Postanesthesia Care Research Articles

Characterization and analysis of adverse events in closed liability cases involving anaesthetists who received legal support from the Colombian Society of Anaesthesia and Resuscitation (S.C.A.R.E.), Colombia, 1993–2012

IntroductionAdverse events are the source of significant care-related morbidity and mortality in surgical patients. ObjectiveTo characterize and analyze anaesthesia-related adverse events in closed ethical and legal cases, with the involvement of the Colombian Society of Anaesthesia and Resuscitation (Sociedad Colombiana de Anestesiología y Reanimación – S.C.A.R.E.) between 1993 and 2012. Materials and methodsRetrospective analysis of medical liability cases involving anaesthetists, managed with the support of the Special Fund for Mutual Legal Assistance (FEPASDE). ResultsOverall, 278 proceedings involving anaesthesia-related adverse events were analyzed. The majority (67%) occurred in association with planned surgical procedures (general surgery, orthopaedic surgery, plastic surgery, and obstetrics and gynaecology) performed under general anaesthesia in ASA I patients taken to surgery in Level II complexity settings. A substantial percentage of adverse events (18%) occurred in the Post-Anaesthetic Care Unit (PACU). The most frequent adverse events were cardiovascular and respiratory (55.4% and 36.7% respectively). The most predominant outcomes were death (50.3%) and cerebral insult (22.3%). The analysis found flaws in the completion of the pre-anaesthetic assessment and informed consent forms, compliance with guidelines, standards or protocols, communication with the patient or the family after the event, and communication among the members of the healthcare team. ConclusionsIn the cases reviewed, the majority of adverse events happened in low risk patients, in low complexity institutions. The PACU was a sensitive setting for the occurrence of adverse events. It is important to consider environmental factors when analysing adverse events.

Adverse event surveillance in small animal anaesthesia: an intervention-based, voluntary reporting audit

ObjectiveTo develop, test and refine an ‘intervention-based’ system for the surveillance of adverse events (AEs) during small animal anaesthesia. Study designProspective, voluntary reporting audit. AnimalsA total of 1386 consecutive small animal anaesthetics (including 972 dogs and 387 cats). MethodsAdverse events were defined as undesirable perianaesthetic events requiring remedial intervention to prevent or limit patient morbidity. Using previous reports, 11 common AEs were selected and ‘intervention-based’ definitions were devised. A voluntary reporting audit was performed over 1 year at a university teaching hospital. Data on AEs were collected via paper checkbox forms completed after each anaesthetic and were assimilated using an electronic database. Interventions were performed entirely at the discretion of the attending anaesthetist. Comparisons between dogs and cats were made using Fisher's exact tests. ResultsForms were completed for 1114 anaesthetics (a compliance of 80.4%), with 1001 AEs reported in 572 patients. The relative frequency of AEs reported were as follows: arousal or breakthrough pain (14.9%), hypoventilation (13.5%), hypotension (10.3%), arrhythmias (5.8%), hyperthermia/hypothermia (5.0%), airway complications (4.8%), recovery excitation (4.6%), aspiration risk (4.5%), desaturation (2.8%), hypertension (1.7%) and ‘other’ (3.7%). Canine anaesthetics (57.3%) were more likely to involve AEs than were feline anaesthetics (35.5%, p < 0.01). Escalation in postanaesthetic care was required in 20% of cases where an AE was reported (8% of anaesthetics overall). In 6% of cases (2% overall), this involved management in an intensive care unit. There were six intra-anaesthetic fatalities (0.43%) during this period. The tool was widely accepted, being considered quick and easy to complete, but several semantic, logistical and personnel factors were encountered. Conclusions and clinical relevanceSimple intervention-based surveillance tools can be easily integrated into small animal anaesthetic practice, providing a valuable evidence base for anaesthetists. A number of considerations must be addressed to ensure compliance and the quality of data collected.

Applying healthcare failure mode and effect analysis to patient pain management in the anesthesia recovery period

Abstract Objective To standardize pain management in the anesthesia recovery period and improve the effects of analgesia on acute postoperative pain. Methods Using healthcare failure mode and effect analysis (HFMEA), we analyzed the primary cause of patients' pain and subsequently determined the process and risk priority number (RPN). Results Actions were taken to improve patients' pain. After using HFMEA, the experimental group's visual analog scale (VAS) scores were lower than those of the control group at 1 h and at discharge from the post-anesthetic intensive care unit (PAICU). The differences were statistically significant (P Conclusions The application of failure mode and effect analysis can relieve pain and improve the quality of nursing.

Handover between anaesthetists and post-anaesthetic care unit nursing staff using ISBAR principles: A quality improvement study

A structured approach to communication between health care professionals contains introduction/identification; situation; background; assessment and request/recommendation (ISBAR). ISBAR was introduced into the post anaesthetic care unit (PACU) of a large Victorian health service in 2013. The aim of this study was to measure the effect of an education program on ISBAR compliance.A pre/post-test design using a 14-item audit tool was used to measure compliance to ISBAR before and after an education intervention in two acute hospitals in Melbourne, Victoria. The intervention consisted of one 30-minute education session to anaesthetists, and two 30-minute education sessions to PACU nurses, combined with visual cues using ISBAR wall posters.In Hospital A, significant improvement from pre- to post-audit was found in the items of cardiovascular assessment and actions (Fisher's exact test p < .05) and (X² (1) = 4.06, p < .05), respiratory assessment (X² (1) = 12.85, p < .01), analgesia assessment and responsibility + referral (X² (1) = 4.44, p < .05. For Hospital B significant improvement was found in communication difficulties (X² (2)= 13.55, p-< .01) and significant decreased performance was found in respiratory assessment (X² (1) = 8.98, p < .01) and responsibility + referral (X² (1) = 13.26, p < .01).The results from this study cohort suggest an augmented education program may produce mixed results for ISBAR compliance. More than education and visual tools may be required to improve PACU ISBAR compliance.

Editorial introductions

Editorial introductions

Acoustic method respiratory rate monitoring is useful in patients under intravenous anesthesia

Respiratory depression can occur during intravenous general anesthesia without tracheal intubation. A new acoustic method for respiratory rate monitoring, RRa® (Masimo Corp., Tokyo, Japan), has been reported to show good reliability in post-anesthesia care and emergency units. The purpose of this study was to investigate the reliability of the acoustic method for measurement of respiratory rate during intravenous general anesthesia, as compared with capnography. Patients with dental anxiety undergoing dental treatment under intravenous anesthesia without tracheal intubation were enrolled in this study. Respiratory rate was recorded every 30s using the acoustic method and capnography, and detectability of respiratory rate was investigated for both methods. This study used a cohort study design. In 1953 recorded respiratory rate data points, the number of detected points by the acoustic method (1884, 96.5%) was significantly higher than that by capnography (1682, 86.1%) (P<0.0001). In the intraoperative period, there was a significant difference in the LOA (95% limits of agreement of correlation between difference and average of the two methods)/ULLOA (under the lower limit of agreement) in terms of use or non-use of a dental air turbine (P<0.0001). In comparison between capnography, the acoustic method is useful for continuous monitoring of respiratory rate in spontaneously breathing subjects undergoing dental procedures under intravenous general anesthesia. However, the acoustic method might not accurately detect in cases in with dental air turbine.

Efficacy of dexmedetomidine and fentanyl on pressor response and pneumoperitoneum in laparoscopic cholecystectomy.

Background:The advent of laparoscopic surgeries has proved to be beneficial for both patient and surgeon although increased morbidity may result from hemodynamic changes associated with laryngoscopy, intubation, and pneumoperitoneum (PNP).Aim:The present study was prospective, randomized, double-blind conducted to evaluate the efficacy of dexmdetomidine and fentanyl in attenuation of pressor responses to laryngoscopy, intubation, and PNP in laparoscopic cholecystectomy (LC).Materials and Methods:A total of 60 patients of 18–65 years, American Society of Anaesthesiologists Class I/II of either sex for elective LC, were included. The patients were divided into two groups of 30 patients each. Group I received dexmedetomidine and Group II Fentanyl loading 1 μg/kg over 15 min followed by maintenance 0.2 μg/kg/h throughout the PNP.Measurements:Heart rate (HR), systolic blood pressure, diastolic blood pressure, and mean arterial blood pressure (MAP) were recorded preoperatively, 15 min after infusion of study drug, 1 min after induction, 1 min after intubation, throughout the PNP, end of surgery, and until 60 min in postoperative period. Sedation score, visual analog scale score along with modified Alderete score applied in postanesthesia care unit.Results:Control of HR and MAP in Group I was better than in Group II during laryngoscopy, intubation and PNP. There was also smooth extubation, less sedation and better control of pain in Group I than in Group II.Conclusion:The present study demonstrates the benefits of dexmedetomidine over fentanyl in hemodynamic stability and analgesic quality in LC. Thus, it is establishing its utility over for attenuation of pressor response.

Regional Anaesthesia Is Associated with Shorter Postanaesthetic Care and Less Pain Than General Anaesthesia after Upper Extremity Surgery.

Introduction. For surgery on the upper extremity, the anaesthetist often has a choice between regional anaesthesia (RA) and general anaesthesia (GA). We sought to investigate the possible differences between RA and GA after upper extremity surgery with regard to postoperative patient comfort. Methods. This is a retrospective observational study that was performed at an acute care secondary referral centre. One hundred and eighty-seven procedures involving orthopaedic surgery on the upper extremity were included. The different groups (RA and GA) were compared regarding the primary outcome variable, length of stay in Postanaesthesia Unit, and secondary outcome variables, opioid consumption and nausea treatment. Results. RA was associated with significantly shorter median length of stay (99 versus 171 minutes). In the GA group, 32% of the patients received opioid analgesics and 21% received antiemetics. In the RA group, none received opioid analgesics and 3% received antiemetics. Conclusion. In this observational study, RA was superior to GA for surgery of the upper extremity regarding Postanaesthesia Care Unit length of stay, number of doses of analgesic, and number of doses of antiemetic administered.

Quality of Recovery after Anesthesia: Validation of the Portuguese Version of the 'Quality of Recovery 15' Questionnaire.

The "Quality of Recovery 15" questionnaire is used for the study of quality recovery after anesthesia. The aim of this study was to validate the Portuguese version of "Quality of Recovery 15" questionnaire. After study approval by the institutional ethics committee, an observational and cohort prospective study was conducted on patients scheduled for elective surgery from June to August 2013. The "Quality of Recovery 15" questionnaire was translated in accordance with available guidelines. The "Quality of Recovery 15" Portuguese version was used before surgery (T0) and 24h postoperatively (T1) on 170 patients. Patients who were unable to give informed consent or had cognitive impairment were excluded. Poor quality of recovery was defined for "Quality of Recovery 15" score at T1 lower than the mean "Quality of Recovery 15" score minus 1 standard deviation. Reliability and observer disagreement was assessed using interclass correlation. Non-parametric tests were used for comparisons. There was a negative correlation between "Quality of Recovery 15" score and time spent in the postanesthesia care(p = -0.264, p = 0.004) and length of hospital stay (p = -0.274, p = 0.004). Thirty-two patients (19%) had poor quality of recovery. Patients with poor quality of recovery had more frequently diabetes mellitus and hypertension and they were taking antidepressants drugs more frequently. Patients with poor quality of recovery were more frequently submitted to combined anesthesia and less frequently to general anesthesia and locoregional anesthesia (p = 0.008). The questionnaire had a good internal consistency and test-retest reliability was good. The Portuguese version of the "Quality of Recovery 15" showed a good correlation with the original. This questionnaire appears to be an accurate and reliable assessment for quality of recovery.

Alpha-2 adrenergic agonists for the prevention of shivering following general anaesthesia.

Shivering after general anaesthesia is common. It is unpleasant but can also have adverse physiological effects. Alpha-2 (α-2) adrenergic agonist receptors, which can lead to reduced sympathetic activity and central regulation of vasoconstrictor tone, are a group of drugs that have been used to try to prevent postoperative shivering. To assess the following: the effects of α-2 agonists on the prevention of shivering and subsequent complications after general anaesthesia in people undergoing surgery; the effects of α-2 agonists on the risk of inadvertent perioperative hypothermia; and whether any adverse effects are associated with these interventions. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE on 13 June 2014. Our search terms were relevant to the review question and limited to studies that assessed shivering or hypothermia. We also carried out searches of clinical trials registers, and forward and backward citation tracking. We considered all randomized controlled trials, quasi-randomized studies, and cluster-randomized studies with adult participants undergoing surgery with general anaesthesia in which an α-2 agonist was compared with another α-2 agonist or a placebo for the prevention of shivering. Two review authors independently assessed trial quality and extracted data, consulting a third review author in the case of disagreements. We used standard Cochrane methodological procedures, including an assessment of risk of bias and use of GRADEpro software to interpret findings. We included 20 studies with 1401 surgical participants comparing an α-2 agonist against a control. Thirteen studies compared clonidine with a control, whilst seven compared dexmedetomidine with a control. The doses, methods, and time of administration varied between studies: three studies gave the drug orally or as an intravenous bolus preoperatively and nine intraoperatively; one study gave the drug as an infusion starting preoperatively and seven started at varying points from anaesthetic induction to the end of surgery. Whilst all the studies were described as randomized, many provided insufficient detail on methods used. We had anticipated that attempts would be made to reduce performance bias by blinding of personnel and participants, however this was detailed in only six of the papers. Similarly, in some studies detail was lacking on methods to reduce the risk of detection bias. We therefore downgraded the quality of evidence in our 'Summary of findings' table by one level for risk of bias using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach.All 20 included studies presented outcome data for postoperative shivering, and in meta-analysis α-2 agonists were shown to significantly reduce the risk of shivering (Mantel-Haenszel risk ratio 0.28, 95% confidence interval 0.18 to 0.43, P value < 0.0001). We found significant evidence of heterogeneity (I(2) = 80%) for this result that was not explained by sensitivity or subgroup analysis; we therefore downgraded the inconsistency of the evidence by one level. Although we did not feel that there were concerns with imprecision or indirectness of the data, we downgraded the quality of the evidence for the risk of publication bias following visual analysis of a funnel plot. Using GRADEpro, we rated the overall quality of the data for shivering as very low. Only one study reported the incidence of core hypothermia, whilst 12 studies measured core temperature. However, as the results for core temperature were reported in different styles, pooling the results was inappropriate. We found no studies with participant-reported outcomes such as experience of shivering or participant satisfaction. We found limited data for the outcomes of length of stay in the postanaesthetic care unit (three studies, 200 participants) and the following adverse effects: sedation (nine studies, 875 participants), bradycardia (eight studies, 716 participants), and hypotension (seven studies, 688 participants). Unpooled analysis suggested that sedation and bradycardia were significantly more common with dexmedetomidine than placebo, with all seven dexmedetomidine studies and none of the clonidine studies reporting statistically significantly higher levels of sedation as an adverse effect. There is evidence that clonidine and dexmedetomidine can reduce postoperative shivering, but patients given dexmedetomidine may be more sedated. However, our assessment of the quality of this evidence is very low.

Children's Immediate Postoperative Distress and Mothers' and Fathers' Touch Behaviors.

This study examined mothers' and fathers' use of child-directed touch in the postanesthesia care unit. In all, 142 mothers and 112 fathers of 143 children aged 2-11 years undergoing outpatient surgery participated. Parent touch (instrumental, empathic) and child distress were coded. Mothers' and fathers' rates of touch were compared, and interrelations between touch and child distress were examined (overall and sequentially). The proportion of mothers and fathers who used touch did not differ, but mothers' rates of touch were higher than fathers'. Parental instrumental touch and mothers embracing touch were positively correlated with children's distress. Mothers were more likely to use embracing touch in response to children's distress than at any other time. Results point to potential differences in mothers' and fathers' roles in the postoperative setting, and potentially different functions of touch. Results suggest that mothers may provide embracing touch to soothe or prevent children's distress.

Complete blood count before and after total hip or knee arthroplasty.

To validate our transfusion protocol based on pre- and post-operative complete blood count (CBC) data in patients undergoing primary total hip or knee arthroplasty (THA or TKA). Records of 113 men and 205 women aged 32 to 94 (mean, 70) years who underwent primary uncemented THA (n=123) or cemented TKA (n=195) for osteoarthritis by 2 senior surgeons were reviewed. A post-surgical drain was used in 29 THA patients and 74 TKA patients, based on the surgeon's preference. CBC was assessed preoperatively, during postanaesthesia care, and at the beginning of postoperative days 1, 2, and 3 to determine their predictive power for transfusion rate. According to our transfusion protocol, blood was transfused when the haemoglobin (Hb) level was <80 g/l, or when hypotension, tachycardia, light-headedness, dizziness, or syncope occurred. Respectively in 123 and 195 patients who underwent THA and TKA, the transfusion rates within 3 days were 31.7% (n=39) and 25.6% (n=50). No patient required transfusion during postanaesthesia care; the transfusion rates of all patients during day 1 to day 2 and day 2 to day 3 were 15.1% (n=48) and 12.9% (n=41), respectively. The transfusion rate was higher in women than men (36.6% vs. 12.4%, p<0.001), but did not differ significantly in patients with or without a post-surgical drain (29.1% vs. 27.4%, p=0.754). Respectively for the Hb level of <130 g/l, 130-150 g/l, and >150 g/l, the overall transfusion rates were 48.5%, 22.0%, and 4.3% based on the preoperative level; 32.6%, 7.6%, and 0% based on the postanaesthesia care level; and 28.9%, 8.3%, and 0% based on the day 1 level. The predictive power of the preoperative Hb level was highest, followed by that during postanaesthesia care and the on day 1. CBC during postanaesthesia care is no more predictive than preoperative CBC. Preoperative optimisation and close monitoring of the Hb level from day 1 to day 3 is recommended.

Does previous chemotherapy-induced nausea and vomiting predict postoperative nausea and vomiting?

Postoperative nausea and vomiting (PONV) remains a problem in the postoperative period. Previous PONV in oncology patients has recently been associated with chemotherapy-induced nausea and vomiting (CINV). We assessed if CINV could improve Apfel's heuristic for predicting PONV. We conducted a retrospective study of 1500 consecutive patients undergoing intermediate or major cancer surgery between April and July 2011. PONV was assessed in the first postoperative day during post-anaesthesia care. The assigned anaesthetist completed an electronic medical record with all of the studied variables. Multiple logistic regression analyses were performed to assess whether any of the variables could add predictive ability to Apfel's tallying heuristic, and receiver operating characteristic (ROC) curves were modelled. The areas under the curve (AUC) were used to compare the model's discriminating ability for predicting patients who vomited from those who did not vomit. The overall incidence of PONV was 26%. Multiple logistic regressions identified two independent predictors for PONV (odds ratio; 95% CI), Apfel's score (1.78; 1.23-2.63) and previous chemotherapy-induced vomiting (3.15; 1.71-5.9), Hosmer-Lemeshow's P < 0.0001. Previous CINV was the most significant predictor to be added to Apfel's heuristic in this population. A history of chemotherapy-induced nausea vomiting was a strong predictor for PONV and should be investigated as an added risk factor for PONV in the preoperative period of oncology surgery in prospective studies.

Minimising post-operative risk using a Post-Anaesthetic Care Tool (PACT): protocol for a prospective observational study and cost-effectiveness analysis

IntroductionWhile the risk of adverse events following surgery has been identified, the impact of nursing care on early detection of these events is not well established. A systematic review of...

Interprofessional interactions influence nurses' adoption of handover improvement

Aim: The purpose of this study was to explore clinician experiences of adopting quality improvement tools to standardise interprofessional (anaesthetist-to-nurse) handover communication when patients arrive in the post-anaesthetic care unit (PACU). Method: In this study, factors that impacted PACU nurses' adoption of the quality improvement tools were explored using pre- and postimplementation, semi-structured focus group interviews. Interview data was analysed using the PARiHS1 (context, evidence and facilitation) framework as a deductive analysis tool. Results: PACU nurses recognised that PACU handover from anaesthetists to PACU nurses was suboptimal and described the tools as useful for their practice. However, PACU nurses frequently cited fear of anaesthetists' reactions as reasons not to insist on the use of the handover improvement tools. PACU nurses at Hospital 2 identified lacking authority (Hospital 2 FG 2) in the OR as hindering their willingness to use the tools against these behaviours. In comparison, visible support from leadership at Hospital 1 was described as encouraging nurses to be assertive (Hospital 1 FG 2) and take charge of their patients' care. Conclusion: PACU nurses perceived the handover tools were useful and helped them identify gaps in handover practice; however, PACU nurses described difficult relationships as hindering communication effectiveness and discouraging their adoption of the tools. However, strong leadership and organisational support of change emerged as essential to mitigate the effects of these difficult relationships.

Postanaesthetic emergence agitation in adult patients after general anaesthesia for urological surgery.

To investigate the incidence and risk factors for emergence agitation in the postanaesthetic care unit (PACU), in adult patients undergoing urological surgery. Medical records were retrospectively reviewed. Preoperative, intraoperative and postoperative variables were evaluated. Emergence agitation was defined as a Riker sedation-agitation score ≥ 5. Logistic regression analysis was used to determine independent risk factors for emergence agitation. Emergence agitation was observed in 48/488 (9.8%) patients. Chronic lung disease (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.03, 7.17), duration of surgery (OR 1.01, 95% CI 1.00, 1.01), history of social drinking (OR 2.48, 95% CI 1.25, 4.93), postoperative pain score (OR 1.32, 95% CI 1.14, 1.53), voiding urgency (OR 2.20, 95% CI 1.01, 4.77) and presence of gastric tube (OR 2.85, 95% CI 1.07, 7.54) were independent risk factors for emergence agitation. Adequate postoperative pain management and prevention of catheter-related bladder discomfort may be helpful in reducing the incidence of emergence agitation in urology patients.

Rectus sheath block for laparoscopic appendicectomy: a randomized clinical trial

The rectus sheath block is effective in elective paediatric operations, but has not been previously studied in acute laparoscopic surgery. We investigated its effect on pain after laparoscopic appendicectomy for acute appendicitis. Children aged 8-14 years admitted to a paediatric teaching hospital participated in a randomized clinical trial comparing a rectus sheath block using bupivacaine plus adrenaline with saline control. The primary outcomes were pain scores and opiate use, and secondary outcomes were time in the post-anaesthetic care unit, duration of hospitalization and recovery. Children in the nerve block group reported significantly reduced global pain scores compared with controls in the first 3 h after surgery, estimated mean 2.22 versus 3.94, effect size -1.80 (P = .008). Pain scores after 3 h did not differ between the groups. The groups did not differ in opiate requirements, length of hospital stay or recovery after discharge. In children undergoing acute laparoscopic appendicectomy, a rectus sheath block reduced early post-operative pain, and could contribute to a multimodal recovery programme.

Efficacy of different doses of sugammadex after continuous infusion of rocuronium.

To evaluate the effects of two different doses of sugammadex after maintenance anesthesia with sevofluorane and remifentanil and deep rocuronium-induced neuromuscular blockade (NMB). Patients between 20 and 65 years of age, with American Society of Anesthesiologists physical status classification I-II, undergoing gynecological surgery were included in a prospective, comparative and randomized study. NMB was induced with an injection of 0.6 mg/kg of rocuronium followed by continuous infusion of 0.3-0.6 mg/kg per hour to maintain a deep block. Anesthesia was maintained with sevofluorane and remifentanil. Finally, when surgery was finished, a bolus of 2 mg/kg (group A) or 4 mg/kg (group B) of sugammadex was applied when the NMB first response in the train-of-four was reached. The primary clinical endpoint was time to recovery to a train-of-four ratio of 0.9. Other variables recorded were the time until recovery of train-of-four ratio of 0.7, 0.8, hemodynamic variables (arterial blood pressure and heart rate at baseline, starting sugammadex, and minutes 2, 5 and 10) and adverse events were presented after one hour in the post-anesthesia care unit. Thirty-two patients were included in the study: 16 patients in group A and 16 patients in group B. Only 14 patients each group were recorded because arterial pressure values were lost in two patients from each group in minute 10. The two groups were comparable. Median recovery time from starting of sugammadex administration to a train-of-four ratio of 0.9 in group A and B was 129 and 110 s, respectively. The estimated difference in recovery time between groups was 24 s (95%CI: 0 to 45 s, Hodges-Lehmann estimator), entirely within the predefined equivalence interval. Times to recovery to train-of-four ratios of 0.8 (group A: 101 s; group B: 82.5 s) and 0.7 (group A: 90 s; group B: 65 s) from start of sugammadex administration were not equivalent between groups. There was not a significant variation in the arterial pressure and heart rate values between the two groups and none of the patients showed any clinical evidence of residual or recurrent NMB. A dose of 2 mg/kg of sugammadex after continuous rocuronium infusion is enough to reverse the NMB when first response in the Train-Of-Four is reached.

Considerações da comissão de saúde suplementar do CBO sobre o tratamento com antiangiogenicos

Considerações da comissão de saúde suplementar do CBO sobre o tratamento com antiangiogenicos

Sodium Homeostasis During Liver Transplantation and Correlation with Outcomes

Reports of perioperative serum sodium increase in liver transplant (LT) recipients are mostly restricted to unintentional rapid serum sodium overcorrection with subsequent development of central pontine myelinolysis. We examined intraoperative serum sodium changes and their effect on short-term outcomes after LT. We retrospectively analyzed data of all LT recipients over a period of 3.5 years. Collected information included preoperative and postoperative serum sodium (Napre and Napost), delta sodium (ΔNa), intraoperative serum sodium peak and trough with corresponding maximum ΔNa, intraoperative peak blood glucose, history of hepatic encephalopathy, perioperative diuretics, intraoperative administration of vasopressin, dopaminergic agents, alkalizing drugs (sodium bicarbonate [NaHCO3], tromethamine), crystalloids, colloids, fresh frozen plasma (FFP), and packed red blood cells (PRBC). The delta of serum osmolality (ΔOsm) was calculated from Napre and Napost, blood urea nitrogen, and blood glucose values, and the correlation between ΔNa and ΔOsm was examined. Outcomes analyzed included intubation for ≥2 days, postanesthesia care unit/surgical intensive care unit (PACU/SICU) length of stay (LOS) for ≥2 days, need of SICU admission, hospital LOS, postoperative neurological complications, and mortality. Univariate and multivariate analyses were performed to test associations between ΔNa and outcomes. A P value <0.005 was considered significant. Data of 164 patients were analyzed. Their ΔNa was 5.3 ± 4.5 (mean ± SD) mEq/L. A lower Napre was associated with greater ΔNa, a relationship likely due to the regression to the mean. In a subgroup of patients with Napre < 130 mEq/L, ΔNa was 11.0 ± 3.6 mEq/L, significantly higher than in normonatremic patients (P < 0.0001). Mortality and neurologic complications were not affected by changes in ΔNa (all P ≥ 0.41). An increase in ΔNa was associated with higher odds of prolonged intubation and prolonged PACU/SICU LOS in univariate and multivariate regression analyses (P = 0.0003 and P = 0.0049, respectively, for adjusted odds ratios). The odds ratios for associations of ΔNa with those outcomes did not differ between patients treated versus not treated with NaHCO3. The intraoperative ΔNa was significantly higher in patients with intraoperative hyperglycemia (P < 0.0001). Intraoperative administration of NaHCO3 and the number of transfused FFP and PRBC units were also associated with a significantly higher ΔNa (P = 0.0001). The ΔNa correlated significantly with ΔOsm. A larger intraoperative increase in ΔNa is associated with worse recipient short-term outcomes. Patients with preoperative hyponatremia may be at particular risk. ΔNa increases with the intraoperative use of NaHCO3, quantity of FFP, and PRBCs transfused, as well as with intraoperative hyperglycemia. Potential differences on sodium homeostasis between NaHCO3 and tromethamine use for intraoperative pH adjustment should be prospectively investigated.