Postoperative pulmonary complications and mortality after major abdominal surgery. An observational multicenter prospective study.

BACKGROUND: Postoperative pulmonary complications (PPCs) significantly contribute to postoperative morbidity and mortality. We conducted a study to determine the incidence of PPCs after major elective abdominal surgery and their association with early and 1-year mortality in patient without pre-existing respiratory disease. METHODS: We conducted a multicenter observational prospective clinical study in 40 Italian centers. 1542 patients undergoing elective major abdominal surgery were recruited in a time period of 14 days and clinically managed according to local protocol. The primary outcome was to determine the incidence of PPCs. Further, we aimed to identify independent predictors for PPCs and examine the association between PPCs and mortality. RESULTS: PPCs occurred in 12.6% (95% CI 11.1-14.4%) of patients with significant differences among general (18.3%, 95% CI 15.7-21.0%), gynecological (3.7%, 95% CI 2.1-6.0%) and urological surgery (9.0%, 95% CI 6.0-12.8%). PPCs development was associated with known pre- and intraoperative risk factors. Patients who developed PPCs had longer length of hospital stay, higher risk of 30-days hospital readmission, and increased in-hospital and one-year mortality (OR 3.078, 95% CI 1.825-5.191; P<0.001). CONCLUSIONS: The incidence of PPCs in patients without pre-existing respiratory disease undergoing elective abdominal surgery is high and associated with worse clinical outcome at one year after surgery. General surgery is associated with higher incidence of PPCs and mortality compared to gynecological and urological surgery.

Sedation in digestive endoscopy: innovations for an old technique.

Patient complexity, along with duration, number and invasiveness of procedures, increase every year in digestive endoscopy; so deep sedation, analgesia or general anesthesia requests are rising. The need for a safe, flexible, low cost and high-profile service play a central role in drugs, devices and monitoring development. The patient's degree of comfort and anxiety are also critical. On the other hand, the role of the anesthesiologist is still debated, and many European countries are promoting non-anesthesiologist administration of propofol (NAAP). For high risk patients, anesthesiologists play an important role in choosing sedative drugs, kind of anesthesia/analgesia and devices for airway control. New drugs with safe profile, low costs, and favorable pharmacokinetics are now available for digestive endoscopy. Among these, fospropofol, a water-soluble prodrug of Propofol, is a very promising compound. Moreover, new devices and different modalities of ventilation can help anesthesiologists in management of high-risk patients, like obese patients and others patients at risk of hypopnea/apnea. The main challenges for anesthesiologists in this setting are endoscopic retrograde cholangiopancreatography, management of obese patients and recovery time after procedure, since digestive endoscopies are frequently performed as outpatient procedures. Nevertheless, these short and at low risk procedures can induce cognitive impairment. Currently, only anesthesiologists seem to have the competences to maintain high levels of safety by an appropriate evaluation and sedatives' choice, and a detailed protocol should be present in each gastrointestinal endoscopy department. In conclusion, the role of the anesthetist should be to supervise endoscopy activities at every level.

Recurrent postoperative delirium in spinocerebellar ataxia type 2: a case report.

BACKGROUND: Postoperative delirium is a relatively uncommon condition in middle aged patients, but very widespread in patients with psychiatric and neurological diseases undergoing general anesthesia. Few studies are currently available in the literature on the perioperative anesthesiological management of patients suffering from spinocerebellar ataxia. CASE PRESENTATION: A 58-year-old Caucasian woman affected by spinocerebellar ataxia type 2 underwent total hip arthroplasty for advanced osteoarthritis. One month later, debridement, antibiotics, and implant retention was performed for periprosthetic hip infection. Both times she underwent general anesthesia and developed an early postoperative delirium treated successfully with chlorpromazine. CONCLUSIONS: This case report highlights the need to correctly manage patients at high risk of developing postoperative delirium, especially if suffering from degenerative neurological diseases. On the other hand, further studies will be needed in order to evaluate if spinocerebellar ataxia is an independent risk factor for the development of this acute and transient pathological condition.

Effect of different doses of remifentanil on stress response during laparoscopic cholecystectomy.

OBJECTIVES: An adequate perioperative analgesia reduces neuroendocrine stress response and postoperative complica-tions. Opioids are the most effective parenteral drugs to control pain and stress response. DESIGN: This is a prospective randomized double-blinded controlled study. SETTING: Institutional tertiary level. PATIENTS, PARTICIPANTS: Fifty patients underwent general anesthesia with desflurane for laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: To compare two different doses of remifentanil (0.15 mcg/kg/min or 0.3 mcg/kg/min) in reducing markers of stress. Perioperative stress was assessed through the dosage of adrenocorticotropic hormone (ACTH), cortisol, growth hormone (GH), and prolactin (PRL). Three venous blood samples were collected from patients: before transferring the patient to the operating room (Time 0), at the trocar insertion (Time 1), and 1 hour after the end of the surgery (Time 2). RESULTS: Hemodynamic parameters showed no differences between the two groups. The authors observed an increase of GH and PRL in both groups at trocar insertion (Time 1) (p = 0.473 and 0.754, respectively). ACTH and cortisol showed a decrease at Time 1 and an increase after surgery (p = 0.586). The modification of stress parameters levels showed no significant differences between the two groups. CONCLUSIONS: The results of our study showed that a lower dose of remifentanil is equally effective in controlling stress hormones during laparoscopic cholecystectomy.

Effect of remifentanil and fentanyl on postoperative cognitive function and cytokines level in elderly patients undergoing major abdominal surgery.

PURPOSE: Postoperative cognitive dysfunction is a frequent complication occurring in geriatric patients. Type of anesthesia and the patient's inflammatory response may contribute to postoperative cognitive dysfunction (POCD). In this prospective randomized double-blinded controlled study we hypothesized that intraoperative remifentanil may reduce immediate and early POCD compared to fentanyl and evaluated if there is a correlation between cognitive status and postoperative inflammatory cytokines level. METHODS: Six hundred twenty-two patients older than 60 years undergoing major abdominal surgery were randomly assigned to two groups and treated with different opioids during surgery: continuous infusion of remifentanil or fentanyl boluses. Twenty-five patients per group were randomly selected for the quantitative determination of serum interleukin (IL)-1ß, IL-6, and IL-10 to return to the ward and to the seventh postoperative day. RESULTS: Cognitive status and its correlation with cytokines levels were assessed. The groups were comparable regarding to POCD incidence; however, IL-6 levels were lower the seventh day after surgery for remifentanil group (P= .04). No correlation was found between POCD and cytokine levels. CONCLUSIONS: The use of remifentanil does not reduce POCD.

An unusual case of acute unilateral parotitis following abdominal surgery. Report of a case and review of the literature.

BACKGROUND: Postoperative parotitis is a well known entity which can develop in patients who undergo major abdominal surgery. METHODS: We present a case of postoperative parotitis which occurred after a laparotomy for incisional hernia repair. RESULTS: After establishing diagnosis by ultrasonography assessment and blood chemical tests, patient was successfully treated by morphine discontinuing and antibiotics therapy. CONCLUSION: Beside sialolithiasis, sitting position or dehydratation we suggest that morphine could play a substantial role in the development of postoperative parotitis.

Preoperative psychologic and demographic predictors of pain perception and tramadol consumption using intravenous patient-controlled analgesia.

OBJECTIVES: Postoperative pain is characterized by a wide variability of patients' pain perception and analgesic requirement. The study investigated the extent to which demographic and psychologic variables may influence postoperative pain intensity and tramadol consumption using patient-controlled analgesia (PCA) after cholecystectomy. METHODS: Eighty patients, aged 18 to 70 years, with an American Society of Anesthesiologists physical status I or II and a body mass index between 18.5 and 24.9, undergoing laparoscopic cholecystectomy were enrolled. Self-rating anxiety scale (SAS) and self-rating questionnaire for depression (SRQ-D) were used--1 day before surgery--to assess patients' psychologic status. General anesthesia was standardized. PCA pump with intravenous tramadol was used for a 24-hour postoperative analgesia. Visual analog scale at rest (VASr) and after coughing (VASi) and tramadol consumption were registered. Pearson's and point biserial correlations, analysis of variance, and step-wise regression were used for statistical analysis. RESULTS: Pearson r showed positive correlations between anxiety, depression, and pain indicators (P<0.05). Moreover, female patients had higher pain indicators (P<0.05). Analysis of variance showed that anxious (P<0.05) and depressed (P<0.001) patients had higher pain indicators, which significantly decreased during the postoperative 24 hours (P<0.00001). Regression analysis revealed that tramadol consumption was predicted by preoperative depression (P<0.001). VASr was predicted by sex and SRQ-D (P<0.05). VASi was predicted by sex and SAS (P<0.05). DISCUSSION: Pain perception intensity was primarily predicted by sex with an additional role of depression and anxiety in determining VASr and VASi, respectively. Patients with high depression levels required a larger amount of tramadol.

Extraparenchymal control of hepatic veins during mesohepatectomy.

BACKGROUND: Bleeding is the most relevant operative risk during mesohepatectomy because of the wideness of the resection surfaces and the exposure of main intrahepatic vascular structures. Preliminary extraparenchymal exposure of the main hepatic veins, with the possibility of clamping them in association with the Pringle maneuver, and the maintenance of a low central venous pressure during mesohepatectomy, can contribute to substantially reducing operative bleeding. STUDY DESIGN: We report the results obtained in 18 mesohepatectomies, performed for liver metastases (13 patients) and for hepatocellular carcinoma (5 patients). Liver resection was performed without preliminary exposure of the main hepatic veins in nine patients (group A) and with preliminary looping of the main hepatic veins in nine patients (group B), without complications related to the maneuver. RESULTS: Intermittent pedicle clamping was used in all patients; in six patients in group B (66.7%), clamping of the main hepatic veins was also performed (mean duration, 37 minutes; range 16 to 68 minutes). Intraoperative blood transfusions were needed in 5 patients (5 of 18, 27.8%): 4 belonged to group A (44.4%) and 1 to group B (11.1%). Mortality was nil and morbidity was 33.3%, involving four patients in group A and two in group B (none related to the exposure, looping, and clamping of the main hepatic veins). CONCLUSIONS: Preliminary control of the main hepatic veins is a safe maneuver. During mesohepatectomy, clamping of these veins, associated with pedicle clamping, is effective in reducing operative bleeding. In our patients, this resulted in a low blood transfusion rate, similar to that of classic major hepatectomies, despite the higher complexity of mesohepatectomy.

Dreams recall and auditory evoked potentials during propofol anaesthesia.

It is unclear whether shorter wave latencies of middle-latency-auditory-evoked-potentials may be associated to cognitive function other than nondeclarative memory. We investigated the presence of declarative, nondeclarative and dreaming memory in propofol-anaesthetized patients and any relationship to intraoperatively registered middle-latency-auditory-evoked-potentials. An audiotape containing one of two stories was presented to patients during anaesthesia. Patients were interviewed on dream recall immediately upon emergence from anaesthesia. Declarative and nondeclarative memories for intraoperative listening were assessed 24 h after awakening without pointing out positive findings. Six patients who reported dream recall showed an intraoperative Pa latency less than that of patients who were unable to remember any dreams (P<0.001). A high responsiveness degree of primary cortex was associated to dream recall formation during anaesthesia.

Monitoring cerebral oxygen saturation in elderly patients undergoing general abdominal surgery: a prospective cohort study.

BACKGROUND AND OBJECTIVES: The aim of this prospective, observational study was to evaluate changes in regional cerebral oxygen saturation (rSO2) and incidence of intraoperative cerebral desaturation in a cohort of elderly patients undergoing major abdominal surgery. METHODS: rSO2 was continuously monitored on the left and right sides of the forehead in 60 patients older than 65 yr (35 males and 25 females; ASA II-III; age: 72 +/- 5 yr; without pre-existing cerebral pathology, and baseline Mini Mental State Examination (MMSE) score >23) undergoing sevoflurane anaesthesia for major abdominal, non-vascular surgery >2 h. RESULTS: Baseline rSO2 was 63 +/- 8%; cerebral desaturation (rSO2 decrease <75% of baseline or <80% in case of baseline rSO2 <50%) occurred in 16 patients (26%). The MMSE decreased from 28 +/- 1 before surgery to 27 +/- 2 on 7th postoperative day (P = 0.05). A decline in cognitive function (decrease in MMSE score > or = 2 points one week after surgery as compared to baseline value) was observed in six patients without intraoperative cerebral desaturation (13.6%) and six patients who had intraoperative cerebral desaturation (40%) (P = 0.057) (odds ratio: 4.22; CI95%: 1.1-16). Median (range) hospital stay was 14 (5-41) days in patients with an area under the curve of rSO2 <50% (AUCrSO2<50%) >10 min%, and 10 (4-30) days in those with an AUCrSO2<50% <10 min% (P = 0.0005). CONCLUSIONS: In a population of healthy elderly patients, undergoing non-vascular abdominal surgery cerebral desaturation can occur in up to one in every four patients, and the occurrence of cerebral desaturation is associated with a higher incidence of early postoperative cognitive decline and longer hospital stay.

Perioperative evaluation of myasthenia gravis.

Myasthenia gravis (MG) is the prototype of antibody mediated autoimmune disease and results from the production of autoantibodies against the acetylcholine receptor (AChR) of the neuromuscular synapse. Adequate preoperative evaluation of the myasthenic patient must be carried out carefully. Age, sex, onset and duration of the disease as well as the presence of thymoma may determine the response to thymectomy. Specific attention should be paid to voluntary and respiratory muscle strength. The preoperative preparation of MG patients is essential for the success of surgery. It depends on the severity of clinical status and changes if myasthenic patients receive anticholinesterase therapy. Myasthenic patients may have little respiratory reserve, and hence depressant drugs for preoperative premedication should be used with caution and avoided in patients with bulbar symptoms. The anaesthetic management of myasthenic patient must be individualized in according to the severity of the disease and the type of surgery required. The use of regional or local anaesthesia seems warranted whenever possible. General anaesthesia can be performed safely when patient is optimally prepared and neuromuscular transmission is adequately monitored during and after surgery. Adequate postoperative pain control, pulmonary toilet, and avoidance of drugs that interfere with neuromuscular transmission will facilitate tracheal extubation. Myasthenia gravis is a disease with many implications for the safe administration of anaesthesia. The potential for respiratory compromise in these patients requires the anaesthesiologist to be familiar with the underlying disease state, as well as the interaction of anaesthetic and non-anaesthetic drugs with MG.

Perioperative management of thymectomy.

Thymoma is the most frequent type of tumor in the anterior-superior mediastinum. The presentation of thymomas is variable; most are asymptomatic and others present themselves with local compression syndrome or parathymic syndrome; rarely thymomas appear as an acute emergency. Surgery is the treatment of choice for thymic tumors and complete resection is the most important prognostic factor. Surgery with adjuvant radiation is recommended for invasive thymoma. The anaesthetic management of patients with mediastinal thymoma undergoing thymectomy is associated with several risks related to potential airway obstruction, hypoxia and cardiovascular collapse. Patients at high risk of perioperative complications can be identified by the presence of cardiopulmonary signs and symptoms. However, asymptomatic thymomas have been occurred with acute cardiorespiratory complications under general anaesthesia. A careful preoperative evaluation of signs, symptoms, chest X-ray, CT scan, MRI, cardiac echogram and venous angiogram should be helpful to investigate neoplasm presence and the area of invasion; moreover, an adequate airway and cardiovascular management, such as performing an awake intubation in the sitting position, allowing spontaneous and non-controlled ventilation, a rigid bronchoscope available and a standby cardiopulmonary bypass, is suggested to prevent the main life-threatening cardiorespiratory complications.

Sedation in PACU: the role of propofol.

In critically ill patients, adequate sedation increases comfort, minimizes stress response and facilitates diagnostic and therapeutic procedures. Propofol (2-, 6-diisopropylphenol) is an intravenous sedative-hypnotic agent popular for sedation in the Intensive Care Unit. The favorable propofol pharmacokinetic, characterized by a three compartment linear model, allows rapid onset and short duration of action. The emergence time from sedation with propofol varies with the depth and the duration of sedation and the patient's bodyweight. Propofol causes hypotension, particularly in volume depleted patients, decreases cerebral oxygen consumption, reduces intracranial pressure and has potent anti-convulsant properties. It is a potent antioxidant, has anti-inflammatory properties and is a bronchodilator. As a consequence of these properties, propofol is being increasingly used in the management of traumatic head injury, status epilepticus, delirium tremens, status asthmaticus and in septic patients. Prolonged use (>48 h) of high doses of propofol (>66 mcg/Kg/min) has been associated with lactic acidosis, bradycardia, and lipidemia in pediatric patients. A rare complication firstly reported in pediatrics patients and also observed in adults is known as "propofol syndrome" characterized by myocardial failure, metabolic acidosis and rhabdomiolysis. Hyperkalemia and renal failure have also been associated with this syndrome. Hypertriglyceridemia and pancreatitis are uncommon complications. A large number of trials have compared the use of propofol with midazolam. Sedation with propofol is associated with adequate sedation in ICU patients, shorter weaning time and earlier tracheal extubation compared to midazolam, but not before ICU discharge.

Continuous monitoring of cerebral oxygen saturation in elderly patients undergoing major abdominal surgery minimizes brain exposure to potential hypoxia.

Elderly patients are more prone than younger patients to develop cerebral desaturation because of the reduced physiologic reserve that accompanies aging. To evaluate whether monitoring cerebral oxygen saturation (rSO(2)) minimizes intraoperative cerebral desaturation, we prospectively monitored rSO(2) in 122 elderly patients undergoing major abdominal surgery with general anesthesia. Patients were randomly allocated to an intervention group (the monitor was visible and rSO(2) was maintained at > or =75% of preinduction values; n = 56) or a control group (the monitor was blinded and anesthesia was managed routinely; n = 66). Cerebral desaturation (rSO(2) reduction <75% of baseline) was observed in 11 patients of the treatment group (20%) and 15 patients of the control group (23%) (P = 0.82). Mean (95% confidence intervals) values of mean rSO(2) were higher (66% [64%-68%]) and the area under the curve below 75% of baseline (AUCrSO2(2)< 75% of baseline) was lower (0.4 min% [0.1-0.8 min%]) in patients of the treatment group than in patients of the control group (61% [59%-63%] and 80 min% [2-144 min%], respectively; P = 0.002 and P = 0.017). When considering only patients developing intraoperative cerebral desaturation, a lower Mini Mental State Elimination (MMSE) score was observed at the seventh postoperative day in the control group (26 [25-30]) than in the treatment group (28 [26-30]) (P = 0.02), with a significant correlation between the AUCrSO(2) < 75% of baseline and postoperative decrease in MMSE score from preoperative values (r(2)= 0.25, P = 0.01). Patients of the control group with intraoperative cerebral desaturation also experienced a longer time to postanesthesia care unit (PACU) discharge (47 min [13-56 min]) and longer hospital stay (24 days [7-53] days) compared with patients of the treatment group (25 min [15-35 min] and 10 days [7-23 days], respectively; P = 0.01 and P = 0.007). Using rSO(2) monitoring to manage anesthesia in elderly patients undergoing major abdominal surgery reduces the potential exposure of the brain to hypoxia; this might be associated with decreased effects on cognitive function and shorter PACU and hospital stay.

Postoperative management of elective esophagectomy for cancer.

Postoperative management after elective esophagectomy for cancer has not been standardized. Thoracoabdominal incision with associated pain, extended operative time with consequent extracellular fluid shifts, single lung ventilation, potential for prolonged postoperative mechanical ventilation and comorbidities in patients with esophageal cancer, all contribute to high perioperative risk. Respiratory problems remain the major cause of both mortality and morbidity after esophagectomy for cancer. A specific pulmonary disorder, acute respiratory distress syndrome (ARDS) occurs in 10-20% of patients after esophagectomy. ARDS mortality exceeds 50%. Atrial fibrillation, that complicates recovery in 20 to 25% of patients after esophagectomy, contributes to make outcome worse. Anesthesiologists should adopt strategies known to be able to optimize patient outcome. Decreased postoperative mortality and morbidity have been associated with epidural analgesia, bronchoscopy to clear persistent bronchial secretions, intraoperative fluid restriction and early extubation. It has been shown that setting up early respiratory physiotherapy and mobilitation may improve functional recovery.