scores than non-survivors group (P < .001). With the increase of BI score, postoperative ICU survival rate gradually increased. The ICU survivals in patients with BI 0–20, BI 21–40, BI 41–60, BI 61–80 and BI 81–100 were 55.7%, 67.6%, 72.4%, 83.3% and 84.2%, respectively. In logistic regression, The Barthel Index (BI) was significantly correlated with the postoperative ICU survival in elderly patients following elective major abdominal surgery (OR = 1.33, 95% CI: 1.20–1.47, P = .02). The area under the receiver operating characteristic (ROC) curve of Barthel Index in predicting postoperative ICU survival was 0.704 (95% CI, 0.638–0.771). Kaplan–Meier survival curve in BI≥30 patients and BI < 30 patients showed significantly different.Activity of daily living upon admission was associated with postoperative intensive care unit survival in elderly patients following elective major abdominal surgery. The Barthel Index(BI) ≥30 was associated with increased postoperative ICU survival. For the elderly with better functional status, they could be given more surgery opportunities. For those elderly patients BI < 30, these results provide useful information for clinicians, patients and their families to make palliative care decisions.

Effect of driving pressure-guided positive end-expiratory pressure (PEEP) titration on postoperative lung atelectasis in adult patients undergoing elective major abdominal surgery: A randomized controlled trial

BackgroundAs respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions. MethodsEighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmH2O was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally. ResultsMean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5–8] vs 4 [2–6] before extubation and 8 [6–9] vs 5 [3–7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%–1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO2 >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups. ConclusionIntraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.

Perioperative corticosteroids for patients undergoing elective major abdominal surgery (CORPUS)

Perioperative corticosteroids for patients undergoing elective major abdominal surgery (CORPUS)

Preoperative intravenous iron for anaemia in elective major open abdominal surgery: the PREVENTT RCT.

Anaemia affects 30-50% of patients before they undergo major surgery. Preoperative anaemia is associated with increased need for blood transfusion, postoperative complications and worse patient outcomes after surgery. International guidelines support the use of intravenous iron to correct anaemia in patients before surgery. However, the use of preoperative intravenous iron for patient benefit has not been assessed in the setting of a formal clinical trial. To assess if intravenous iron given to patients with anaemia before major abdominal surgery is beneficial by reducing transfusion rates, postoperative complications, hospital stay and re-admission to hospital, and improving quality of life outcomes. A multicentre, double-blinded, randomised, controlled, Phase III clinical trial, with 1 : 1 randomisation comparing placebo (normal saline) with intravenous iron (intravenous ferric carboxymaltose 1000 mg). Randomisation and treatment allocation were by a secure web-based service. The study was conducted across 46 hospitals in England, Scotland and Wales between September 2013 and September 2018. Patients aged > 18 years, undergoing elective major open abdominal surgery, with anaemia [Hb level of > 90 g/l and < 120 g/l (female patients) and < 130 g/l (male patients)] who could undergo randomisation and treatment 10-42 days before their operation. Double-blinded study comparing placebo of normal saline with 1000 mg of ferric carboxymaltose administered 10-42 days prior to surgery. Co-primary end points were risk of blood transfusion or death at 30 days postoperatively, and rate of blood transfusions at 30 days post operation. A total of 487 patients were randomised (243 given placebo and 244 given intravenous iron), of whom 474 completed the trial and provided data for the analysis of the co-primary end points. The use of intravenous iron increased preoperative Hb levels (mean difference 4.7 g/l, 95% confidence interval 2.7 to 6.8 g/l; p < 0.0001), but had no effect compared with placebo on risk of blood transfusion or death (risk ratio 1.03, 95% confidence interval 0.78 to 1.37; p = 0.84; absolute risk difference +0.8%, 95% confidence interval -7.3% to 9.0%), or rates of blood transfusion (rate ratio 0.98, 95% confidence interval 0.68 to 1.43; p = 0.93; absolute rate difference 0.00, 95% confidence interval -0.14 to 0.15). There was no difference in postoperative complications or hospital stay. The intravenous iron group had higher Hb levels at the 8-week follow-up (difference in mean 10.7 g/l, 95% confidence interval 7.8 to 13.7 g/l; p < 0.0001). There were a total of 71 re-admissions to hospital for postoperative complications in the placebo group, compared with 38 re-admissions in the intravenous iron group (rate ratio 0.54, 95% confidence interval 0.34 to 0.85; p = 0.009). There were no differences between the groups in terms of mortality (two per group at 30 days post operation) or in any of the prespecified safety end points or serious adverse events. In patients with anaemia prior to elective major abdominal surgery, there was no benefit from giving intravenous iron before the operation. The impact of iron repletion on recovery from postoperative anaemia, and the association with reduced re-admission to hospital for complications, should be investigated. In the preoperative intravenous iron to treat anaemia in major surgery (PREVENTT) trial, all patients included had anaemia and only 20% had their anaemia corrected before surgery. The definition and causality of iron deficiency in this setting is not clear. Current Controlled Trials ISRCTN67322816 and ClinicalTrials.gov NCT01692418. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25 No. 11. See the NIHR Journals Library website for further project information.

The role of ultrasonographic lung aeration score in the prediction of postoperative pulmonary complications: an observational study

BackgroundPostoperative pulmonary complications (PPCs) are important contributors to mortality and morbidity after surgery. The available predicting models are useful in preoperative risk assessment, but there is a need for validated tools for the early postoperative period as well. Lung ultrasound is becoming popular in intensive and perioperative care and there is a growing interest to evaluate its role in the detection of postoperative pulmonary pathologies.ObjectivesWe aimed to identify characteristics with the potential of recognizing patients at risk by comparing the lung ultrasound scores (LUS) of patients with/without PPC in a 24-h postoperative timeframe.MethodsObservational study at a university clinic. We recruited ASA 2–3 patients undergoing elective major abdominal surgery under general anaesthesia. LUS was assessed preoperatively, and also 1 and 24 h after surgery. Baseline and operative characteristics were also collected. A one-week follow up identified PPC+ and PPC- patients. Significantly differing LUS values underwent ROC analysis. A multi-variate logistic regression analysis with forward stepwise model building was performed to find independent predictors of PPCs.ResultsOut of the 77 recruited patients, 67 were included in the study. We evaluated 18 patients in the PPC+ and 49 in the PPC- group. Mean ages were 68.4 ± 10.2 and 66.4 ± 9.6 years, respectively (p = 0.4829). Patients conforming to ASA 3 class were significantly more represented in the PPC+ group (66.7 and 26.5%; p = 0.0026). LUS at baseline and in the postoperative hour were similar in both populations. The median LUS at 0 h was 1.5 (IQR 1–2) and 1 (IQR 0–2; p = 0.4625) in the PPC+ and PPC- groups, respectively. In the first postoperative hour, both groups had a marked increase, resulting in scores of 6.5 (IQR 3–9) and 5 (IQR 3–7; p = 0.1925). However, in the 24th hour, median LUS were significantly higher in the PPC+ group (6; IQR 6–10 vs 3; IQR 2–4; p < 0.0001) and it was an independent risk factor (OR = 2.6448 CI95% 1.5555–4.4971; p = 0.0003). ROC analysis identified the optimal cut-off at 5 points with high sensitivity (0.9444) and good specificity (0.7755).ConclusionPostoperative LUS at 24 h can identify patients at risk of or in an early phase of PPCs.

Intraoperative oliguria does not predict postoperative acute kidney injury in major abdominal surgery: a cohort analysis.

Background:Acute kidney injury (AKI) is a common complication in patients undergoing major abdominal surgery and is associated with considerable morbidity and mortality. Several studies investigating the association between intraoperative urine output and postoperative AKI have shown conflicting results. Here, we investigated the association of intraoperative oliguria with postoperative AKI in a cohort of patients submitted to elective major abdominal surgery.Methods:This was a single-center retrospective analysis of adult patients who underwent elective major abdominal surgery from January 2016 to December 2018. AKI was defined according to the serum creatinine criteria of the KDIGO classification. Intraoperative oliguria was defined as urine output of less than 0.5 mL/kg/h. Risk factors were evaluated using multivariate logistic regression analysis.Results:A total of 165 patients were analyzed. In the first 48 h after surgery the incidence of AKI was 19.4%. Postoperative AKI was associated with hospital mortality (p=0.011). Twenty percent of patients developed intraoperative oliguria. There was no association between preexisting comorbidities and development of intraoperative oliguria. There was no correlation between the type of anesthesia used and occurrence of intraoperative oliguria, but longer anesthesia time was associated with intraoperative oliguria (p=0.007). Higher baseline SCr (p=0.001), need of vasoactive drugs (p=0.007), and NSAIDs use (p=0.022) were associated with development of intraoperative oliguria. Intraoperative oliguria was not associated with development of postoperative AKI (p=0.772), prolonged hospital stays (p=0.176) or in-hospital mortality (p=0.820).Conclusion:In this cohort of patients we demonstrated that intraoperative oliguria does not predict postoperative AKI in major abdominal surgery.

Validity and Utility Testing of a Criteria-led Discharge Checklist to Determine Post-operative Recovery after Abdominal Surgery: an International Multicentre Prospective Cohort Trial.

Criteria-led discharge (CLD) has promising potential to reduce unnecessary hospital stay after abdominal surgery; however, the validity and utility of CLD is uncertain as studies are limited to small single-centre studies involving predominantly elective colorectal surgery. This prospective international multicentre cohort study explored the relationship between a CLD checklist, post-operative recovery, and hospital length of stay using patient-level data from four clinical trials involving 1071 adults undergoing all types of emergency and elective abdominal surgery at five hospitals across Australia and New Zealand. Patients were assessed daily for 21 post-operative days using a standardised CLD checklist. Surgeons and hospital clinicians were masked to findings. Criterion, construct, and content validity of the checklist to accurately reflect discharge decisions by surgical teams, assess physiological recovery, and encompass parameters signalling physiological readiness to discharge were tested. Potential utility of CLD to minimise unnecessary hospital stay was assessed by comparing day of readiness to discharge to actual day of discharge. The CLD checklist had concordance with existing discharge planning practices and accurately measured a longer post-operative recovery in more complex clinical situations. The CLD checklist in its current format did not detect all legitimate medical and surgical reasons necessitating a continued stay in hospital. Day of readiness to discharge was 0.8days (95% CI 0.7 to 0.9, p < 0.001) less than actual day of discharge. A CLD checklist has excellent criterion and construct validity in measuring physiological recovery following all types of major elective and emergency abdominal surgery. Content validity could be improved. The use of CLD has the potential to reduce unnecessary hospital stay although the safety of discharging patients according to the criteria requires investigation prior to implementation. Trials were prospectively registered at the Australian New Zealand Clinical Trials Registry (LIPPSMAck POP 12613000664741, ICEAGE 12615000318583, PLASTIC 12619001344189, NIPPER PLUS 12617000269336).

Association Between Lower Preoperative Cognition With Intraoperative Electroencephalographic Features Consistent With Deep States of Anesthesia in Older Patients: An Observational Cohort Study.

Patients with low cognitive performance are thought to have a higher risk of postoperative neurocognitive disorders. Here we analyzed the relationship between preoperative cognition and anesthesia-induced brain dynamics. We hypothesized that patients with low cognitive performance would be more sensitive to anesthetics and would show differences in electroencephalogram (EEG) activity consistent with a brain anesthesia overdose. This is a retrospective analysis from a previously reported observational study. We evaluated cognitive performance using the Montreal cognitive assessment (MoCA) test. All patients received general anesthesia maintained with sevoflurane or desflurane during elective major abdominal surgery. We analyzed the EEG using spectral, coherence, and phase-amplitude modulation analyses. Patients were separated into a low MoCA group (<26 points, n = 12) and a high MoCA group (n = 23). There were no differences in baseline EEG, nor end-tidal age-corrected minimum alveolar concentration (MACage). However, under anesthesia, the low MoCA group had lower α-β power (high MoCA: 2.9 [interquartile range {IQR}: 0.6-5.8 dB] versus low MoCA: -1.2 [IQR: -2.1 to 0.6 dB], difference 4.1 [1.0-5.7]) and a lower α peak frequency (high MoCA: 9.0 [IQR: 8.3-9.8 Hz] versus low MoCA: 7.5 [IQR: 6.3-9.0 Hz], difference 1.5 [0-2.3]) compared to the high MoCA group. The low MoCA group also had a lower α band coherence and a stronger peak-max phase-amplitude coupling (PAC). Finally, patients in the low MoCA group had longer emergence times (high MoCA 663 ± 345 seconds versus low MoCA: 960 ± 352 seconds, difference 297 [15-578]). Multiple linear regression shows up that both age and MoCA scores are independently associated with intraoperative α-β power. All these EEG features, together with a prolonged emergence time, are consistent with the possibility that older patients with low cognitive performance are receiving a brain anesthesia overdose compare to cognitive normal patients.

Correlation of postoperative fluid balance and weight and their impact on outcomes

IntroductionNormovolemia after major surgery is critical to avoid complications. The aim of the present study was to analyze correlation between fluid balance, weight gain, and postoperative outcomes.MethodsAll consecutive patients undergoing elective or emergency major abdominal surgery needing intermediate care unit (IMC) admission from September 2017 to January 2018 were included. Postoperative fluid balances and daily weight changes were calculated for postoperative days (PODs) 0–3. Risk factors for postoperative complications (30-day Clavien) and prolonged length of IMC and hospital stay were identified through uni- and multinominal logistic regression.ResultsOne hundred eleven patients were included, of which 55% stayed in IMC beyond POD 1. Overall, 67% experienced any complication, while 30% presented a major complication (Clavien ≥ III). For the entire cohort, median cumulative fluid balance at the end of PODs 0–1–2–3 was 1850 (IQR 1020–2540) mL, 2890 (IQR 1610–4000) mL, 3890 (IQR 2570–5380) mL, and 4000 (IQR 1890–5760) mL respectively, and median weight gain was 2.2 (IQR 0.3–4.3) kg, 3 (1.5–4.7) kg, and 3.9 (2.5–5.4) kg, respectively. Fluid balance and weight course showed no significant correlation (r = 0.214, p = 0.19). Extent of surgery, analyzed through Δ albumin and duration of surgery, significantly correlated with POD 2 fluid balances (p = 0.04, p = 0.006, respectively), as did POD 3 weight gain (p = 0.042). Prolonged IMC stay of ≥ 3 days was related to weight gain ≥ 3 kg at POD 2 (OR 2.8, 95% CI 1.01–8.9, p = 0.049).ConclusionFluid balance and weight course showed only modest correlation. POD 2 weight may represent an easy and pragmatic tool to optimize fluid management and help to prevent fluid-related postoperative complications.

Intra-abdominal hypertension and abdominal compartment syndrome in patients admitted to the ICU

BackgroundIntra-abdominal hypertension is frequently present in critically ill patients and is an independent predictor for mortality. Risk factors for intra-abdominal hypertension and abdominal compartment syndrome have been widely investigated. However, data are lacking on prevalence and outcome in high-risk patients. Our objectives in this study were to investigate prevalence and outcome of intra-abdominal hypertension and abdominal compartment syndrome in high-risk patients in a prospective, observational, single-center cohort study.ResultsBetween March 2014 and March 2016, we included 503 patients, 307 males (61%) and 196 females (39%). Patients admitted to the intensive care unit with a diagnosis of pancreatitis, elective or emergency open abdominal aorta surgery, orthotopic liver transplantation, other elective or emergency major abdominal surgery and trauma were enrolled. One hundred and sixty four (33%) patients developed intra-abdominal hypertension and 18 (3.6%) patients developed abdominal compartment syndrome. Highest prevalence of abdominal compartment syndrome occurred in pancreatitis (57%) followed by orthotopic liver transplantation (7%) and abdominal aorta surgery (5%). Length of intensive care stay increased by a factor 4 in patients with intra-abdominal hypertension and a factor 9 in abdominal compartment syndrome, compared to patients with normal intra-abdominal pressure. Rate of renal replacement therapy was higher in abdominal compartment syndrome (38.9%) and intra-abdominal hypertension (8.2%) compared to patients with normal intra-abdominal pressure (1.2%). Both intensive care mortality and 90-day mortality were significantly higher in intra-abdominal hypertension (4.8% and 15.2%) and abdominal compartment syndrome (16.7% and 38.9%) compared to normal intra-abdominal pressure (1.2% and 7.1%). Body mass index (odds ratio 1.08, 95% confidence interval 1.03–1.13), mechanical ventilation at admission (OR 3.52, 95% CI 2.08–5.96) and Apache IV score (OR 1.03, 95% CI 1.02–1.04) were independent risk factors for the development of intra-abdominal hypertension or abdominal compartment syndrome.ConclusionsThe prevalence of abdominal compartment syndrome was 3.6% and the prevalence of intra-abdominal hypertension was 33% in this cohort of high-risk patients. Morbidity and mortality increased when intra-abdominal hypertension or abdominal compartment syndrome was present. The patient most at risk of IAH or ACS in this high-risk cohort has a BMI > 30 kg/m2 and was admitted to the ICU after emergency abdominal surgery or with a diagnosis of pancreatitis.

Assessment of predictive validity and feasibility of Edmonton Frail Scale in identifying postoperative complications among elderly patients: a prospective observational study

Frailty is defined as diminished physiological reserve predisposing one to adverse outcomes when exposed to stressors. Currently, there is no standardized Frail assessment tool used perioperatively. Edmonton Frail Scale (EFS), which is validated for use by non-geriatricians and in selected surgical populations, is a candidate for this role. However, little evaluation of its use has been carried out in the Asian populations so far. This is a prospective observational study done among patients aged 70 years and above attended Preoperative Assessment Clinic (PAC) in Singapore General Hospital prior to major abdominal surgery from December 2017 to September 2018. The Comprehensive Complication Index (CCI) and Postoperative Morbidity Survey (POMS) were used to assess their postoperative morbidity respectively. Patient’s acceptability of EFS was measured using the QQ-10 questionnaire and the inter-rater reliability of EFS was assessed by Kappa statistics and Bland Altman plot. The primary aim of this study is to assess if frailty measured by EFS is predictive of postoperative complications in elderly patients undergoing elective major abdominal surgery. We also aim to assess the feasibility of implementing EFS as a standard tool in the outpatient preoperative assessment clinic setting. EFS score was found to be a significant predictor of postoperative morbidity. (OR 1.35, p < 0.001) Each point increase in EFS score was associated with a 3 point increase in CCI score. (Coefficient b 2.944, p < 0.001) EFS score more than 4 has a fair predictability of both early and 30-day postoperative complications. Feasibility study demonstrated an overall acceptance of the EFS among our patients with good inter-rater agreement.

Preoperative intravenous iron to treat anaemia before major abdominal surgery (PREVENTT): a randomised, double-blind, controlled trial

SummaryBackgroundPreoperative anaemia affects a high proportion of patients undergoing major elective surgery and is associated with poor outcomes. We aimed to test the hypothesis that intravenous iron given to anaemic patients before major open elective abdominal surgery would correct anaemia, reduce the need for blood transfusions, and improve patient outcomes.MethodsIn a double-blind, parallel-group randomised trial, we recruited adult participants identified with anaemia at preoperative hospital visits before elective major open abdominal surgery at 46 UK tertiary care centres. Anaemia was defined as haemoglobin less than 130 g/L for men and 120 g/L for women. We randomly allocated participants (1:1) via a secure web-based service to receive intravenous iron or placebo 10–42 days before surgery. Intravenous iron was administered as a single 1000 mg dose of ferric carboxymaltose in 100 mL normal saline, and placebo was 100 mL normal saline, both given as an infusion over 15 min. Unblinded study personnel prepared and administered the study drug; participants and other clinical and research staff were blinded to treatment allocation. Coprimary endpoints were risk of the composite outcome of blood transfusion or death, and number of blood transfusions from randomisation to 30 days postoperatively. The primary analysis included all randomly assigned patients with data available for the primary endpoints; safety analysis included all randomly assigned patients according to the treatment received. This study is registered, ISRCTN67322816, and is closed to new participants.FindingsOf 487 participants randomly assigned to placebo (n=243) or intravenous iron (n=244) between Jan 6, 2014, and Sept 28, 2018, complete data for the primary endpoints were available for 474 (97%) individuals. Death or blood transfusion occurred in 67 (28%) of the 237 patients in the placebo group and 69 (29%) of the 237 patients in the intravenous iron group (risk ratio 1·03, 95% CI 0·78–1·37; p=0·84). There were 111 blood transfusions in the placebo group and 105 in the intravenous iron group (rate ratio 0·98, 95% CI 0·68–1·43; p=0·93). There were no significant differences between the two groups for any of the prespecified safety endpoints.InterpretationPreoperative intravenous iron was not superior to placebo to reduce need for blood transfusion when administered to patients with anaemia 10–42 days before elective major abdominal surgery.FundingUK National Institute of Health Research Health Technology Assessment Program.

Impact of preoperative HbA1c on postoperative complications after elective major abdominal surgery: a systematic review protocol.

IntroductionDiabetes has an increasing worldwide prevalence. It is known to be a predisposing factor for postoperative complications. Preoperative glycaemic control strategies should be pursued as glycaemic control could serve as a modifiable risk factor. Glycated haemoglobin (HbA1c), a marker of 3-month average glycaemic control, has been shown in meta-analyses to predict postoperative complications in cardiothoracic, bariatric and orthopaedic surgery. However, there is no meta-analysis in the major abdominal surgery population, in whom morbidity may be higher due to the nature of the surgery. Understanding the association between HbA1c and postoperative complications could help in preoperative risk prognostication, counselling and glycaemic target selection. The aim of this systematic review and meta-analysis is to evaluate all evidence on the association between preoperative HbA1c and postoperative complications in elective major abdominal surgery, and to investigate the threshold HbA1c level before postoperative complication rates increase.Methods and analysisThis review will be performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure will be searched for all original studies. Study selection, data extraction, risk of bias and quality assessment will be conducted by two independent reviewers. The primary outcome is the association between preoperative HbA1c and major postoperative complications (Clavien Dindo 3–5), and the secondary outcome is the association between HbA1c and overall postoperative complications. Data management and synthesis will be performed using Microsoft Excel and Stata to derive pool estimates.Ethics and disseminationNo ethics approval is required as only secondary data will be used. Findings will be disseminated through peer-reviewed journals and conference presentations.PROSPERO registration numberCRD42020167347.

The effect of perioperative nutritional support on readmission ratios in elective major abdominal surgery

Objective: Postoperative results will be poor when major surgeries are performed on patients with malnutrition. Therefore, it is recommended in the perioperative period to provide nutritional support (NS) to patients with malnutrition for surgeries especially for cancer. Although different opinions on the timing of NS continue, data on the effect of this treatment on readmission rates are also insufficient. Methods: A study was planned on patients undergoing resective surgery for intraabdominal malignancy between January 2010 and December 2018. Patients who were given preoperative oral nutritional supplementation (ONS) constituted group A and those who were given perioperative NS constituted group B. Demographic data, comorbidities, preoperative prealbumin values, surgeries performed, postoperative complications, length of hospital stay, rehospitalization rates within the first 30 days after discharge, and prealbumin values at readmission were compared between the 2 groups. Results: The data of 371 patients (157 in group A and 214 in group B) who met the inclusion criteria for the study were evaluated. No statistical difference was found between the 2 groups in terms of demographic data and comorbid diseases. Postoperative complications were observed in 42 patients (26.7%) in group A and in 53 patients (24.7%) in group B (p&gt;0.05). The number of patients who developed problems requiring rehospitalization within the first 30 days was 18 (11.4%) in group A and 11 (5.1%) in group B (p&lt;0.05). The number of patients with more than 5% weight loss at the time of readmission compared with the day of discharge was 9 (50%) in group A and 1 (20%) in group B (p&lt;0.05). A statistical difference was found in prealbumin levels at the time of readmission (p&lt;0.05). Conclusion: NS treatment, which is started in the preoperative period and continued postoperatively, has more positive effects on readmission rates and postoperative nutritional status.

Major elective abdominal surgery acutely impairs lower limb muscle pyruvate dehydrogenase complex activity and mitochondrial function

SummaryBackground & aimsThis post hoc study aimed to determine whether major elective abdominal surgery had any acute impact on mitochondrial pyruvate dehydrogenase complex (PDC) activity and maximal mitochondrial ATP production rates (MAPR) in a large muscle group (vastus lateralis -VL) distant to the site of surgical trauma.MethodsFifteen patients undergoing major elective open abdominal surgery were studied. Muscle biopsies were obtained after the induction of anesthesia from the VL immediately before and after surgery for the determination of PDC and maximal MAPR (utilizing a variety of energy substrates).ResultsMuscle PDC activity was reduced by >50% at the end of surgery compared with pre-surgery (p < 0.05). Muscle MAPR were comprehensively suppressed by surgery for the substrate combinations: glutamate + succinate; glutamate + malate; palmitoylcarnitine + malate; and pyruvate + malate (all p < 0.05), and could not be explained by a lower mitochondrial yield.ConclusionsPDC activity and mitochondrial ATP production capacity were acutely impaired in muscle distant to the site of surgical trauma. In keeping with the limited data available, we surmise these events resulted from the general anesthesia procedures employed and the surgery related trauma. These findings further the understanding of the acute dysregulation of mitochondrial function in muscle distant to the site of major surgical trauma in patients, and point to the combination of general anesthesia and trauma related inflammation as being drivers of muscle metabolic insult that warrants further investigation.Clinical trial registrationRegistered at (NCT01134809).

Ketamine Versus Tramadol As an Adjunct To PCA Morphine for Postoperative Analgesia After Major Upper Abdominal Surgery: a Prospective, Comparative, Randomized Trial.

Background and aimsPatient-controlled analgesia (PCA) with morphine is commonly used to provide analgesia following major surgery, but is not sufficient as a monotherapy strategy. This study aimed to compare the adjunctive analgesic effect of ketamine versus tramadol on postoperative analgesia provided via PCA-morphine in patients undergoing major upper abdominal surgeries.MethodsForty-two patients undergoing elective major upper abdominal surgery under general anesthesia were allocated to receive either ketamine (load dose of 0.5 mg kg−1 followed by a continuous infusion of 0.12 mg kg−1 h−1 up to 48 postoperative hours; ketamine group, n = 21) or tramadol (load dose of 1 mg kg−1 followed by a continuous infusion of 0.2 mg kg−1 h−1 up to 48 postoperative hours; tramadol group, n = 21) in addition to their standard postoperative analgesia with PCA-morphine. Postoperative data included morphine consumption, visual analog scale (VAS) scores, and side effects during the first 48 postoperative hours after PCA-morphine initiation.ResultsThere were no significant differences in patient demographic and intraoperative data between the two groups. Tramadol group had significantly less total morphine consumption during the first 48 postoperative hours (28.905 [16.504] vs 54.524 [20.846] mg [p < 0.001]) and presented significantly lower VAS scores at rest and mobilization (p < 0.05) than the ketamine group. No statistical difference was recorded between the two groups (p > 0.05) regarding postoperative cough, sedation, hallucinations, pruritus, urine retention, and postoperative nausea and vomiting. However, patients in the ketamine group reported dry mouth more frequently than patients in the tramadol group (p = 0.032).ConclusionsPostoperative administration of tramadol was superior to ketamine due to significantly reduced opioid consumption and better pain scores in patients receiving PCA-morphine after major upper abdominal surgery.

Incidence of infection in non-tunnelled thoracic epidural catheters after major abdominal surgery.

Thoracic epidural analgesia is beneficial after major abdominal surgery, though side-effects and complications are rare but potentially devastating. The incidence of catheter-related infection is approximately 5.5%. Several guidelines have been recommended to prevent complications during thoracic epidural catheterization. Tunnelling is often recommended to reduce the incidence of infections and dislocations. A retrospective, single-centre analysis of our acute pain service database was performed between 2010 and 2018. The hygiene measures of the German Society of Anaesthesiology have been incorporated in our standard operating protocol since 2009. The procedure remained constant, but the skin disinfectant was changed from propan-2-ol to propan-2-ol with octenidine in 2014. Tunnelling of catheters was not performed. We analysed the incidence of catheter-related infections (primary endpoint) and effect of the used disinfectant (secondary endpoint). A total of 2755 patients underwent elective major abdominal surgery with thoracic epidural catheterization. Sixteen patients (0.6%) showed symptoms of mild catheter-related infection. Moderate or severe infections were not observed in any patient. The type of disinfectant did not show any significant effect on the incidence of infection. The incidence of catheter-related infections was low, and only mild signs of infection were observed. Non-tunnelling could be an alternative to tunnelling, especially if hygiene protocols are followed, and the duration of catheter use is short. A comprehensive database and regular examinations by trained staff are essential for early detection of abnormalities and immediate removal of the catheter, if required.

Impact of a Preoperative Video-Based Educational Intervention on Postoperative Outcomes in Elective Major Abdominal Surgery: a Randomized Controlled Trial

Impact of a Preoperative Video-Based Educational Intervention on Postoperative Outcomes in Elective Major Abdominal Surgery: a Randomized Controlled Trial

Estimated oxygen extraction versus dynamic parameters of fluid-responsiveness for perioperative hemodynamic optimization of patients undergoing non-cardiac surgery: a non-inferiority randomized controlled trial

BackgroundGoal directed therapy (GDT) is able to improve mortality and reduce complications in selected high-risk patients undergoing major surgery. The aim of this study is to compare two different strategies of perioperative hemodynamic optimization: one based on optimization of preload using dynamic parameters of fluid-responsiveness and the other one based on estimated oxygen extraction rate (O2ER) as target of hemodynamic manipulation.MethodsThis is a multicenter randomized controlled trial. Adult patients undergoing elective major open abdominal surgery will be allocated to receive a protocol based on dynamic parameters of fluid-responsiveness or a protocol based on estimated O2ER. The hemodynamic optimization will be continued for 6 h postoperatively. The primary outcome is difference in overall postoperative complications rate between the two protocol groups. Fluids administered, fluid balance, utilization of vasoactive drugs, hospital length of stay and mortality at 28 day will also be assessed.DiscussionAs a predefined target of cardiac output (CO) or oxygen delivery (DO2) seems to be not adequate for every patient, a personalized therapy is likely more appropriate. Following this concept, dynamic parameters of fluid-responsiveness allow to titrate fluid administration aiming CO increase but avoiding fluid overload. This approach has the advantage of personalized fluid therapy, but it does not consider if CO is adequate or not. A protocol based on O2ER considers this second important aspect. Although positive effects of perioperative GDT have been clearly demonstrated, currently studies comparing different strategies of hemodynamic optimization are lacking.Trial registrationClinicalTrials.gov, NCT04053595. Registered on 12/08/2019.

Comparison of Perioperative Standard and Immunomodulating Enteral Nutrition in Patients Received Major Abdominal Cancer Surgery: a Prospective, Randomized, Controlled Clinical Trial

The aim of this study was to compare the effects of standard and immunomodulating enteral nutrition on the clinical outcomes of the patients undergoing major abdominal cancer surgery. Patients who underwent a major elective abdominal cancer surgery in our clinic were randomly assigned preoperatively to two groups according to enteral nutritional intervention; Standard (ST) or Immunomodulating (IM) group. The patients who were randomized to ST and IM groups received Resource® 2.0 fiber and OraI Impact® RTD 7 days prior to surgery and 30 days after surgery, respectively. The outcome variables were as follows; infections (surgical site infection, pneumonia, abdominal abscess or septicemia), non-infectious complications (wound dehiscence, anastomotic leak, adult respiratory distress syndrome (ARDS), multi-organ failure), need for intensive care unit admission, need for re-operation, length of hospital stay, and hospital mortality. A total of 78 patients were randomized (n = 39 in each group). Forty-five (58%) of patients were male and mean age was 62.9 ± 13.4 (25–85). The mean pre-operative Body Mass Index (BMI) and Nutritional Risk Screening (NRS-2002) scores were 26.5 ± 5.4 and 2.3 ± 1.1, respectively. There were no significant differences in gender, age, BMI, and NRS-2002 scores between groups (p ≥ 0.05). ASA scores, surgical interventions also were similar in two groups. Rate of surgical site infection in groups ST and IM was 72% (n = 28) and 15% (n = 6), (p < 0.001). Rate of pneumonia in groups ST and IM was 25% (n = 10) and 0% (n = 0), (p < 0.001). Rate of urinary tract infection in groups ST and IM was 33.3% (n = 13) and 5.1% (n = 2), (p < 0.03). Length of hospital stay in groups ST and IM was 8.4 ± 4.8 and 6.1 ± 1.4, respectively (p < 0,003). There were no significant differences in other outcome variables between groups (p ≥ 0.05, for all comparisons). Perioperative immunomodulating enteral nutrition may reduce the incidence of surgical site infection, pneumonia, urinary tract infection and length of hospital stays in patients who received abdominal cancer surgery.