Morning Of Surgery Research Articles

Continuation of Angiotensin-Converting Enzyme Inhibitors on the Day of Surgery Is Not Associated With Increased Risk of Hypotension Upon Induction of General Anesthesia in Elective Noncardiac Surgeries

The aim of this study was to find out whether the preoperative continuation of angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin II receptor blocker (ARB) treatment is associated with intraoperative hypotension immediately after induction of general anesthesia in elective noncardiac surgeries. Retrospective cohort study. Single institutional university hospital. Four hundred patients who underwent elective noncardiac surgery under general anesthesia, with ACE-I or ARB on their list of preoperative home medications, were included. Preoperative ACE-I and ARB use was evaluated, and patients were divided into an ACE-I/ARB group versus non-ACE-I/ARB group. The primary outcome measure was intraoperative hypotension after induction of general anesthesia. The secondary outcome measure was preoperative medication use, medications taken the morning of surgery, induction medication and dosage, and vasopressor medication use during induction. Three hundred forty-nine patients were included for final analysis. The mean admission American Society of Anesthesiologists status was 2.7 ± 0.5, age 65 ± 11 years, and body mass index 31 ± 6.9 kg/m2. There were no statistically significant changes between the no ACE-I/ARB group and the ACE-I/ARB group in systolic blood pressure (p = 0.853), diastolic blood pressure (p = 0.357), and heart rate (p = 0.220) change over the 15 minutes. There was no statistical difference in induction medication dose (propofol, fentanyl, and rocuronium) and pressor use (p = 0.137) for hypotension between the 2 groups. Statistically significant hypotension (p < 0.001) occurred in both groups equally over 15 minutes. Continuation of ACE-I/ARB on the day of surgery was not associated with increased risk of intraoperative hypotension upon induction and within 15 minutes of general anesthesia in elective noncardiac surgeries.

Comparison of perioperative patient comfort with 'enhanced recovery after surgery (ERAS) approach' versus 'traditional approach' for elective laparoscopic cholecystectomy.

Background:Perioperative anxiety, hunger, thirst, fatigue, pain along with nausea and vomiting can influence a patient's recovery after surgery. We aimed to compare 'enhanced recovery after surgery' (ERAS) protocol with a traditional perioperative approach to evaluate a patient's recovery after elective laparoscopic cholecystectomy.Methods:A prospective randomised controlled study was conducted after institutional ethical clearance on 50 patients undergoing elective laparoscopic cholecystectomy, and divided equally into two groups. In group 1 (traditional); standard fasting guidelines and routine perioperative management was implemented. In group 2 (ERAS); patients received appropriate multimedia information about surgery and anaesthesia besidecarbohydrate loading with tender coconut water on the previous night and on the morning of surgery. Standard guidelines of fasting for solids were followed. Intraoperatively, goal-directed fluid therapy and an inspired oxygen concentration of 60% were administered. Postoperatively, early diet and mobilisation were initiated. The primary outcome was the assessment of perioperative anxiety. Hunger, thirst, fatigue, pain, nausea, vomiting and overall perioperative experience were also evaluated.Results:ERAS group had reduced anxiety prior to surgery: median (interquartile range) 3 (3–4) vs 2 (2–3) (P = 0.003), and at 6 h postoperatively: 4 (3–6) vs 3 (1–4) (P = 0.001). Hunger, thirst and fatigue (P < 0.01) were also decreased with better overall perioperative experience (5 [4–5] vs 6 [5–7], P = 0.004). Pain, nausea, vomiting and blood glucose were similar between the groups.Conclusion:'ERAS approach reduces anxiety in addition to hunger, thirst and fatigue with enhanced overall perioperative comfort in patients undergoing laparoscopic cholecystectomy.

Oral tranexamic acid for bleeding during spinal surgery: A randomized double-blind placebo clinical trial

&lt;abstract&gt;&lt;sec&gt; &lt;title&gt;Objectives&lt;/title&gt; &lt;p&gt;This study aimed to evaluate the oral Tranexamic acid (TXA) effect on the bleeding during spine surgery amounts.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Patients and Methods&lt;/title&gt; &lt;p&gt;In this randomized double-blind placebo clinical trial, patients with lumbar spinal cord and back pain disease, those who needed fusion or were candidates for bilateral or more or equal to two levels surgeries, and those who referred to the Neurosurgery Department, were included and randomly divided into two equal groups. TXA was orally administered at 25 mg/kg dosages four times a day before surgery and 500 mg in the morning of surgery. The bleeding amount during the operation was calculated based on the number of sterile pads used during the operation and the amount of bleeding collected in the suction device (suction) in milliliters. Each sterile pad soaked in blood is equal to 50 ml of bleeding. The suction blood content at the end of the operation (in milliliters), was also collected by bleeding in sterile pads and reported in milliliters. The difference in hemoglobin level 24 after surgery was compared to before surgery. The follow-up period was until discharge from the hospital.&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Results&lt;/title&gt; &lt;p&gt;No significant difference was seen in the demographic data between the two groups (&lt;italic&gt;p&lt;/italic&gt; &amp;lt; 0.05). Oral TXA had a positive effect on the intraoperative and postoperative bleeding amounts, and hospitalization duration, and it significantly reduced bleeding in the mentioned cases (&lt;italic&gt;p&lt;/italic&gt; &amp;lt; 0.05 in all cases). Moreover, no significant differences were observed in coagulation factors, including PT, INR, and coagulation tests between the two groups, even PTT was increased. Oral TXA increased nausea and vomiting experienced by patients in the intervention group (&lt;italic&gt;p&lt;/italic&gt; &amp;lt; 0.05).&lt;/p&gt; &lt;/sec&gt;&lt;sec&gt; &lt;title&gt;Conclusions&lt;/title&gt; &lt;p&gt;Overall, oral TXA significantly reduced the intraoperative and postoperative bleeding, as well as the hospitalization duration in patients undergoing spinal surgery in comparison with the placebo group. Because of its anti-fibrinolytic properties, TXA effectively controlled bleeding. Thus, the intraoperative bleeding amount was decreased with the TXA administration.&lt;/p&gt; &lt;/sec&gt;&lt;/abstract&gt;

A comparison of preoperative psychological preparation with midazolam premedication to reduce anxiety in children undergoing adenotonsillectomy.

Introduction:Considering the multiplicity of adenotonsillectomy in children 2–10-year old at the paediatric surgery centres, patient anxiety leads to an increase in surgical and anaesthetic complications. Patients' unfamiliarity with surgical and anaesthetic interventions may increase their stress. Midazolam premedication reduces patient anxiety. In previous studies, psychological preparation before surgery using understandable terms to children, has reduced their anxiety. The aim of this study was to compare and study behavioural reflections among the children in two groups: the first group was prescribed oral midazolam, and the second group received psychological preparation with the booklet about anaesthesia and anaesthesia-resident explanation.Materials and Methods:This study is a clinical trial conducted on 48 children undergoing adenotonsillectomy. Children in the first group (midazolam group) received oral midazolam 0.5 mg/kg, 20 min before surgery. A booklet containing pictures and information about anaesthesia and the operating room was given to the second group (psychological preparation group) the night before surgery and anaesthesia resident explained the booklet to the children. The anxiety level was measured in both groups using the State-Trait Anxiety Inventory for Children questionnaire the night before surgery and on the morning of surgery (after giving midazolam to Group II). The results were analysed using SPSS.Results:In this study, 58.3% of the first group and 45.8% of the second group were male. The mean age of the first and second groups was 8.45 ± 1.86 and 9.12 ± 1.72 years, respectively. The anxiety in the first group significantly decreased in the morning before surgery compared to the night before operation (P < 0.001). The anxiety in the second group significantly decreased in the morning before surgery compared to the night before as well (P < 0.001).Conclusion:The results showed that midazolam and psychological preparation prior to surgery can reduce the anxiety of children before adenotonsillectomy.

Post-operative delirium associated with metabolic alterations following hemi-arthroplasty in older patients.

post-operative delirium (POD) is a common complication in older patients, though a possible link between metabolic changes and POD development has yet to be investigated. older patients with hip fracture who underwent hemi-arthroplasty were recruited, and delirious states were assessed for 3 days after surgery using the confusion assessment method-Chinese revision. Simultaneously, fasting blood samples were collected on the morning of surgery and on the first post-operative day. Ultimately, 244 older patients who met the inclusion and exclusion criteria were assessed. Blood samples from 60 patients with POD and 60 matched controls were analysed using metabolomics platforms. sixty patients (24.6%) developed POD. Principal component analysis scores plot and cross-validated scores plots from orthogonal partial least squares-discriminant analysis were implemented to visualise the differences in metabolites between the two groups before and after surgery (P < 0.05). Our data indicate that levels of ω3 and ω6 fatty acids were lower in the POD group than in the NPOD (non-POD) group both before and after surgery; tricarboxylic cycle intermediate levels were lower in the POD group than in the NPOD group, but glycolysis products were higher in the POD group than in the NPOD group after surgery. Furthermore, the branched-chain amino acid (BCAA)/aromatic amino acid ratio was lower in the POD group than in the NPOD group after surgery. metabolic abnormalities, including deficiencies in ω3 and ω6 fatty acids, perturbations in tricarboxylic cycle and oxidative stress and metabolic imbalances in BCAA and AAA might contribute to POD development.

A Pilot Quality Improvement Project to Reduce Preoperative Fasting Duration in Pediatric Inpatients.

At an academic pediatric hospital, we created the preanesthesia diet order, a standardized, clear liquid diet for eligible inpatients undergoing anesthesia to decrease preoperative fasting duration. After implementation in January 2018, a statistical process control chart was used to measure the fasting duration of all eligible inpatients by month, and the Wilcoxon rank-sum test assessed differences. A Poisson test was used to determine differences in aspiration rates. Over the first year of our pilot intervention, 127 inpatients received the preanesthesia diet. The average fasting duration before its implementation was 12.5 and 5.7 hours postimplementation. The average adoption rate for eligible inpatients was 17.6%, and there was no difference in aspiration rates. This quality improvement project demonstrated that a standardized, clear liquid diet on the morning of surgery could reduce preoperative fasting times among pediatric inpatients. The adoption of this pilot intervention was limited, highlighting the challenges of implementing a practice change.

Local release of metalloproteinases and their inhibitors after a successful revascularisation procedure.

An altered balance between metalloproteinases (MMPs) and their inhibitor tissue inhibitor of metalloproteinases (TIMPs) may influence the healing process of a minor amputation following a successful vein graft. To speed up this process, negative pressure wound therapy (NPWT) and advanced moist wound dressing have been proposed. We determined the systemic and local release of MMP-1, -2, -3, -9, TIMP-1, and TIMP-2 by enzyme linked immunosorbent assay (ELISA) technique and their influences in the healing process in 26 patients who underwent minor amputation after a successful revascularisation procedure. Twelve patients (group 1) were medicated with NPWT and 14 (group 2) with advanced moist wound dressing. Plasma samples were collected on the morning of surgery and thereafter at 1, 3, and 5 months; exudates were collected 3 days after surgery when amputation was performed and thereafter at 1, 3, and 5 months. Fifteen age-matched healthy male volunteers served as controls. All wounds healed in 5 ± 0.5 months. Follow-up plasma and local release of MMP-1, -2, -3, and -9 were overall significantly lower when compared with the preoperative levels, while those of TIMP-1 and -2 were significantly higher with no differences among the groups. Despite no differences in the healing process being observed among the two types of medications, at 1 month the local release of MMP-2 and -9 was significantly lower (P = .013 and .047, respectively) and that of TIMP-1 was significantly higher (P = .042) in group 1 as compared to group 2. A correct and aggressive local approach to the wound is able to promote the healing of the lesion stimulating the extracellular matrix turnover with local MMP/TIMP adequate balance and favouring the creation of granulation tissue. However, a successful restoration of an adequate blood flow remains the key point of a durable and rapid wound healing.

Eliminating Opioid Use After Mini-Laparoscopic Gynecologic Surgery: Effectiveness of a Multimodal Pain Management Approach Adopted into Clinical Practice.

Video Objective The objective of this video is to identify an effective, non-opioid, multimodal pain medication regimen, in women undergoing mini-laparoscopic gynecologic surgery, defined in this study as using laparoscopic instrument ports with an inner diameter of ≤5 mm. Setting A 1 year quality improvement, single-institution study was conducted on consecutive patients undergoing laparoscopic gynecologic surgery procedures, using 3 laparoscopic instrument ports with an inner diameter measuring 5 mm or less. Interventions A multimodal pain medication regimen was given in the perioperative period, consisting of one oral dose of gabapentin 300 mg the evening prior to surgery. Oral Acetaminophen 1000 mg and a second dose of oral gabapentin 300 mg given the morning of surgery. Intraoperative infiltration of local Ropivacaine was administered at the incision sites. Postoperatively, patients were started on around-the-clock oral gabapentin 300 mg every 12 hours, acetaminophen 500 mg every 6 hours, and ketorolac 30 mg IV for 3 doses, followed by celecoxib 200 mg every 12 hours. Hospitalization records were reviewed, measuring the number of opioid doses given to these patients on the day of surgery after transfer from the post-anesthesia care unit (PACU), on postoperative day 1, and after discharge. The primary comparative outcome was the number of opioid doses the patient received during each phase of the observation period. Conclusion When combined with reduced (≤ 5mm) diameter laparoscopic instrumentation, a non-opioid, multimodal pain medication regimen, consisting of ropivacaine local anesthesia, and an around-the-clock oral regimen consisting of acetaminophen, NSAIDS, and gabapentin is able to effectively eliminate the need for postoperative opioid use in patients undergoing laparoscopic gynecologic surgery. The objective of this video is to identify an effective, non-opioid, multimodal pain medication regimen, in women undergoing mini-laparoscopic gynecologic surgery, defined in this study as using laparoscopic instrument ports with an inner diameter of ≤5 mm. A 1 year quality improvement, single-institution study was conducted on consecutive patients undergoing laparoscopic gynecologic surgery procedures, using 3 laparoscopic instrument ports with an inner diameter measuring 5 mm or less. A multimodal pain medication regimen was given in the perioperative period, consisting of one oral dose of gabapentin 300 mg the evening prior to surgery. Oral Acetaminophen 1000 mg and a second dose of oral gabapentin 300 mg given the morning of surgery. Intraoperative infiltration of local Ropivacaine was administered at the incision sites. Postoperatively, patients were started on around-the-clock oral gabapentin 300 mg every 12 hours, acetaminophen 500 mg every 6 hours, and ketorolac 30 mg IV for 3 doses, followed by celecoxib 200 mg every 12 hours. Hospitalization records were reviewed, measuring the number of opioid doses given to these patients on the day of surgery after transfer from the post-anesthesia care unit (PACU), on postoperative day 1, and after discharge. The primary comparative outcome was the number of opioid doses the patient received during each phase of the observation period. When combined with reduced (≤ 5mm) diameter laparoscopic instrumentation, a non-opioid, multimodal pain medication regimen, consisting of ropivacaine local anesthesia, and an around-the-clock oral regimen consisting of acetaminophen, NSAIDS, and gabapentin is able to effectively eliminate the need for postoperative opioid use in patients undergoing laparoscopic gynecologic surgery.

Feasibility of perioperative volatile organic compound breath testing for prediction of paralytic ileus following laparoscopic colorectal resection.

Despite implementation of enhanced recovery after surgery (ERAS) and laparoscopic techniques, postoperative ileus (POI) remains frequent after colorectal surgery, impacting the patient, their recovery and health-care resources. Presently there are no tests that reliably predict or enable early POI diagnosis. Volatile organic compounds (VC) are products of human and microbiota cellular metabolism and we hypothesised that a detectable alteration occurs in POI. This was a prospective observational study of patients undergoing laparoscopic colorectal resection within an established ERAS programme. Standardized end-expiratory breath sampling was performed on the morning of surgery and on the first three postoperative mornings. The concentrations of VCs commonly found in intestinal gas were analysed using selected ion flow tube mass spectrometry and GastroCH4 ECK®. Feasibility data, bowel preparation, postoperative oral intake, POI and 30-day morbidity were recorded. Of the 75 potentially eligible patients, 58 (77%) agreed to participate. Per-protocol breath sampling was successfully completed in 94%. There were no analytical failures. Baseline and postoperative concentrations of VCs were broadly comparable and were not altered by bowel preparation or postoperative oral intake. POI developed in 14 (29%) patients. Preoperative ammonia concentration was higher in patients who developed POI [830parts per billion (ppb) vs 510ppb, P=0.027]. There was an increase in the concentration of acetic acid detected on day 2 in patients who developed POI (99ppb vs 171ppb, P=0.021). Repeated VC breath sampling and analysis is feasible in the perioperative setting. An elevated ammonia concentration on the morning of surgery may be a potential predictor of POI.

A Survey of Chemoprophylaxis Techniques in Spine Surgery Among American Neurosurgery Training Programs

A paucity of randomized trials have compared prophylactic dose of unfractionated heparin (UFH) versus low-molecular-weight heparin (LMWH) for the prevention of venous thromboembolic events in spinal surgery. Our objective was to determine the most prevalent chemoprophylactic techniques in spine surgery. The Accreditation Council for Graduate Medical Education was queried for all neurosurgical residency programs, which were subsequently sent an electronic survey about prophylactic UFH versus LMWH in spine surgery for (1) degenerative/deformity, (2) traumatic, and (3) neoplastic pathologies. Of 69 unique responding residencies, the first dose of chemoprophylaxis for degenerative/deformity spinal disease started most commonly on postoperative day (POD) 1 in 75.3% of neurosurgery programs, followed by POD 2 in 10.1% of programs, POD 0 (same day of surgery) in 8.7% of programs, POD 3 in 1.4% of programs, and morning of surgery in 1.4% of programs. Choice of postoperative chemoprophylaxis did not differ statistically significantly between UFH versus LMWH: 56.5% versus 36.2% in degenerative/deformity pathologies (P= 0.080) and 50.7% versus 43.4% in traumatic pathologies (P= 0.535). Three programs (4.3%) in both the degenerative/deformity and trauma groups documented no chemoprophylaxis. Neoplastic pathologies saw a statistically significantly higher proportion of prophylactic UFH (60.8%) compared with prophylactic LMWH (36.2%) (P= 0.037). One program (1.4%) in the neoplastic group did not utilize chemoprophylaxis. Two institutions (2.8%) in the degenerative/deformity cohort and 1 institution (1.4%) in the trauma and cancer cohorts reported "other". Prophylactic UFH was statistically more common than LMWH in neoplastic spinal surgery, but not in the degenerative/deformity and trauma groups (cohorts). Further trials are warranted.

Different inflammatory cytokines release after open and endovascular reconstructions influences wound healing.

Prodromal signs of a non-healing wound after revascularisation, which might be strictly linked with impending failure of vascular reconstructions, are associated with an inflammatory response mediated by several circulating adhesion molecules, extracellular endopeptidases, and cytokines. The aim of our study was to investigate the role of selected plasma biomarkers in the prediction of both wound healing and failure of infrapopliteal vein graft or percutaneous trans-luminal angioplasty (PTA) with selective stent positioning of the superficial femoral artery (SFA) in a population affected with critical limb ischaemia. A total of 68 patients who underwent either surgical or endovascular revascularisation of the inferior limb with autologous saphenous vein infrapopliteal bypass or PTA and selective stenting of the SFA were enrolled in our study. Patients were divided into two groups according to treatment: 41 patients were included in Group 1 (open surgery) and 27 in Group 2 (endovascular procedure). Plasma and blood samples were collected on the morning of surgery and every 6 months thereafter for up to 2 years of follow-up or until an occlusion occurred of either the vein bypass graft or the vessel treated endovascularly. Fifteen age-matched healthy male volunteers were considered a reference for biological parameters. Vascular cell adhesion molecule 1 [VCAM-1]/CD106, inter-cellular adhesion molecule-1 [ICAM-1]/CD54), interleukin-1 (IL-1), interleukin-6 (IL-6), tumour necrosis factor alpha (TNF-α), and metalloproteinases (MMP)-2 and -9 plasma levels were measured with enzyme-linked immunosorbent assay (ELISA) kits. The mean observed time to heal of 54 wounds was 13 ± 4 months, with no statistically significant differences among the groups. The healing failure of the remaining wounds was strictly related to an unsuccessful open (n = 12) or endovascular (n = 8) treatment. The 2-year primary patency rate was 65% (SE = .09) in Group 1 and 52% (SE = .1) in Group 2. When compared with mean concentration values of Group 1, VCAM-1 and ICAM-1 were always significantly higher during follow-up in patients of Group 2 (P < .05). Furthermore, in the same group, IL-6 and tumour necrosis factor alpha (TNF-α) were found to be significantly higher at 6- and 12-month (P < .05) when compared with surgically treated patients. Cox regression analysis showed that elevated plasma levels of VCAM-1, ICAM-1, IL-6, and TNF-α during follow up were strongly related to impaired wound healing and/or revascularisation failure (P < .05). Elevated plasma levels of inflammatory markers VCAM-1, ICAM-1, IL-6, and TNF-α may be related to the failure of wound healing and revascularisation procedures. Interestingly, we have observed that endovascular treatments cause a higher level of these inflammation biomarkers when compared with a vein graft, although wound-healing and patency and limb salvage rates are not influenced.

Telemedicine in thoracic surgery

Background: We describe the safety, feasibility and patient satisfaction using telemedicine in the preoperative as well as postoperative period of thoracic surgery. Methods: A prospective safety, proof of concept and quality improvement project on a consecutive series of patients who had preoperative and/or part of their postoperative care via telemedicine. Results: Fifty-six patients (18% outside the United States) agreed to participate. A video conversation with patients and families was used to decide resectability, discuss risks, benefits, and alternatives of treatment and to agree on the date and type of surgery after medical records and imaging reviewed initially via email. All 56 underwent the planned operation, 55 on the date agreed upon. Eight (14%) patients met the surgeon for the first time on the morning of surgery: 38 (68%) had robotic pulmonary resection, 9 (16%) robotic esophagectomy and 9 (16%) robotic thymectomy. All had R0 resection. There was minor morbidity in 10 patients. There was no major morbidity or 30- or 90-day mortality. Postoperative visits via telemedicine only was performed in 25 of 56 patients (45%). Unscheduled postoperative telemedicine visits prevented six patients from unnecessary visits to local emergency departments. Patient satisfaction achieved the highest scores in the four areas of provider communication. Conclusions: Telemedicine is safe and avoids some preoperative and postoperative visits to surgeons’ offices. In selected patients it safely determines oncologic surgical resectability and patient fitness for major thoracic surgery, provide outstanding early safety and oncologic outcomes and high patient satisfaction. In addition, it reduces the need for some postoperative emergency department visits and in most patients it can eliminate postoperative travel to the surgeon’s office.

SAT-143 The Effect of an Enhanced Recovery Protocol on the Length of Stay in Persons with Diabetes Requiring Colorectal Surgery

ABSTRACT: Background: Enhanced recovery protocols (ERP) are designed to achieve early improvement post-operatively by maintaining organ function and reducing stress response. Stress stimulates the hypothalamus-pituitary-adrenal (HPA) axis resulting in marked hyperglycemia1. Previous studies have shown that patients experience better outcomes and fewer complications when they use ERP2,3. ERP utilizes a high carbohydrate load in the form of liquid shakes or juice the night before and the morning of surgery. It remains to be seen how the use of this carbohydrate load can affect outcomes in persons with diabetes. The goal of this study is to determine the effectiveness of ERP on the length of stay (LOS) in persons with diabetes requiring colorectal surgery. Methods: A retrospective chart review was performed on 74 patients with diabetes: 37 received ERP and 37 did not. The participants had their surgery between September 2012 and February 2018. Both groups were matched according to age and sex and LOS was compared as the primary outcome. Secondary variables explored were race, insurance, and benign vs. malignant pathology results. A p-value of <0.05 was considered statistically significant. Results: Majority of patients were white (76%) and male (57%) with Medicare insurance. In the group of persons with diabetes who received the ERP, the average LOS was three days (95% CL of 3.0324-5.7244) as compared to an average of eight days (95% CL of 6.6450-10.5442) in the group who did not receive ERP (p=0.0006). Older age was the only variable which correlated positively (p=0.046) and significantly with LOS; there was no difference seen amongst race, insurance or pathology results. Conclusion: This study showed that using ERP in the form of carbohydrate loading in patients with diabetes can significantly reduce LOS as compared to those who did not receive the protocol. Utilization of an ERP has the potential to improve patient outcomes, especially in persons with diabetes. The limitations of our study include that it was retrospective in design and had a small sample size. As a result, future research should include large prospective trials which would help to determine the safety and efficacy of ERP in patients with diabetes. REFERENCES: 1) Hall GM. The anesthetic modification of the endocrine and metabolic response to surgery. Ann R Coll Surg Engl. 1985;67(1):25-9. 2) Cakir H, et al. Adherence to Enhanced Recovery after Surgery and length of stay after colonic resection. Colorectal Dis. 2013:15:1019-1025. 3) Ljungqvist O, et al. Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc. 2002; 61(3): 329-336.

The AAHKS Clinical Research Award: Prophylactic Tamsulosin Does Not Reduce the Risk of Urinary Retention Following Lower Extremity Arthroplasty: A Double-Blinded Randomized Controlled Trial

BackgroundPostoperative urinary retention (POUR) is common. Selective alpha-1 adrenergic antagonists, such as tamsulosin, are effective for treating urinary retention. The purpose of this study is to determine whether perioperative prophylactic tamsulosin reduces the incidence of POUR following total hip and knee arthroplasty. MethodsMale patients 35 years of age and older undergoing primary total hip or knee arthroplasty at a single center from 2015 to 2018 were eligible for inclusion. Patients were randomized to receive tamsulosin 0.4 mg or placebo daily for 5 days preoperatively, the morning of surgery, and the first postoperative day. The incidence of POUR was determined during the postoperative hospitalization. ResultsA total of 176 patients were enrolled in the study. Two patients were withdrawn prior to randomization. The remaining 174 were randomized to tamsulosin (n = 87) or placebo (n = 87). After an additional 43 patients were withdrawn prior to surgery, 131 patients completed the study (tamsulosin, n = 64; placebo, n = 67). A total of 42 patients (32.1%) developed POUR, with 18 cases (28.1%) in the tamsulosin group and 24 cases (35.8%) in the placebo group (P = .345), resulting in an odds ratio of 0.701 and a risk difference of 7.69%. ConclusionProphylactic tamsulosin did not reduce the incidence of POUR after hip and knee arthroplasty compared to placebo. The odds ratio indicates an approximately 30% decreased odds of developing POUR in the tamsulosin group, albeit not statistically significant. Tamsulosin does not appear to be effective as a prophylactic measure for reducing POUR in male hip and knee arthroplasty patients.

Sedation induced by antiepileptic drugs polytherapy: A note of caution during anesthesia.

Sir, Sedation is a common complaint among patients with epilepsy taking antiepileptic drugs (AEDs). This side-effect is compounded in patients taking multiple AEDs.[123] An 18-year-old male presented with history of seizures (since day 3 of life) refractory to multiple AEDs. He was taking twice daily doses of valproate 500 mg, clonazepam 20 mg, oxcarbazepine 450 mg, and levetiracetam 1500 mg; and zonisamide 100 mg in the morning and 200 mg at bed time. He had no other co-morbidities. The patient was scheduled for vagal nerve stimulation under general anesthesia for diffuse, bilateral, non-localizing seizure foci. In the preoperative period, the patient was oriented to time, place, and person despite periods of mood swings, during which he became restless and aggressive. Baseline laboratory parameters including liver function tests were within normal limits. The patient was advised to continue AEDs on the morning of surgery. On arrival at the operating room (OR), he was deeply sedated and responded only to painful stimuli. The baseline vitals were BP 129/64 mmHg, HR 88/min, and SpO2 99% on room air. The bispectral index (BIS) value was found to be between 77 and 80. Anesthesia was induced with fentanyl 120 μg and propofol 100 mg, and tracheal intubation was facilitated with rocuronium 50 mg. The maintenance of anesthesia was done with O2: air (FiO2 0.5), sevoflurane (0.8–1 Minimum alveolar concentration [MAC]) along with continuous infusions of fentanyl (60 μg/h), and rocuronium (12 mg/h). However, the BIS value started decreasing progressively below 40 [Figure 1]. Accordingly, the sevoflurane dial concentration was tapered, and to our surprise, even at zero end-tidal concentration of sevoflurane and a MAC of 0, the BIS value consistently remained between 40 and 45 with no change in hemodynamic parameters. As a result, sevoflurane was avoided. Infusions of fentanyl and rocuronium were discontinued 45 min prior to completion of surgery. At the end of surgery (160 min), BIS value reached between 50 and 55. After confirming return of spontaneous respiration, neuromuscular reversal agent was administered. However, the patient was not able to follow the verbal commands even though gag and cough reflexes were intact, and spontaneous movement of all four limbs was present. Trachea was extubated at a BIS value of 65. The patient was shifted to the ICU and closely monitored. He showed gradual improvement in sensorium over the next 1 hour and started obeying verbal commands. On interrogation, the patient could not recall any intraoperative event.Figure 1: Shows the trend of bispectral index (BIS) during the intraoperative periodThrough this correspondence, we wish to highlight certain important issues with multiple AED therapy. First, many AEDs have sedation as an important side-effect, particularly at high doses. Our patient received five AEDs on the morning of surgery, and by the time he reached the OR, he was deeply sedated. As informed by his parents, it was a regular phenomenon, and after morning doses, he frequently slept till mid-afternoon. Second, loss of verbal responsiveness as end point of induction with propofol was not possible here. That is why a fixed dose of propofol was administered. Third, we also bring forth the importance of BIS monitoring in such cases to titrate drug doses. Had we not applied BIS monitoring, we would have unnecessarily administered higher concentrations of sevoflurane than required thereby causing further delay in anesthetic recovery. Fourth, one of the classical extubation criteria of obeying to commands by the patient at the end of the surgery was not followed. However, adequate return of spontaneous breathing and airway reflexes along with spontaneous movement of all four limbs were ensured. Moreover, the intraoperative period was uneventful, and no neurological worsening was expected. Finally, the patient could not recollect any intraoperative event in the postoperative period suggesting absence of awareness. Thus, patients taking multiple AEDs should be evaluated thoroughly during pre-anesthetic check-up. The modification of anesthetic drugs and doses should be done, accordingly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Effect of Perioperative Pregabalin on Incidence of Chronic Postmastectomy Pain Syndrome: A Prospective Randomized Placebo-Controlled Pilot Study.

Background:Breast cancer is the most common malignancy among women. Chronic pain after breast surgeries is a well-known entity and is mainly neuropathic in nature. The primary aim of this study was to assess the effect of pregabalin given as preventive analgesic on the incidence of chronic postmastectomy pain.Methods:A randomized control trial (RCT) was performed on 80 patients. Patients were allocated into two groups. Group 1 received pregabalin (Lyrica, Pfizer) 75 mg. BD starting from the morning of surgery and continued for 1 week. Group 2 received placebo capsules at identical time intervals. Patients were followed up for 3 months postoperatively. Incidence, severity, and location of chronic pain were recorded. The primary objective was to evaluate the effect of perioperative oral pregabalin on the incidence of chronic postmastectomy pain (at 3 months postoperatively).Results:Of the 80 patients enrolled, 71 patients completed the study and were assessed for final outcomes. Incidence of chronic pain was comparable in both groups, with 16 out of 35 patients in Group 1 (44.7%) and 20 out of 36 patients in Group 2 (55.6%) reported chronic pain (P = 0.407). There was no difference between the severity of chronic pain (numeric rating scale ≥ 4) in both groups (P = 0.307). Incidence of adverse effects was comparable in both groups.Conclusion:This RCT shows that perioperative pregabalin may not have a role in the prevention of chronic pain after breast surgeries.

Optimisation of perioperative investigations among elective orthopaedic patients in a Dublin-based teaching hospital.

Background The current National Institute for Health and Care Excellence guidelines, in accordance with the Association of Anaesthetists of Great Britain and Ireland guidelines, recommend the following haematological investigations for all patients undergoing major elective surgery: full blood count, renal profile and coagulation screen if clinically indicated. However, the guidelines fail to specify a time-interval for which normal blood results remain valid. Currently all patients in Ireland undergoing substantial elective surgery requiring general or regional anaesthetic have a preoperative assessment prior to the surgery. Patients have phlebotomy performed as part of this assessment. Patients admitted for elective surgery often have these bloods repeated on the morning of surgery. Objectives To determine if blood investigations taken over a one-year period prior to surgery can be used as a baseline for clinically stable patients undergoing elective surgery. Study design and methods All consecutive day of surgery admission patients &gt;18 years of age undergoing elective orthopaedic surgery in Tallaght Hospital between 1 December 2014 and 1 December 2015 were identified using hospital records. Their blood results in the one-year period prior to surgery were compared to the blood results on the morning of surgery, using a McNemar’s test. A further clinical analysis was performed. Results There was no statistically significant change between blood results from three months prior to the surgery and the morning of surgery (P &lt; 0.05). Furthermore, the blood results remained largely unchanged in the one year prior to surgery. No patient had the operation deferred due to aberrant blood results, following previously normal results prior to surgery. The potential cost-saving of omitting bloods is enormous. Conclusions There appears to be neither a statistical nor clinical benefit to repeating blood tests on the morning of surgery, following normal bloods &lt;3 months in a clinically stable individual.

Cirugía mayor ambulatoria de la glándula tiroides y paratiroides. Resultados tras 6 años de experiencia

Objetive: Ambulatory or overnight stay surgery have been consolidated in many different procedures. However, its use in thyroid and parathyroid surgery is still controversial. The aim of this report is to present the results of 6 years of ambulatory patients undergoing surgery of the thyroid or parathyroid glands. Material and Methods: Prospective observational study of patients who underwent hemithyroidectomy or selective parathyroidectomy in the ambulatory program from January 2011 to December 2016. All patients included met the general criteria of ambulatory surgery. During the first years nodules bigger than 3cm and patients classified as ASA III were excluded. Patients arrive at hospital the morning of surgery. After the operation, patients pass to the post-anesthesia care unit and then to the hospitalization room. 8 hours after surgery patients are discharged home if they meet the criteria. Results: 270 patients were operated, 159 of them met the inclusion criteria. The overall applicability rate was 59%. The acceptance rate was 83.6% and the substitution index was 49.2%. The unwanted hospital admission was 10.4% for the parathyroidectomy and 17.6% for the hemithyroidectomy. Any patient presented major complications at home. The satisfaction rate was high or very high for 94% of the patients. Conclusion : Selective parathyroidectomy and hemithyroidectomy performed by experienced surgeons in selected patients can be safely and effectively carried out in ambulatory surgery (outpatient). It would be possible to improve the substitution index by increasing the application and acceptability ratios.

Fish Oil and Perioperative Bleeding.

Background Fish oil is among the most common natural supplements for treatment of hypertriglyceridemia or prevention of cardiovascular disease. However, concerns about theoretical bleeding risk have led to recommendations that patients should stop taking fish oil before surgery or delay in elective procedures for patients taking fish oil by some health care professionals. Methods and Results We tested the effect of fish oil supplementation on perioperative bleeding in a multinational, placebo-controlled trial involving 1516 patients who were randomized to perioperative fish oil (eicosapentaenoic acid+docosahexaenoic acid; 8-10 g for 2-5 days preoperatively, and then 2 g/d postoperatively) or placebo. Primary outcome was major perioperative bleeding as defined by the Bleeding Academic Research Consortium. Secondary outcomes include perioperative bleeding per thrombolysis in myocardial infarction and International Society on Thrombosis and Hemostasis definitions, chest tube output, and total units of blood transfused. Participants' mean (SD) age was 63 (13) years, and planned surgery included coronary artery bypass graft (52%) and valve surgery (50%). The primary outcome occurred in 92 patients (6.1%). Compared with placebo, risk of Bleeding Academic Research Consortium bleeding was not higher in the fish oil group: odds ratio, 0.81; 95% CI, 0.53-1.24; absolute risk difference, 1.1% lower (95% CI, -3.0% to 1.8%). Similar findings were seen for secondary bleeding definitions. The total units of blood transfused were significantly lower in the fish oil group compared with placebo (mean, 1.61 versus 1.92; P<0.001). Evaluating achieved plasma phospholipid omega-3 polyunsaturated fatty acids levels with supplementation (on the morning of surgery), higher levels were associated with lower risk of Bleeding Academic Research Consortium bleeding, with substantially lower risk in the third (odds ratio, 0.30 [95% CI, 0.11-0.78]) and fourth (0.36 [95% CI, 0.15-0.87]) quartiles, compared with the lowest quartile. Conclusions Fish oil supplementation did not increase perioperative bleeding and reduced the number of blood transfusions. Higher achieved n-3-PUFA levels were associated with lower risk of bleeding. These novel findings support the need for reconsideration of current recommendations to stop fish oil or delay procedures before cardiac surgery. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00970489.

The Possible Preventive Role of Pregabalin in Postmastectomy Pain Syndrome: A Double-Blinded Randomized Controlled Trial

ContextChronic postmastectomy pain syndrome (PMPS) has a considerable negative impact on the quality of life of breast cancer patients. ObjectiveThe objective of this study was to assess the possible preventive role of perioperative pregabalin in PMPS. MethodsThis randomized controlled study included 200 patients with breast cancer scheduled for elective breast cancer surgery. They were randomly assigned to one of two treatment groups. The pregabalin group received 75 mg of pregabalin twice daily for seven days and the control group received oral equivalent placebo capsules. The primary outcome was development of neuropathic PMPS. Neuropathic pain was assessed using the Grading System for Neuropathic Pain. Secondary outcome measures were safety and Visual Analogue Scale scores. ResultsNeuropathic pain was significantly less frequent in the pregabalin group compared to the control group at four weeks (P = 0.005), 12 weeks (P = 0.002), and 24 weeks (P < 0.001) postoperatively. PMPS was diagnosed in 11 patients (11%) of the pregabalin group and 29 patients (29%) of the control group (P < 0.001, relative risk: 0.26, 95% CI: 0.12–0.56). At the three follow-up time points, Visual Analogue Scale scores during the first three postoperative weeks were comparable in both groups while they were significantly lower in the pregabalin group at 4, 12, and 24 weeks. These two groups were comparable in the frequency of adverse events (P = 0.552). ConclusionPerioperative oral pregabalin 75 mg twice daily, starting at the morning of surgery and continued for one week, could reduce the frequency of postmastectomy pain syndrome.