Effects In Postoperative Patients Research Articles

Ketamine intolerance in patients on enhanced recovery after surgery protocols undergoing colorectal operations

BackgroundKetamine is used in enhanced recovery after surgery (ERAS) protocols because of its beneficial antihyperalgesic and antitolerance effects. However, adverse effects such as hallucinations, sedation, and diplopia could limit ketamine’s utility. The main objective of this study was to identify rates of ketamine side effects in postoperative patients after colorectal surgery and, secondarily, to compare short-term outcomes between patients receiving ketamine analgesia and controls. MethodsThis was a retrospective observational cohort study. Subjects were adults who underwent ERAS protocol-guided colorectal surgery at a large, integrated health system. Patients were grouped into ketamine-receiving and preketamine cohorts. Patients receiving ketamine were divided into tolerant and intolerant groups. Propensity score-adjusted models tested multivariate associations of ketamine tolerance/intolerance vs control group. ResultsA total of 732 patients underwent colorectal surgery within the ERAS program before ketamine’s introduction (control). After ketamine’s introduction, 467 patients received the medication. Intolerance was seen in 29% of ketamine recipients, and the most common side effect was diplopia. Demographics and surgical variables did not differ between cohorts. Multivariate models revealed no significant differences in hospital stays. Pain scores in the first 24 hours after surgery were slightly higher in patients receiving ketamine. Opiate consumption after surgery was lower for both ketamine tolerant and ketamine intolerant cohorts than for controls. ConclusionRates of ketamine intolerance are high, which can limit its use and potential effectiveness. Ketamine analgesia significantly reduced opiate consumption without increasing hospital stays after colorectal surgery, regardless of whether it was tolerated.

Analysing Correlation Between the Facial Nerve Notch at the Root Exit Zone and Long-term Effect in Patients with Hemifacial Spasm After Microvascular Decompression: A Prospective Study.

Microvascular decompression (MVD) has become widely accepted for hemifacial spasm (HFS). The significance of facial nerve notch (FNN) for the outcome after MVD is still unknown. To investigate the correlative analysis between the FNN at the root exit zone (REZ) and the curative effect of MVD for HFS. A prospective study was performed, which included 232 patients with Cohen score ≥2 who had undergone MVD. The patients were divided into two groups: the group with facial nerve notch (FNN) and the group without FNN, according to whether there is FNN caused by the offending vessels during the MVD operation. All the patients were followed up for 24 months. The group with FNN caused by offending vessels at the REZ area was confirmed in 119 patients, of which 117 patients were immediately cured and two patients received partial relief on the 1st day of postoperation. The group without FNN at the REZ area was confirmed in 113 patients, of which 43 patients were immediately completely cured while 70 patients were not immediately completely cured after MVD operation. After 24 months of follow-up, 119 patients with FNN were all completely cured, 71 patients without FNN were completely cured, and 42 patients without FNN were not completely cured. Multivariate logistic regression analysis shows that compared with without FNN group, the FNN group had statistical significance for the clinical results both on the-1st -day (P < 0.01) and 2 years of follow-up (P < 0.05) after MVD operation. FNN is an important reference factor to evaluate both the short-term and long-term curative effect of microvascular decompression for hemifacial spasm. The postoperative effect of patients with FNN is much better than that of patients without FNN.

Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery.

ABSTRACTSodium-glucose cotransporter-2 inhibitors (SGLT2i) are the second line of therapy in diabetes mellitus type 2. They are frequently coprescribed with other noninsulin glucose-lowering medications. Diabetic ketoacidosis (DKA) with lower-than-anticipated glucose levels is an important SGLT2i-related adverse effect in postoperative patients. This case highlights the need for increased postoperative surveillance of patients on this group of medications. Ketonuria was managed with short-acting insulin infusion with dextrose-containing intravenous fluid, as a part of the ongoing intensive care treatment to which the patient responded well. Awareness of DKA with lower-than-anticipated glucose levels is an important clinical challenge, an entity that can be confused in the setting of major and complex surgeries. The frequency of this arcane and underreported diagnosis in the perioperative setting is unknown.How to cite this article: Vadi S, Lad V, Kapoor D. Perioperative Implication of Sodium-glucose Cotransporter-2 Inhibitor in a Patient Following Major Surgery. Indian J Crit Care Med 2021;25(8):958–959.

Influence of Nanoparticle-Loaded Edaravone on Postoperative Effects in Patients with Cerebral Hemorrhage.

In order to explore the influence of nanoparticle-loaded edaravone on postoperative effects in patients with cerebral hemorrhage, a total of 120 patients who were diagnosed as cerebral hemorrhage and underwent minimally invasive hematoma removal at the designated hospital by the study from December 2014 to December 2018 were selected as research objects and divided into three groups according to the random number table method: edaravone treatment (ET) group, nanoparticle-loaded edaravone treatment (NET) group, and combined treatment (CT) group with 40 patients in each group. Three groups of patients underwent routine treatments based on their conditions, including regulating blood sugar, regulating blood pressure, anti-infection, nutritional support, and managing complications, in which 25 mg edaravone injection and 100 ml saline were added for patients in NET and CT group on the basis of the routine treatment of patients in ET group. The results showed that, after 15 days of standard treatment, the 40 patients in NET group had significantly improved neurological function than that before the treatment; the secretion of inflammatory factors in peripheral serum increased on the 7th day of treatment and decreased on the 14th day of treatment; there was no statistically significant difference in edema volume before treatment and the edema volume in the NET group was (11.56±0.44) mL after treatment, which was significantly smaller than that in ET group of (14.63±1.15) mL and the difference between the three groups was statistically significant (P <0.05). Therefore, it is believed that nanoparticle-loaded edaravone has an important effect on the postoperative effect of patients with cerebral hemorrhage; it can significantly improve the neurological function of patients with cerebral hemorrhage after minimally invasive drainage, and obviously reduce the production and release of interleukin and tumor necrosis factor, which is beneficial to protect healthy brain tissue and other organs throughout the body, and is conducive to the recovery and healing of cerebral hemorrhage. The results of this study provide a reference for further research on the influence of nanoparticle-loaded edaravone on postoperative effects in patients with cerebral hemorrhage.

Emerging effect of anesthesia on post-operative tumor recurrence and metastasis.

Post-operative recurrence and metastasis of malignant tumors are difficult to control, which probably results from multiple factors that affect the prognosis and the undefined mechanism. Anesthesia may be an influential factor. Researchers have performed many meaningful studies on the relationship between anesthetic drugs/methods and tumor growth/immune function, which provide important references for the anesthetic selection and peri-operative management of tumor patients. Anesthetics, analgesics, and sedatives should be used with caution because their effects in post-operative patients remain controversial. This review summarizes the emerging progress on the effect of anesthesia on post-operative tumor recurrence and metastasis, particularly focusing on the effects of anesthetic drugs, anesthetic methods, and post-operative analgesia on tumor growth and metastasis. Future studies should provide strict criteria for the proper use of anesthetics in patients with malignant tumors and provide experimental evidence for the improvement and development of novel anesthetics and anesthetic methods that have the important clinical significance.

Estudo do efeito do exercício de vibração de corpo inteiro no pós-operatório de cirurgia cardíaca: proposição de um protocolo

Introdução: A cirurgia cardíaca é uma intervenção de grandeimportância no tratamento de doenças cardiovasculares, asquais contribuem para o aumento da morbimortalidade. Avibração mecânica gerada por uma plataforma oscilante/vibratória pode ser usada para exercícios de vibração no corpointeiro (EVCI), modalidade de exercício físico aqui proposta.Objetivo: Apresentar protocolo para avaliação de efeitos doEVCI em indivíduos no pós-operatório de cirurgia cardíaca.Métodos: Indivíduos adultos, submetidos a cirurgia cardíaca,que receberem alta da Unidade de Tratamento intensivo atéo quarto dia de pós-operatório, serão distribuídos randomicamenteem 2 grupos: grupo controle (GC), que receberá atendimentofisioterapêutico convencional; e grupo Intervenção(GI), que, além do atendimento convencional, será submetidoao EVCI. Os pacientes do GI permanecerão com os joelhosflexionados a 15° na plataforma osclante/vibratória alternada,realizarão três séries de 1 min (por 1 min de repouso) a 5 Hz e 8mm de deslocamento pico a pico, duas vezes ao dia. A cada dia,as sessões serão modificadas, atingindo o máximo sete séries de1 min e 9 Hz, no sétimo dia de pós-operatório. Serão avaliadas aforça muscular respiratória, função pulmonar, força muscularperiférica, capacidade funcional e sensação de dor através damanovacuometria, espirometria, dinamometria, Time Up andGo (TUG), Medida de Independência Funcional (MIF), EscalaVisual Analógica de Dor (EVA), POWERbreathe K5. Discussão:Estudos recentes demonstraram efeitos benéficos com EVCIem diferentes condições clínicas, que se apresenta como umapromissora forma de intervenção durante a reabilitação nopós-operatório de cirurgia cardíaca. Conclusão: A aplicaçãodesse protocolo de estudo poderá preencher as lacunas sobreevidências que justificam um programa de reabilitação comEVCI para o indivíduo submetido à cirurgia cardíaca.Descritores: Exercício de vibração de corpo inteiro; Terapia porexercício; Unidade de Terapia Intensiva. Cirurgia cardíaca.

Network meta-analysis of the effectiveness of various drugs in preventing allergic hypersensitivity in patients after anesthesia.

Objective: To explore the effect of different drugs on postoperative hyperalgesia in general anesthesia patients. Methods: A randomized controlled trial was conducted to detect the hyperalgesia of patients with general anesthesia from PubMed, Embase, Medline, CNKI and Wanfang databases. The visual analogue scale (VAS) assessment of hyperalgesia patients after anesthesia was extracted as well as the effects of various prophylactic agents on the incidence of side effects in postoperative patients. Multivariables meta-analysis was performed by Stata 14.0 software to explore the effectiveness of various drugs in preventing postoperative hyperalgesia and side effects. Results: A total of 12 articles included 983 patients were included in this study. The results showed that the selected drugs had a certain effect on the prevention of hyperalgesia after anesthesia, but the incidence of side effects caused by dexmedetomidine and diazepam was the lowest. Conclusion: From the prevention of hypersensitivity after anesthesia and reduce the incidence of postoperative side effects, it is recommended that the clinical preferred dextromethorphan, followed by the selective application of diazepam or flurbiprofen ester.

Adjuvant interferon therapy after surgical treatment for hepatitis B/C virus‐related hepatocellular carcinoma: A meta‐analysis

This meta-analysis aimed to determine whether interferon (IFN) therapy could improve clinical effects of patients with chronic hepatitis B virus (HBV)or hepatitis C virus (HCV) infection-related primary hepatocellular carcinoma (HCC) after surgery. An electronic search from January 1998 to December 2012 was conducted to identify comparative studies evaluating IFN therapy on recurrence and survival after surgical treatment of HCC. The estimated odds ratios (OR) for the 1-, 2-, 3- and 5-year overall survival rates of HBV-related HCC were 3.37 (95% confidence interval [CI], 1.18-6.27), 2.36 (95% CI, 1.45-3.83), 1.81 (95% CI, 1.21-2.72) and 1.93 (95% CI, 1.35-2.75), respectively; and the OR for the 1-, 2-, 3- and 5-year recurrence rates were 0.63 (95% CI, 0.44-0.91), 0.84 (95% CI, 0.60-1.18), 0.88 (95% CI, 0.63-1.22) and 0.78 (95% CI, 0.56-1.07), respectively. The overall survival rates of HCV-related HCC were significantly higher in IFN groups than in control groups at 1, 2, 3 and 5 years (OR, 2.10; 95% CI, 0.96-4.55; OR, 1.71; 95% CI, 1.01-2.89; OR, 1.76; 95% CI, 1.09-2.83; and OR, 3.03; 95% CI, 1.97-4.65, respectively); and the recurrence rates of IFN groups were lower than control groups at 1, 2, 3 and 5 years (OR, 0.60; 95% CI, 0.38-0.92; OR, 0.57; 95% CI, 0.41-0.81; OR, 0.58; 95% CI, 0.41-0.80; and OR, 0.52; 95% CI, 0.36-0.75, respectively). In conclusion, IFN therapy in this meta-analysis shows a significant clinical effect in postoperative patients of HCC, particularly in HCV-related HCC.

T297 THE EFFECT OF ADDING NEOSTIGMINE IN PARAVERTEBRAL BLOCK ON POSTOPERATIVE EXTUBATION TIME IN ELECTIVE CORONARY ARTERY BYPASS GRAFT SURGERIES

Introduction-Paravertebral block is a technique of regional anesthesia and is used for a number of purposes. The aim of this study was to assess the effects of adjuvant neostigmine in paravertebral block with bupivacaine for in coronary artery bypass grafting surgery (CABG). Materials and methods-In total, 68 patients were randomly assigned into two groups: bupivacaine alone (B group) and bupivacaine with neostigmine (BN group) for bilateral paravertebral thoracic block at T6 level. Postoperative times for extubation, morphine requirements, and acute pain scores were assessed. ResultsThe BN group patients were extubated sooner. Also, they needed less morphine in the first twenty-four hours. DiscussionThe study suggests that adding neostigmine to bupivacaine in paravertebral block as an adjuvant can have beneficial postoperative effects in patients undergoing elective CABG (Iranian Heart Journal 2011; 12 (1):35 -39).

Intravenous Acetaminophen

OPIOIDS are the cornerstone of moderate to severe acute postoperative pain treatment, particularly when the patient is not a candidate for a regional analgesic technique (such as continuous epidural analgesia or peripheral nerve blockade) or is unresponsive to other (nonopioid) analgesics. Adverse effects of opioids, however, often present a major barrier to achieving excellent analgesia. In a systematic review examining opioid-associated adverse effects in postoperative patients, approximately 30% of patients reported an adverse gastrointestinal (nausea, vomiting, ileus, constipation) or central nervous system (sedation, somnolence) effect.

Letter to the Editor: New Equations for Predicting Postoperative Risk in Patients with Hip Fracture

To the Editor: We read with interest the recent article “New Equations for Predicting Postoperative Risk in Patients with Hip Fracture” by Hirose et al. [4] and their previous relevant reports [5, 6]. In their series of studies, they reportedly validated the effectiveness of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system to predict postoperative risk in patients with hip fracture based on significant correlations between E-PASS scores and hospitalization outcomes. However, we consider the correlation coefficients in their studies [4–6] low (the majority of which were less than 0.2). The degree of the correlation of two variables is determined by the absolute value of either Pearson’s correlation coefficient r or ranked Spearman correlation coefficient ρ. Commonly, |r| > 0.7 or |ρ| > 0.7 indicates a strong correlation, |r| or |ρ| between 0.3 and 0.7 indicates a moderate correlation, and |r| < 0.3 or |ρ| < 0.3 indicates a weak correlation [2]. Thus, although statistically significant, most correlations in their studies were weak. We wonder if one variable can be effective for predicting the other when they are weakly related. In addition, the square of Pearson’s correlation coefficient (r2) may provide an easier interpretation, which represents the proportion of the variation of one variable “explained” by the other [2]; for example, the strongest correlation in one [5] of the articles: surgical stress score (SSS) and costs of postoperative hospitalization (r = 0.44), which correlated significantly (p < 0.0001). However, only approximately 19% (r2 = 0.44 × 0.44%) of the variation of costs can be “explained” by SSS. Considering the even smaller parts of variation of costs “explained” by preoperative risk score and comprehensive risk score (1.4% = 0.12 × 0.12%, 5.3% = 0.23 × 0.23%, respectively), the conclusion that E-PASS was useful for estimating costs should be interpreted with caution. The E-PASS scoring system originally was established to predict adverse postoperative effects in patients undergoing elective gastrointestinal surgery [3]. Although it has been verified to be effective in other types of surgery, such as elective repair of abdominal aortic aneurysms [7] and thoracic surgery [8], it was a poor predictor of complications in patients requiring liver resection [1], and the authors recommended a new modified logistic regression to better predict the postoperative outcome. Therefore, the E-PASS scoring system is not applicable to every surgery without adjustment. Because the majority of the correlations between each E-PASS score and hospitalization outcomes were weak in the serial studies of Hirose et al., we suggest this system may not be a useful predictor for patients with hip fractures, and the E-PASS system might need to be modified for better evaluation.

Efficacy and safety of morphine-6-glucuronide (M6G) for postoperative pain relief: A randomized, double-blind study

Aims The aim of the study was to assess analgesia and safety effects of a range of intravenous doses of M6G (10, 20 and 30 mg/70 kg), compared to placebo, in postoperative patients. Methods In a randomized, multicentre, double-blind study, patients undergoing knee replacement surgery under spinal anaesthesia were administered one of three doses of M6G, or placebo, 150 min after spinal nerve block. Morphine rescue medication was available via a PCA pump. The key index of analgesic activity was determined as the amount of morphine consumed by the patient over 12 and 24 h after M6G administration. Time to first use of rescue medication, VAS and global pain assessment scales were also recorded. Safety was assessed by monitoring supine blood pressure, heart rate, respiratory rate and body temperature and typical opioid side-effects of PONV and sedation. Results A total of 170 patients were dosed with study medication. M6G induced a dose-related reduction in morphine use over 24-h that reached statistical significance compared to placebo at M6G 30 mg/70 kg. There was no clear relationship between M6G dose and time to first use of PCA morphine. Pain relief was similar in all groups. M6G showed small, but inconsistent effects on the cardiovascular system and on sedation and no effects were observed on respiration or PONV. Conclusion M6G induced long-lasting dose-related analgesic effects in postoperative patients with limited effects on cardiorespiratory systems or of opioid-like side-effects. M6G is an effective opioid for the treatment of moderate to severe postoperative pain.

Parecoxib sodium has opioid-sparing effects in patients undergoing total knee arthroplasty under spinal anaesthesia

This multicentre, double-blind, placebo-controlled study compared the opioid-sparing effectiveness and clinical safety of parecoxib sodium over 48 h, in 195 postoperative patients after routine total knee replacement surgery. Elective total primary knee arthroplasty was performed under spinal anaesthesia, with a single dose of spinal bupivacaine 10-20 mg, and intraoperative sedation with midazolam 0.5-1.0 mg i.v., or propofol <6 mg kg(-1)h(-1). Patients were randomized to receive either parecoxib sodium 20 mg twice daily (bd) i.v. (n=65), parecoxib sodium 40 mg bd i.v. (n=67), or placebo (n=63) at the completion of surgery, and after 12, 24, and 36 h. Morphine (1-2 mg) was taken by patient-controlled analgesia or by bolus doses after 30 min. Patients receiving parecoxib sodium 20 mg bd and 40 mg bd consumed 15.6% and 27.8% less morphine at 24 h than patients taking placebo (both P<0.05). Both doses of parecoxib sodium administered with morphine provided significantly greater pain relief than morphine alone from 6 h (P<0.05). A global evaluation of study medication demonstrated a greater level of satisfaction among patients taking parecoxib sodium than those taking placebo. Parecoxib sodium administered in combination with morphine was well tolerated. However, a reduction in opioid-type side-effects was not demonstrated in the parecoxib sodium groups. Parecoxib sodium provides opioid-sparing analgesic effects in postoperative patients.

Effects of NMDA receptor antagonists on inhibition of morphine tolerance in rats: binding at μ-opioid receptors

Past studies have shown antagonists of excitatory amino acid receptors, both N-methyl- d-aspartate (NMDA) and non-NMDA, to produce an antinociceptive effect in vitro and in vivo. Additionally, NMDA receptor antagonists have been demonstrated to prevent morphine tolerance. We had found that one NMDA receptor antagonist, ketamine, potentiates morphine's analgesic effect in post-operative patients. Our latest experiment was performed to examine the modulatory effect of competitive and non-competitive NMDA receptor antagonists on morphine antinociception and tolerance. A PE 10 catheter was intrathecally (i.t.) implanted in male Sprague-Dawley rats for drug administration. The antinociceptive effect of morphine, d-(−)-2-amino-5-phosphonovaleric acid (D-AP5) and (+)-5-methyl-10,110-dihydro-5 H-dibenzo[ a,d] cyclohepten-5,10-imine maleate (MK-801) was measured using the hot-water tail immersion test. Neither competitive nor non-competitive NMDA receptor antagonists had an antinociceptive effect by themselves, but they did potentiate the antinociceptive effect of morphine. Both D-AP5 (AD 50 = 0.18 μg) and MK-801 (AD 50 = 0.57 μg) shifted the antinociceptive dose-response curve of morphine (AD 50 = 4.2 μg) to the left. Both D-AP5 (4 μg/h) and MK-801 (10 μg/h) when co-administered with i.t. morphine infusions (10 μg/h) also inhibited the development of tolerance. In [ 3H][ d-Ala 2, N-Me-Phe 4,Gly 5-ol]enkephalin ([ 3H]DAMGO) binding assays, MK-801 ( B ax = 32.90 ± 3.33 fmol/mg) treatment prevented the down-regulation of μ-opioid receptor high-affinity sites induced by continuous morphine infusions alone ( B max = 13.97 ± 1.47 fmol/mg). D-AP5 ( B max = 20.78 ± 3.36 fmol/mg) did not prevent the reduction of μ-opioid receptor high-affinity sites. However, high-affinity sites in rats treated with D-AP5 and morphine displayed a higher affinity ( K D = 0.45 ± 0.09 nM) than those of control animals ( K D = 0.95 ± 0.08 nM). Results of this study indicate that competitive as well as non-competitive NMDA receptor antagonists enhance morphine's antinociceptive effect, and prevent the development of morphine tolerance. Thus, in our opinion, there opens a new frontier in clinical pain management, especially for those patients who require long-term opioid treatment for pain relief.

Can arginine and ornithine support gut functions?

Arginine and ornithine are precursors of nitric oxide and polyamines, respectively. These metabolites intimately participate in permeability and adaptive responses of the gut. The liver possesses high arginase activity as an intrinsic part of urea synthesis and would consume most of the portal supply of dietary arginine. The gut reduces this possibility by converting dietary arginine to citrulline, which effectively bypass the liver and is resynthesized to arginine in the kidney. Dietary ornithine supplementation, in the form of ornithine alpha-ketoglutarate (OKG) can be considered as an arginine precursor. Several supplement studies have shown both amino acids to promote growth hormone and insulin secretion with anabolic effects in postoperative patients. Their intermediary metabolites (for example, glutamine, proline) may also be of benefit in trauma metabolism. Specific effects of either amino acid on the gut are poorly reported. One recent animal study showed improved morphology after OKG administration, perhaps through increased polyamine secretion. Generation of nitric oxide from arginine has two facets. Excess production from high dose arginine potentiated the effects of experimentally induced sepsis, whereas low doses improved survival. These considerations suggest that the role of enteral diet supplementation with arginine or OKG should be urgently examined for any benefits it may have on mucosal barrier function.