Hydroxyethyl starch is associated with early postoperative delirium in patients undergoing esophagectomy.

OBJECTIVE: Postoperative delirium is associated with longer hospital stay and increased morbidities. Patients undergoing esophagectomy have a high chance of developing postoperative delirium because of their advanced age, comorbidities, and intensive care unit care. In this study, we investigated the risk factors of early postoperative delirium in patients undergoing esophagectomy, focusing on perioperative fluid type to test the hypothesis that colloids with high oncotic pressure and anti-inflammatory action would decrease the incidence of postoperative delirium compared with crystalloids. METHODS: All patients who underwent esophagectomy from 2010 to 2015 in a tertiary care center were reviewed in this retrospective study (n = 1041). Patients who showed positive Confusion Assessment Method or received haloperidol within 4 days postoperatively were enrolled as those with postoperative delirium (+). Multivariable logistic regression was performed to identify risk factors for postoperative delirium. Incidence of postoperative delirium was compared among crystalloids, hydroxyethyl starch, and albumin groups after propensity score matching. RESULTS: The incidence of delirium within postoperative 4 days was 22.7%. Infusion of hydroxyethyl starch was an independent risk factor (odds ratio [OR], 1.53; 95% confidence interval [CI], 1.09-2.14; P = .0151). Other risk factors were age (OR, 1.04; 1.02-1.06, per year; P = .0002), preoperative cerebrovascular disease (OR, 2.18; 1.15-4.12; P = .0170), pulmonary dysfunction (OR, 1.85; 1.33-2.58; P = .0003), and transfusion (OR, 1.76; 1.22-2.53; P = .0023). Propensity score matching analysis confirmed that administration of hydroxyethyl starch, but not albumin, is related to postoperative delirium. CONCLUSIONS: Old age, preoperative cerebrovascular disease, pulmonary dysfunction, transfusion, and hydroxyethyl starch administration were related to early postoperative delirium. If colloid must be administered, albumin is preferred to hydroxyethyl starch.

Paravertebral Block Does Not Reduce Cancer Recurrence, but Is Related to Higher Overall Survival in Lung Cancer Surgery: A Retrospective Cohort Study.

BACKGROUND: Postoperative analgesic methods are suggested to have an impact on long-term prognosis after cancer surgery through opioid-induced immune suppression. We hypothesized that regional analgesia that reduces the systemic opioid requirement would be related to lower cancer recurrence and higher overall survival compared to intravenous patient-controlled analgesia (PCA) for lung cancer surgery. METHODS: Records for all patients who underwent open thoracotomy for curative resection of primary lung cancer between 2009 and 2013 in a tertiary care hospital were retrospectively analyzed. Patients were divided by postoperative analgesic methods: PCA (n = 574), thoracic epidural analgesia (TEA, n = 619), or paravertebral block (PVB, n = 536). Overall and recurrence-free survivals were compared among 3 analgesic methods via a multivariable Cox proportional hazard model and a log-rank test after adjusting confounding factors using propensity score matching (PSM). RESULTS: Analgesic method was associated with overall survival (P= .0015; hazard ratio against TEA [95% confidence intervals]: 0.58 [0.39-0.87] for PCA, 0.60 [0.45-0.79] for PVB). After confounder adjustment using PSM, PVB showed higher overall survival than PCA (log-rank P= .0229) and TEA (log-rank P= .0063) while PCA and TEA showed no difference (log-rank P= .6). Hazard ratio for PVB was 0.66 [0.46-0.94] against PCA and 0.65 [0.48-0.89] against TEA after PSM. However, there was no significant association between the analgesic methods and recurrence-free survival (P= .5; log-rank P with PSM = .5 between PCA and TEA, .5 between PCA and PVB, .1 between TEA and PVB). CONCLUSIONS: Pain-control methods are not related to cancer recurrence. However, PVB may have a beneficial effect on overall survival of patients with lung cancer.

Apneic oxygen insufflation decreases the incidence of hypoxemia during one-lung ventilation in open and thoracoscopic pulmonary lobectomy: A randomized controlled trial.

OBJECTIVE: Hypoxemia is common during one-lung ventilation (OLV) for thoracic surgery. When hypoxemia occurs, surgery is interrupted for rescue ventilation. Apneic oxygen insufflation (AOI), which provides O2 without applying pressure, may prevent hypoxemia and does not interrupt surgery. The aim of this study was to determine the effectiveness of the AOI technique for preventing hypoxemia during OLV in thoracic surgery. METHODS: Patients undergoing open or thoracoscopic pulmonary lobectomy from September to December 2015 were included. Patients were assigned randomly to a non-AOI group or an AOI group (n = 45 each). OLV was initiated and at the 15-minute mark (OLV15), patients in the AOI group received oxygen insufflation at 3 L/min to the nonventilated lung for 30 minutes (OLV45). The primary endpoint was the occurrence of hypoxemia (SaO2 <90%) during OLV. RESULTS: The demographic and operative data were similar between the 2 groups. The incidence of hypoxemia was greater in the non-AOI than the AOI group (18% vs 0%; P = .009). ΔPaO2 (the difference in partial pressure of oxygen in arterial blood between OLV 45 and 15 minutes) was smaller in the AOI than the non-AOI group (-29 mm Hg vs -69 mm Hg; P = .005). Duration of surgery and incidence of complications did not vary between groups. CONCLUSIONS: AOI decreases the incidence of hypoxemia and improves arterial oxygenation during OLV for open and thoracoscopic surgery. AOI may be a valuable option to prevent hypoxemia. It can be used before relying on continuous positive airway pressure or intermittent two-lung ventilation and result in fewer interruptions in surgery.