Perioperative Intensive Care Research Articles

Measurement of Dead Space During Anesthesia

To the Editor Badal et al.1 were neither precise nor consistent in the terminology and abbreviations used as part of the article describing measurements of dead space during anesthesia. They state that Bohr's equation was used to calculate alveolar dead space when, in fact, Enghoff's modification of Bohr's original equation (VD/VT = PaCO2 − PECO2/PaCO2) measuring physiologic dead space (which contains alveolar dead space and airway-anatomic dead space) was used.2 Because such imprecise terminology (apparatus, anatomic, pulmonary, alveolar, physiologic) and abbreviations (VDS/VT, VDC, VDc, VD) appear throughout the text, figures, and table, it is difficult to judge the results unless one is very familiar with the subject. A second point concerns study design and results. Referencing their previous work,3 the authors acknowledge the inherent limitations of their methods providing “an accurate approximation” of mixed expired PCO2. Therefore, a randomized study with a larger, more uniform population combined with measurement of true alveolar dead space using standard mainstream volumetric capnography would provide more insights into the real clinical value of the proposed method. Third, the method is presented as simple and inexpensive. However, it requires an additional capnograph as well as significant modification of the anesthesia circuit with the potential of leakage at the entrance of the sample line into the ventilator bellows. Yves P. S. Moens, DVM Division of Anaesthesiology and perioperative Intensive Care University of Veterinary Medicine Vienna, Austria [email protected] Gerardo Tusman, MD Department of Anaesthesiology Hospital Privado de Comunidad Mar del Plata, Argentina Martina Mosing, DVM Section of Anaesthesiology Vetsuisse Faculty University of Zürich Zürich, Switzerland Stephan Böhm, MD CSEM Centre Suisse d'Electronique et de Microtechnique SA Research Centre for Nanomedicine Landquart, Switzerland

The perioperative nursing of pedicled greater omentum displacement for the repair of vesicovaginal fistulas

Objective To investigate the therapeutic effects of which pedicled greater omentum displacement for the repair of vesicovaginal fistulas and perioperative care elements.Methods Twenty eight cases of vesicovaginal fistulas patients, with pedicled greater omentum displacement which covered the wound repaired between bladder and vesicovaginal fistula,and through improving the perioperative nursing, promoting fistula healing and increasing the cure rate.Results All the operations were successfully completed fully recouered.Conclusions The pedicled greater omentum displacement for the repair of vesicovaginal fistulas,which can improve the success rate of operation. Intensive perioperative care,with particular attention to preoperative psychological counseling after partial cleaning and properly handle the various drainage tubes,etc,which are help to reduce perioperative complications. Key words: Vesicovaginal fistulas; Perioperative; Nursing; Pedicled greater omentum

Contemporary surgical outcome for skull base meningiomas

Although surgical excision of meningioma and its dural base is the most common primary management, skull base meningiomas are quite different, and contemporary management usually consists of multimodal treatment with the aim of achieving the best possible functional outcome and quality of life (QOL) for these patients. As surgery plays an important role in the treatment of skull base meningiomas, it is crucial for neurosurgeons to appreciate the surgical outcome and QOL after meningioma surgery. Outcome is usually measured for meningiomas in terms of morbidity, mortality, time to recurrence, and QOL. The extent of resection, tumor grade, proliferative markers, and tumor location are significant factors in predicting the surgical outcome. Therefore, we address each of these factors in detail in this review. Advances in recent decades in microsurgical techniques, neuroimaging modalities, neuroanesthesia, and perioperative intensive care have substantially improved the surgical outcome; therefore, most surgical outcomes discussed in this review are cited from contemporary literature (2000 to the present) in order to depict the surgical outcome of contemporary microsurgery.

Perioperative intensive care in patients with brain tumours

The surgery of brain tumours is not free from complications, above all taking into account that today the patients operated are even older and with multiple comorbidities associated. The multidisciplinary preoperative evaluation aims at minimising the risks; nevertheless this evaluation has not yet been defined and is not based on a strong evidence. The detailed clinical history, the physical examination including functional status and the neuroimaging are the fundamental pillars.The more critical complications occur in the immediate postoperative period: cerebral oedema, postoperative haemorrhage, intracranial hypertension and convulsions; other complications, such as pulmonary thromboembolism or infections, develop lately but are not less severe. Every surgical approach has its own complications in addition to the ones common to the whole neurosurgery.

The use of beta-blockers and the importance of heart rate control in the perioperative and surgical intensive care settings

The use of beta-blockers and the importance of heart rate control in the perioperative and surgical intensive care settings

Impact of Congenital Heart Disease on Brain Development and Neurodevelopmental Outcome

Advances in cardiac surgical techniques and perioperative intensive care have led to improved survival in babies with congenital heart disease (CHD). While it is true that the majority of children with CHD today will survive, many will have impaired neurodevelopmental outcome across a wide spectrum of domains. While continuing to improve short-term morbidity and mortality is an important goal, recent and ongoing research has focused on defining the impact of CHD on brain development, minimizing postnatal brain injury, and improving long-term outcomes. This paper will review the impact that CHD has on the developing brain of the fetus and infant. Neurologic abnormalities detectable prior to surgery will be described. Potential etiologies of these findings will be discussed, including altered fetal intrauterine growth, cerebral blood flow and brain development, associated congenital brain abnormalities, and risk for postnatal brain injury. Finally, reported neurodevelopmental outcomes after surgical repair of CHD will be reviewed.

Two-stage liver transplantation in a surgically complicated liver failure patient after hepatic tumor resection -A case report-

Two-stage liver transplantation, involving a total hepatectomy with a temporary portocaval shunt followed by liver transplantation, requires intensive perioperative care, especially during the prolonged anhepatic period. The pathophysiology and management of this prolonged anhepatic state is not fully elucidated and the proper management during this period is a great challenge to clinicians in the intensive care unit and anesthesiologists. We report a case and management of a total hepatectomy with a temporary portocaval shunt followed by living-donor liver transplantation in a patient with a surgically complicated liver failure after a hepatic tumor resection.

Tailored antireflux surgery.

With increasing age, the functional condition of the lower esophageal sphincter is getting weaker. Recent progress in peri-operative intensive care and the development of laparoscopic technique makes antireflux surgery a safe choice of GERD treatment in the elderly. This work evaluated the long-term results of tailored antireflux surgery in a group of elderly (more than 60 years old) patients. Five hundred and eighty one patients underwent antireflux surgery in our department from 1999 to 2005. Seventy of them (12.0%) were older than 60 years. Exclusion criteria of surgery were ASA IV classification and high grade esophageal dysmotility. Toupet's wrap was offered to patients with esophageal dysmotility or esophageal sphincter pressure higher than 15 mm Hg (16 cases). The rest were offered Nissen-Rossetti's complete wrap (54 cases). There was zero mortality and no further significant dysphagia. Pathological gastro-esophageal reflux after the surgery was detected in 6 patients (8.6%), which was a higher proportion than in the group of patients under 60 years. Good results of antireflux surgery with zero mortality and low morbidity can be achieved even in the elderly (more frequent use of incomplete Toupet's wrap).

Acute Renal Failure and Outcome of Children with Solitary Kidney Undergoing Cardiac Surgery

The aim of this study was to investigate the risk of acute renal failure (ARF), the need for renal replacement therapy, and the outcome of children with a solitary functioning kidney undergoing open heart surgery. The study was performed retrospectively on all children diagnosed with solitary functioning kidney and who required open heart surgery between January 2003 and January 2007. Demographic, perioperative renal function and intensive care course data were documented. Eight patients (six females) fulfilled the study criteria and were included in the study. Their median age and weight were 4.5 months and 3.6 kg, respectively. Their mean +/- standard deviation (SD) preoperative blood urea nitrogen (BUN) and creatinine levels were 3.7 +/- 1.6 mmol/L and 55 +/- 10 micromol/L, respectively. Postoperatively, the mean BUN and creatinine levels peaked on the first postoperative day to reach 7.8 +/- 2.6 mmol/L and 76 +/- 22 micromol/L, respectively, before starting to return to their preoperative values. Two out of eight patients (25%) developed ARF after surgery, but only one of them (12.5%) required renal replacement therapy. Open heart surgery on bypass can be performed safely for children with solitary functioning kidney with a good outcome. ARF requiring renal replacement therapy might occur temporarily after bypass surgery in a minority of cases.

Children with cardiomyopathy: complications after noncardiac procedures with general anesthesia

Children with cardiomyopathy (CM) often undergo procedures that require general anesthesia (GA) but little is known about anesthesia-related adverse events or postprocedural outcomes. After approval, all children with CM who underwent nonopen heart surgical procedures and/or diagnostic imaging under GA at a tertiary children's hospital during January 2002 to May 2005 were identified from a clinical database. Based on their preprocedure fractional shortening (FS) on echocardiogram, systemic ventricular dysfunction was categorized as mild (FS 23-28%), moderate (FS 16-22%), or severe (FS < 16%) and those with normal (FS > 28%) were excluded from review. Twenty-six patients underwent 34 procedures under GA, of whom 13 (38%) had mild or moderate ventricular dysfunction and 21 (62%) had severe dysfunction. Common procedures included pacer/defibrillator placement (43%) and imaging studies (18%). Eighteen complications were noted in 12 patients. Fifteen (83%) complications occurred in patients with severe ventricular dysfunction. One patient with severe ventricular dysfunction died (3% mortality). Hypotension requiring inotropic support was the most frequent complication (61%). Children with severe ventricular dysfunction often required hospital support pre- and postprocedure with 67% requiring intensive care. Hospital stay was longer for patients with severe ventricular dysfunction compared with children with mild or moderate ventricular dysfunction (P = 0.006). The 30-day mortality rate was low but complications were common, especially in patients with severe ventricular dysfunction. For these patients, we recommend early consideration of perioperative intensive care support to optimize cardiovascular therapy and monitoring.

Gallengangsprobleme in der Leberchirurgie und Lebertransplantation

Despite advanced surgical techniques and improved perioperative intensive medical care of the patients, including immunosuppressive therapy, bile duct complications remain a profound clinical problem in liver surgery and liver transplantation, associated to extensive morbidity and mortality. Although, postoperative leakages are significant in liver surgery, bile duct stenosis remains a major problem after liver transplantation. Due to the development of various different methods of segmental liver transplantation, the spectrum of biliary complications has been significantly enhanced. Crucial for the prognosis is the early diagnosis and therapy of bile duct complications, and a prerequisite for a long-term therapeutical success is the interdisciplinary collaboration between the surgeons, endoscopists and radiologists.

Time Course of Changes in the Concentration of Peroxides and Superoxide Dismutase in Females with Gestosis in the Perioperative Period

Objective: to study the level of peroxides and the activity of superoxide dismutase (SOD) in females with gestosis in the perioperative period. Materials and methods: 85 females in whom delivery had been performed under spinal anesthesia using conventional perioperative intensive care were examined. A control group comprised 30 females with uncomplicated pregnancy; Group 1 included 26 females with moderate gestosis; Group 2 consisted of 29 females with severe gestosis. The severity of gestosis was determined by means of the Goecke scale that had been modified by G. M. Savelyeva. The groups of the examinees were matched by height, weight, age, and gender. Results: there is intensification of free radical processes and a standard adaptive response of the antioxidative system forms in the pregnant females exposed to surgical delivery under spinal anesthesia. In dynamics, this reaction is characterized by a certain pattern: the maximum activation on the first postoperative day, some depletion on day 3, and recovery of compensatory capacities on day 5. The antioxidative system of the females with uncomplicated pregnancy generally shows a balanced response to activated free radical processes during surgical delivery and in the postoperative period. There is stress in moderate gestosis-complicated pregnancy and depletion of the antiox-idative system in severely progressive gestosis, which diminishes the body’s adaptive capacities and leads to the formation of chronic oxidative stress as a leading factor of the pathogenesis of the disease. Imbalance between free radical oxidation processes and the antioxidative system increases when surgical delivery is performed. In the females with moderate gestosis, oxidative stress may be characterized as subcompensated with a moderate increase in the concentration of peroxides in the intra- and postoperative period, as compared with those with physiological pregnancy. Conclusion. Severe gestosis is characterized by a decompensated stress with a pronounced increase in the level of peroxides before and during surgical delivery and within 5 postoperative days.

SURGERY FOR ACUTE ABDOMINAL CONDITIONS IN INTELLECTUALLY‐DISABLED ADULTS

Intellectually-disabled patients with acute abdominal conditions are susceptible to late diagnosis and adverse outcome due to impaired communication, altered behaviour, neurological impairment, associated congenital anomalies, variable reaction to pain and drugs and various difficulties in perioperative management. The present study aims to present the experience of surgery for acute abdominal conditions in intellectually-disabled patients. Various difficulties encountered during the management are highlighted and measures to overcome these problems are discussed. A prospective descriptive population study was performed through the prospective collection of data on consecutive intellectually-disabled adults operated for acute abdominal conditions over a 5-year period. Study parameters included demographic details, clinical presentation, diagnostic modalities, operative findings and outcome in terms of morbidity and mortality. Of 19 men and three women with a mean age of 28.3 years, anorexia, vomiting, and increasing abdominal distension were the most common presenting features. History of pica was available in 36.4% of patients. Intestinal obstruction, acute appendicitis, volvulus and pseudo-obstruction of the colon were the most frequently encountered conditions. Postoperative morbidity and mortality were 33 and 23%, respectively. Intellectually-disabled patients demand particular clinical expertise owing to various difficulties inherent to their mental and physical disabilities. Short history, anorexia, vomiting and abdominal distension should make the clinician aware of the possibility of an acute abdominal condition. History of pica should be considered a serious clinical correlate. A high index of clinical suspicion, intensive perioperative care and low threshold for an early operation are recommended to reduce the higher morbidity and mortality figures.

Important Excess Morbidity Due to Upper Airway Anomalies in the Perioperative Course in Infant Cardiac Surgery

The study aimed at defining the excess morbidity or mortality caused by an additional airway malformation in children with congenital heart disease requiring surgery. All patients requiring surgery for heart disease during an 8-year period ending in 2003 who had an associated upper airway malformation were retrospectively studied. All patients were seen in 2004 for a prospective follow-up examination. Eleven patients with upper airway anomalies were identified (tracheobronchial malacia in 6 patients, long-segment tracheal stenosis in 3, and bilateral vocal cord paralysis and tracheal hemangioma in 1 patient each). They accounted for 1.5% of the entire cardiac surgical load of 764 patients. In 5 infants, the airway anomaly was diagnosed before cardiac repair, in 6 patients thereafter. Diagnosis was made by bronchoscopy in all patients, by additional bronchography in 2. Failure of rapid postoperative extubation was the most common finding. Airway management was surgical in 2 and conservative in 8 patients, 1 newborn having been denied therapy because of the severity of airway hypoplasia. Compared with patients with isolated cardiac disease, those with additional airway anomalies had significantly longer duration of postoperative mechanical ventilation (median, 24 days versus 3), perioperative hospitalization (median, 72 days versus 11) and total number of days of hospitalization during the first year of life (median, 104 days versus 14). After a maximum follow-up of 8 years (median, 37 months) only 3 of 10 surviving patients remained symptomatic owing to the airway malformation. Upper airway anomalies accompanying heart disease in infancy resulted in a significant prolongation of perioperative intensive care and hospital stay, as well as duration of mechanical ventilation. Failure of early postoperative extubation was the leading symptom.

Clinicopathologic characteristics of esophagectomy for esophageal carcinoma in elderly patients

To evaluate the risk of esophagectomy for carcinoma of the esophagus in the elderly (70 years or more) compared with younger patients (< 70 years) and to determine whether the short-term outcomes of esophagectomy in the elderly have improved in recent years. Preoperative risks, postoperative morbidity and mortality in 60 elderly patients (> or = 70 years) with esophagectomy for carcinoma of the esophagus were compared with the findings in 1782 younger patients (< 70 years) with esophagectomy between January 1990 and December 2004. Changes in perioperative outcome and short-time survival in elderly patients between 1990 to 1997 and 1998 to 2004 were separately analyzed. Preoperatively, there were significantly more patients with hypertension, pulmonary dysfunction, cardiac disease, and diabetes mellitus in the elderly patients as compared with the younger patients. No significant difference was found regarding the operation time, blood loss, organs in reconstruction and anastomotic site between the two groups, but elderly patients were more often to receive blood transfusion than younger patients. Significantly more transhiatal and fewer transthoracic esophagectomies were performed in the elderly patients as compared with the younger patients. Resection was considered curative in 71.66% (43/60) elderly and 64.92% (1157/1782) younger patients, which was not statistically significant (P>0.05). There were no significant differences in the prevalence of surgical complications between the two groups. Postoperative cardiopulmonary medical complications were encountered more frequently in elderly patients. The hospital mortality rate was 3.3% (2/60) for elderly patients and 1.1% (19/1 782) for younger patients without a significant difference. When the study period was divided into a former (1990 to 1997) and a recent (1997 to 2004) period, operation time, blood loss, and percentage of patients receiving blood transfusion of the elderly patients significantly improved from the former period to the recent period. The hospital mortality rate of the elderly patients dropped from the former period (5.9%) to the recent period (2.3%), but it was not statistically significant. Preoperative medical risk factors and postoperative cardiopulmonary complications after esophagectomy are more common in the elderly, but operative mortality is comparable to that of younger patients. These encouraging results and improvements in postoperative mortality and morbidity of the elderly patients in recent period are attributed to better surgical techniques and more intensive perioperative care in the elderly.

The Therapy of Infantile Malignant Brain Tumors: Current Status?

Malignant brain tumors are not uncommon in infants as their occurrence before the age of three represents 20-25% of all malignant brain tumors in childhood [1]. Genetic predisposition to infantile malignant brain tumors are known in Gorlin syndrome for example who present with desmoplastic medulloblastoma in about 5% of the affected patients. In addition, sequelae from tumor and its treatment are more severe at this age [2]. Thus, malignant brain tumors represent a true therapeutic challenge in neuro-oncology. Before the era of modern imaging and modern neurosurgery these malignant brain tumors were misdiagnosed or could not benefit of the surgical procedures as well as older children because of increased risks in this age group. Since the end of the 80s, noninvasive imaging procedures produce accurate diagnosis of brain tumors and improvement in neurosurgery, neuroanesthesia and perioperative intensive care permit safe tumor resections or at least biopsies. Consequently, the pediatric oncologists are more often confronted with very young children who need a complementary treatment. Before the development of specific approaches for this age group, these children received the same kind of treatment than the older children did, but their survival and quality of life were significantly worse. The reasons of these poor results were probably due in part to the fear of late effects induced by radiation therapy, leading to decrease the necessary doses of irradiation which increased treatment failures without avoiding treatment related complications [3]. At the end of the 80s, pilot studies were performed using postoperative chemotherapy in young medulloblastoma patients. Van Eys treated 12 selected children with medulloblastoma with MOPP regimen and without irradiation; 8 of them were reported to be long term survivors [4]. Subsequently, the pediatric oncology cooperative groups studies have designed therapeutic trials for very young children with malignant brain tumors. Different approaches have been explored: * Prolonged postoperative chemotherapy and delayed irradiation as designed in the POG (Pediatric Oncology Group). * Postoperative chemotherapy without irradiation in the SFOP (Société Française d'Oncologie Pédiatrique) and in the GPO (German Pediatric Oncology) studies. * The role of high-dose chemotherapy with autologous stem cells transplantation was explored in different ways: High-dose chemotherapy given in all patients as proposed in the Head Start protocol. High-dose chemotherapy given in relapsing patients as salvage treatment in the French strategy. In the earliest trials, the same therapy was applied to all histological types of malignant brain tumors and whatever the initial extension of the disease. This attitude was justified by the complexity of the classification of all brain tumors that has evolved over the past few decades leading to discrepancy between the diagnosis of different pathologists for a same tumor specimen. Furthermore, it has become increasingly obvious that the biology of brain tumors in very young children is different from that seen in older children. However, in the analysis of these trials an effort was made to give the results for each histological groups, according to the WHO classification and after a central review of the tumor specimens. All these collected data have brought to an increased knowledge of infantile malignant brain tumors in terms of diagnosis, prognostic factors and response to chemotherapy. Furthermore a large effort was made to study long term side effects as endocrinopathies, cognitive deficits, cosmetic alterations and finally quality of life in long term survivors. Prospective study of sequelae can bring information on the impact of the different factors as hydrocephalus, location of the tumor, surgical complications, chemotherapy toxicity and irradiation modalities. With these informations it is now possible to design therapeutic trials devoted to each histological types, adapted to pronostic factors and more accurate treatment to decrease long term sequelae.

Péritonites

Peritonitis is an acute inflammation of the peritoneum due, most of the time, to infection and resulting from acute bowel perforation. The microorganisms involved are those originating from bowel flora (enterobacteriaceae and anerobes), but Gram positive cocci and fungi can also be cultured in case of hospital-acquired infections. These diseases require urgent management, combining surgical and medical treatments. Etiological treatment is based on surgery to eliminate the infectious source, to perform peritoneal lavage and to prevent relapse. Medical treatment is based on perioperative intensive care management and antibiotic therapy targeting the microorganisms cultured from perioperative samplings. Antibiotic therapy not taking into account all cultured organisms and delayed management are factors of poor prognosis. Similarly, peritonitis remains a life-threatening disease when occurring in elderly patients, in patients with underlying diseases, in case of delayed surgery, and especially in case of postoperative infection.

Geriatrische Probleme im perioperativ-chirurgischen Management

Improved healthcare and longer life expectancy have led to more and overall, healthier older patients. As a consequence, we now see more surgical complications attributable to an ever-increasing spectrum of the physiologic changes of aging. These include functional decline, psychiatric as well as medical co-morbidities, medication effects and peri-operative environmental changes. To maintain high patient care standards in geriatric operative patients, surgeons face challenges in peri-operative care (co-morbidities), anesthesia (intra-operative circulatory depression, cardiac insufficiency and limited organ reserve), and intensive care (cardiopulmonary surveillance and delirium). In contrast to the normally temporary surgical period, interdisciplinary approaches are essential during extended peri-operative, convalescent, rehabilitation and follow-up phases of care in the geriatric patient. This will require competency in the realm of geriatrics, on behalf of the treating surgeon who, as a result, will become increasingly more specialized in the future. This article addresses current epidemiology and symptomatology of particular diseases, and as well, offers treatment suggestions with explanations of geriatric pathophysiology and functional decline from a clinically relevant perspective. This review highlights the increased difficulty in treatment of multiple disease processes in the elderly as a result of natural decline in function of all organ systems.

Early postoperative complications following liver transplantation

Liver transplantation is a highly successful treatment for patients with end-stage liver disease and acute liver failure. However, serious postoperative complications can significantly compromise patient survival. Complications can be technical, medical, or immunological in nature. The risk of developing early postoperative complications is associated with the patient's preoperative condition, the quality of the donor liver, the quality of the donor and recipient procedure, initial graft function, and perioperative anaesthesiological and intensive care management. The patient's preoperative condition can include gastrointestinal bleeding, acute renal failure, a requirement for cathecholamines or mechanical ventilation, and prolonged encephalopathy for the most detrimental risk factors for developing early postoperative complications. The necessity for prolonged mechanical ventilation or the requirement for reintubation after transplantation can significantly increase the risk of developing pneumonia, sepsis, and multiple organ dysfunction. A decrease in infectious and other complications can be achieved by early postoperative enteral nutition, including the application of probiotics.

Acute renal failure in the surgical setting.

Acute renal failure (ARF) is an unwelcome complication of major surgical procedures that contributes to surgical morbidity and mortality. Acute renal failure associated with surgery may account for 18-47% of all cases of hospital-acquired ARF. The overall incidence of ARF in surgical patients has been estimated at 1.2%, although is higher in at-risk groups. Mortality of patients with ARF remains disturbingly high, ranging from 25% to 90%, despite advances in dialysis and intensive care support. Appreciation of at-risk surgical populations coupled with intensive perioperative care has the capacity to reduce the incidence of ARF and by implication mortality. Developments in understanding the pathophysiology of ARF may eventually result in newer therapeutic strategies to either prevent or accelerate recovery from ARF. At present the best form of treatment is prevention. In this review the epidemiology, pathophysiology, diagnosis, treatment and possible prevention of ARF will be discussed.