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Au E, Zhao K, Belley-Côté E, Song Y, Al-Hazzani W, Sadeghirad B, Wang E, Young J, Kashani H, Kavosh M, Inami T, Beaver C, Kloppenburg S, Mazer D, Jacobsohn E, Um K, Spence J. The effect of perioperative benzodiazepine administration on postoperative nausea and vomiting: a systematic review and meta-analysis of randomised controlled trials. Br J Anaesth 2024; 132:469-482. [PMID: 38177006 DOI: 10.1016/j.bja.2023.11.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/30/2023] [Accepted: 11/07/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Despite recent systematic reviews suggesting their benefit for postoperative nausea, vomiting, or both (PONV) prevention, benzodiazepines have not been incorporated into guidelines for PONV prophylaxis because of concerns about possible adverse effects. We conducted an updated meta-analysis to inform future practice guidelines. METHODS We included randomised controlled trials (RCTs) of all languages comparing benzodiazepines with non-benzodiazepine comparators in adults undergoing inpatient surgery. Our outcomes were postoperative nausea, vomiting, or both. We assessed risk of bias for RCTs using the Cochrane Risk of Bias tool. We pooled data using a random-effects model and assessed the quality of evidence for each outcome using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. RESULTS We screened 31 413 abstracts and 950 full texts. We included 119 RCTs; 104 were included in quantitative synthesis. Based on moderate certainty evidence, we found that perioperative benzodiazepine administration reduced the incidence of PONV (52 studies, n=5086, relative risk [RR]: 0.77, 95% confidence interval [CI] 0.66-0.89; number needed to treat [NNT] 16; moderate certainty), postoperative nausea (55 studies, n=5916, RR: 0.72, 95% CI 0.62-0.83; NNT 21; moderate certainty), and postoperative vomiting (52 studies, n=5909, RR: 0.74, 95% CI 0.60-0.91; NNT 55; moderate certainty). CONCLUSIONS Moderate quality evidence shows that perioperative benzodiazepine administration decreases the incidence of PONV. The results of this systematic review and meta-analysis will inform future clinical practice guidelines. SYSTEMATIC REVIEW PROTOCOL The protocol for this systematic review was pre-registered with PROSPERO International Prospective Register of Systematic Reviews (CRD42022361088) and published in BMJ Open (PMID 31831540).
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Affiliation(s)
- Emily Au
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Karen Zhao
- Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Department of Medicine (Cardiology and Critical Care), Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Yuri Song
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Waleed Al-Hazzani
- Departments of Critical Care, Medicine (Gastroenterology), Health Research Methods, Evaluation, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Behnam Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evaluation, and Impact, McMaster University, Hamilton, ON, Canada
| | - Eugene Wang
- Department of Family Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jack Young
- Health Sciences Library, McMaster University, Hamilton, ON, Canada
| | - Hessam Kashani
- Department of Anesthesia and Perioperative Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morvarid Kavosh
- Department of Medicine, Coney Island Hospital, New York, NY, USA
| | - Toru Inami
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | | | | | - David Mazer
- Department of Anesthesia and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Jacobsohn
- Department of Anesthesia and Perioperative Medicine and Medicine (Critical Care), University of Manitoba, Winnipeg, MB, Canada
| | - Kevin Um
- Department of Medicine (Cardiology), McMaster University, Hamilton, ON, Canada
| | - Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evaluation, and Impact, Perioperative Research Division, Population Health Research Institute, McMaster University, Hamilton, ON, Canada.
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Hanalis-Miller T, Nudelman G, Ben-Eliyahu S, Jacoby R. The Effect of Pre-operative Psychological Interventions on Psychological, Physiological, and Immunological Indices in Oncology Patients: A Scoping Review. Front Psychol 2022; 13:839065. [PMID: 35572335 PMCID: PMC9094613 DOI: 10.3389/fpsyg.2022.839065] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/22/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction The stressful pre-operative period exerts a profound impact on psychological, physiological and immunological outcomes. Oncological surgeries, in particular, elicit significantly higher stress responses than most other surgeries. Managing these responses through psychological interventions may improve long-term outcomes. The purpose of the current research was to review studies that have explored pre-operative psychological interventions in cancer patients in order to map the types of current interventions and provide an initial assessment of whether these interventions improved psychological, physiological, and/or immunological indices as well as long-term cancer outcomes. Methods A systematic literature search for studies that included pre-operative psychological interventions in oncology patients was conducted, using the databases PubMed and Web of Science. Inclusion criteria included studies pertaining to oncological surgery in adults, study designs that included a clearly defined pre-operative psychological intervention and control group. Results We found 44 studies, each using one of the following interventions: psychoeducation, cognitive interventions, relaxation techniques, integrated approaches. All the studies reported improved immediate post-operative psychological, physiological, and/or immunological outcomes. Only a few studies addressed long-term cancer outcomes, and only one reported improved survival. Conclusions Research on pre-operative interventions with cancer patients is missing systematic methods. Studies provide varying results, which makes it difficult to compare them and reach reliable conclusions. There is considerable heterogeneity in the literature regarding the specific intervention used, the timing of intervention, the characteristics of the patients studied and the outcome measures. In order to improve research in this field, including the measurement of long-term outcomes, we suggest some steps that should be taken in further research.
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Affiliation(s)
| | - Gabriel Nudelman
- School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
| | - Shamgar Ben-Eliyahu
- Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Rebecca Jacoby
- Stress, Hope and Cope Laboratory, School of Behavioral Sciences, The Academic College of Tel Aviv-Yaffo, Tel Aviv-Yafo, Israel
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Cozowicz C, Zhong H, Illescas A, Athanassoglou V, Poeran J, Reichel JF, Poultsides LA, Liu J, Memtsoudis SG. The Perioperative Use of Benzodiazepines for Major Orthopedic Surgery in the United States. Anesth Analg 2022; 134:486-495. [PMID: 35180165 DOI: 10.1213/ane.0000000000005854] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite numerous indications for perioperative benzodiazepine use, associated risks may be exacerbated in elderly and comorbid patients. In the absence of national utilization data, we aimed to describe utilization patterns using national claims data from total hip/knee arthroplasty patients (THA/TKA), an increasingly older and vulnerable surgical population. METHODS We included data on 1,863,996 TKAs and 985,471 THAs (Premier Healthcare claims data, 2006-2019). Benzodiazepine utilization (stratified by long- and short-acting agents) was assessed by patient- and health care characteristics, and analgesic regimens. Given the large sample size, standardized differences instead of P values were utilized to signify meaningful differences between groups (defined by value >0.1). RESULTS Among 1,863,996 TKA and 985,471 THA patients, the utilization rate of benzodiazepines was 80.5% and 76.1%, respectively. In TKA, 72.6% received short-acting benzodiazepines, while 7.9% received long-acting benzodiazepines, utilization rates 68.4% and 7.7% in THA, respectively. Benzodiazepine use was particularly more frequent among younger patients (median age [interquartile range {IQR}]: 66 [60-73]/64 [57-71] among short/long-acting compared to 69 [61-76] among nonusers), White patients (80.6%/85.4% short/long-acting versus 75.7% among nonusers), commercial insurance (36.5%/34.0% short/long-acting versus 29.1% among nonusers), patients receiving neuraxial anesthesia (56.9%/56.5% short/long-acting versus 51.5% among nonusers), small- and medium-sized (≤500 beds) hospitals (68.5% in nonusers, and 74% and 76.7% in short- and long-acting benzodiazepines), and those in the Midwest (24.6%/25.4% short/long-acting versus 16% among nonusers) in TKA; all standardized differences ≥0.1. Similar patterns were observed in THA except for race and comorbidity burden. Notably, among patients with benzodiazepine use, in-hospital postoperative opioid administration (measured in oral morphine equivalents [OMEs]) was substantially higher. This was even more pronounced in patients who received long-acting agents (median OME with no benzodiazepines utilization 192 [IQR, 83-345] vs 256 [IQR, 153-431] with short-acting, and 329 [IQR, 195-540] with long-acting benzodiazepine administration). Benzodiazepine use was also more frequent in patients receiving multimodal analgesia (concurrently 2 or more analgesic modes) and regional anesthesia. Trend analysis showed a persistent high utilization rate of benzodiazepines over the last 14 years. CONCLUSIONS Based on a representative sample, 4 of 5 patients undergoing major orthopedic surgery in the United States receive benzodiazepines perioperatively, despite concerns for delirium and delayed postoperative neurocognitive recovery. Notably, benzodiazepine utilization was coupled with substantially increased opioid use, which may project implications for perioperative pain management.
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Affiliation(s)
- Crispiana Cozowicz
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Haoyan Zhong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Alex Illescas
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Vassilis Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals, Oxford, United Kingdom
| | - Jashvant Poeran
- Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai/Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, New York, New York
| | - Julia Frederica Reichel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Lazaros A Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Thessaloniki, Greece.,Centre of Orthopedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.,Division of Adult Reconstruction and Joint Replacement, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, New York, New York
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4
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Pekcan YO, Tuncalı B, Erol V. Effect of preoperative anxiety level on postoperative pain, analgesic consumption in patients undergoing laparoscopic sleeve gastrectomy: an observational cohort study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2021; 73:85-90. [PMID: 34848318 PMCID: PMC9801190 DOI: 10.1016/j.bjane.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 02/01/2023]
Abstract
BACKGRAUND This prospective observational cohort study aimed to investigate the relationship between preoperative anxiety levels and postoperative pain and analgesic requirement in patients undergoing laparoscopic sleeve gastrectomy. METHODS Forty two female patients with body mass index ≥ 35, who underwent laparoscopic sleeve gastrectomy for treatment of obesity were included in the study. Spielberger's state and trait anxiety scales were used in this study. Demographic data of the patients, anesthetic and analgesic drugs during the surgery, pain levels measured with verbal analog scale at the postoperative 1st, 4th, 12th, and 24th hour, sedation levels measured with the Ramsay sedation scale, and the amount of analgesic consumed were recorded. Anesthesiologist, surgeon, and patient were not informed of the anxiety level results. The relationship between preoperative anxiety and postoperative pain and analgesic consumption was evaluated by Spearman's correlation analysis. Stepwise multiple linear regression analysis was applied. Normal Distribution control was performed by applying the Shapiro-Wilk test to residual values obtained from the final model. RESULTS There was no relationship between trait anxiety level and postoperative pain and analgesic consumption. A correlation was found between state anxiety level and pain level up to 24 hours and analgesic consumption (p < 0.05). According to the obtained model it had been observed that the university graduates consumed more analgesic compared to other education level groups. CONCLUSION In this study, a relationship was found between preoperative state anxiety level and 24-hour pain scores and analgesic consumption in patients who underwent laparoscopic sleeve gastrectomy under general anesthesia.
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Affiliation(s)
- Yonca Ozvardar Pekcan
- Başkent University School of Medicine, Department of Anesthesiology and Reanimation, Ankara, Turkey.
| | - Bahattin Tuncalı
- Başkent University School of Medicine, Department of Anesthesiology and Reanimation, Ankara, Turkey
| | - Varlık Erol
- Medicana Hospital Izmir, Department of General Surgery, Izmir, Turkey
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5
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Tanaka M, Tanaka T, Takamatsu M, Shibue C, Imao Y, Ando T, Baba H, Kamiya Y. Effects of the Kampo medicine Yokukansan for perioperative anxiety and postoperative pain in women undergoing breast surgery: A randomized, controlled trial. PLoS One 2021; 16:e0260524. [PMID: 34818363 PMCID: PMC8612547 DOI: 10.1371/journal.pone.0260524] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Yokukansan (YKS) is a traditional Japanese herbal (Kampo) medicine prescribed for anxiety. In this randomized controlled trial, we compared the subjective assessment of anxiety using questionnaires and its objective assessment using salivary alpha-amylase concentrations in YKS and control (CNT) groups of women undergoing breast surgery. The trial was registered at the University Hospital Medical Information Network Clinical Trials Registry (registration number: UMIN000028998), and the investigators were blinded to drug administration. One hundred patients who underwent breast cancer surgery were allocated to either the YKS or the CNT group. Finally, 35 and 42 patients in the YKS and CNT groups were analyzed, respectively. The YKS group received two 2.5 g doses of the medication before sleeping on the night before surgery and 2 h before inducing anesthesia, while the CNT group did not receive medication preoperatively. Patients answered two questionnaires, the Hospital Anxiety and Depression Scale and the State-Trait Anxiety Inventory, pre-and postoperatively as subjective anxiety assessments. As an objective anxiety indicator, salivary alpha-amylase levels were measured the day before, directly before, and the day after surgery (T3). In the YKS group, salivary alpha-amylase scores directly before operation were significantly lower than those on the day before surgery and at one day postoperatively (F [2,150] = 3.76, p = 0.03). Moreover, the Hospital Anxiety and Depression Scale-Anxiety and State-Trait Anxiety Inventory-Trait scores were significantly more improved postoperatively in the YKS group than in the CNT group (difference in Hospital Anxiety and Depression Scale-Anxiety: YKS, mean -2.77, 95% confidence interval [-1.48 --4.06], p <0.001, and CNT, -1.43 [-0.25--2.61], p = 0.011; and difference in State-Trait Anxiety Inventory: YKS group, -4.23 [-6.95--1.51], p = 0.0004; and CNT group, 0.12 [-2.36-2.60], p = 0.92). No side effects were associated with YKS. YKS may reduce perioperative anxiety in patients undergoing surface surgery.
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Affiliation(s)
- Moegi Tanaka
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Tsunehiko Tanaka
- Educational Psychology Course, Faculty of Education, Niigata University, Niigata, Japan
| | - Misako Takamatsu
- Department of Anesthesiology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Chieko Shibue
- Department of Anesthesiology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Yuriko Imao
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Takako Ando
- Department of Anesthesiology, Niigata Cancer Center Hospital, Niigata, Japan
- Department of Anesthesiology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroshi Baba
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshinori Kamiya
- Division of Anesthesiology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
- * E-mail:
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Allopurinol attenuates postoperative pain and modulates the purinergic system in patients undergoing abdominal hysterectomy: a randomized controlled trial. J Anesth 2021; 35:818-826. [PMID: 34390392 DOI: 10.1007/s00540-021-02983-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/04/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used primarily in the treatment of hyperuricemia and gout. The aim of this study was to compare the analgesic efficacy of preanesthetic allopurinol versus placebo on postoperative pain and anxiety in patients undergoing abdominal hysterectomy. METHODS This is a prospective, double-blinded, placebo-controlled, randomized clinical trial. We investigated 54 patients scheduled to undergo elective abdominal hysterectomy. Patients were randomly assigned to receive either oral allopurinol 300 mg (n = 27) or placebo (n = 27) the night before and 1 h before surgery. Patients were submitted to evaluation of pain and anxiety before the treatment, for 24 h postoperatively, 30 and 90 days after surgery. Cerebrospinal fluid was collected at the time of the spinal anesthesia to perform the measurement of the central levels of purines. RESULTS Preoperative administration of allopurinol was effective in reducing postoperative pain 2 h after surgery. Allopurinol caused a reduction of approximately 40% in pain scores measured by the visual analogue pain scale after surgery (p < 0.05). No differences were found between groups in anxiety scores after surgery. There was a significant change in the cerebrospinal fluid concentrations of xanthine and uric acid before surgery (p < 0.01). CONCLUSION This study showed a short-term benefit of the use of allopurinol as a preanesthetic medication since it was related to a reduction on pain scores 2 h after surgery. The purinergic system is a potential target for new analgesic drugs. New studies investigating more selective purine derivatives in the management of pain should be performed. TRIAL NUMBER REGISTRATION Brazilian Registry of Clinical Trials-ReBEC #RBR-9pw58p.
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7
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Fagundes AC, de Oliveira ED, Ferrari SG, Dos Santos LMM, Botelho LM, Schmidt SRG, Andrade CF, Lara DR, Souza DO, Schmidt AP. Allopurinol for fibromyalgia pain in adults: A randomized controlled trial. Pain Pract 2021; 22:19-27. [PMID: 33864725 DOI: 10.1111/papr.13019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/09/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Allopurinol is a potent inhibitor of the enzyme xanthine oxidase used in the treatment of hyperuricemia and gout. Because it is well known that purines exert multiple affects on pain transmission, we hypothesized that the inhibition of xanthine oxidase by allopurinol could be a valid strategy to treat pain in humans. This study aimed to compare the analgesic efficacy of oral allopurinol versus placebo as an adjuvant therapy in patients displaying fibromyalgia. METHODS This randomized, double-blinded, placebo-controlled study included 60 women with the diagnosis of fibromyalgia. Patients were randomly assigned to receive either oral allopurinol 300 mg (n = 31) or placebo (n = 29) twice daily during 30 days. The patients were submitted to evaluation for pain sensitivity, anxiety, depression, and functional status before treatment, and 15 and 30 days thereafter. RESULTS Oral administration of allopurinol 300 mg twice daily was ineffective in improving pain scores measured by several tools up to 30 days of treatment (P > 0.05). Additionally, no significant effects of allopurinol over anxiety, depressive symptoms, and functional status of fibromyalgia patients were observed in the present study. CONCLUSIONS Although previous findings indicated that allopurinol could present intrinsic analgesic effects in both animals and humans, this study showed no benefit of the use of oral allopurinol as an adjuvant strategy during 30 days in women displaying fibromyalgia. However, considering previous promising results, new prospective studies are still valid to further investigate allopurinol and more selective purine derivatives in the management of pain syndromes.
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Affiliation(s)
- Aécio C Fagundes
- Department of Biochemistry, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Enderson D de Oliveira
- Department of Biochemistry, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Samira G Ferrari
- Department of Anesthesia and Perioperative Medicine, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Lúcia M M Dos Santos
- Department of Pain and Palliative Care, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Leonardo M Botelho
- Department of Pain and Palliative Care, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil
| | - Sérgio R G Schmidt
- Pain S.O.S., Pain Relief Center, Medical Center of Hospital Mãe de Deus, Porto Alegre, RS, Brazil
| | - Cristiano F Andrade
- Postgraduate Program in Pneumological Sciences, UFRGS, Porto Alegre, RS, Brazil
| | - Diogo R Lara
- Cingulo Mental Health App, Porto Alegre, RS, Brazil
| | - Diogo O Souza
- Department of Biochemistry, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - André P Schmidt
- Department of Biochemistry, Instituto de Ciências Básicas da Saúde (ICBS), Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil.,Department of Anesthesia and Perioperative Medicine, Hospital de Clínicas de Porto Alegre (HCPA), UFRGS, Porto Alegre, RS, Brazil.,Pain S.O.S., Pain Relief Center, Medical Center of Hospital Mãe de Deus, Porto Alegre, RS, Brazil.,Postgraduate Program in Pneumological Sciences, UFRGS, Porto Alegre, RS, Brazil.,Department of Anesthesia, Santa Casa de Porto Alegre, Universidade Federal de Ciências Médicas de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.,Department of Anesthesia, Hospital Nossa Senhora da Conceição, Porto Alegre, RS, Brazil
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8
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Hübner M, Kusamura S, Villeneuve L, Al-Niaimi A, Alyami M, Balonov K, Bell J, Bristow R, Guiral DC, Fagotti A, Falcão LFR, Glehen O, Lambert L, Mack L, Muenster T, Piso P, Pocard M, Rau B, Sgarbura O, Somashekhar SP, Wadhwa A, Altman A, Fawcett W, Veerapong J, Nelson G. Guidelines for Perioperative Care in Cytoreductive Surgery (CRS) with or without hyperthermic IntraPEritoneal chemotherapy (HIPEC): Enhanced recovery after surgery (ERAS®) Society Recommendations - Part I: Preoperative and intraoperative management. Eur J Surg Oncol 2020; 46:2292-2310. [PMID: 32873454 DOI: 10.1016/j.ejso.2020.07.041] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/14/2020] [Accepted: 07/28/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Enhanced recovery after surgery (ERAS) pathways have been shown to considerably reduce complications, length of stay and costs after most of surgical procedures by standardised application of best evidence-based perioperative care. The aim was to elaborate dedicated recommendations for cytoreductive surgery (CRS) ± hyperthermic intraperitoneal chemotherapy (HIPEC) in a two-part series of guidelines based on expert consensus. The present part I of the guidelines highlights preoperative and intraoperative management. METHODS The core group assembled a multidisciplinary panel of 24 experts involved in peritoneal surface malignancy surgery representing the fields of general surgery (n = 12), gynaecological surgery (n = 6), and anaesthesia (n = 6). Experts systematically reviewed and summarized the available evidence on 72 identified perioperative care items, following the GRADE (grading of recommendations, assessment, development, evaluation) system. Final consensus (defined as ≥50%, or ≥70% of weak/strong recommendations combined) was reached by a standardised 2-round Delphi process, regarding the strength of recommendations. RESULTS Response rates were 100% for both Delphi rounds. Quality of evidence was evaluated high, moderate low and very low, for 15 (21%), 26 (36%), 29 (40%) and 2 items, respectively. Consensus was reached for 71/72(98.6%) items. Strong recommendations were defined for 37 items, No consensus could be reached regarding the preemptive use of fresh frozen plasma. CONCLUSION The present ERAS recommendations for CRS±HIPEC are based on a standardised expert consensus process providing clinicians with valuable guidance. There is an urgent need to produce high quality studies for CRS±HIPEC and to prospectively evaluate recommendations in clinical practice.
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Affiliation(s)
- Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Switzerland.
| | - Shigeki Kusamura
- Peritoneal Surface Malignancy Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Laurent Villeneuve
- Clinical Research and Epidemiological Unit, Department of Public Health, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Ahmed Al-Niaimi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, USA
| | - Mohammad Alyami
- Department of General Surgery and Surgical Oncology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Konstantin Balonov
- Department of Anesthesiology and Perioperative Medicine, Tufts Medical Center, Boston, USA
| | - John Bell
- Department of Anesthesiology, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Robert Bristow
- Department of Obstetrics and Gynecologic Oncology, University of California, Irvine School of Medicine, Orange, USA
| | - Delia Cortés Guiral
- Department of General Surgery (Peritoneal Surface Surgical Oncology). University Hospital Principe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Catholic University of the Sacred Heart, 00168, Rome, Italy
| | - Luiz Fernando R Falcão
- Discipline of Anesthesiology, Pain and Critical Care Medicine, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Olivier Glehen
- Department of Digestive Surgery, Lyon University Hospital, EA 3738, University of Lyon, Lyon, France
| | - Laura Lambert
- Peritoneal Surface Malignancy Program, Section of Surgical Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Lloyd Mack
- Department of Surgical Oncology, University of Calgary, Calgary, Alberta, Canada
| | - Tino Muenster
- Department of Anaesthesiology and Intensive Care Medicine. Hospital Barmherzige Brüder, Regensburg, Germany
| | - Pompiliu Piso
- Department of General and Visceral Surgery, Hospital Barmherzige Brüder, Regensburg, Germany
| | - Marc Pocard
- Department of Digestive Surgery, Lariboisière University Hospital, Paris, France
| | - Beate Rau
- Department of Surgery, Campus Virchow-Klinikum and Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Germany
| | - Olivia Sgarbura
- Department of Surgical Oncology, Cancer Institute Montpellier (ICM), University of Montpellier, Montpellier, France
| | - S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Bengaluru, India
| | - Anupama Wadhwa
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Canada
| | - William Fawcett
- Anaesthesia and Pain Medicine, Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - Jula Veerapong
- Department of Surgery, Division of Surgical Oncology, University of California San Diego, La Jolla, CA, USA
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Turksal E, Alper I, Sergin D, Yuksel E, Ulukaya S. [The effects of preoperative anxiety on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy]. Rev Bras Anestesiol 2020; 70:271-277. [PMID: 32653228 DOI: 10.1016/j.bjan.2020.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Revised: 02/19/2020] [Accepted: 03/20/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES It is suggested that 38-45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient's recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy. METHODS Forty-eight individuals undergoing living-related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI-I and STAI-II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated. RESULTS The findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p<0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24hours (p<0.05). A significantly negative correlation was also determined between anxiety scores and patients' satisfaction. CONCLUSION Our study showed that patients undergoing living-related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.
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Affiliation(s)
- Erbil Turksal
- Ankara Kecioren Education and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turquia.
| | - Isik Alper
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Demet Sergin
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Esra Yuksel
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Sezgin Ulukaya
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
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Turksal E, Alper I, Sergin D, Yuksel E, Ulukaya S. The effects of preoperative anxiety on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 32653228 PMCID: PMC9373665 DOI: 10.1016/j.bjane.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background and objectives It is suggested that 38-45% of patients experience preoperative anxiety. We observe that patients undergoing living donor nephrectomy suffer from anxiety. Preoperative anxiety may complicate a patient’s recovery from anesthesia and postoperative pain control. This study investigates the preoperative anxiety rate and its effect on anesthetic recovery and postoperative pain in patients undergoing donor nephrectomy. Methods Forty-eight individuals undergoing living-related renal donor nephrectomy were included in this analytic prospective observational cohort study. Their preoperative anxiety was measured with the STAI-I and STAI-II inventories. The relationships between anxiety scores with data regarding demographics, recovery from anesthesia, and postoperative pain scores were investigated. Results The findings were remarkable in that the anxiety scores of living renal donors were significantly correlated with their recovery variables, which are spontaneous respiration time, sufficient respiration time, extubation time, and PACU discharge time (p < 0.01). Anxiety scores were significantly positively correlated with the pain scores of the 30th minute, 1st, 2nd, 4th, 8th, 12th, 24th hours, and the total amounts of analgesic administered in 24 hours (p < 0.05). A significantly negative correlation was also determined between anxiety scores and patients’ satisfaction. Conclusion Our study showed that patients undergoing living-related donor nephrectomy with high anxiety levels had late recovery times and high postoperative pain scores. Thus, determining those patients with high preoperative anxiety level is crucial to providing patients with satisfactory emerging from anesthesia and the control of their postoperative pain during donor nephrectomy.
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Affiliation(s)
- Erbil Turksal
- Ankara Kecioren Education and Research Hospital, Department of Anesthesiology and Reanimation, Ankara, Turquia.
| | - Isik Alper
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Demet Sergin
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Esra Yuksel
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
| | - Sezgin Ulukaya
- Ege University, Faculty of Medicine, Department of Anesthesiology and Reanimation, İzmir, Turquia
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Abstract
Ventral hernia repair with abdominal wall reconstruction can be a challenging endeavor, as patients commonly present not only with complex and recurrent hernias but also often with comorbidities that increase the risk of postoperative complications including wound morbidity and hernia recurrence, among other risks. By optimizing patient comorbidities in the preoperative setting and managing postoperative care in a regimented fashion, enhanced recovery after surgery pathways allow for a systematic approach to reduce complications and speed up recovery following ventral hernia repair.
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Abstract
STUDY DESIGN This is a cross-sectional study. OBJECTIVE To investigate spine surgeons' attitudes regarding preoperative anxiety measurement, management, and responsibility. SUMMARY OF BACKGROUND DATA The vast majority of patients scheduled for spine surgery experience preoperative anxiety. However, there are currently no consensus guidelines for measure or management of preoperative anxiety in spinal operations. MATERIALS AND METHODS An anonymous questionnaire was sent online to spine surgeons of AO Spine North America to capture their views regarding preoperative anxiety. RESULTS Of 69 complete responses, most respondents were male (n=66, 95.7%), orthopedic surgeons (n=52, 75.4%), and practicing at an academic setting (n=39, 56.5%). Most spine surgeons practiced for at least 20 years (n=52, 75.4%), operated on 100-300 patients per year (n=48, 69.6%), and were attending physicians (n=61, 88.4%). Most did not measure preoperative anxiety (n=46, 66.7%) and would not use a rating scale to measure it (n=38, 55.1%). However, most would discuss it if mentioned by the patient (n=40, 58.0%). Other spine surgeons measured anxiety verbally (n=22, 31.9%) or with a rating scale or survey (n=6, 8.7%). Although preferences for preoperative anxiety management varied, most respondents used patient education (n=54, 78.3%) and permitting family members' presence (n=36, 52.2%) to reduce patient anxieties. Spine surgeons held themselves, anesthesiologists, and patients most responsible to manage preoperative anxiety. CONCLUSIONS The majority of spine surgeons surveyed did not regularly measure preoperative anxiety, but would discuss its management if the subject was broached by the patient. Spine surgeons relied on a variety of methods to manage a patient's anxiety, but most preferred preoperative education and permitting the presence of family members. Responsibility for controlling preoperative anxiety was chiefly allocated to surgeons, anesthesiologists, and patients. Future avenues for research may include developing a preoperative anxiety measurement scale and management protocol specific to spine surgery. LEVEL OF EVIDENCE Level IV.
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Singh D, Yadav JS, Jamuda BK, Singh P. Oral Pregabalin as Premedication on Anxiolysis and Stress Response to Laryngoscopy and Endotracheal Intubation in Patients Undergoing Laparoscopic Cholecystectomy: A Randomized Double-Blind Study. Anesth Essays Res 2019; 13:97-104. [PMID: 31031488 PMCID: PMC6444940 DOI: 10.4103/aer.aer_12_19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Direct laryngoscopy and tracheal intubation lead to increase in heart rate and blood pressure. This can cause serious complications in patients with coronary artery disease, reactive airways, or intracranial neuropathology. Preoperative anxiety is associated with greater level of postoperative pain. Attenuation of anxiety and hemodynamic response to laryngoscopy and intubation are cornerstone of better anesthetic outcome. Gabapentinoids (gabapentin and pregabalin) have been known to possess anxiolytic, analgesic, and anticonvulsant properties. Aim The aim of this study is to determine the effects of oral pregabalin on anxiolysis and attenuation of stress response to laryngoscopy and endotracheal intubation. Study Design This was a prospective randomized double-blind placebo controlled study. Materials and Methods A total of 60 patients ASA physical status Class I and II, undergoing elective laparoscopic cholecystectomy, were randomly allocated into two groups receiving either oral placebo or oral pregabalin 150 mg, 60 min before induction of anesthesia. Visual analog scale (VAS) for anxiety was recorded before, and 60 min after giving the drug. Hemodynamic parameters (heart rate, systolic blood pressure, diastolic blood pressure, and mean arterial pressure) were recorded before, and 60 min after giving drug, during and 2, 4, 6, 8, and 10 min after intubation. Results During preinduction, pregabalin showed a decrease in VAS and attenuation of stress response to laryngoscopy and intubation compared to that of placebo. The premedicated patients were hemodynamically stable perioperatively without side effects. Conclusion Pregabalin is effective in attenuating preoperative anxiety and stress response to endotracheal intubation.
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Affiliation(s)
- Dheer Singh
- Department of Anesthesia and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Jaybrijesh Singh Yadav
- Department of Anesthesia and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Birendra Kumar Jamuda
- Department of Anesthesia and Critical Care, Uttar Pradesh University of Medical Sciences, Etawah, Uttar Pradesh, India
| | - Pooja Singh
- Department of Anesthesia, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am J Obstet Gynecol 2017; 217:303-313.e6. [PMID: 28351670 DOI: 10.1016/j.ajog.2017.03.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 03/07/2017] [Accepted: 03/13/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objective of the study was to investigate the effectiveness of preemptive analgesia at pain control in women undergoing total abdominal hysterectomy. DATA SOURCES Eligible studies, published through May 31, 2016, were retrieved through Medline, Cochrane Central Register for Controlled Trials, and Cochrane Database of Systematic Reviews. STUDY ELIGIBILITY We included randomized controlled trials with the primary outcome of pain control in women receiving a preemptive medication prior to total abdominal hysterectomy. Comparators were placebo, different doses of the same medication as intervention, or other nonnarcotic or narcotic medication. STUDY APPRAISAL AND SYNTHESIS METHODS Study data were extracted by one reviewer and confirmed by a second reviewer. For each outcome we graded the quality of the evidence. Studies were classified by the type of medication used and by outcome type. RESULTS Eighty-four trials met eligibility, with 69 included. Among nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin resulted in improvements in pain assessment compared with placebo and other nonnarcotic medications. Patient satisfaction was higher in patients who were given gabapentin combined with paracetamol compared with gabapentin alone. Use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo. All narcotics (ketamine, morphine, fentanyl) resulted in improved pain control compared with placebo. Narcotics had a greater reduction in pain assessment scores compared with nonnarcotics, and their use resulted in lower total narcotic usage. CONCLUSION Preemptive nonnarcotic and narcotic medications prior to abdominal hysterectomy decrease total narcotic requirements and improve patient postoperative pain assessment and satisfaction scores.
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Li L, Jin J, Min S, Liu D, Liu L. Compliance with the enhanced recovery after surgery protocol and prognosis after colorectal cancer surgery: A prospective cohort study. Oncotarget 2017; 8:53531-53541. [PMID: 28881829 PMCID: PMC5581128 DOI: 10.18632/oncotarget.18602] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/23/2017] [Indexed: 12/13/2022] Open
Abstract
We explored the effects of different levels of compliance with an enhanced recovery after surgery (ERAS) protocol on the short-term prognosis of patients who underwent colorectal cancer surgery. We conducted a single-center prospective cohort study in which 254 patients who received surgical treatment in a teaching tertiary care hospital were enrolled from March 2016 to November 2016. The patients were divided into four groups (I, II, III, and IV) based on individual compliance rates; the corresponding range of compliance rates was 0-60%, 60-70%, 70-80%, and 80-100%, and the number of patients in each group was 66, 63, 53, and 72, respectively. In the four groups from low to high compliance with ERAS (group I, II, III, and IV), the incidence of surgical site infections was 24.2%, 20.6%, 9.4%, and 6.9% (P < 0.05); the overall incidence of postoperative complications was 41.3%, 33.3%, 26.4%, and 16.7% (P < 0.05); the median length of postoperative hospital stay (in days) was 12.5, 10, 9, 8 (P < 0.05); and the median total hospital cost (Chinese Yuan) was 71,733, 73,632, 65,861, and 63,289 (P < 0.05), respectively. These results suggest that higher compliance with the ERAS protocol was associated with a lower incidence of surgical site infections, lower overall postoperative complication rate, shorter postoperative hospital stays, and lower total hospital costs.
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Affiliation(s)
- Liang Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Juying Jin
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dan Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ling Liu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Lu C, Zhang LM, Zhang Y, Ying Y, Li L, Xu L, Ruan X. Intranasal Dexmedetomidine as a Sedative Premedication for Patients Undergoing Suspension Laryngoscopy: A Randomized Double-Blind Study. PLoS One 2016; 11:e0154192. [PMID: 27196121 PMCID: PMC4873234 DOI: 10.1371/journal.pone.0154192] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 04/09/2016] [Indexed: 12/18/2022] Open
Abstract
Background Intranasal dexmedetomidine, a well-tolerated and convenient treatment option, has been shown to induce a favorable perioperative anxiolysis in children. We investigate intranasal dexmedetomidine as a sedative premedication for anesthesia recovery in an adult population. Methods A prospective randomized controlled trial; 81 adult patients scheduled for elective suspension laryngoscopy received intranasal dexmedetomidine (1 μg∙kg–1) or a placebo 45–60 min before anesthetic induction. Extubation time was used as the primary outcome measure. Secondary variables included the levels of sedation (Observer’s Assessment of Alertness/Sedation scale, OAA/S) and anxiety (4-point anxiety score), anesthetic and analgesic requirements, hemodynamic fluctuations, and anesthesia recovery as well as side effects. Results The levels of sedation and anxiety differed significantly between the two groups at anesthesia pre-induction (p < 0.001 and = 0.001, respectively). Repeated-measure general linear model determined no significant interaction effect between group and time on the targeted concentration of propofol (F = 1.635, p = 0.200), but a significant main effect of group existed (F = 6.880, p = 0.010). A moderate but significant decrease in the heart rate was recorded in the dexmedetomidine group at pre-induction. Episodes of tachycardia and hypertension after tracheal intubation and extubation were more frequent in the placebo group. Conclusions Intranasal dexmedetomidine as a sedative premedication induced a favorable perioperative anxiolysis without prolongation in anesthesia recovery; the hemodynamic effect was modest. Trial Registration ClinicalTrials.gov NCT 02108171
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Affiliation(s)
- Chengxiang Lu
- Department of Anesthesiology, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
| | - Li-Ming Zhang
- University of Pittsburgh Medical Centre, Pittsburgh, Pennsylvania, United States of America
| | - Yuehong Zhang
- Department of Ophthalmology, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
| | - Yanlu Ying
- Department of Anesthesiology, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
| | - Ling Li
- Department of Medical Infomation, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
| | - Lixin Xu
- Department of Anesthesiology, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
| | - Xiangcai Ruan
- Department of Anesthesiology, First Municipal People’s Hospital of Guangzhou, an Affiliate Hospital of Guangzhou Medical College, Guangzhou, China
- * E-mail: ;
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Majumder A, Fayezizadeh M, Neupane R, Elliott HL, Novitsky YW. Benefits of Multimodal Enhanced Recovery Pathway in Patients Undergoing Open Ventral Hernia Repair. J Am Coll Surg 2016; 222:1106-15. [PMID: 27049780 DOI: 10.1016/j.jamcollsurg.2016.02.015] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/17/2016] [Accepted: 02/18/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Use of Enhanced Recovery After Surgery (ERAS) pathways have evidenced improved outcomes in several surgical specialties. The effectiveness of ERAS pathways specific to hernia surgery, however, has not yet been investigated. We hypothesized that our ERAS pathway would accelerate functional recovery and shorten hospitalization in patients undergoing open ventral hernia repair (VHR). STUDY DESIGN Consecutive patients undergoing open major VHR using transversus abdominis release and sublay synthetic mesh placement, with use of our ERAS pathway, were compared with a historical cohort before ERAS implementation. Main outcomes measures were time to diet advancement, time to return of bowel function, time to oral narcotics, length of stay (LOS), and 90-day readmissions. RESULTS Between January 2014 and January 2015, 100 patients undergoing VHR with ERAS implementation were compared with a historical cohort. The ERAS group demonstrated significantly shorter times to liquid and regular diet: 1.1 vs 2.7 and 3.0 vs 4.8 days, respectively (p < 0.001). Furthermore, ERAS patients demonstrated significantly shorter times to flatus and bowel movement: 3.1 vs 3.9 and 3.6 vs 5.2 days, respectively (p < 0.001). Average LOS was reduced from 6.1 to 4.0 days (p < 0.001), and ERAS patients had significantly fewer 90-day readmissions, 4% vs 16% (p < 0.001). CONCLUSIONS A comprehensive ERAS pathway for major open VHR was implemented safely. Multimodal perioperative pain management, oral opioid-receptor blockade, and early feeding strategies resulted in accelerated intestinal recovery, shorter hospitalizations, and fewer readmissions. Use of our ERAS pathway appears to result in improved outcomes in patients undergoing open VHR.
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Affiliation(s)
- Arnab Majumder
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Mojtaba Fayezizadeh
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Ruel Neupane
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Heidi L Elliott
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH
| | - Yuri W Novitsky
- Case Comprehensive Hernia Center, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH.
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Esakov YS, Raevskaya MB, Sizov VA, Pechetov AA, Ruchkin DV, Gorin DS, Kazennov VV, Khlan TN. [The philosophy of rapid rehabilitation in thoracoabdominal surgery]. Khirurgiia (Mosk) 2016. [PMID: 28635762 DOI: 10.17116/hirurgia20161188-92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yu S Esakov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - M B Raevskaya
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - V A Sizov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - A A Pechetov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - D V Ruchkin
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - D S Gorin
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - V V Kazennov
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
| | - T N Khlan
- Vishnevsky Institute of Surgery, Ministry of Health of the Russian Federation, Moscow, Russia
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Beydon L, Rouxel A, Camut N, Schinkel N, Malinovsky JM, Aveline C, Marret E, Bildea A, Dupoiron D, Liu N, Daniel V, Darsonval A, Chrétien JM, Rault L, Bruna J, Alberti C. Sedative premedication before surgery – A multicentre randomized study versus placebo. Anaesth Crit Care Pain Med 2015; 34:165-71. [DOI: 10.1016/j.accpm.2015.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 01/21/2015] [Indexed: 10/23/2022]
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Enhanced Recovery after Surgery Pathway for Abdominal Wall Reconstruction. Plast Reconstr Surg 2014; 134:151S-159S. [DOI: 10.1097/prs.0000000000000674] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Mortensen K, Nilsson M, Slim K, Schäfer M, Mariette C, Braga M, Carli F, Demartines N, Griffin SM, Lassen K, Fearon KCF, Ljungqvist O, Lobo DN, Revhaug A. Consensus guidelines for enhanced recovery after gastrectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Br J Surg 2014; 101:1209-29. [PMID: 25047143 DOI: 10.1002/bjs.9582] [Citation(s) in RCA: 440] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 01/20/2014] [Accepted: 05/08/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Application of evidence-based perioperative care protocols reduces complication rates, accelerates recovery and shortens hospital stay. Presently, there are no comprehensive guidelines for perioperative care for gastrectomy. METHODS An international working group within the Enhanced Recovery After Surgery (ERAS®) Society assembled an evidence-based comprehensive framework for optimal perioperative care for patients undergoing gastrectomy. Data were retrieved from standard databases and personal archives. Evidence and recommendations were classified according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system and were discussed until consensus was reached within the group. The quality of evidence was rated 'high', 'moderate', 'low' or 'very low'. Recommendations were graded as 'strong' or 'weak'. RESULTS The available evidence has been summarized and recommendations are given for 25 items, eight of which contain procedure-specific evidence. The quality of evidence varies substantially and further research is needed for many issues to improve the strength of evidence and grade of recommendations. CONCLUSION The present evidence-based framework provides comprehensive advice on optimal perioperative care for the patient undergoing gastrectomy and facilitates multi-institutional prospective cohort registries and adequately powered randomized trials for further research.
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Affiliation(s)
- K Mortensen
- Department of Gastrointestinal and Hepatobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
| | | | | | | | | | | | | | | | | | | | | | - K C F Fearon
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, UK
| | - O Ljungqvist
- Department of Surgery, Örebro University Hospital, Örebro and Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - D N Lobo
- Division of Gastrointestinal Surgery, Nottingham Digestive Diseases Centre National Institute for Health Research, Biomedical Research Unit, Nottingham University Hospitals, Queen's Medical Centre, Nottingham, UK
| | - A Revhaug
- Department of Gastrointestinal and Hepatopancreaticobiliary Surgery, University Hospital of Northern Norway, Tromsø, Norway
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Abstract
BACKGROUND A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery (ERAS) programs. Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce. We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease. METHODS The ERAS program was initiated in 2009. Patients who underwent esophagectomy and were treated according to the ERAS program were included. Items of ERAS included preoperative nutrition, early extubation, early removal of nasogastric tube, and early mobilization. Primary outcome parameters were hospital stay and the incidence of postoperative complications. Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol. A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient. RESULTS Between 2008 and August 2010, 181 patients in our department underwent esophagectomy. Of these, 103 patients were included in the ERAS program (ERAS+ group) and were compared to 78 patients who had undergone an esophagectomy in 2008 (ERAS- group). Overall hospital stay was 14 days versus 15 days (ERAS+ and ERAS-, respectively; p = 0.013). There were no significant differences in the incidence of postoperative complications in either group. The percentage of achieved items varied between 42 and 93 % per item. CONCLUSIONS The implementation of an ERAS program in esophageal surgery was feasible and resulted in a small but significant reduction in overall hospital stay, whereas overall morbidity was not affected.
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Ali A, Altun D, Oguz BH, Ilhan M, Demircan F, Koltka K. The effect of preoperative anxiety on postoperative analgesia and anesthesia recovery in patients undergoing laparascopic cholecystectomy. J Anesth 2013; 28:222-7. [DOI: 10.1007/s00540-013-1712-7] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Accepted: 08/30/2013] [Indexed: 11/25/2022]
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Caumo W, Ferreira MBC. Perioperative anxiety: psychobiology and effects in postoperative recovery. ACTA ACUST UNITED AC 2013. [DOI: 10.1163/156856903321579217] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Fernández MD, Luciano C, Valdivia-Salas S. Impact of acceptance-based nursing intervention on postsurgical recovery: preliminary findings. SPANISH JOURNAL OF PSYCHOLOGY 2012; 15:1361-70. [PMID: 23156939 DOI: 10.5209/rev_sjop.2012.v15.n3.39421] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Research has shown that teaching individuals to experience pain and anxiety as inevitable products of the actions they freely and responsibly undertake yields healthier reactions to suffering. This preliminary study assesses whether a brief acceptance-based psychological intervention along with the usual presurgical protocol for a laparoscopic cholecystectomy will produce healthier reactions to postsurgical pain, and will reduce anxiety, duration of postsurgical hospitalization, and demand of analgesics. After admission, screening, and consent procedures, we assessed pain and anxiety. Patients in the experimental condition (n = 6) then received a brief acceptance-based nursing intervention addressing the individual meaning of surgery, and including a metaphor and defusion practice, along with routine care. Patients in the control condition (n = 7) received routine care only. Twenty-four hr following the intervention, surgery took place. Pain, anxiety, and patients' demand for analgesics were assessed 24 hr or 48 hr after surgery. All six experimental patients, as compared to three of seven control patients, demanded fewer analgesics and left the hospital within 24 hr or 48 hr from surgery even in the presence of frequent and/or intense pain. Anxiety slightly decreased in the experimental patients. The brief acceptance-based intervention was effective in improving postsurgical recovery. These preliminary findings support the potential of this type of intervention as a cost-effective strategy to be implemented in the sanitary context.
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Lassen K, Coolsen MM, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KC, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CH. Guidelines for perioperative care for pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clin Nutr 2012; 31:817-30. [DOI: 10.1016/j.clnu.2012.08.011] [Citation(s) in RCA: 357] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/19/2012] [Indexed: 02/06/2023]
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Lassen K, Coolsen MME, Slim K, Carli F, de Aguilar-Nascimento JE, Schäfer M, Parks RW, Fearon KCH, Lobo DN, Demartines N, Braga M, Ljungqvist O, Dejong CHC. Guidelines for Perioperative Care for Pancreaticoduodenectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2012; 37:240-58. [DOI: 10.1007/s00268-012-1771-1] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Chandrakantan A, Glass PSA. Multimodal therapies for postoperative nausea and vomiting, and pain. Br J Anaesth 2012; 107 Suppl 1:i27-40. [PMID: 22156268 DOI: 10.1093/bja/aer358] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Postoperative nausea and vomiting (PONV) and pain are two of the major concerns for patients presenting for surgery. The causes of PONV are multifactorial and can largely be categorized as patient risk factors, anaesthetic technique, and surgical procedure. Antiemetics work on several different receptor sites to prevent or treat PONV. This is probably why numerous studies have now demonstrated that using more than one antiemetic is usually more effective and results in fewer side-effects than simply increasing the dose of a single antiemetic. A multimodal approach to PONV should not be limited to drug therapy alone but should involve a holistic approach starting before operation and continuing intraoperatively with risk reduction strategies to which are added prophylactic antiemetics according to the assessed patient risk for PONV. With the increasing understanding of the pathophysiology of acute pain, especially the occurrence of peripheral and central hypersensitization, it is unlikely that a single drug or intervention is sufficiently broad in its action to be adequately effective, especially with moderate or greater pain. Although morphine and its congeners are usually the foundation of pain management regimens, as their dose increases so does the incidence of side-effects. Thus, the approach for the management of acute postoperative pain is to use multiple drugs or modalities (e.g. regional anaesthesia) to maximize pain relief and reduce side-effects.
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Affiliation(s)
- A Chandrakantan
- Department of Anesthesiology, Stony Brook University Medical Center, Stony Brook, NY, USA.
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Pinto PR, McIntyre T, Almeida A, Araújo-Soares V. The mediating role of pain catastrophizing in the relationship between presurgical anxiety and acute postsurgical pain after hysterectomy. Pain 2012; 153:218-226. [DOI: 10.1016/j.pain.2011.10.020] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 09/13/2011] [Accepted: 10/12/2011] [Indexed: 10/15/2022]
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Salvans S, Gil-Egea MJ, Martínez-Serrano MA, Bordoy E, Pérez S, Pascual M, Alonso S, Parés D, Courtier R, Pera M, Grande L. [Multimodal (fast-track) rehabilitation in elective colorectal surgery: evaluation of the learning curve with 300 patients]. Cir Esp 2010; 88:85-91. [PMID: 20579980 DOI: 10.1016/j.ciresp.2010.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 04/15/2010] [Accepted: 04/16/2010] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The aim of this paper is to assess the learning curve on compliance to the application of a multimodal rehabilitation program (MMRP) protocol and patient recovery after elective colorectal surgery. MATERIAL AND METHODS A comparative prospective study of 3 consecutive cohorts of 100 patients (P1, P2 and P3) who had colonic or rectal surgery. The same MMRP protocol was applied in all cases. Compliance to the protocol, tolerance to the diet and walking have been analysed. The percentages of early hospital discharges have also been compared. RESULTS Compliance gradually improved, reaching statistical significance between P1 and P3. Starting the diet on day 1 post-surgery was 52% vs 86% (p=0.0001) and the removal of drips was 21% vs 40% (p=0.005). This difference remained during days 2 and 3. Tolerance to the diet on day 1 (P1: 34% vs. P3: 66%; p=0.0001) and walking on day 2 (P1: 41% vs. P3: 68%; p=0.0002) were also better in the third period. No differences in morbidity were found between the three periods. The percentage of hospital discharges on day 3 P1: 1% vs. P3: 15%; p=0.0003), day 4 (P1: 12% vs. P3: 32%; p=0.001) and day 5 (P1: 30% vs. P3: 50%; p=0.002) was higher in the third period. CONCLUSIONS The compliance to the protocol and the results of applying the MMRP improved significantly with the greater experience of the professionals involved.
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Affiliation(s)
- Silvia Salvans
- Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario del Mar, Barcelona, España
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Kaipper MB, Chachamovich E, Hidalgo MPL, Torres ILDS, Caumo W. Evaluation of the structure of Brazilian State-Trait Anxiety Inventory using a Rasch psychometric approach. J Psychosom Res 2010; 68:223-33. [PMID: 20159207 DOI: 10.1016/j.jpsychores.2009.09.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2008] [Revised: 09/22/2009] [Accepted: 09/22/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study evaluates the State-Trait Anxiety Inventory (STAI) structure using a Rasch psychometric approach, and a refined and shorter STAI version is proposed. METHODS A cross-sectional study was performed with 900 inpatients scheduled for elective surgery. Age varied from 18 to 60 years (American Society of Anesthesiologists physical status I-III). Demographic information was collected using a structured questionnaire. The measuring instrument (the STAI) was applied to all patients in the afternoon before the surgery and prior to the patients receiving preoperative sedatives. RESULTS Rasch analysis of the state and trait anxiety scales was performed separately. This analysis demonstrated that the original format of state and trait scales fails to show invariance across the trait-state anxiety level, which results in the unstable performance of items. The refined scale was retested in two subsequent random samples of 300 subjects each, and the results were confirmed. The performance was adequate regardless of gender. In the analysis, some items of the state scale (items 3,4,9,10,12,15, and 20) were deleted due to poor fit statistics. The remaining 13 items showed unidimensionality, local independence, and adequate index of internal consistency. Also, the original trait scale displayed several weaknesses. First, the four-point Likert response scale proved to be inadequate, and threshold disorders were found in all 20 items. Also, the original trait scale showed insufficient item-trait interaction and several individual item misfits. Following the rescoring process, and retesting in a second random sample, items were excluded (namely Items 3, 4, 11, 13, 14, 15, 18, and 19). The refined version showed local independence, unidimensionality, and adequate fit statistics. DISCUSSION The results indicate that the application of the Rasch model led to the refinement of the classic STAI state and trait scales. In addition, they suggest that these shorter versions have a more suitable psychometric performance and are free of threshold disorders and differential item functioning problems.
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Affiliation(s)
- Márcia Balle Kaipper
- Post-Graduate Program in Medical Sciences, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Brazil
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Caumo W, Levandovski R, Hidalgo MPL. Preoperative anxiolytic effect of melatonin and clonidine on postoperative pain and morphine consumption in patients undergoing abdominal hysterectomy: a double-blind, randomized, placebo-controlled study. THE JOURNAL OF PAIN 2008; 10:100-8. [PMID: 19010741 DOI: 10.1016/j.jpain.2008.08.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2008] [Revised: 08/08/2008] [Accepted: 08/20/2008] [Indexed: 10/21/2022]
Abstract
UNLABELLED Recent evidence has demonstrated analgesic, anti-inflammatory, and anxiolytic properties of melatonin. Taking into account that higher anxiety makes the control of postoperative pain more difficult, one can hypothesize that melatonin anxiolytic and analgesic effects improve the control of postoperative pain. Thus, we conducted a randomized, double-blind, placebo-controlled study with 59 patients undergoing abdominal hysterectomy to test the hypothesis that melatonin is as effective as clonidine and that both are more effective than placebo in reducing postoperative pain. Additionally, we compared their anxiolytic effects on postoperative pain. Patients were randomly assigned to receive oral melatonin (5 mg) (n = 20), clonidine (100 microg) (n = 19), or placebo (n = 20) orally. In addition to primary outcomes of pain intensity and analgesic consumption, secondary outcome measures included postoperative state anxiety. In anxious patients 6 hours after surgery, the number of patients needed to be to prevent moderate to intense pain during the first 24 hours after surgery was 1.52 (95% CI, 1.14 to 6.02) and 1.64 (95% CI, 1.29 to 5.93), respectively, in the melatonin and clonidine groups compared with placebo. Also, the anxiolytic effect of melatonin and clonidine resulted in reduced postoperative morphine consumption by more than 30%. However, in the mildly anxious, it was not observed the treatment effect on pain. PERSPECTIVES The preoperative anxiolysis with melatonin or clonidine reduced postoperative pain and morphine consumption in patients undergoing abdominal hysterectomy. The effects these 2 drugs were equivalent and greater than with placebo.
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Affiliation(s)
- Wolnei Caumo
- Anesthesia Service and Perioperative Medicine, Hospital de CLíNICAS DE Porto Alegre/Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
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Abstract
This article reinforces the clinical points of emphasis that have been stressed throughout this issue in a case scenario format. Common situations dealt with by physicians are examined to highlight the underlying physiology of the specific complaints and treatment interventions. The goal of this article is to present an evidenced-based review of pain management interventions in a format that allows for reader incorporation.
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Abstract
Surgery is a circumstance in which we know that we will cause pain. Although most of our perioperative pain management interventions are symptomatic, several strategies can reduce and even prevent pain in the perioperative setting. Because the physiologic mechanisms of postoperative pain are understood, it is possible to interrupt these mechanisms before the patient actually becomes symptomatic. This article reviews the literature and presents these strategies with the hope of implementation of the readers.
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Affiliation(s)
- Robert Hallivis
- Podiatric Surgery Section, Department of Orthopedics, INOVA Fairfax Hospital, Falls Church, VA 20042, USA
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Hannemann P, Lassen K, Hausel J, Nimmo S, Ljungqvist O, Nygren J, Soop M, Fearon K, Andersen J, Revhaug A, von Meyenfeldt MF, Dejong CHC, Spies C. Patterns in current anaesthesiological peri-operative practice for colonic resections: a survey in five northern-European countries. Acta Anaesthesiol Scand 2006; 50:1152-60. [PMID: 16939479 DOI: 10.1111/j.1399-6576.2006.01121.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND For colorectal surgery, evidence suggests that optimal management includes: no pre-operative fasting, a thoracic epidural analgesia continued for 2 days post-operatively, and avoidance of fluid overload. In addition, no long-acting benzodiazepines on the day of surgery and use of short-acting anaesthetic medication may be beneficial. We examined whether these strategies have been adopted in five northern-European countries. METHODS In 2003, a questionnaire concerning peri-operative anaesthetic routines in elective, open colonic cancer resection was sent to the chief anaesthesiologist in 258 digestive surgical centres in Scotland, the Netherlands, Denmark, Sweden and Norway. RESULTS The response rate was 74% (n = 191). Although periods of pre-operative fasting up to 48 h were reported, most (> 85%) responders in all countries declared to adhere to guidelines for pre-operative fasting and oral clear liquids were permitted until 2-3 h before anaesthesia. Solid food was permitted up to 6-8 h prior to anaesthesia. In all countries more than 85% of the responders indicated that epidural anaesthesia was routinely used. Except for Denmark, long-acting benzodiazepines were still widely used. Short-acting anaesthetics were used in all countries except Scotland where isoflurane is the anaesthetic of choice. With the exception of Denmark, intravenous fluids were used unrestrictedly. CONCLUSION In northern Europe, most anaesthesiologists adhere to evidence-based optimal management strategies on pre-operative fasting, thoracic epidurals and short-acting anaesthetics. However, premedication with longer-acting agents is still common. Avoidance of fluid overload has not yet found its way into daily practice. This may leave patients undergoing elective colonic surgery at risk of oversedation and excessive fluid administration with potential adverse effects on surgical outcome.
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Affiliation(s)
- P Hannemann
- Department of Surgery, University Hospital Maastricht and NUTRIM Institute, Maastricht, The Netherlands
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Fearon KCH, Ljungqvist O, Von Meyenfeldt M, Revhaug A, Dejong CHC, Lassen K, Nygren J, Hausel J, Soop M, Andersen J, Kehlet H. Enhanced recovery after surgery: a consensus review of clinical care for patients undergoing colonic resection. Clin Nutr 2005; 24:466-77. [PMID: 15896435 DOI: 10.1016/j.clnu.2005.02.002] [Citation(s) in RCA: 924] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Accepted: 02/08/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Clinical care of patients undergoing colonic surgery differs between hospitals and countries. In addition, there is considerable variation in rates of recovery and length of hospital stay following major abdominal surgery. There is a need to develop a consensus on key elements of perioperative care for inclusion in enhanced recovery programmes so that these can be widely adopted and refined further in future clinical trials. METHODS Medline database was searched for all clinical studies/trials relating to enhanced recovery after colorectal resection. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A combination of evidence-based and consensus methodology was used to develop the resulting enhanced recovery after surgery (ERAS) clinical care protocol. RESULTS AND CONCLUSIONS Within traditional perioperative practice there is considerable evidence supporting a range of manoeuvres which, in isolation, may improve individual aspects of recovery after colonic surgery. The present manuscript reviews these issues in detail. There is also growing evidence that an integrated multimodal approach to perioperative care can result in an overall enhancement of recovery. However, effects on major morbidity and mortality remain to be determined. A protocol is presented which is in current use by the ERAS Group and may provide a standard of care against which either current or future novel elements of an enhanced recovery approach can be tested for their effect on outcome.
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Affiliation(s)
- K C H Fearon
- Clinical and Surgical Sciences (Surgery), School of Clinical Sciences and Community Health, The University of Edinburgh, Royal Infirmary, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Hidalgo MPL, Auzani JAS, Rumpel LC, Moreira NL, Cursino AWC, Caumo W. The clinical effect of small oral clonidine doses on perioperative outcomes in patients undergoing abdominal hysterectomy. Anesth Analg 2005; 100:795-802. [PMID: 15728070 DOI: 10.1213/01.ane.0000143568.59766.b2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We assessed the effect of small clonidine doses on anxiolysis, analgesia, and hemodynamic stability in patients undergoing abdominal hysterectomy. A total of 61 patients, ASA status I-II, were randomly assigned to receive either oral clonidine 100 microg (n = 29) or placebo (n = 32) before surgery and 24 h after surgery. The use of clonidine resulted in anxiolysis and analgesia throughout the 72 h after surgery, although the subjects who received clonidine were sleepier than the control group for the first 6 h after surgery. The number needed to treat was 3 (95% confidence interval [CI], 1.72-9.42) to prevent intense anxiety in patients with moderate to intense postoperative pain, compared with 40 (95% CI, 18.79-99.68) in the absence of pain or with mild pain. In the treated patients, 68% had an average heart rate less than 70 bpm during surgery, compared with 21.40% in the placebo group (number needed to treat, 2; 95% CI, 1.29-2.80). The clonidine patients required small ropivacaine doses during the surgery but not less morphine by patient-controlled analgesia. A clinically relevant anxiolytic effect was found in patients who received oral clonidine in the perioperative period, and this suggests that clonidine might be a useful therapeutic alternative to other preoperative sedatives.
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Affiliation(s)
- Maria Paz Loayza Hidalgo
- *Psychiatric Service, Hospital Materno Infantil Presidente Vargas; †Anesthesia Service, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil; ‡Universidade Federal do Rio Grande do Sul; and §Pharmacology Department, Instituto de Ciências Básicas da Saúde, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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Vaughn F, Wichowski H, Bosworth G. Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis. AORN J 1978; 85:589-604. [PMID: 17352896 DOI: 10.1016/s0001-2092(07)60130-6] [Citation(s) in RCA: 119] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.
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