Preoperative Baseline Value Research Articles

Preliminary experience on systemic effects of perineural dexamethasone sodium phosphate and methylprednisolone acetate through adductor canal block in total knee arthroplasty: A single center retrospective study.

Glucocorticoids are commonly utilised as adjuvants to enhance nerve block quality and prolong the analgesic duration. Its systemic effects, after a single-injection adductor canal block (ACB) followed by a continuous infusion, are unclear. The aim of the study was to assess the systemic effects of a single dose of dexamethasone sodium phosphate (DEX), or a combination of DEX and methylprednisolone acetate (MPA), on fasting blood glucose (FBG) and white blood cell count (WBC) when administered perineurally via ACB. A single-center retrospective study on total knee arthroplasty (TKA) was performed and a total of 95 patients were included in the final analysis. Patients were divided into three groups based on adjuvants received in ACB: Control group (N = 41) and two treatment groups, DEX group (N = 33) and DEX/MPA group (N = 21). Our primary outcomes were the change of FBG from its preoperative baseline value on postoperative day (POD) 2. The secondary outcomes included change of FBG on POD 0 and POD 1, and change of WBC on POD 0, POD 1, and POD 2. The FBG change from baseline in the DEX group was significantly higher than that in the control group (difference = 14.04, 95% CI: 1.3 to 26.77), P = 0.031) on POD 0. The WBC change from baseline in the DEX/MPA group was statistically significant higher than control on POD 0 (2.62 (1.52 to 3.37), P < 0.0001). No significant differences between DEX and DEX/MPA group were found on any given postoperative days for FBG and WBC. This study provided preliminary safety data on the use of a combination of glucocorticoids with hydrophilic (DEX) and lipophilic (MPA) properties as local anesthetic adjuvants in ACB, which induced similar levels of changes on FBG and WBC as those from both control and DEX alone group.

Does stature of female affect Knee Injury and Osteoarthritis Outcome Score following knee arthroplasty surgery: an observational pilot study

BackgroundKnee osteoarthritis (OA) occurs frequently in females. So far, no study has evaluated postoperative outcome measures in females based on body height. We aimed to evaluate postoperative pain relief and Knee Injury and Osteoarthritis Outcome Score (KOOS) at 6 months in women following total knee arthroplasty (TKA).In this prospective, observational pilot study, 20 women, 50–70 years, American Society of Anesthesiologist (ASA) physical status I and II, undergoing TKA surgery were enrolled. The patients were allocated to Group I (n = 10), women with a height less than 153 cm, and Group II (n= 10), women with a height greater than 153 cm. All patients received paracetamol, diclofenac, and epidural analgesia postoperatively for up to 72 h. The primary outcome was a comparison of KOOS scores from preoperative baseline value to 6 months following TKA.ResultsThe baseline demographics, KOOS, waist-hip ratio, and knee range of motion were similar. The height mean ± standard deviation (SD) (range) in Group I was 149.85 ± 3.28 (142.5–152.5) cm versus 157.25 ± 2.99 (155–165) cm in Group II, p = 0.001. KOOS score improved in patients of both Groups I and II as compared to the respective baseline. At 6 months, the KOOS pain score improved to 96.50 ± 3.14 [94.26–98.74 (89–100)] in Group I as compared to 89.40 ± 6.45 [84.79–94.01 (81–100)] in Group II, p value = 0.02.ConclusionsPostoperative KOOS pain score at 6 months was superior in short stature versus normal stature women following TKA surgery.

Effect on determinants of dry eye after phacoemulsification

Quantitative analysis of determinants of dry eye among patients undergoing phacoemulsification surgery. This was a single-centered hospital-based, prospective observational study. Sixty eyes of sixty patients suffering from senile cataract undergoing phacoemulsification surgery were evaluated after randomly selecting them and were followed up postoperatively on day 1 and week 4 to evaluate the dry eye parameters selected for the study.A total of 60 eyes of 60 patients were chosen with a mean age of 63.96 ± 6.95 (mean ± SD) years. The mean baseline Schirmer’s test I, tear break-up time, lissamine test, and OSDI values were 25.45 ± 4.68 mm, 14.15±2.79 s, 1.26 ± 0.44 s, and 7.28 ± 3.13 respectively, whereas post-operatively day 1 the values were 14.75 ± 4.32 mm, 8.91 ± 2.93 s, 3.11 ± 0.78, and 22.85 ± 6.80 respectively. On 4 week follow-up, the value were 22.60 ± 4.54 mm, 13.30 ± 2.79 s, 1.43 ± 0.67, and 12.13 ± 5.45 respectively.Dry eye after cataract surgery is mainly because of tear film stability.The study points to the fact that patients experience increase in dry eye symptoms postoperatively. We also observed a very predictable trend of dry eye in our study, wherein the incidence increases immediately in the early postoperative period, followed by a gradual decrease in dry eye parameters approaching their preoperative baseline value.

Psoas weakness following oblique lateral interbody fusion surgery: a prospective observational study with an isokinetic dynamometer

BACKGROUND CONTEXTAlthough the surgical corridor used for oblique lateral interbody fusion (OLIF) protects the intrapsoas nerves by causing minimal compression, transient weakness remains the most commonly reported postoperative complication. PURPOSEUsing a dynamometer to evaluate how the hip flexor strength changes following OLIF. STUDY DESIGN/SETTINGA prospective observational study. PATIENT SAMPLEForty-six patients who underwent single or multi-level OLIF for lumbar spondylolisthesis. OUTCOME MEASURESIsokinetic dynamometer values (peak torque, total work, average power), visual analogue scale (VAS) scores for leg pain, hypoesthesia, subjective weakness of the left hip flexor muscle, Oswestry disability index, body mass index, bone mineral density, radiologic findings of the psoas muscle (cross-sectional area, Hounsfield unit (HU), fat portion grade), and psoas retraction time. METHODSThe isokinetic muscle strength of the hip flexor was measured five times (preoperatively and postoperatively at 2 days, 1 week, 1 month, and 3 months) for both legs. The peak torque was defined as the postoperative strength of the left hip flexor muscles, and was compared to the preoperative baseline value. The strength of the left and right hip flexor muscles were also compared at each time point. For logistic regression analysis, when the peak torque was below the median value, it was defined as lower peak torque. RESULTSUp to 1 week after surgery, the strength of the left hip flexor muscle decreased significantly (paired difference in peak torque was 22.6%, p<.001). In the results of multivariate logistic regression analysis, diabetes (odds ratio [OR]=8.43, p=.020) and the HU of the psoas muscle (OR=0.916, p=.034) were associated with lower peak torque 1 week after surgery. From 1 month after surgery, postoperative weakness of the psoas muscle was not significant. In the questionnaire survey, subjective left hip flexion weakness was reported in 8.5% (4/47) of patients 1 week after surgery, and it remained in only 2.1% (1/47) of patients after 3 months of operation. The frequency of left anterior thigh pain and hypoesthesia decreased from 85.1% (40/47) at 1 week to 2.1% (1/47) at 3 months after surgery. The mean VAS score for left anterior thigh or groin pain decreased significantly at 1 month after surgery (PO2D: 4.04±1.84, PO1M: 1.67±1.10, p<.001). CONCLUSIONSDynamometer measurement showed that psoas strength declined significantly up to 1 week after OLIF surgery. Patients with diabetes or lower HU of the psoas muscle showed delayed recovery from postoperative weakness of the psoas muscle. However, the weakness was insignificant from 1 month after surgery. At 3 months after surgery, the other psoas-related problems (left anterior thigh pain and hypoesthesia) also disappeared.

Prospective, randomized, controlled, double-blind, multi-center, multinational study on the safety and efficacy of 6% Hydroxyethyl starch (HES) sOlution versus an Electrolyte solutioN In patients undergoing eleCtive abdominal Surgery: study protocol for the PHOENICS study

BackgroundHydroxyethyl starch (HES) solutions are used for volume therapy to treat hypovolemia due to acute blood loss and to maintain hemodynamic stability. This study was requested by the European Medicines Agency (EMA) to provide more evidence on the long-term safety and efficacy of HES solutions in the perioperative setting.MethodsPHOENICS is a randomized, controlled, double-blind, multi-center, multinational phase IV (IIIb) study with two parallel groups to investigate non-inferiority regarding the safety of a 6% HES 130 solution (Volulyte 6%, Fresenius Kabi, Germany) compared with a crystalloid solution (Ionolyte, Fresenius Kabi, Germany) for infusion in patients with acute blood loss during elective abdominal surgery. A total of 2280 eligible patients (male and female patients willing to participate, with expected blood loss ≥ 500 ml, aged > 40 and ≤ 85 years, and ASA Physical status II–III) are randomly assigned to receive either HES or crystalloid solution for the treatment of hypovolemia due to surgery-induced acute blood loss in hospitals in up to 11 European countries. The dosing of investigational products (IP) is individualized to patients’ volume needs and guided by a volume algorithm. Patients are treated with IP for maximally 24 h or until the maximum daily dose of 30 ml/kg body weight is reached.The primary endpoint is the treatment group mean difference in the change from the pre-operative baseline value in cystatin-C-based estimated glomerular filtration rate (eGFR), to the eGFR value calculated from the highest cystatin-C level measured during post-operative days 1-3. Further safety and efficacy parameters include, e.g., combined mortality/major post-operative complications until day 90, renal function, coagulation, inflammation, hemodynamic variables, hospital length of stay, major post-operative complications, and 28-day, 90-day, and 1-year mortality.DiscussionThe study will provide important information on the long-term safety and efficacy of HES 130/0.4 when administered according to the approved European product information. The results will be relevant for volume therapy of surgical patients.Trial registrationEudraCT 2016-002162-30. ClinicalTrials.govNCT03278548

Evaluation of Routine Postoperative Labs Following Robotic Assisted Partial Nephrectomy in Patients With Normal Preoperative Renal Function

ObjectiveTo evaluate predictors of abnormal routine postoperative day 1 (POD1) labs in patients with normal pre-operative renal function following robotic assisted partial nephrectomy (RAPN) and the associated clinical outcomes of these lab results. MethodsWe analyzed 500 consecutive RAPN from a single surgeon series. Patients with chronic kidney disease (CKD) III or greater were excluded from the study. Three hundred ninty-three RAPN were included in the analysis. Routine POD1 lab tests including hemoglobin (Hgb), creatinine, potassium, and sodium were evaluated to determine rates of abnormal values and rates of clinical intervention. Abnormal Hgb at POD1 was defined as <8 g/dL or ≥3 g/dL decrease from the preoperative (baseline) value. Abnormal sodium (Na) preoperatively and postoperatively was defined as <135 mEq/L or >145 mEq/L. Abnormal potassium (K) was defined preoperatively and POD1 as <3.5 mEq/L or >5 mEq/L. ResultsOf 37.4% (147/393) had one or more abnormal labs at POD1. Of the 101 patients with abnormal Hgb, 15 patients required blood transfusion. Twenty-six patients had abnormal sodium for which two were treated with IV fluids. Twenty-seven patients had potassium abnormalities (12/25 were hypokalemia). Acute kidney injury stage I was seen in 27 patients (6.9%) and stage II in 3 (0.8%). Patients with abnormal labs were more likely to have larger renal mass, higher R.E.N.A.L. scores, intraoperative complications, longer operative times, and higher EBL on multivariate analysis. ConclusionPOD1 serum laboratory tests appear to be necessary following RAPN in patients with normal pre-operative renal function.

External Validation of a Prediction Model for Acute Kidney Injury Following Noncardiac Surgery

The Simple Postoperative AKI Risk (SPARK) index is a prediction model for postoperative acute kidney injury (PO-AKI) in patients undergoing noncardiac surgery. External validation has not been performed. To externally validate the SPARK index. This single-center retrospective cohort study included adults who underwent noncardiac surgery under general anesthesia from 2007 to 2011. Those with obstetric or urological surgery, estimated glomerular filtration rate (eGFR) of less than 15 mL/min/1.73 m2, preoperative dialysis, or an expected surgical duration of less than 1 hour were excluded. The study was conducted at Nara Medical University Hospital. Data analysis was conducted from January to July 2021. Risk factors for AKI included in SPARK index. PO-AKI, defined as an increase in serum creatinine of at least 0.3 mg/dL within 48 hours or 150% compared with preoperative baseline value or urine output of less than 0.5 mL/kg/h for at least 6 hours within 1 week after surgery, and critical AKI, defined as either AKI stage 2 or greater and/or any AKI connected to postoperative death or requiring kidney replacement therapy before discharge. The discrimination and calibration of the SPARK index were examined with area under the receiver operating characteristic curves (AUC) and calibration plots, respectively. Among 5135 participants (2410 [46.9%] men), 303 (5.9%) developed PO-AKI, and 137 (2.7%) developed critical AKI. Compared with the SPARK cohort, participants in our cohort were older (median [IQR] age, 56 [44-66] years vs 63 [50-73] years), had lower baseline eGFR (median [IQR], 82.1 [71.4-95.1] mL/min/1.73 m2 vs 78.2 [65.6-92.2] mL/min/1.73 m2), and had a higher prevalence of comorbidities (eg, diabetes: 3956 of 51 041 [7.8%] vs 802 [15.6%]). The incidence of PO-AKI and critical AKI increased as the scores on the SPARK index increased. For example, 10 of 593 participants (1.7%) in SPARK class A, indicating lowest risk, experienced PO-AKI, while 53 of 332 (16.0%) in SPARK class D, indicating highest risk, experienced PO-AKI. However, AUCs for PO-AKI and critical AKI were 0.67 (95% CI, 0.63-0.70) and 0.62 (95% CI, 0.57-0.67), respectively, and the calibration was poor (PO-AKI: y = 0.24x + 3.28; R2 = 0.86; critical AKI: y = 0.20x + 2.08; R2 = 0.51). Older age, diabetes, expected surgical duration, emergency surgery, renin-angiotensin-aldosterone system blockade use, and hyponatremia were not associated with PO-AKI in our cohort, resulting in overestimation of the predicted probability of AKI in our cohort. In this study, the incidence of PO-AKI increased as the scores on the SPARK index increased. However, the predicted probability might not be accurate in cohorts with older patients with more comorbidities.

PD16-02 EVALUATING THE NECESSITY OF ROUTINE POST-OPERATIVE LABS FOLLOWING ROBOTIC ASSISTED PARTIAL NEPHRECTOMY

You have accessJournal of UrologyKidney Cancer: Localized: Surgical Therapy II (PD16)1 Sep 2021PD16-02 EVALUATING THE NECESSITY OF ROUTINE POST-OPERATIVE LABS FOLLOWING ROBOTIC ASSISTED PARTIAL NEPHRECTOMY Amanda Myers, Laura Geldmaker, Daniela Haehn, Colleen Ball, and David Thiel Amanda MyersAmanda Myers More articles by this author , Laura GeldmakerLaura Geldmaker More articles by this author , Daniela HaehnDaniela Haehn More articles by this author , Colleen BallColleen Ball More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001998.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Robotic assisted partial nephrectomy (RAPN) has been classified as an outpatient procedure. There have been reports of same day discharge following RAPN. We aimed to evaluate the necessity of post-operative day one (POD1) labs in patients that could be candidates for same day discharge. METHODS: We analyzed 500 consecutive RAPN from a single surgeon series. Patients with chronic kidney disease (CKD) III or greater were excluded from evaluation. Routine POD1 lab tests were acquired on every patient and included hemoglobin (Hgb), creatinine (Cr), potassium (K), and sodium (Na). Labs were evaluated to determine rates of abnormal values and rates of clinical intervention. Abnormal Hgb was defined as <8 g/dL or ≥3 unit decrease from the preoperative (baseline) value. Abnormal Na was defined as <135 mEq/L or >145 mEq/L. Abnormal K defined as <3.5 mEq/L or >5 mEq/L. POD1 Cr 1.5-1.9 times preoperative (baseline) Cr or ≥0.3 mg/dL increase from baseline to POD1 was defined as Stage I acute kidney injury (AKI). POD1 Cr 2.0-2.9 times preoperative Cr was defined as Stage II AKI. RESULTS: 38.3% (147/384) had one or more abnormal labs at POD1. Of the 101 patients with abnormal hgb, 15 patients required transfusion. Patients with abnormal hgb had longer median length of stay 3 vs 2 days (p<0.001), higher median estimated blood loss, 500 vs 300 ml (p<0.001), longer operative time, 211 vs 194 min (p<0.001), and larger tumor size 3.5 vs 2.5 cm (p<0.001). 26 patients had abnormal sodium for which two were treated with IV fluids. 25 patients had potassium abnormalities. All patients with hypokalemia received repletion with oral potassium agents. Five electrocardiograms were performed for abnormal K values, all without acute abnormality. AKI stage I was seen in 27 patients (7%) and stage II in 3 (1%). AKI was treated in one third of the cases with infusion of intravenous fluid and monitored in two thirds of the cases. Patients with acute kidney injury were more likely to have renal mass >4cm (p=0.006), higher RENAL scores (p=0.014), and intraoperative complications (p=0.077). CONCLUSIONS: This study demonstrates evidence that lab tests on POD1 after RAPN are necessary in many patients especially those with large complex tumors. The decision to obtain labs should be based on risk on individual risk factors and clinical course. This data calls into question the classification of RAPN as an outpatient procedure. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e278-e278 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Myers More articles by this author Laura Geldmaker More articles by this author Daniela Haehn More articles by this author Colleen Ball More articles by this author David Thiel More articles by this author Expand All Advertisement Loading ...

Objective postoperative pain assessment using incentive spirometry values: a prospective observational study.

Aim: Determine if incentive spirometry (IS) values correlate with postoperative pain control. Design: Prospective observational study. Setting & participants: A total of100 patients undergoing major abdominal procedures at theUniversity of North Carolina Medical Center. Interventions: Patients studied as a single cohort. All patients received thoracic epidural analgesia preoperatively. Outcome: Preoperative and daily postoperative numeric pain scores, subjective pain description and IS values were collected for all patients. Results: There was a strong correlation with IS values relative to baseline for both the numeric pain scores (p<0.0001), postoperative day (p<0.0001) and the subjective pain score (p<0.0007). Conclusion: IS values are an objective surrogate data point for pain control after surgery, particularly when followed over time and compared with a preoperative baseline value.

The first 10 years’ experience in radical retropubic prostatectomy: Complications, lower urinary tract symptoms, and quality of life - a single-center experience

Introduction/Objective. This 10-year prospective study?s primary objective was to evaluate the incidence of complications of radical retropubic prostatectomy (RRP). The secondary objective was to analyze how RRP affects lower urinary tract symptoms (LUTS) and quality of life (QoL) by using the International Prostate Symptom Score (IPSS). Methods. We analyzed 254 patients who underwent RRP in the period 2009?2018. All complications were graded according to the Clavien?Dindo classification. To assess urinary symptoms and the QoL, all the examinees filled out the IPSS and the International Prostate Symptom Score for QoL (IPSS QoL) questionnaires during preoperative preparation and three, six, and 12 months after surgery. Results. The incidence of complications Clavien?Dindo grade ? II and grade ? III were 26.4% and 16.5%, respectively. The mean overall IPSS for the entire group of patients after 12 months of follow-up was significantly different from the preoperative baseline value (p &lt; 0.001). Patients with preoperative moderate (IPSS 8?19) and severe urinary symptoms (IPSS 20+) had a statistically significant reduction of urinary symptoms after RRP (p &lt; 0.001). After 12 months, IPSS QoL was statistically significantly lower than the preoperative one (p &lt; 0.05). Conclusion. For patients with clinically localized prostate cancer, RRP is a safe and effective treatment option. It is associated with a higher rate of complications from the Clavien?Dindo grade ? II group. RRP has clinically beneficial effects on LUTS in patients with moderate and severe urinary symptoms and the QoL related to LUTS.

The correlation between tissue oxygen saturation and postoperative cognitive dysfunction in elderly patients with one lung ventilation

Objective: To investigate the correlation between tissue oxygen saturation during one lung ventilation and postoperative neuro cognitive dysfunction (PND) in elderly patients in thoracic surgery. Methods: One hundred and twenty-eight elderly patients who underwent selective lobectomy from August 2017 to September 2018 in the Forth Hospital of Hebei Medical University were enrolled. The patients were divided into PND group (n=34) and non-PND group (n=94) according to whether PND occurred 3 days after surgery. Tissue oxygenation was monitored at bilateral forebrain, brachioradialis muscle and quadriceps. Cognitive function was assessed by the Montreal Cognitive Assessment (MoCA) at baseline and the third day after the operation. Postoperative cognitive dysfunction was diagnosed if postoperative MoCA decreased at least 2 scores compared with preoperative baseline value. Outcomes included the incidence of PND, the incidence of tissue oxygen desaturation during one lung ventilation, postoperative complications within 30 days and length of postoperative in-hospital stay. Logistic regression was used to screen independent risk factors of PND. Results: The incidence of postoperative cognitive dysfunction was 26.6% (34/128). The two groups had no significant difference in the incidence of non-neurogenic complications (new occurred arrhythmia, pulmonary infection, pulmonary embolism, acute renal insufficiency, sepsis, deep vein thrombosis, all P>0.05). However, the length of postoperative in-hospital stay of PND group was 7.0 (6.0, 8.5) d, which was longer than that of non-PND group [6.0 (5.0, 8.0) d]. There was significant difference (U=2.394, P=0.017) . There was no correlation between the two groups within the minimum of SmtO(2) in upper limbs (OR=0.988, 95%CI: 0.954-1.024, P=0.519) and the range of desaturation (OR=1.010, 95%CI: 0.979-1.042, P=0.514) , as well as the minimum of SmtO(2) in legs (OR=0.996, 95%CI: 0.961-1.032, P=0.832) and the range of desaturation (OR=0.997, 95%CI: 0.971-1.025, P=0.851) . Multivariate logistic regression analysis showed that the high ASA grade (OR=2.617, 95%CI: 1.112-6.157, P=0.029) and the minimum of cerebral oxygen saturation during one lung ventilation (OR=0.931, 95%CI: 0.880-0.986, P=0.014) were independent risk factors of PND. There was no statistical correlation between muscle oxygen saturation and PND. Conclusion: Cerebral desaturation during one lung ventilation increased the risk of PND in elderly patients, while the muscle desaturation has no statistical correlation with PND.

Evidence of Post Trabeculectomy Optic Nerve Reperfusion by OCT Angiography

Aim: To describe a case of glaucoma which showed increase in optical coherence tomography (OCT) angiographic vessel densities after intraocular pressure reduction suggesting reperfusion of optic nerve.&#x0D; Presentation of Case: A 55 year old female with primary open angle glaucoma was taken up for trabeculectomy in view of inadequate control of intraocular pressure (IOP) despite maximal medical therapy. In addition to routine glaucoma assessment by visual fields and nerve fiber layer assessment by OCT, OCT angiographic evaluation of peripapillary vessel density was done preoperatively. Three months after trabeculectomy, her intraocular pressure decreased from 35mmHg to 14mmHg. Compared with the preoperative baseline value, the vessel density increased significantly in all quadrants after three months from surgery as demonstrated by OCT angiography.&#x0D; Discussion: This case report suggests that decreased optic nerve head perfusion due to high IOP can be reversed by reduction of IOP.&#x0D; Conclusion: Vascular parameters like angiographic vessel density can show reversible changes as decreased blood flow reinstates and thus can be better prognostic indicators than structural parameters like OCT retinal nerve fiber layer (RNFL) in glaucoma patients.

Perioperative blood pressure management : What is the optimal pressure?

Measurement of blood pressure is part of standard monitoring procedures in anesthesia, in addition to the other vital parameters of heart frequency and peripheral oxygen saturation. In recent years the relevance of the duration and extent of perioperative episodes of hypotension for the occurrence of postoperative complications or even increased mortality have become the focus of scientific investigations. The aim of this review is to briefly recapitulate the physiological aspects of blood pressure and to describe the pathophysiology and risk factors of perioperative hypotension. It describes which potential organ damage can be caused by hypotension and discusses which perioperative blood pressure values are acceptable without harming the patient. Review and analysis of the currently available literature. Perioperative hypotension is defined by either absolute systolic arterial pressure (SAP) or mean arterial pressure (MAP) thresholds and by relative blood pressure declines from an individual preoperative baseline value. For the definition of absolute and relative thresholds it needs to be considered that the ultimate target is an adequate perfusion pressure (and not the MAP) and that the preinduction blood pressure is a poor reflection of the patients' normal blood pressure profile. Risk factors for an intraoperative drop in blood pressure are advanced age, higher American Society of Anesthesiologists (ASA) status, low blood pressure prior to induction of anesthesia, the premedication, e.g. angiotensin-converting enzyme (ACE) inhibitors, the anesthesia technique (combination of general and epidural anesthesia) and emergency surgery. The lowest tolerable intraoperative blood pressure should be defined according to the individual patient's preoperative blood pressure and risk profile. Individual thresholds should be determined for the severity and duration of intraoperative hypotension. Empirically, MAP values <65 mm Hg and relative pressure declines of >20-30% are often recommended as thresholds. Below critical blood pressure values the risk of postoperative organ damage (myocardium, kidneys and central nervous system) and mortality increases with longer duration of hypotension. Older people and high-risk patients (e.g. patients in vascular surgery) have a poorer and shorter tolerance of low blood pressure. Postoperative organ complications can be minimized by maintenance of an adequate intraoperative blood pressure CONCLUSION: Anesthesiologists should avoid extensive and prolonged hypotension by timely interventions in order to improve the postoperative outcome of patients.

CLINICAL AND RADIOGRAPHIC OUTCOMES OF RADICULAR CYST ENUCLEATION USING PIEZOSURGERY VERSUS CONVENTIONAL SURGERY

Abstract AIM: The study was intended to evaluate the effectiveness of piezosurgery in enucleation of radicular odontogenic cysts in comparison to the conventional technique. METHODS: Fourteen patients who had radicular cysts associated with non-vital teeth, were operated at the Oral and Maxillofacial Surgery Department, Faculty of Dentistry, Alexandria University. The patients were randomly divided into 2 groups;1) the study group in which cyst enucleation was using piezosurgery, 2) control group in which the cysts were removed using the conventional technique. The following were assessed; operation time, hemorrhage control and field visibility, ease of operation, neurosensory evaluation and radiographic percentage of change in bone defect volume. RESULTS: The piezosurgery group showed a statistically significant control over heamorrhage and a clearer, more visible field when compared to the conventional group. The difference between the times required for cyst enucleation in both groups was statistically significant, with longer time recorded with piezosurgery. No complications were observed with the piezosurgery technique. However, with the conventional technique, 2 patients complained of neurosensory involvement which was resolved over time. Also, with piezosurgery, there was a significant reduction of bone defect volume than the conventional surgery, 3 months after the operation in comparison to the preoperative baseline value. CONCLUSIONS: Piezosurgery proved to be more effective for cyst enucleation than the conventional method. The piezosurgery was more efficient for preserving important anatomical structures while providing a clearer field of surgery. Also, better early healing potential of the bone defect resulting from cyst enucleation was detected.

Peripapillary Vessel Density Reversal after Trabeculectomy in Glaucoma.

Purpose To evaluate the microvascular changes at the peripapillary area and optic disc in glaucomatous eyes after IOP lowering by trabeculectomy using OCT angiography. Methods 25 patients with primary open-angle glaucoma (POAG) who underwent trabeculectomy by a single surgeon were evaluated. Using optical coherence tomography angiography, vessel density was evaluated within the whole image, peripapillary, nasal region, and temporal region. Peripapillary vessel density was measured preoperative, 1 week, 1 month, and 3 months postoperatively in POAG patients. Reversal of vessel density was calculated for all analyzed areas. Results The intraocular pressure (IOP) decreased from 30.92 ± 6.32 mmHg (range, 18–44) to 12.64 ± 3.35 mmHg (range, 8–22) at 3-month postoperatively. Compared with the preoperative baseline value, whole vessel density, peripapillary vessel density (PvD), and PvD in nasal region and temporal region were significantly increased at 3-month postoperatively. The magnitude of the vessel density reversal was significantly associated with higher preoperative IOP and greater IOP reduction. Conclusions A significant increase in the peripapillary vessel density was demonstrated after trabeculectomy using OCT angiography. The reversal of peripapillary vessel density was associated with higher preoperative IOP and greater IOP reduction. Our postoperative results suggest that the ocular perfusion impairment by high intraocular pressure can be improved by IOP reduction, and the reversal of microvasculature may contribute to the rate of glaucoma progression.

Quantitative Relationships between Pulmonary Function and Residual Neuromuscular Blockade.

Background Neuromuscular blockade is a risk factor for postoperative respiratory weakness during the immediate postoperative period. The quantitative relationships between postoperative pulmonary-function impairment and residual neuromuscular blockade are unknown. Methods 113 patients who underwent elective laparoscopic cholecystectomy were enrolled in this study. They all had a pulmonary-function test (PFT) during the preoperative evaluation. Predictive values based on demographic data were also recorded. The train-of-four ratio (TOFR) was recorded at the same time as the PFT and at every 5 minutes in the qualified 98 patients in the postanesthesia care unit (PACU). We analyzed the degree of PFT recovery when the TOFR had recovered to different degrees. Results There was a significant difference (P < 0.05) between the preoperative baseline value and the postoperative forced vital capacity at each TOFR point, except at a TOFR value of 1.1. There was also a significant difference (P < 0.05) between the preoperative baseline value and the postoperative peak expiratory flow at each TOFR point. Conclusions Postoperative residual neuromuscular blockade was common (75.51%) after tracheal extubation, and pulmonary function could not recover to an acceptable level (85% of baseline value), even if TOFR had recovered to 0.90. Trial Registration Chinese Clinical Trial Register is ChiCTR-OOC-15005838.

Recovery and prediction of postoperative muscle power \u2013 is it still a problem?

BackgroundIn the postoperative period, immediate recovery of muscular power is essential for patient safety, but this can be affected by anaesthetic drugs, opioids and neuromuscular blocking agents (NMBA). In this cohort study, we evaluated anaesthetic and patient-related factors contributing to reduced postoperative muscle power and pulse oximetric saturation.MethodsWe prospectively observed 615 patients scheduled for minor surgery. Premedication, general anaesthesia and respiratory settings were standardized according to standard operating procedures (SOP). If NMBAs were administered, neuromuscular monitoring was applied to establish a Train of four (TOF)-Ratio of >0.9 before extubation. After achieving a modified fast track score > 10 at 4 time points up to 2 h postoperatively, we measured pulse oximetric saturation and also static and dynamic muscle power, using a high precision digital force gauge. Loss of muscle power in relation to the individual preoperative baseline value was analysed in relation to patient and anaesthesia-related factors using the T-test, simple and multiple stepwise regression analysis.ResultsDespite having achieved a TOF ratio of >0.9 a decrease in postoperative muscle power was detectable in most patients and correlated with reduced postoperative pulse oximetric saturation. Independent contributing factors were use of neuromuscular blocking agents (p < 0.001), female gender (p = 0.001), TIVA (p = 0.018) and duration of anaesthesia >120 min (p = 0.019).ConclusionSignificant loss of muscle power and reduced pulse oximetric saturation are often present despite a TOF-Ratio > 0.9. Gender differences are also significant. A modified fast track score > 10 failed to predict recovery of muscle power in most patients.Trial registrationGerman Clinical Trial Register DRKS-ID DRKS00006032; Registered: 2014/04/03

Can postoperative renal dysfunction be predicted by measuring intraoperative glomerular filtration rate in patients undergoing coronary artery bypass grafting without cardiopulmonary bypass? A pilot study

Currently, there is no effective paradigm to identify patients who are at risk for renal dysfunction following cardiac surgery. The specific mechanisms of renal injury during surgery are incompletely understood. The aim of the study was to evaluate whether postoperative renal dysfunction can be predicted from intraoperative glomerular filtration rate (GFR). This is a prospective study. The study was conducted in a tertiary care multi-specialty hospital. GFR was measured in 24 patients (mean age 56.6 ± 11.09 years, 20 male) undergoing elective off-pump coronary artery bypass grafting during preoperative period, intraoperative period, 24 h after surgery (ICU GFR), and on the fifth postoperative day (final GFR ). Patients were divided into two groups depending upon changes in intraoperative GFR. Group 1 (n = 10): who had a rise in intraoperative GFR in comparison with preoperative baseline measurement. All these 10 (41.7 %) patients with a rise in intraoperative GFR had an uneventful hospital course and achieved an improvement in final GFR. Group 2 (n = 14): 14 (58.3 %) patients had a fall in intraoperative GFR (mean 36.4 %) in comparison with preoperative baseline value. Of these 14 patients, 1 patient required dialysis support and 3 patients required ionotropic support. Among these 14 patients in group two, 7 had deterioration in final GFR (mean 28.7 %), when compared to preoperative baseline value. Postoperative renal dysfunction can be predicted from intraoperative GFR. Patients who have a rise in intraoperative GFR do not develop postoperative renal dysfunction, and only patients with intraoperative fall in GFR are at risk of postoperative renal dysfunction.

Serial Peak Expiratory Flow Rates in Patients Undergoing Upper Abdominal Surgeries Under General Anaesthesia and Thoracic Epidural Analgesia.

Anaesthesia and upper abdominal surgeries alter lung compliance and functional residual capacity resulting from atelectasis. Upper abdominal surgeries also cause a decrease in peak expiratory flow rates, cough reflex due to pain limited inspiration. This study aimed to study the effect of thoracic epidural analgesia (TEA) on the peak expiratory flow rates in patients undergoing upper abdominal surgeries. A total of 44 patients posted for elective surgery were enrolled. Group 1 patients received GA + 0.125% bupivacaine infusion TEA and Group 2 received GA + Inj. Diclofenac sodium 50 mg slow i.v. TID for Postoperative analgesia. Haemodynamics, VAS pain score, PEFR measurements were done at 60 minutes, 24 hours, 48 hours and 4 days after surgery in both groups. ABG analysis was taken pre operatively and 24 hours after surgery. The SBP and DBP values obtained at 60 minutes (p<0.016) 24 and 48 hours (p<0.001) and day 4 (p<0.02) postoperative showed highly significant difference between the two groups which indicate better haemodynamic parameters in patients receiving epidural analgesia. Postoperatively the difference in PEFR values at 60 minutes, 24 hour, 48 hour and day 4 were very highly significant. (p<0.001). Group1 had a 10.739% deficit on day 4 from its pre operative baseline value while group 2 showed a 34.825 % deficit which was very highly significant (p<0.001). The difference in VAS scores recorded at 60 minutes, 24 hours, 48 hours and day 4 post op were very highly statistically significant (p < 0.001). The ABG taken at 24 hours shows statistically significant difference with patients in group 2 showing decreased values in pCO2 and pO2 reflecting poorer ventilation and oxygenation. Thoracic epidural analgesia provides superior analgesia, better cough reflex as seen by better PEFR values, were haemodynamically more stable and their ABG values were better than the NSAID group.

The Role of Regional Oxygen Saturation Using Near-Infrared Spectroscopy and Blood Lactate Levels as Early Predictors of Outcome After Pediatric Cardiac Surgery

BackgroundThe purpose of the study was to evaluate the association between regional oxygen saturation (rSO2) desaturation score (calculated by multiplying the rSO2 < 50% by time in seconds the preoperative baseline value) measured with near-infrared spectroscopy and the peak of lactate with postoperative major morbidities in pediatric patients who undergo cardiac surgery. MethodsWe retrospectively analyzed the postoperative course of 152 patients between January 2012 and December 2013, for whom we continuously monitored cerebral rSO2 using near-infrared spectroscopy and serial arterial blood lactate levels for at least 48 hours. ResultsThe median age at surgery was 128 days (interquartile range [IQR], 17-537 days). Thirty-nine patients had a single ventricle physiology (26%) and 135 patients (89%) required the use of cardiopulmonary bypass (median time of 130 minutes; IQR, 93-172 minutes). Median postoperative peak lactate level was 3 mmol/L (IQR, 2-5.3 mmol/L); 52 patients (34%) had a postoperative lactate level > 4.6 mmol/L. The median postoperative rSO2 desaturation score was 157 (IQR, 0-2050); 62 patients (41%) had an rSO2 desaturation score > 345. Fifty-seven patients (37%) had postoperative major morbidities. Using a multivariable regression model only rSO2 desaturation score > 345 was independently associated with major morbidities after surgery (odds ratio, 27.26; 95% confidence interval, 10.18-73.00). The proportion of patients with an rSO2 desaturation score > 345 within 240 minutes after surgery was higher than the rate of those who showed a peak of lactate > 4.6 mmol/L (84% vs 59%; P = 0.05). ConclusionsThe postoperative rSO2 desaturation score has a stronger association with major postoperative morbidities than lactate and it also provides an earlier warning sign of hemodynamic or metabolic compromise.