Journal of perioperative practice最新文献

Background: The optimal length of epidural use following open pancreaticoduodenectomy has not been defined. The aim of this study was to investigate whether the length of patient-controlled epidural analgesia affected pain and ability to mobilise on epidural termination following open pancreaticoduodenectomy in the context of enhanced recovery after surgery.

Methods: A retrospective single-centre cohort analysis was performed between November 2015 and December 2021 on patients who underwent open pancreaticoduodenectomy. As part of a continual review process of the enhanced recovery after surgery protocol, patient-controlled epidural analgesia duration changed allowing stratification of patients into either three- or five-day patient-controlled epidural analgesia groups.

Results: Of the 196 patients identified, 157 were included with 80 (50.9%) and 77 (49.1%) allocated to the three-day and five-day patient-controlled epidural analgesia groups, respectively. Patient-controlled epidural analgesia termination on postoperative day 3 was associated with transiently higher pain and less mobilisation, although no greater rescue analgesia requirement. Conversely, longer patient-controlled epidural analgesia usage following open pancreaticoduodenectomy was associated with less pain and greater mobilisation in the immediate postoperative period.

Conclusions: Earlier patient-controlled epidural analgesia termination transiently leads to increased pain and decreased mobilisation following open pancreaticoduodenectomy. Ensuring appropriate analgesia requirements or longer patient-controlled epidural analgesia usage should be considered to avoid patient discomfort and enhance recovery.

BackgroundThe COVID-19 pandemic challenges the recommendations for patients' preoperative assessment for preventing severe acute respiratory syndrome coronavirus type 2 transmission and COVID-19-associated postoperative complications and morbidities.PurposeTo evaluate the contribution of chest computed tomography for preoperatively assessing patients who are not suspected of being infected with COVID-19 at the time of referral.MethodsCandidates for emergency surgery screened via chest computed tomography from 8 to 27 April 2020 were retrospectively evaluated. Computed tomography images were analysed for the presence of COVID-19-associated intrapulmonary changes. When applicable, laboratory and recorded clinical symptoms were extracted.ResultsEighty-eight patients underwent preoperative chest computed tomography; 24% were rated as moderately suspicious and 11% as highly suspicious on computed tomography. Subsequent reverse transcription polymerase chain reaction (RT-PCR) was performed for seven patients, all of whom tested negative for COVID-19. Seven patients showed COVID-19-associated clinical symptoms, and most were classified as being mildly to moderately severe as per the clinical classification grading system. Only one case was severe. Four cases underwent RT-PCR with negative results.ConclusionIn a cohort without clinical suspicion of COVID-19 infection upon referral, preoperative computed tomography during the COVID-19 pandemic can yield a high suspicion of infection, even if the patient lacks clinical symptoms and is RT-PCR-negative. No recommendations can be made based on our results but contribute to the debate.

Our understanding of the effects of anaesthesia is incomplete. Anaesthesia works primarily by causing widespread depression of the central nervous system. This article will consider the anaesthesia provided for a patient undergoing a hysteroscopy, endometrial ablation and biopsy for abnormal uterine bleeding. The relationship between physiology and the effects of anaesthesia is discussed. Several effects of anaesthesia are observed during the case. Relating to the respiratory system, preoxygenation increased end tidal oxygen by 39%, delaying desaturation during apnoea. Propofol had a profound effect on the patient's respiratory rate by inhibiting the ventilatory drive, resulting in apnoea. The cardiovascular system was affected by tracheal intubation. Stimulation of the sympathetic nervous system caused a 96% increase in heart rate. Induction of anaesthesia resulted in hypotension, treated with the administration of ephedrine, causing vasoconstriction. Modified rapid sequence induction required an increased dose of rocuronium, resulting in an increased duration of action at the neuromuscular junction. The prolonging muscle paralysis required sugammadex as a reversal agent. This case demonstrated the effects of anaesthesia on the respiratory, cardiovascular and nervous systems.

Difficult ventilation and intubation in anaesthesia are highly complex and challenging for the anaesthetist. We aim to present a case of successful nasotracheal intubation with surgical incision and video laryngoscope in a patient with anticipated difficult ventilation and intubation due to a limited mouth opening. A patient was an 81-year-old female scheduled for oral surgery for lip cancer. The patient's American Society of Anesthesiologists (ASA) physical classification was class III, and the oral airway was assessed as a Mallampati Class IV. A comprehensive preoperative evaluation of the patient revealed limited mouth opening (distance between incisors 1cm) and multiple decayed and broken teeth. A 2cm surgical incision of the skin was performed by plastic surgery under local anaesthesia and sedation without general anaesthesia. A high-flow nasal cannula (HFNO) was used for preoxygenation and to prevent desaturation during a difficult intubation. The oral cavity was topicalised with 2% lidocaine, and after the topical nasal vasoconstrictor to the nasal cavity, we selected a 7.0mm nasal flexible endotracheal tube (ETT). We inserted it into the right nostril with a video laryngoscope under local anaesthesia and sedation without general anaesthesia, and then, the patient's nasotracheal intubation was successfully performed. A multidisciplinary team approach to airway management should include all participants in planned patient care in the operating room, intensive care unit (ICU), post-anaesthesia care unit, or ward.

In this prospective randomised controlled trial, we compared the impact of the lateral versus supine position for tracheal extubation among infants aged two months to two years after intraabdominal surgery on the incidence of respiratory adverse events that may occur after extubation. The anaesthesia protocol was standardised. Among the 120 infants included (60 in each group), the demographic and perioperative data were comparable between both groups. The incidence of perioperative respiratory adverse events after tracheal extubation was 21.6% and 5% in the supine and lateral position groups, respectively, with p = 0.007 and odds ratio = 3.87; 95% confidence interval: 1.18-12.6. Lateral position also reduced the incidence of airway obstruction with p = 0.004 and odds ratio = 11.8; 95% confidence interval: 1.46-95.3 and oxygen desaturation below 92% with p = 0.008 and odds ratio = 11.8; 95% confidence interval: 1.46-95. The lateral position seems to be practical and beneficial for tracheal extubation among infants.

Background: Preoperative cognitive impairment is a strong risk factor for the development of postoperative delirium in older patients. The cognitive screening of patients in low- and middle-income countries remains a challenge due to socio-economic and cultural differences.

Method: This study was performed in 153 older patients undergoing lower limb orthopaedic surgery. Patients who were unable to speak and understand the Hindi language, patients with hearing (unaided) or speaking impairment, and patients with altered mental status were excluded. One day prior to the scheduled surgery, cognitive screening of patients using the animal fluency test and six-item screener was performed. Patients were screened daily for postoperative delirium using the confusion assessment method until 3 days after the surgery.

Results: The incidence of postoperative delirium was 6% in our study population. We found that statistically significant difference between the patients who developed postoperative delirium and those who remained unaffected, in terms of frailty, animal fluency test score, and duration of surgery. Frailty and the duration of surgery independently affected postoperative delirium. The receiver operating characteristic curve of animal fluency test and six-item screener showed areas under the curve of 0.796 and 0.656, respectively. The best cut-off point of animal fluency test for prediction of postoperative delirium was less than 8.50 with a sensitivity of 77.8% and a specificity of 66%.

Conclusion: The preoperative cognitive screening using animal fluency test can predict the occurrence of postoperative delirium with fair accuracy in older patients undergoing orthopaedic surgery. In contrast, the six-item screener demonstrated a weak association with postoperative delirium within our study population.

Background: The transverse abdominis plane block is increasingly being used as a less-invasive alternative to thoracic epidural analgesia for effective pain management. This study aimed to compare transverse abdominis plane block with opioid-based thoracic epidural analgesia in terms of postoperative opioid consumption.

Methods: Patients in the thoracic epidural analgesia group received a continuous infusion of 0.1% levobupivacaine with 2mcg/ml of fentanyl, while those in the transverse abdominis plane group received 6-hourly boluses of 0.4ml/kg of 0.25% levobupivacaine. The primary objective was to compare the average fentanyl consumption, measured as intravenous fentanyl equivalents, over 72 hours.

Results: Data of 35 patients were analysed. Fentanyl consumption at the end of 72 hours was significantly lower in the transverse abdominis plane group (median [interquartile range] 495 mcg (255, 750), and mean (95% confidence interval) 717.35mcg (403.54-1031.16)) compared to the thoracic epidural analgesia group (median [interquartile range] 760mcg (750, 760), and mean (95% confidence interval) 787mcg (746.81-827.19)) with a p value of 0.010. Pain scores at rest and during movement were comparable between the groups (p > 0.05). However, the median pain scores during movement were significantly lower in the thoracic epidural analgesia group at 60 and 72 hours (p ⩽ 0.05).

Conclusion: Multimodal analgesia with transverse abdominis plane resulted in lower opioid consumption over 72 hours compared to thoracic epidural analgesia.

Studies comparing the intentional increase in oxygen delivery and normal oxygen delivery during general anaesthesia in elderly patients undergoing major abdominal surgery are limited and have reported contradictory findings. Therefore, the study aimed to evaluate the effect of intraoperative increase in systemic oxygen delivery on postoperative outcomes and quality of life in elderly patients undergoing major abdominal surgery. This randomised, blinded, parallel-arm, pragmatic clinical trial included elderly patients of >60 years of age undergoing major abdominal surgery. The patients in the intervention arm received noradrenaline or increased fractional inspiration of oxygen to augment central venous oxygen saturation ⩾75%. The primary outcome measure was composite of in-hospital mortality and major organ complications. The secondary outcome measure included comparison of quality of life. A total of 160 patients were assessed for eligibility, and 146 were randomised in the study groups. The mean arterial and central venous oxygen saturation increased and were significantly higher in the intervention arm. The composite primary outcome occurred in 49.31% in the intervention arm and 57.53% in the usual care arm (relative risk; 95% confidence interval: 0.85; 0.63-1.16; absolute risk reduction; 8.22%; p = 0.32). Furthermore, quality of life at the end of three months was similar (0.658 ± 0.19 versus 0.647 ± 0.19; p = 0.771). In conclusion, central venous oxygen saturation-guided increase in systemic oxygen delivery during the intraoperative period of major abdominal surgery in elderly patients did not reduce predefined composite outcome of in-hospital mortality or organ-specific complications.