Comparison of tools for nutrition assessment and screening for predicting the development of complications in orthopedic surgery.

BACKGROUND: Malnutrition in hospitalized patients is a significant problem. The purpose of this study was to compare 2 assessment tools-the Nutritional Risk Screening 2002 (NRS 2002) and subjective global assessment (SGA)-in predicting development of complications in patients undergoing orthopedic surgery. METHODS: Nutrition status was assessed by the SGA, and nutrition screening was performed using the NRS 2002 in 256 consecutively admitted patients scheduled for orthopedic surgery. Additional information recorded for all patients included age, gender, body mass index, and American Society of Anesthesiologists (ASA) physical status. Patient outcomes (postoperative complications), mortality rate, and length of hospital stay (LOS) were investigated. RESULTS: Malnourished or nutritionally at-risk patients were significantly older than nonmalnourished or not at-risk patients according to the SGA and NRS 2002. Also, ASA physical status was correlated with malnutrition or malnutrition risk. Malnourished and at-risk patients in both the SGA and NRS 2002 groups showed longer LOS and higher morbidity and mortality rates. Sensitivity was 50% with the SGA and 69% with the NRS 2002; specificity was 77% with the SGA and 80% with the NRS 2002. Agreement between 2 methods was 0.672. The odds ratio for the association between malnutrition or risk of malnutrition and the occurrence of complications was 3.5 (1.7-7.1) for the SGA and 4.1 (2.0-8.5) for NRS 2002. CONCLUSIONS: Age and ASA physical status are risk factors for malnutrition. In patients undergoing orthopedic surgery, NRS 2002 predicted development of complications better than the SGA. Malnutrition also increased length of hospital stay.

Bupivacaine infusion above or below the fascia for postoperative pain treatment after abdominal hysterectomy.

BACKGROUND: We evaluated in which anatomic layer (above the fascia [AF] or below the fascia [BF]) wound infusion of bupivacaine has the best effect on postoperative pain after abdominal hysterectomy. METHODS: Sixty-two ASA physical status I and II patients undergoing total abdominal hysterectomy and bilateral salpingo-oophorectomy were enrolled into this prospective randomized, double-blind study. A standard general anesthetic was administered. On completion of the operation, a multiorifice 20-gauge epidural catheter was placed above (group AF, n = 29) or below (group BF, n = 31) the superficial abdominal fascia and 0.25% bupivacaine was administered via a patient-controlled analgesia device, programmed to deliver 9.0 mL with a 60-min lockout interval for 24 h. During the first 6 h after surgery, rescue i.v. fentanyl (25 microg) was administered to achieve a visual analog scale score of <4 cm. Total bupivacaine consumption, total rescue fentanyl consumption, pain scores (with resting, coughing, and leg raising), and patient satisfaction scores were compared in both groups. RESULTS: Total bupivacaine consumption over 24 h was significantly lower in group AF rather than group BF (90 +/- 26 mL vs 104 +/- 28 mL, respectively, P < 0.05). The total fentanyl consumption during the first 6 h after surgery was 109 +/- 59 microg in group AF and 166 +/- 70 microg in group BF (P < 0.01). Pain scores were lower in group AF at rest and coughing for the first 5 h and for the first 12 h with leg raise (P < 0.05 for all measurements). Thirteen patients (68%) in group AF defined their satisfaction as excellent whereas six patients (32%) in group BF defined their satisfaction as excellent (P = 0.034). CONCLUSION: We conclude that bupivacaine wound infusion AF provides better postoperative analgesia compared with infusion BF in the first 12 h after abdominal hysterectomy.

The effects of an epidural infusion of ropivacaine versus saline on sensory block after spinal anesthesia.

BACKGROUND AND OBJECTIVES: Several investigators have described the effect of bolus injections on sensory block during combined spinal epidural anesthesia. This study investigates the effects of the immediate epidural infusion of 0.2% ropivacaine versus 0.9% saline on spinal anesthesia. METHODS: Forty-four patients undergoing partial hip replacement were randomly assigned to 2 groups, receiving epidural infusion of 0.2% ropivacaine 10 mL/h (group R, n = 22) or 0.9% NaCl 10 mL/h (group S, n = 22), immediately after spinal anesthesia with 7.5 mg 0.5% hyperbaric bupivacaine. Postoperative analgesia was provided in both groups using a ropivacaine patient-controlled epidural analgesia technique. Sensory block, motor block, postoperative pain scores, ropivacaine consumption, and patient satisfaction were recorded. RESULTS: There was no difference between the 2 groups in the characteristics of the sensory block. The duration of motor block was prolonged in group R (312 +/- 95 minutes vs 198 +/- 78 minutes; P < .001). Postoperative pain scores and 24-hour ropivacaine consumption were similar among groups. Demand/delivery ratio was 1.6 in group R and 3.5 in group S (P = .048). A significantly higher number of patients in group R described their satisfaction as excellent (20 patients vs 6 patients; P < .001). CONCLUSIONS: Epidural infusion of ropivacaine 0.2% initiated immediately after spinal anesthesia prolonged the regression of motor block but not the regression of sensory block when compared with saline infusion.

Reversal of prilocaine epidural anesthesia using epidural saline or ringer's lactate washout.

BACKGROUND AND OBJECTIVES: Several investigators have described the phenomena of epidural saline washout using bolus injections. This study was designed to determine whether epidural block could be reversed more effectively by infusion of crystalloid solutions via the epidural catheter. METHODS: One hundred male patients scheduled for outpatient surgery were enrolled in this study. After 30 min of 2% prilocaine epidural anesthesia, patients were randomly assigned to receive 45 mL of study solution as follows: (1) normal saline bolus (group NSB); (2) Ringer's lactate bolus (group RLB); (3) normal saline infusion (group NSI); (4) Ringer's lactate infusion (group RLI). Patients in the control group received no washout fluid. Motor, sensory blockade and side effects were compared among 5 groups. Ambulation time is defined as the recovery time. RESULTS: In the control group, ambulation time (139 +/- 15 min) was significantly longer than in the washout groups (NSB 90 +/- 10, RLB 88 +/- 10, NSI 85 +/- 8, RLI 91 +/- 6 minutes) (P < .001). Two-segment sensory regression time in the control group (86 +/- 15 min) was significantly longer than in groups NSB, RLB, NSI and RLI (55 +/- 8, 51 +/- 4, 58 +/- 8, and 53 +/- 10 minutes, respectively) (P < .001). CONCLUSIONS: We concluded that a more rapid recovery of motor and sensory blockade in patients undergoing epidural anesthesia may be achieved by the use of an epidural washout with either bolus or infusion of 45 mL normal saline or Ringer's lactate.

Airway management of a patient with Forestier's disease.

Forestier's disease, also called diffuse idiopathic skeletal hyperostosis (DISH), is a noninflammatory enthesopathy, ossifying the anterolateral spine and sparing the disc and joint space in elderly men, mostly at thoracic levels. Intubation difficulty and spinal cord injury are potential problems when managing the airway in DISH patients. We report a patient with Forestier's disease who was admitted for osteophyte resection. After taking a detailed history, we evaluated the airway carefully. Also, preparation for difficult intubation was done. After a rapid sequence induction, we performed mask ventilation and laryngoscopy without hyperextension of the neck, to prevent spinal cord injury. Although the worldwide standard for management of the airway in DISH patients is awake fiberoptic intubation, we chose conventional laryngoscopy because a fiberoptic bronchoscope was not available.

Intraoperative fetal heart rate monitoring during emergency neurosurgery in a parturient.

Malignant brain tumors during pregnancy are rare, and these patients seldom require immediate surgical intervention. A 27-year-old pregnant woman underwent emergency craniotomy. Anesthesia was induced with intravenous thiopental-fentanyl; it was maintained with isoflurane in oxygen and continuous intravenous remifentanil infusion. We used full stomach precautions but omitted succinylcholine for fear of increasing the intracranial pressure during induction of anesthesia. To detect fetal hypoxia and the effects of anesthesia on fetal hemodynamics, the fetal heart rate (FHR) was monitored using a fetal Doppler ultrasonography unit fixed to the mother's abdominal wall. Intraoperative and recovery periods were uneventful. Use of an isoflurane and remifentanil combination provided stable hemodynamics with adequate arterial blood pressure to avoid uterine hypoperfusion and fetal hypoxia. In this case, using FHR monitoring we found that craniotomy can be performed safely under isoflurane/remifentanil based-general anesthesia during the second trimester of pregnancy.