Error traps and preventative strategies for adolescent idiopathic scoliosis spinal surgery

Anesthesia for posterior spinal fusion for adolescent idiopathic scoliosis remains one of the most common surgeries performed in adolescents. These procedures have the potential for significant intraprocedural and postoperative complications. The potential for pressure injuries related to prone positioning must be understood and addressed. Additionally, neuromonitoring remains a mainstay for patient care in order to adequately assess patient neurologic integrity and alert the providers to a reversible action. As such, causes of neuromonitoring signal loss must be well understood, and the provider should have a systematic approach to signal loss. Further, anesthetic design must facilitate intraoperative wake-up to allow for a definitive assessment of neurologic function. Perioperative bleeding risk is high in posterior spinal fusion due to the extensive surgical exposure and potentially lengthy operative time, so the provider should undertake strategies to reduce blood loss and avoid coagulopathy. Pain management for adolescents undergoing spinal fusion is also challenging, and inadequate analgesia can delay recovery, impede patient/family satisfaction, increase the risk of chronic postsurgical pain/disability, and lead to prolonged opioid use. Many of the significant complications associated with this procedure, however, can be avoided with intentional and evidence-based approaches covered in this review.

Effects of different sponge implantation methods of negative pressure wound therapy on wound healing of deep surgical site infection after spinal surgery

PURPOSE

After spinal surgery, negative pressure wound treatment (NPWT) improves deep surgical site infection (DSSI) wound healing. This research compared the healing benefits of two sponge implantation strategies in NPWT for DSSI.

METHODS

21 patients with DSSI utilized NPWT to improve wound healing following spine surgery were followed from January 1, 2012 to December 31, 2021. After antibiotic treatment failure, all these patients with DSSI received extensive debridement and NPWT. They are grouped by sponge placement method: centripetal reduction and segment reduction. The two groups' hospital stays, NPWT replacement frequency, wound healing time, healing speed, and quality of wound healing (POSAS score) were compared.

RESULTS

All patients had been cured by the end of December 2022, and the mean follow-up time was 57.48 ± 29.6 months. Surgical incision length did not vary across groups (15.75±7.61 vs. 15.46±7.38 cm, P = 0.747). The segmental reduction approach had shorter hospital stay and NPWT treatment times than the centripetal reduction method (39.25±16.04 vs. 77.38±37.24 days, P = 0.027). Although there is no statistically significant difference, the mean wound healing duration of segmental reduction group is faster than that of centripetal reduction group (0.82±0.39 vs 0.45±0.28 cm/d, P = 0.238), wound healing quality (POSAS) (33.54±8.63 vs 48.13±12.17, P = 0.408) is better in segmental reduction group, and NPWT replacement frequency (2.62 ± 1.04 vs 3.88 ± 1.25, P < .915) is smaller in segmental reduction group.

CONCLUSIONS

NPWT heals wounds and controls infection. Segmental reduction method accelerates wound healing, reduces hospital stay, and improves wound quality compared to central reduction method.

Crystalloids vs. colloids for fluid optimization in patients undergoing brain tumour surgery

BACKGROUND

This randomised, double-blinded, single-centre study prospectively investigated the impact of goal directed therapy and fluid optimization with crystalloids or colloids on perioperative complications in patients undergoing brain tumour surgery. Main aim of the study was to investigate the impact of fluid type on postoperative complications.

PATIENTS AND METHODS

80 patients were allocated into two equal groups to be optimised with either crystalloids (n = 40) or colloids (n = 40). Invasive hemodynamic monitoring was used to adjust and maintain mean arterial pressure and cerebral oxygenation within the baseline values (± 20%) and stroke volume variation (SVV) ≤ 10%. Postoperative complications from different organ systems were monitored during the first 15 days after surgery. Hospital stay was also recorded.

RESULTS

Crystalloid group received significantly more fluids (p = 0.003) and phenylephrine (p = 0.02) compared to colloid group. This did not have any significant impact on perioperative complications and hospital stay, since no differences between groups were observed.

CONCLUSIONS

Either crystalloids or colloids could be used for fluid optimization in brain tumour surgery. If protocolised perioperative haemodynamic management is used, the type of fluid does not have significant impact on the outcome.

Enhanced Recovery after Surgery: History, Key Advancements and Developments in Transplant Surgery

Enhanced recovery after surgery (ERAS) aims to improve patient outcomes by controlling specific aspects of perioperative care. The concept was introduced in 1997 by Henrik Kehlet, who suggested that while minor changes in perioperative practise have no significant impact alone, incorporating multiple changes could drastically improve outcomes. Since 1997, significant advancements have been made through the foundation of the ERAS Society, responsible for creating consensus guidelines on the implementation of enhanced recovery pathways. ERAS reduces length of stay by an average of 2.35 days and healthcare costs by $639.06 per patient, as identified in a 2020 meta-analysis of ERAS across multiple surgical subspecialties. Carbohydrate loading, bowel preparation and patient education in the pre-operative phase, goal-directed fluid therapy in the intra-operative phase, and early mobilisation and enteral nutrition in the post-operative phase are some of the interventions that are commonly implemented in ERAS protocols. While many specialties have been quick to incorporate ERAS, uptake has been slow in the transplantation field, leading to a scarcity of literature. Recent studies reported a 47% reduction in length of hospital stay (LOS) in liver transplantation patients treated with ERAS, while progress in kidney transplantation focuses on pain management and its incorporation into enhanced recovery protocols.

Blood metabolomic profiling predicts postoperative gastrointestinal function of colorectal surgical patients under the guidance of goal-directed fluid therapy

Postoperative gastrointestinal function influences postoperative recovery and length of hospital stay for patients undergoing colorectal surgery. Goal-directed fluid therapy (GDFT) restricts fluid administration to an amount required to prevent dehydration. Although the fluid management of GDFT could decrease the incidence of postoperative complications in patients who undergo high-risk surgery, certain patients may not respond to GDFT. Thus, to achieve optimal treatment, identification of patients suitable for GDFT is necessary. Metabolomic profiling of 48 patients undergoing surgery for colorectal cancer was performed. Patients were divided into delayed- and enhanced-recovered groups based on gastrointestinal function within 72 hours, and the results of omics analysis showed differential serum metabolites between the two groups of patients in the post anesthesia care unit 24 hours after surgery. A support vector machine model was applied to evaluate the curative effects of GDFT in different patients. Four metabolites, oleamide, ubiquinone-1, acetylcholine, and oleic acid, were found to be highly associated with postoperative gastrointestinal function and could be used as potential biomarkers. Moreover, four pathways were found to be highly related to postoperative gastrointestinal recovery. Among them, the vitamin B6 metabolism pathway may be a common pathway for improving postoperative recovery in various diseases. Our findings proposed a novel method to predict postoperative recovery of gastrointestinal function based on metabolomic profiling and suggested the potential mechanisms contributing to gastrointestinal function after surgical resection of colorectal cancer under the fluid management of GDFT.

Correlation between Intraoperative Fluid Administration and Outcomes of Pancreatoduodenectomy

Background

Intraoperative fluid (IOF) administration plays an important role during major abdominal surgery although increased fluid intake can adversely influence postoperative outcomes. However, the effect of the IOF rate on the outcomes of pancreatoduodenectomy (PD) is unclear.

Methods

151 patients, who underwent PD at Binzhou Medical University Hospital between January 2010 and May 2017, were categorized into three groups according to IOF rates (ml/kg/hr): restricted (<10, n = 47), standard (10–15, n = 76), and liberal (>15, n = 28).

Results

The overall postoperative morbidity was 56.95%. The incidence of postoperative pancreatic fistula (POPF) was 11.26%. The in-hospital mortality rate was 7.28% with the most common cause being grade C POPF and secondary intra-abdominal infections. The patients in the liberal group had significantly higher incidences of POPF (25%) and respiratory complications (21.43%). The other outcome parameters such as recovery of bowel function, hospital stay, and postoperative daily drainage were similar among the groups. Multivariable analysis confirmed the IOF rate to be most strongly associated with POPF (odds ratio: 5.195, confidence interval: 1.142–23.823, P = 0.023) and respiratory complications (odds ratio: 7.302, confidence interval: 0.676–58.231, P = 0.025).

Conclusions

The IOF rate significantly affects the incidence of POPF and respiratory complications after PD. Careful patient-oriented fluid therapy may help to prevent these complications.

Intraoperative Fluid Management in Patients Undergoing Spine Surgery: A Narrative Review

Fluid management has been widely recognized as an important component of the perioperative care in patients undergoing major procedures including spine surgeries. Patient- and surgery-related factors such as age, length of the surgery, massive intraoperative blood loss, and prone positioning, may impact the intraoperative administration of fluids. In addition, the type of fluid administered may also affect post-operative outcomes. Published literature describing intraoperative fluid management in patients undergoing major spine surgeries is limited and remains controversial. Therefore, we reviewed current literature on intraoperative fluid management and its association with post-operative complications in spine surgery.

Cystic adventitial disease of femoral vein presenting as enlarging lower limb swelling and pain: Two case reports and review of the literature

Cystic adventitial disease (CAD) is a condition that mainly affects the arterial system but rarely involves the venous system. The present study reported on two cases of CAD of femoral veins. The clinical manifestations in the two patients included pain and swelling of the lower limbs, but they had no risk factors for venous thrombosis. Color ultrasonography indicated cystic space-occupying lesions around the femoral veins, and enhanced computed tomography (CT) revealed vascular compression and space-occupying properties of the femoral veins. The two patients underwent open surgery, the postoperative treatment was uneventful, and swelling and tenderness were completely resolved. The pathological examination confirmed CAD of femoral vein in the two patients. The enhanced CT venography scan indicated patency of the femoral vein in the two patients following the operation. The circumferences of the two patients' lower limbs had returned to normal at the 2-month follow-up. A review of the literature was performed, and the presentation, diagnosis, treatment and pathology of this rare condition were discussed.

Anesthetic Management for Paraesophageal Hernia Repair

Paraesophageal hernia repairs are complex surgical cases frequently performed on patients of advanced age with multiple comorbidities, both of which create difficulties in the anesthetic management. Preoperative evaluation is challenging because of overlapping cardiopulmonary symptoms. The patient's symptoms and anatomy lead to an increased aspiration risk and the potential need for a rapid sequence induction. Depending on the surgical approach, lung isolation may be required. Communication with the surgeon is vital throughout the case, especially when placing gastric tube and bougies. Multimodal analgesia should include regional and/or neuraxial techniques, in addition to the standard intravenous and oral pain medications.

Associations of Fluid Amount, Type, and Balance and Acute Kidney Injury in Patients Undergoing Major Surgery

Fluid administration has been reported to be associated with an increased risk of acute kidney injury (AKI). We assessed whether, after correction for fluid balance, amount and chloride content of fluids administered have an independent association with AKI. We performed an observational study in patients after major surgery assessing the independent association of AKI with volume, chloride content and fluid balance, after adjustment for Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) score, age, elective versus emergency surgery, and duration of surgery. We studied 542 consecutive patients undergoing major surgery. Of these, 476 patients had renal function tested as part of routine clinical care and 53 patients (11.1%) developed postoperative AKI. After adjustments, a 100 ml greater mean daily fluid balance was artificially associated with a 5% decrease in the instantaneous hazard of AKI: adjusted Hazard Ratio (aHR) 0.951, 95% confidence intervals (CI) 0.935 to 0.967, P <0.001. However, after adjustment for the proportion of chloride-restrictive fluids, mean daily fluid amounts and balances, POSSUM morbidity, age, duration and emergency status of surgery, and the confounding effect of fluid balance, every 5% increase in the proportion of chloride-liberal fluid administered was associated with an 8% increase in the instantaneous hazard of AKI (aHR 1.079, 95% CI 1.032 to 1.128, P=0.001), and a 100 ml increase in mean daily fluid amount given was associated with a 6% increase in the instantaneous hazard of AKI (aHR 1.061, 95% CI 1.047 to 1.075, P <0.001). After adjusting for key risk factors and for the confounding effect of fluid balance, greater fluid administration and greater administration of chloride-rich fluid were associated with greater risk of AKI.