Case-matched series of enhanced versus standard recovery pathway in minimally invasive colorectal surgery.

BACKGROUND: Accelerated recovery pathways may reduce length of hospital stay after surgery but there are few data on minimally invasive colorectal operations. METHODS: An enhanced recovery pathway (ERP) was instituted, including preoperative analgesia, limited intravenous fluids and opiates, and early feeding. Intrathecal analgesia was administered as needed, but epidural analgesia was not used. The first 66 patients subjected to the ERP were case-matched by surgeon, procedure and age (within 5 years) with patients treated previously in a fast-track pathway (FTP). Short-term and postoperative outcomes to 30 days were compared. RESULTS: Hospital stay was shorter with the ERP than the FTP: median (interquartile range, i.q.r.) 3 (2-3) versus 3 (3-5) days (P < 0·001). A 2-day hospital stay was achieved in 44 and 8 per cent of patients respectively (P < 0·001). Patients in the ERP had a shorter time to recovery of bowel function: median (i.q.r.) 1 (1-2) versus 2 (2-3) days (P < 0·001). Thirty-day complication rates were similar (32 per cent ERP, 27 per cent FTP; P = 0·570). Readmissions within 30 days were more common with ERP, but the difference was not statistically significant (10 versus 5 patients; P = 0·170). Total hospital stay for those readmitted was shorter in the ERP group (18 versus 23 days). CONCLUSION: ERP decreased the length of hospital stay after minimally invasive colorectal surgery.

Perianaesthetic risks and outcomes of abdominal surgery for metastatic carcinoid tumours.

Patients with metastatic carcinoid tumours often undergo surgical procedures to reduce the tumour burden and associated debilitating symptoms. These procedures and anaesthesia can precipitate a life-threatening carcinoid crisis. To assess perioperative outcomes, we studied retrospectively the medical records of adult patients from 1983 to 1996 who underwent abdominal surgery for metastatic carcinoid tumours. Preoperative risk factors, intraoperative complications and complications occurring in the 30 days after surgery were recorded. Perioperative complications or death occurred in 15 of 119 patients (12.6%, exact confidence interval 7.2-19.9). None of the 45 patients who received octreotide intraoperatively experienced intraoperative complications compared with eight of the 73 patients (11.0%) who did not receive octreotide (P=0.023). The presence of carcinoid heart disease and high urinary output of 5-hydroxyindoleacetic acid preoperatively were statistically significant risk factors for perioperative complications.

Lower extremity neuropathies associated with lithotomy positions.

BACKGROUND: The goal of this project was to study the frequency and natural history of perioperative lower extremity neuropathies. METHODS: A prospective evaluation of lower extremity neuropathies in 991 adult patients undergoing general anesthetics and surgical procedures while positioned in lithotomy was performed. Patients were assessed with use of a standard questionnaire and neurologic examination before surgery, daily during hospital stay in the first week after surgery, and by phone if discharged before 1 postoperative week. Patients in whom lower extremity neuropathies developed were observed for 6 months. RESULTS: Lower extremity neuropathies developed in 15 patients (1.5%; 95% confidence interval, 0.8-2.5%). Unilateral or bilateral nerves were affected in patients as follows: obturator (five patients), lateral femoral cutaneous (four patients), sciatic (three patients), and peroneal (three patients). Paresthesia occurred in 14 of 15 patients, and 4 patients had burning or aching pain. No patient had weakness. Symptoms were noted within 4 h of completion of the anesthetic in all 15 patients. These symptoms resolved within 6 months in 14 of 15 patients. Prolonged positioning in a lithotomy position, especially for more than 2 h, was a major risk factor for this complication (P = 0.006). CONCLUSIONS: In this surgical population, lower extremity neuropathies were infrequent complications that were noted very soon after surgery and anesthesia. None resulted in prolonged disability. The longer patients were positioned in lithotomy positions, the greater the chance of development of a neuropathy. These findings suggest that a reduction of duration of time in lithotomy positions may reduce the risk of lower extremity neuropathies.

Perianesthetic risks and outcomes of pheochromocytoma and paraganglioma resection.

UNLABELLED: Pheochromocytomas and paragangliomas are often surgically curable. However, resection of these tumors can be life threatening. We undertook this study to determine the frequency of, and risk factors for, perioperative complications in patients undergoing resection of pheochromocytoma or paraganglioma. We retrospectively reviewed the medical records of patients during 1983-1996 who underwent surgical resection of catecholamine-secreting pheochromocytoma or paraganglioma. Preoperative risk factors, adverse intraoperative events, and complications occurring in the 30 days after operation were recorded. Blood pressures were collected from manual records. The ranked sum test and Fisher's exact test were used for analyses. Adverse perioperative events or complications occurred in 45 of 143 patients (31.5%; exact 95% confidence interval, 24.0% to 39.8%). Of these 45 patients, 41 experienced one or more adverse intraoperative events. The most common adverse event was sustained hypertension (36 patients). There were no perioperative deaths, myocardial infarctions, or cerebrovascular events. Preoperative factors univariately associated with adverse perioperative events included larger tumor size (P: = 0.007), prolonged duration of anesthesia (P: = 0.015), and increased levels of preoperative urinary catecholamines and catecholamine metabolites: vanillylmandelic acid (P: = 0.019), metanephrines (P: = 0.004), norepinephrine (P: = 0. 014), and epinephrine (P: = 0.004). Despite premedication of most patients with phenoxybenzamine and a beta-adrenergic blocker, varying degrees of intraoperative hemodynamic lability occurred. IMPLICATIONS: Few patients who had pheochromocytoma or paraganglioma resection experienced significant perioperative morbidity and none died in the largest retrospective study on this topic to date. This study confirms the very good perioperative outcomes demonstrated in smaller studies on this high-risk population, and identifies several risk factors for adverse outcomes.

Detectable blood alcohol after a motor vehicle crash and screening for alcohol abuse/dependence.

OBJECTIVE: To determine the percentage of patients hospitalized after an alcohol-related motor vehicle crash (MVC) who underwent a screening evaluation for alcohol abuse/dependence and had a diagnosis of alcohol abuse/dependence. PATIENTS AND METHODS: Medical and emergency trauma records were reviewed retrospectively for 1994 through 1996 to identify patients who were hospitalized as a result of being involved in an MVC with any detected blood alcohol at the time of admission to a large midwestern Level I trauma center. The primary outcome measure was the performance of alcohol abuse/dependence screening by a psychiatrist or a chemical dependency counselor. A univariate analysis was performed to identify factors associated with the performance of alcohol abuse/dependence screening. The Fisher exact test and the 2-sample rank sum test were used in the analyses. RESULTS: Of the 294 study patients, 78 (26.5%) underwent a screening evaluation for alcohol abuse/dependence by a psychiatrist or a chemical dependency counselor during hospitalization, and 69 (88%) of the 78 patients screened had a diagnosis of alcohol abuse/dependence. Factors associated with the performance of alcohol abuse/dependence evaluation included a known prior history of alcohol abuse, suspicion of alcohol consumption documented by emergency department personnel, higher blood alcohol level at admission, and longer length of hospitalization (all P < .001). CONCLUSION: While the high rate of alcohol abuse/dependence may be explained partially by distinguishing factors in those screened, these findings suggest that routine alcohol abuse/dependence screening of persons presenting with a detectable blood alcohol level following an MVC may identify patients who would benefit from a chemical dependency intervention.

Risk of surgery and anesthesia for ischemic stroke.

BACKGROUND: The goal of this study was to determine if the combination of surgery and anesthesia is an independent risk factor for the development of incident (first-time) ischemic stroke. METHODS: All residents of Rochester, MN, with incident ischemic stroke from 1960 through 1984 (1,455 cases and 1,455 age- and gender-matched controls) were used to identify risk factors associated with ischemic stroke. Cases and controls undergoing surgery involving general anesthesia or central neuroaxis blockade before their stroke/index date of diagnosis were identified. A conditional logistic regression model was used to estimate the odds ratio of surgery and anesthesia for ischemic stroke while adjusting for other known risk factors. RESULTS: There were 59 cases and 17 controls having surgery within 30 days before their stroke/index date. After adjusting for previously identified risk factors, surgery within 30 days before the stroke/index date (perioperative period) was found to be an independent risk factor for stroke (P<0.001; odds ratio, 3.9; 95% confidence interval, 2.1-7.4). In an analysis that excluded matched pairs where the case and/or control underwent surgery considered "high risk" for stroke (cardiac, neurologic, or vascular procedures), "non-high-risk surgery" was also found to be an independent risk factor for perioperative stroke (P = 0.002; odds ratio, 2.9; 95% confidence interval, 1.5-5.7). CONCLUSION: Our results suggest that there is an increased risk of ischemic stroke in the 30 days after surgery and anesthesia. This risk remains elevated even after excluding surgeries (cardiac, neurologic, and vascular surgeries) considered to be high risk for ischemic stroke.

Probable alcohol abuse or dependence: a risk factor for intensive-care readmission in patients undergoing elective vascular and thoracic surgical procedures. Mayo Perioperative Outcomes Group.

OBJECTIVE: To determine whether alcohol abuse or dependence is a risk factor for perioperative complications, increased duration of hospital stay, and increased utilization of nursing resources in patients undergoing thoracic and vascular surgical procedures. MATERIAL AND METHODS: We conducted a prospective study of all adult patients who underwent an elective vascular or thoracic surgical procedure and who received postoperative care in an intensive-care setting. Patients were screened for alcohol abuse or dependence, and actual versus expected durations of stay were evaluated. The patients' medical records were reviewed for preoperative comorbidities and perioperative complications. Fisher's exact test and the rank sum test were used in the analyses. RESULTS: Of 321 study subjects, 290 were classified as nonalcoholic and 31 as probable alcoholic patients. Patients in the probable alcohol abuse group had a significantly increased rate of alcohol withdrawal (12.9% versus 1.7%; P = 0.006) in comparison with patients in the nonalcoholic group. Patients in the probable alcohol abuse group were readmitted to an intensive-care unit more frequently (19.4% versus 7.9%; P = 0.047) and required sedation more often (32.3% versus 13.5%; P = 0.014) than those in the nonalcoholic group. No significant differences were found between the two study groups in intensive-care unit and hospital durations of stay or in utilization of nursing resources. A dismissal diagnosis of alcoholism was recorded for only one of four patients who had a documented withdrawal episode among those categorized in the probable alcoholic group and for three of five patients with alcohol withdrawal symptoms categorized in the nonalcoholic group. CONCLUSION: Except for the occurrence of alcohol withdrawal syndrome, study patients classified in the probable alcohol abuse group did not have more medical or surgical perioperative complications than patients in the nonalcoholic group. They did have significantly more intensive-care setting readmissions. Patients with documented alcohol withdrawal episodes frequently were dismissed without a diagnosis of substance abuse or dependence.

Perianesthetic dental injuries: frequency, outcomes, and risk factors.

BACKGROUND: Dental injury is well-recognized as a potential complication of laryngoscopy and tracheal intubation. However, the frequency, outcomes, and risk factors for this problem have not been documented in a well-defined patient population. METHODS: The authors analyzed the dental injuries of 598,904 consecutive cases performed on patients who required anesthetic services from 1987 through 1997. Dental injuries were defined as perianesthetic events (those occurring within 7 days) that required dental interventions to repair, stabilize, or extract involved dentition or support structures. A 1:3 case-control study of 16 patient and procedural characteristics was performed for cases that occurred during the first 5 yr of the study. Conditional logistic regression was used for data analysis. RESULTS: There were 132 cases (1:4,537 patients) of dental injury. One half of these injuries occurred during laryngoscopy and tracheal intubation. The upper incisors were the most commonly involved teeth, and most injuries were crown fractures and partial dislocations and dislodgements. Multivariate risk factors for dental injury in the case control study included general anesthesia with tracheal intubation (odds ratio [OR] = 89), preexisting poor dentition (OR = 50), and increased difficulty of laryngoscopy and intubation (OR = 11). CONCLUSIONS: Based on these data from a large surgical population at a single training institution, approximately 1:4,500 patients who receive anesthesia services sustain a dental injury that requires repair or extraction. Patients most at risk for perianesthetic dental injury include those with preexisting poor dentition who have one or more risk factors for difficult laryngoscopy and tracheal intubation.

Neurologic complications after placement of cerebrospinal fluid drainage catheters and needles in anesthetized patients: implications for regional anesthesia. Mayo Perioperative Outcomes Group.

UNLABELLED: Subarachnoid or epidural needle placement in an anesthetized patient is controversial because general anesthesia and muscle relaxation may mask neural trauma. However, placement of a needle or catheter in the subarachnoid space for the purpose of cerebral spinal fluid (CSF) drainage is frequently performed in anesthetized patients undergoing neurosurgery. The records from 530 consecutive transsphenoidal surgeries performed with lumbar CSF drainage were reviewed to determine the types of neurologic complications attributable to spinal drainage and their rates of occurrence. All patients were anesthetized during CSF drain placement. A 19-gauge malleable needle was placed in 473 (89%) patients. Subarachnoid catheters (20- or 16-gauge catheters placed via 18- or 14-gauge epidural needles, respectively) were placed in 17 (3%) patients. In 40 (8%) patients, the type of drain was unspecified. No new neurologic deficits attributable to spinal drain insertion were detected in the immediate postoperative period or within 1 yr of surgery. Thirteen patients developed postdural puncture headache (2.5%, exact 95% confidence interval 1.3%-4.2%); seven required epidural blood patch (1.3%, 0.5%-2.7%). The low incidence (0%, 0.0%-0.7%) of neurologic injury from spinal drain insertion in anesthetized patients from this study is similar to the incidence of neurologic complications historically reported for both CSF drain insertion and spinal anesthesia. IMPLICATIONS: The performance of regional anesthesia in an anesthetized patient is controversial due to the possibility of unrecognized nerve injury. We report no cases of nerve injury caused by the placement of cerebrospinal fluid drainage needles and catheters in 530 anesthetized patients undergoing neurosurgery.

The risk of persistent paresthesia is not increased with repeated axillary block.

UNLABELLED: Neurologic deficits are noted on physical examination in approximately 0.2%-19% of patients after regional anesthetic techniques. Laboratory and clinical studies suggest that a subclinical neuropathy occurs much more often. Performing a regional anesthetic technique during this period may result in additional nerve trauma. We evaluated the frequency of neurologic complications in patients undergoing repeated axillary block. A total of 1614 blocks were performed on 607 patients. The median number of blocks per patient was two (range 2-10 blocks). The median interval between blocks was 12.6 wk, including 188 (31%) patients who received multiple blocks within 1 wk. Sixty-two neurologic complications occurred in 51 patients for an overall frequency of 8.4%. Of the 62 nerve injuries, 7 (11.3%) were related to the anesthetic technique; the remaining 55 (88.7%) were a result of the surgical procedure. Patient age and gender, the presence of preexisting neurologic conditions, a surgical procedure to a nerve, and total number of blocks did not increase the risk of neurologic complications. No regional anesthetic technique risk factors, including elicitation of a paresthesia, selection of local anesthetic, or addition of epinephrine, were identified. The success rate was higher with the paresthesia technique than with nerve stimulator technique or transarterial injection, and with use of mepivacaine versus bupivacaine. We conclude that the frequency of neurologic complications in patients undergoing repeated axillary block is similar to that in patients receiving a single regional technique. These patients are not likely to be at increased risk of neurologic complications. IMPLICATIONS: The risk of neurologic complications was not increased in patients who underwent multiple axillary blocks, even within a 1-wk interval. No risk factors for anesthetic-related complications were identified. However, block success rate was increased with the paresthesia technique and the injection of mepivacaine versus bupivacaine.

Ulnar neuropathy in surgical patients.

BACKGROUND: The goal of this project was to study the frequency and natural history of perioperative ulnar neuropathy. METHODS: A prospective evaluation of ulnar neuropathy in 1,502 adult patients undergoing noncardiac surgical procedures was performed. Patients were assessed with a standard questionnaire and neurologic examination before surgery, daily during hospitalization in the first week after surgery, and by telephone if they were discharged before 1 postoperative week. Patients in whom ulnar neuropathy developed were followed for 2 yr. RESULTS: Ulnar neuropathy developed in seven patients (0.5%; 95% confidence interval, 0.2% to 1.0%). Six of the seven patients were men. Symptoms of ulnar neuropathy began 2-7 days after surgery. Manifestations were mild and confined to sensory deficits in six patients. Symptoms resolved in four patients within 6 weeks. The remaining three patients had residual symptoms 2 yr later. CONCLUSIONS: In this surgical population, ulnar neuropathy was an infrequent complication. It occurred primarily in men who were 50-75 yr old and was not symptomatic until several days after surgery. Gender-dependent differences in the anatomy of the ulnar nerve and related structures at the elbow may serve as risk factors for ulnar neuropathy in patients having surgery.

A case for the CNS in acute care.

To ensure a continued place in hospital care, clinical nurse specialists (CNSs) must adapt their role to positively impact the bottom line for hospitals and patients. This article reviews the literature on CNSs' cost-effectiveness in acute care settings.

Diabetes mellitus and difficult laryngoscopy in renal and pancreatic transplant patients.

UNLABELLED: Limited mobility of the cervical spine or temperomandibular joint may contribute to increased difficulty of laryngoscopy in patients who have severe diabetes mellitus. The frequency of difficult laryngoscopy in diabetics undergoing renal and/or pancreatic transplants has been reported to be as high as 32%. We retrospectively reviewed the anesthetic records of all adult patients who underwent renal and/or pancreatic transplant and endotracheal intubation from January 1, 1985 to October 31, 1995. Characteristics specifically reviewed included the presence of diabetes mellitus, type of organ donor, age, gender, body mass index, previous difficult laryngoscopy, known characteristics potentially related to difficult laryngoscopy, and degree of difficulty with laryngoscopy. Laryngoscopy was graded as easy, minimally to moderately difficult, and moderately to extremely difficult to perform. Factors associated with any degree of difficult intubation were univariately assessed by using Fisher's exact test. Of 725 patients, 15 (2.1%) were identified as having difficult laryngoscopies, although all underwent successful endotracheal intubations. Factors associated with difficult laryngoscopy were diabetes mellitus (P = 0.002) and characteristics known to be related to difficult laryngoscopy (P = 0.02). These findings confirm an increase in the frequency of difficult laryngoscopy in diabetic patients undergoing renal and/or pancreatic transplant, although no laryngoscopies were rated as moderately to extremely difficult. We conclude that the frequency of difficult laryngoscopy in these diabetic patients is much lower than previous reports have suggested. IMPLICATIONS: Previous studies have suggested that airway management of many diabetic patients may be difficult. Our medical record review of patients with severe diabetes undergoing organ transplants showed that extraordinary techniques were not required to successfully manage their airways.