ABSTRACT
Acute-on-chronic liver failure (ACLF) is a potentially reversible entity that occurs in patients with chronic liver disease accompanied with or without cirrhosis and is characterized by extrahepatic organ failure and high short-term mortality. Currently, the most effective treatment method for patients with ACLF is liver transplantation; therefore, admission timing and contraindications must be emphasized. The function of vital organs such as the heart, brain, lungs, and kidneys should be actively supported and protected during the liver transplantation perioperative period in patients with ACLF. Focusing on the anesthesia management level during anesthesia selection, intraoperative monitoring, three-stage management, prevention and treatment of post-perfusion syndrome, monitoring and management of coagulation function, volume monitoring and management, and body temperature monitoring management for liver transplantation should strengthen anesthesia management. Additionally, standard postoperative intensive care treatment should be recommended, and grafts and other vital organ functions should be monitored throughout the perioperative period to promote early postoperative recovery in patients with ACLF.
Subject(s)
Humans , Liver Transplantation , Acute-On-Chronic Liver Failure/surgery , Liver Cirrhosis/complications , Perioperative Period , PrognosisABSTRACT
@#Transcatheter mitral valve edge-to-edge repair (TEER) has become an important treatment opinion for patients with severe mitral regurgitation (MR) at high risk for surgery. The devices and procedural techniques of TEER are complex and require excellent team cooperation. However, there is still a lack of standardized clinical pathways in China. Based on the latest evidence, the expert group wrote this clinical pathway to guide and optimize TEER therapy in clinical practice. It demonstrates the following key issues of clinical concern: (1) TEER team building; (2) preoperative clinical evaluation of TEER patients; (3) imaging assessment before TEER procedure; (4) standardized procedures for TEER; (5) TEER for complex MR; (6) the standard process of perioperative comprehensive management; and (7) full life-cycle rehabilitation and follow-up. This clinical pathway might be helpful to facilitate the standardized development of TEER therapy and application, and promote the improvement of management and life quality for patients with MR.
ABSTRACT
@#The technique of transcatheter aortic valve implantation has become increasingly mature. Although the transapical approach has a certain degree of minimally invasive trauma, it still has the characteristics such as heart beating without cardiopulmonary bypass, and the low technical requirements of catheter guide wire. In particular, the valve path is short and coaxial, which is easy to manipulate, and pure regurgitation and stenosis can be easily operated and are not subject to the limit of peripheral artery stenosis. It is still one of China's main approaches for transcatheter aortic valve replacement. Its perioperative management still has specific features and differs from the femoral artery approach. In addition, there is little relevant literature abroad. Therefore, domestic experts in this field were organized to discuss the development of perioperative management specifications to provide reference and techniques support for developing this field in China and further improve the quality of clinical operation and perioperative management. It will provide more safe and more effective medical services to these patients.
ABSTRACT
Liver cancer patients scheduled for liver transplantation (LT) are frequently accompanied by liver cirrhosis.Within a state of long-term malnutrition and inflammatory stress, they are prone to sarcopenia with a poor efficacy of LT.Influenced by such multiple factors as surgery, infections and metabolic disorders, there is an elevated risk of exacerbation or a new onset of sarcopenia after LT.Therefore meticulous managements of sarcopenia are required throughout all aspects and periods of LT.A refined recipient stratification system of sarcopenia can accurately predict the efficacy of LT and its evaluating system has been becoming more precise, diverse and intelligent.Currently basic researches of sarcopenia have remained in infancy and its interactions with the related organs have become a novel research field.Sarcopenia has become an emerging challenge of LT for liver cancer.Further mechanistic explorations of sarcopenia are warranted and clinical precision managements should be further optimized.
ABSTRACT
Correlated with such hepatic-systemic factors as cirrhosis, inflammation and immunity, portal vein thrombosis (PVT) is common in perioperative period of liver transplantation (LT) recipients.It affects negatively surgical procedures and outcomes due to its insidious onset and atypical clinical symptoms.With continuous improvements of LT techniques and refining of medical imaging, researchers have gained further insights into the pathophysiological processes, screening, diagnoses, evaluations, classifications and perioperative managements of PVT.This review focused upon perioperative managements of LT recipients with PVT to enhance the clinical problem-solving capability and long-term patient survival.
ABSTRACT
This systematical review focuse upon the development history of enhanced recovery after surgery(ERAS)and summarized its core strategies and developments in the field of organ transplantation, Clinicians should pay more attention to applying ERAS for perioperative management of transplantation and guiding clinical diagnoses and treatments.
ABSTRACT
Objective:To explore the value of ultrasonic cardiac output monitor(USCOM) in guiding perioperative hemodynamic management of neonatal gastrointestinal surgery.Methods:Seventy-five neonates with hemodynamic changes after gastrointestinal surgery admitted to the Department of Neonatology, Xiamen Children′s Hospital from January 2017 to December 2020 were enrolled, of which the non-USCOM group had 34 cases from January 2017 to December 2018, mainly based on clinical indicators such as heart rate, blood pressure, blood lactate acid to evaluate the hemodynamic status of children after surgery.The USCOM group had 41 cases from January 2019 to December 2020, used USCOM to assist in the evaluation of hemodynamics of children after surgery dynamic state.Another 40 cases were set up as the control group, included neonates with hyperbilirubinemia.The USCOM group and the control group were examined by USCOM to record cardiac output(CO), cardiac index(CI), and systemic vascular resistance(SVR). The changes in CO, CI, SVR between the USCOM group and the control group, the changes in USCOM group before and after the operation were compared, respectively.Changes in heart rate, blood pressure, and lactic acid in the USCOM group before and after the operation were compared.And the differences of vasoactive drug dosage and time of first use after operation, postoperative first expansion time, volume expansion, incidence of anuria or oliguria within 24 hours after operation, and length of hospital stay between USCOM group and non-USCOM group were analyzed.Results:The CO, CI, SVR, heart rate, blood pressure before operation in USCOM group were not significantly different compared with those in the control group and 12 h after the operation.The CO and CI in USCOM group at 1 h after operation were lower than those before operation, and the lactic acid increased, the differences were statistically significant( P<0.05). The SVR of USCOM group at 1 h after operation was higher than that before operation, but there was no significant difference ( P>0.05). The CO and CI at 12 h after operation in USCOM group were higher than those at 1 h after operation, and the SVR at 12 h was lower than that at 1 h after operation , the differences were all statistically significant( P<0.05). There were no significant differences in heart rate and blood pressure in USCOM group before and 1 h after operation ( P>0.05). The blood pressure at 12 h after operation was significantly higher than that at 1 h after operation( P<0.05). The time of first volume expansion and use of vasoactive drugs in USCOM group were significantly earlier than those in non-USCOM group[0.75(0.50, 1.37)h vs.7.00(5.00, 13.25)h, Z=-7.041, P<0.001; (1.39±1.33)h vs.(8.61±5.15)h, t=-7.917, P<0.001], the total volume of expansion was significantly reduced[17.50(10.00, 30.00)mL vs.30.00(20.00, 30.00)mL, t=-3.045, P=0.002], the dosage of dopamine was significantly reduced[8.40(6.20, 10.40)mg/kg vs.8.90(7.20, 14.40)mg/kg, Z=-2.475, P=0.013], the incidence of oliguria or anuria within 24 hours after operation was significantly reduced(12.2% vs.32.3%, t=4.500, P=0.034), the length of hospital stay was significantly shortened[25.00(15.50, 31.00)d vs.28.00(21.75, 34.00)d, Z=-1.985, P=0.047], and the dosage of dobutamine and epinephrine was not significantly changed( P>0.05). Conclusion:Non-invasive hemodynamic monitoring can monitor the hemodynamic changes of the neonatal gastrointestinal tract in real time during the perioperative period, which is helpful to guide the management of vasoactive drugs and fluids after surgery.
ABSTRACT
In the context of shortage of donor livers, split liver transplantation has achieved the goal of "one donor liver for two recipients", which effectively alleviates the shortage of donor livers and has promising development prospect. With the advancement of liver transplant techniques, split liver transplantation may yield clinical prognosis equivalent to total liver transplantation. However, perioperative management of split liver transplantation still encounters multiple challenges, with demanding techniques requirement and high-risk postoperative complications. Besides, there is a possibility of dividing one high-quality donor liver into two marginal donor livers, which will affect the development of liver transplantation. In this article, perioperative management of split liver transplantation was discussed from the perspectives of preoperative evaluation, recipient management and postoperative complication management, aiming to provide reference for promoting the development of split liver transplantation and enhancing clinical prognosis of recipients after split liver transplantation.
ABSTRACT
Objective To develop a risk prediction model combining pre/intraoperative risk factors and intraoperative vital signs for postoperative healthcare-associated infection(HAI)based on deep learning. Methods We carried out a retrospective study based on two randomized controlled trials(NCT02715076,ChiCTR-IPR-17011099).The patients who underwent elective radical resection of advanced digestive system tumor were included in this study.The primary outcome was HAI within 30 days after surgery.Logistic regression analysis and long short-term memory(LSTM)model based on iteratively occluding sections of the input were used for feature selection.The risk prediction model for postoperative HAI was developed based on deep learning,combining the selected pre/intraoperative risk factors and intraoperative vital signs,and was evaluated by comparison with other models.Finally,we adopted the simulated annealing algorithm to simulatively adjust the vital signs during surgery,trying to explore the adjustment system that can reduce the risk of HAI. Results A total of 839 patients were included in this study,of which 112(13.3%)developed HAI within 30 days after surgery.The selected pre/intraoperative risk factors included neoadjuvant chemotherapy,parenteral nutrition,esophagectomy,gastrectomy,colorectal resection,pancreatoduodenectomy,hepatic resection,intraoperative blood loss>500 ml,and anesthesia time>4 h.The intraoperative vital signs significantly associated with HAI were in an order of heart rate>core body temperature>systolic blood pressure>diastolic blood pressure.Compared with multivariable Logistic regression model,random forest model,and LSTM model including vital signs only,this deep learning-based prediction model performed best(ACC=0.733,F1=0.237,AUC=0.728).The simulation via simulated annealing algorithm reduced the incidence of postoperative HAI.Moreover,the incidence decreased most in the case of reducing the initial annealing temperature and choosing the last 20% of surgery procedure. Conclusions This study developed a risk prediction model for postoperative HAI based on deep learning,which combined pre/intraoperative risk factors and intraoperative basic vital signs.Using simulated annealing algorithm to adjust intraoperative vital signs could reduce the incidence of postoperative HAI to some extent.
Subject(s)
Humans , Cross Infection , Deep Learning , Delivery of Health Care , Postoperative Period , Retrospective StudiesABSTRACT
Enhanced recovery after surgery (ERAS) has deeply influenced the clinical practice of surgery, anesthesia and nursing since its inception in 1997. The successful implementation of perioperative ERAS in gastric cancer depends on continually boosting the awareness and acceptance of ERAS among medical staff, carrying out multidisciplinary collaboration, improving patients' compliance and combining key items to the clinical pathways. Future efforts should be made to explore the most appropriate implementation strategy of perioperative ERAS in gastric cancer.
Subject(s)
Humans , Critical Pathways , Enhanced Recovery After Surgery , Perioperative Care , Postoperative Complications/prevention & control , Stomach Neoplasms/therapyABSTRACT
With the acceleration of the aging process of the population, the demand for joint replacement continues to increase. Under the background of enhanced recovery after surgery, outpatient joint replacement has become a safe, economic and effective model to shorten the average length of stay and reduce the cost of hospitalization. It has been widely used in foreign countries, but there are still some limitations in the development and promotion in China. Therefore, this study intends to review the perioperative management plan and implementation effect of joint replacement in foreign countries, in order to provide reference for the implementation and improvement of the concept of fast track surgery for bone and joint in China.
ABSTRACT
Operation is one of the important methods for the treatment of chronic constipation, while the perioperative management is an important part of the operation. This consensus aims to improve the understanding of chronic constipation surgery among Chinese colorectal and anal surgeons and to provide instructions for the perioperative management. This consensus provides detailed recommendations for preoperative assessment, preoperative preparation, the choice of procedures, postoperative management and follow-up. The consensus is intended to reduce complications and improve efficacy.
Subject(s)
Humans , China , Consensus , Constipation/surgery , Postoperative PeriodABSTRACT
In recent years,enhance recovery after surgery (ERAS) has attracted many attentions in the surgical field.ERAS is a new model of perioperative management,in which more attention is paid to patients' perception to the medical treatment.This new medical model is different from the past one which is completely led by medical practitioners,thus full of humanistic concerns and rationality.With the premise of medical safety guaranteed,a series of measures,especially evidence-based medical interventions,are implemented to optimize the perioperative management and promote the recovery of patients in ERAS.A certain level of economic and social benefit will be gained with this process.The development history of ERAS was systemically reviewed in current editorial to help the readers to get a better understanding of the origin and evolving process of ERAS.It tracked back to the 1960s when "two reductions and one guarantee" and "removal of two tubes and one prohibition " were proposed as a revolutional perioperative management mode by the surgical community in our country.The goals pursued and measures implemented by our surgical predecessors back in those days were astonishingly similar to those in today's ERAS practice.They actually enlightened the initiation of ERAS in China.While ERAS is widely implemented nowadays,this new medical model should be objectively evaluated.A patient-centered medical system should be built,and ERAS should be promoted from an academic perspective,through which the ultimate goal of "surgery without danger and pain" could be finally achieved.
ABSTRACT
@#Giant thoracic tumor is currently one of the diagnostic and therapeutic challenges of thoracic surgery, with no established guideline or standard for diagnosis and treatment. The quality control of individualized surgical strategy and perioperative management with multi-disciplinary participation is the key to ensure the safety and improve the prognosis of patients. Based on the clinical experience of our institution and others, we hereby discussed and summarized the basic principles, surgical strategies and perioperative management of giant thoracic tumor, aiming to provide a reference of quality control.
ABSTRACT
In recent years, enhance recovery after surgery (ERAS) has attracted many attentions in the surgical field. ERAS is a new model of perioperative management, in which more attention is paid to patients′ perception to the medical treatment. This new medical model is different from the past one which is completely led by medical practitioners, thus full of humanistic concerns and rationality. With the premise of medical safety guaranteed, a series of measures, especially evidence-based medical interventions, are implemented to optimize the perioperative management and promote the recovery of patients in ERAS. A certain level of economic and social benefit will be gained with this process. The development history of ERAS was systemically reviewed in current editorial to help the readers to get a better understanding of the origin and evolving process of ERAS. It tracked back to the 1960s when "two reductions and one guarantee" and "removal of two tubes and one prohibition" were proposed as a revolutional perioperative management mode by the surgical community in our country. The goals pursued and measures implemented by our surgical predecessors back in those days were astonishingly similar to those in today′s ERAS practice. They actually enlightened the initiation of ERAS in China. While ERAS is widely implemented nowadays, this new medical model should be objectively evaluated. A patient-centered medical system should be built, and ERAS should be promoted from an academic perspective, through which the ultimate goal of "surgery without danger and pain" could be finally achieved.
ABSTRACT
With the maturity of the technique of adult liver transplantation, pediatric liver transplantation has been gradually emerging in major liver transplantation centers throughout China. Pediatric liver transplantation differs from adult liver transplantation in terms of recipient selection, technical details, perioperative management, postoperative treatment and follow-up, etc. Multidisciplinary cooperation is required to continuously improve the clinical efficacy of pediatric liver transplantation. In this article, we reviewed the significance of multidisciplinary cooperation in achieving the optimal clinical efficacy of pediatric liver transplantation, in respect to the recipient selection and extrahepatic organ function evaluation, mastering the technical key points of different types, improving the quality of postoperative follow-up, and formulating clinical diagnosis and treatment strategies, etc.
ABSTRACT
Resumen: En cirugía vascular periférica, el manejo multimodal del dolor permite una movilización temprana, lo cual conlleva a una rápida recuperación y satisfacción del paciente. El fracaso en el control del dolor postoperatorio aumenta los costos, los días de estancia hospitalaria y el riesgo de complicaciones como infecciones y tromboembolismo. Antes de la cirugía, el uso de dexametasona, gabapentina y paracetamol mejora los niveles de analgesia postoperatoria. La analgesia peridural es la técnica que mayor alivio de dolor presenta en el postoperatorio, provocando una incidencia menor de dolor crónico; limitar el uso de opioides neuroaxiales disminuye el tiempo de bloqueo motor, permitiendo la movilización temprana y evitando las complicaciones asociadas con la postración (visita http://www.painoutmexico.com para obtener la versión completa del artículo y el diagrama de recomendaciones).
Abstract: In peripheral vascular surgery, multimodal pain management allows early mobilization, which leads to rapid recovery and patient satisfaction. Failure to control postoperative pain increases costs, days of hospital stay and increases the risk of complications such as infections and thromboembolism. Before surgery, using dexamethasone, gabapentin and paracetamol improves higher leves of postoperative analgesia. Epidural analgesia is the technique that provides the greatest pain relief in the postoperative period, causing a lower incidence of chronic pain; limiting the use of neuroaxial opioids decreases the motor block time, allowing early mobilization and avoiding complications associated with prostration (visit http://www.painoutmexico.com to see the full article and diagram of overall recommendations).
ABSTRACT
Objective To summarize the experience of perioperative management for repair of congenital diaphragmatic hernia (CDH) supported by extracorporeal membrane oxygenation (ECMO). Method Retrospective review was conducted for the clinical data of CDH patients who received surgical repair on ECMO from December 2016 to June 2018 in Guangzhou Women and Children's Medical Center. Result Four fetus with prenatal diagnosis of left-side CDH were transferred to our Center and received standardized perinatal management. Moderate-severe pulmonary hypoplasia was recognized after evaluation by fetal imaging. Four cases were initiated with veno-arterial ECMO at 3, 35, 41, 11 h of life, respectively. Repair of the diaphragmatic defect was performed within two weeks after cannulation of ECMO. Furthermore, activated clotting time goals were adjusted to 180～220 s, activated partial thromboplastin time were stabilized between 50～80 s, platelets count were maintained>100×109/L and hematocrit was kept>30％before the surgery. The surgeries of four patients were completed on the 0.9th, 0.5th, 3.6th, 5.1th day of life on ECMO, respectively. The defect was repaired by parachute patch. The operative time was 85～210 min. According to CDH Staging System defect size (A to D), there were two with defects at grade C and other two at grade D. Postoperative total volume of drainage was 215～1301 ml and ECMO duration was 3.0～39.3 d. Three of them survived during neonatal period, while one died. Conclusion Repair of CDH on ECMO is feasible and help to improve neonatal survival, especially for those with moderate-severe pulmonary hypoplasia.
ABSTRACT
@#Objective To summarize the individualized selection of surgical treatment strategies and the key points of perioperative management for patients with heart valve disease complicated with severe chronic heart failure. Methods The clinical characteristics of 5 male patients with valvular heart disease complicated with severe chronic heart failure (CHF) were analyzed retrospectively from June 2017 to October 2018 in Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, with an average age of 60.21 years. Results Five patients were given angiotensin receptor and neprilysin inhibitor (ARNI)-based anti-heart failure treatment after admission. The operation mode of these patients was decided to be valve replacement under cardiopulmonary bypass after individualized evaluation of patients’ improving symptoms. Three patients were treated with intra-aortic balloon pump (IABP) and continuous renal replacement therapy (CRRT) early after operation to assist patients in improving cardiac function. Five patients recovered oral anti-heart failure after awakening. All patients were discharged smoothly 2 weeks after operation. Conclusion Individualized evaluation is needed for the choice of operation timing and mode, standardized preoperative treatment for heart failure, shortening the aortic blocking time during cardiopulmonary bypass, and early application of left ventricular adjuvant drugs or instruments are all important measures to help patients recover smoothly.
ABSTRACT
Objective To analyse the clinical efficacy of liver transplantation and summarize the clinical experience of perioperative management in patients with hepatic coma. Methods Clinical data of 22 patients with hepatic coma undergoing liver transplantation were retrospectively analyzed. The perioperative conditions of the recipients were observed, including operation time, warm/cold ischemia time of donor liver, intraoperative anhepatic phase of the recipients, intraoperative blood loss, intraoperative blood transfusion, early postoperative blood drug concentration and incidence of postoperative complications. The survival situation of the recipients and the influencing factors of clinical prognosis were analyzed. Results The operation time of 22 recipients was 8 (6-12) h, the warm ischemia time of donor liver was 4 (2-6) min, the cold ischemia time was 7 (5-10) h, intraoperative anhepatic phase of recipients was 80 (55-120) min, intraoperative blood loss was 1 139 (400-4 000) mL and intraoperative blood transfusion was 1 440 (0-3 600) mL.The blood concentration of tacrolimus (FK506) fluctuated between 6 and 11 ng/mL at postoperative one week. Six recipients died after liver transplantation including 1 case of primary graft liver failure, 2 cases of severe infection, 1 case of severe cerebral edema caused by cerebral hemorrhage and 2 cases of multiple organ failure. The postoperative 1 month and 1 year survival rates of hepatic coma recipients were 82% and 77%. Conclusions Liver transplantation can significantly improve the survival rate of patients with hepatic coma. Preoperative decreasing blood ammonia, controlling postoperative infection, improving renal function and formulating precise individualized immunosuppression therapy according to immune status play a pivotal role in enhancing the survival rate.