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Abdelmalak BB, You J, Kurz A, Kot M, Bralliar T, Remzi FH, Sessler DI. The effects of dexamethasone, light anesthesia, and tight glucose control on postoperative fatigue and quality of life after major noncardiac surgery: A randomized trial. J Clin Anesth 2018; 55:83-91. [PMID: 30599425 DOI: 10.1016/j.jclinane.2018.12.038] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/09/2018] [Accepted: 12/18/2018] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVES The postoperative period is associated with an inflammatory response that may contribute to a number of complications including postoperative fatigue (POF) that impair patients' quality of life (QoL). We studied the impact of three potentially anti-inflammatory interventions (steroid administration, tight intraoperative glucose control, and light anesthesia) on POF and QoL in patients having major noncardiac surgery. DESIGN A randomized Trial. SETTING Operating room and postoperative recovery area/ICU/hospital floors. PATIENTS Patients undergoing major noncardiac surgery. INTERVENTIONS Patients were randomized to perioperative IV dexamethasone (a total of 14 mg tapered over 3 days) versus placebo, intensive versus conventional glucose control (target 80-110 vs. 180-200 mg·dL-1), and light versus deep anesthesia (Bispectral Index target of 55 vs. 35) in a 3-way factorial design. MEASUREMENTS In this planned sub-analysis, QoL was measured using SF-12 preoperatively and on postoperative day (POD) 30. POF was measured using Christensen VAS, pre-operatively, POD 1, and POD 3. We assessed the effect of each intervention on POF and on the physical and mental components of SF-12 summary scores with repeated-measures linear regression models. MAIN RESULTS 326 patients with complete data were included in the SF-12 analysis and 306 were included in the QoL analysis. No difference was found between any of the intervention groups on fatigue or mean 30-day physical and mental components of SF-12 scores, after adjusting for preoperative score and imbalanced baseline variables (all P-value >0.07 for POF and >0.40 for QoL). CONCLUSIONS Steroid administration, tight intraoperative glucose control, and light anesthesia do not improve quality of life or postoperative fatigue after major surgery.
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Affiliation(s)
- Basem B Abdelmalak
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America.
| | - Jing You
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Andrea Kurz
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Michael Kot
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Thomas Bralliar
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Feza H Remzi
- Department of Surgery, Inflammatory Bowel Disease Center, NYU Langone Health, NY, NY, United States of America
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States of America
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Defining the cut-off point of clinically significant postoperative fatigue in three common fatigue scales. Qual Life Res 2018; 28:991-1003. [PMID: 30506178 DOI: 10.1007/s11136-018-2068-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 11/12/2022]
Abstract
PURPOSE Postoperative fatigue (POF) is an often underestimated problem after surgery. Studies on POF often report fatigue scores without relating this to the clinical relevance for the patients. The aim of this study was to define the cut-off point for clinically significant POF in three commonly applied fatigue scales; the Postoperative Fatigue Scale, Christensen's Fatigue Scale, and the Chalder Fatigue Questionnaire. The identification of cut-off points will make it possible to indicate whether statistically significant findings of increased fatigue are of clinical relevance. METHODS We combined data from day 0 (pre-operatively) and day 1, 3, 6, and 30 after surgery in two fatigue-related studies with 442 patients. In order to define clinically significant fatigue, a key question was added in each questionnaire; "Given your current description of fatigue, would you say it has been of considerable significance to you?"; "Yes/No". We analysed each scale's ability to identify clinically significant fatigue, by performing receiver-operating characteristics (ROC) analyses, and calculated the optimal cut-off point between Sensitivity and Specificity. RESULTS The average weighted cut-off point for clinically significant POF when measured with the Postoperative Fatigue Scale was ≥ 50 (scale range 0-100), with Christensen's Fatigue Scale ≥ 6 (scale range 1-10) and with the Chalder Fatigue Questionnaire ≥ 16 (scale range 0-33). CONCLUSION In three commonly used fatigue scales, we have identified cut-off points for clinically significant fatigue among patients recovering from surgery. This can be particularly valuable for diagnostic purposes and in treatment evaluation. Further, it may be possible to analyse and review data from earlier studies in light of clinical relevance.
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Nostdahl T, Fredheim OM, Bernklev T, Doksrod TS, Mohus RM, Raeder J. A randomised controlled trial of propofol vs. thiopentone and desflurane for fatigue after laparoscopic cholecystectomy. Anaesthesia 2017; 72:864-869. [DOI: 10.1111/anae.13909] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2017] [Indexed: 12/22/2022]
Affiliation(s)
- T. Nostdahl
- Department of Anaesthesiology; Telemark Hospital; Skien Norway
| | - O. M. Fredheim
- Department of Circulation and Medical Imaging; Faculty of Medicine; Norwegian University of Science and Technology; Trondheim Norway
- Centre of Palliative Medicine, Surgical Division; Akershus University Hospital; Lørenskog Norway
- National Competence Centre for Complex Symptom Disorders; Department of Pain and Complex Disorders; Trondheim Norway
| | - T. Bernklev
- Research and Development; Vestfold Hospital Trust; Tønsberg Norway
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
| | - T. S. Doksrod
- Department of Anaesthesiology; Telemark Hospital; Skien Norway
| | - R. M. Mohus
- Department of Anaesthesiology; St. Olav University Hospital; Trondheim Norway
| | - J. Raeder
- Institute of Clinical Medicine; Medical Faculty; University of Oslo; Oslo Norway
- Department of Anaesthesiology; Oslo University Hospital; Oslo Norway
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Yu J, Zhuang CL, Shao SJ, Liu S, Chen WZ, Chen BC, Shen X, Yu Z. Risk factors for postoperative fatigue after gastrointestinal surgery. J Surg Res 2015; 194:114-9. [DOI: 10.1016/j.jss.2014.09.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/31/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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Zhang XD, Chen BC, Dong QT, Andersson R, Pan XD, Tan SJ, Ye XZ, Yao JG, Yu Z. Establishment and assessments of a new model for the postoperative fatigue syndrome by major small intestinal resection in rats. Scand J Gastroenterol 2011; 46:1302-9. [PMID: 21854092 DOI: 10.3109/00365521.2011.610001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Postoperative fatigue syndrome (POFS) is a general and main complication after surgery. However, there is no stable and standardized animal model for POFS. The aim of the present study was to establish a rodent model of POFS by small intestinal resection, with POFS evaluated by acknowledged physical and behavioral methods. MATERIAL AND METHODS Forty-two Sprague-Dawley rats were randomly divided into four groups according to the length of a "middle" small intestinal resection: 0% (sham group; i.e., laparotomy alone), 10%, 40% and 70% groups, with corresponding lengths of small intestinal resections. Following surgery, the general state of health was evaluated. Tail suspension test, open field test and Morris water maze test were used to evaluate the degree of POFS. Serum albumin, transferrin, prealbumin and fibronectin were measured to assess the nutritional status, and superoxide dismutase (SOD) and malondialdehyde (MDA) were also measured. RESULTS As compared with the other three groups, the 70% small intestinal resection group showed the worst general state of health, decreased strength of the tail suspension test and decreased score of Morris water maze test (p < 0.05) after operation. All rats in whom the small intestinal resection was done demonstrated a certain degree of malnutrition and behavior of depression, and the 70% resection group had the lowest levels of transferrin, prealbumin and fibronectin as compared with the other groups (p < 0.05), as well as decreased SOD and increased MDA in serum (p < 0.05). CONCLUSIONS Resection of 70% of the small intestine resulted in typical characteristics of POFS. As this procedure is simple, stable and easily reproducible, it may serve as a model for research on POFS.
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Affiliation(s)
- Xiao-Dong Zhang
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, Wenzhou Medical College, Wenzhou, China
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Paddison JS, Booth RJ, Fuchs D, Hill AG. Peritoneal inflammation and fatigue experiences following colorectal surgery: a pilot study. Psychoneuroendocrinology 2008; 33:446-54. [PMID: 18258374 DOI: 10.1016/j.psyneuen.2007.12.011] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 12/20/2007] [Accepted: 12/23/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The effect of post-surgical inflammation, as indicated by peritoneal cytokines and neopterin, was assessed on the duration and characteristics of post-surgical fatigue (PSF) experiences. BACKGROUND During the weeks following major colorectal surgery, many patients report experiencing substantial fatigue but the physiological factors contributing to this are not well understood. Because cytokines, particularly pro-inflammatory cytokines, have been found to be important in fatigue-related experiences in experimental systems, they may well be important mediators of PSF. METHODS In 27 patients following colorectal surgery, cytokines and neopterin (a relatively stable immune activation marker) were measured in 24-h peritoneal drain fluid and in serum 2, 5 and 14 days post-operatively. Patient fatigue was assessed using the Identity-Consequence Fatigue Scale questionnaire pre-operatively and 2, 5, 14, 30 and 60 days after surgery. RESULTS Using linear mixed model analysis controlling for age, gender and ASA score, the trajectory of fatigue experience during the first 2 months of surgical recovery was significantly related to intra-peritoneal concentrations of IL-6, IL-10 and TNF-alpha during the first 24h after surgery, while the trajectory of fatigue impacts was related only to IL-6 and TNF-alpha concentrations. Moreover, correlations between neopterin, and post-operative peritoneal (within 24h of surgery) and serum cytokine concentrations permitted neopterin to be used as a surrogate inflammation marker. Patients with elevated neopterin concentrations during the initial weeks following surgery reported significantly more severe and sustained PSF. CONCLUSIONS Locally occurring inflammatory responses may influence reports of fatigue following major surgery in a sustained manner, and, as a consequence, reducing inflammation may be effective in reducing PSF.
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Affiliation(s)
- Johanna S Paddison
- Department of Molecular Medicine and Pathology, The University of Auckland, Auckland, New Zealand
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Abstract
Laparoscopic colonic surgery has an established role in the management of both benign and malignant conditions. Proposed benefits from laparoscopic surgery include decreased pain, decreased metabolic disturbance to the patient and faster recovery. It is now generally accepted that pro-inflammatory mediators, including cytokines, are to a great extent responsible for the metabolic changes associated with injury and surgery, and that these metabolic changes are related to postoperative recovery. Cytokine levels in the serum are decreased after major laparoscopic colorectal surgery compared with open surgery. However, the cytokine concentration in abdominal drain fluid is the same independent of the size of the incision and these concentrations are far higher than those found in the serum suggesting that the peritoneal would from the surgery itself is more important to metabolic events than the skin wound used to access the abdominal cavity to perform the operation. When looked at critically in programmes where patients are optimally managed perioperatively, there appears to be minimal metabolic benefit from performing a major colonic resection using minimal access surgery. Thus, it appears that the wound is critical when the operation involves only minor peritoneal disruption, such as in laparoscopic cholecystectomy, but when large peritoneal defects are created, such as in major colorectal surgery, then the skin wound becomes irrelevant to metabolism and hence recovery. Thus, minimal access does not necessarily equate to minimal invasion and the terms should not be used interchangeably in the context of laparoscopic colorectal surgery.
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Affiliation(s)
- Andrew G Hill
- Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand.
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Chuang D, Power SE, Dunbar PR, Hill AG. Central nervous system interleukin-8 production following neck of femur fracture. ANZ J Surg 2005; 75:813-6. [PMID: 16174000 DOI: 10.1111/j.1445-2197.2005.03530.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To establish a proinflammatory cytokine profile of the cerebrospinal fluid (CSF) following trauma. BACKGROUND Trauma is associated with a postinjury syndrome consisting of loss of weight and nitrogen, pyrexia, anorexia and fatigue. It has been proposed that cytokines are pathophysiologically involved in this syndrome but the site of action of these is unclear. Previous work in head injury models, supported by animal work, has suggested that one important site of action is the central nervous system (CNS). METHODS Women who had sustained neck of femur fractures were enrolled (trauma group). CSF was collected at the time of spinal anaesthetic. Women undergoing elective lower limb surgery were recruited as controls. CSF and serum were assayed for Interleukin (IL) 1, 2, 4, 6, 8, 10, 12, interferon gamma, and tumour necrosis factor by cytometric bead array. RESULTS In the trauma group, IL-8 was elevated in the CSF but not in the serum, while IL-6 was elevated in the serum but not in the CSF. IL-1beta, associated with elevated IL-12, was also detected in the serum of three of 11 trauma patients but none of the nine controls. No other cytokines were consistently detected. CONCLUSIONS This study raises the possibility that IL-8, acting in the CNS, plays a role in the postinjury syndrome. It is unclear as to the mechanism by which CNS IL-8 is produced in trauma but a physiological role is supported by the known ability of the CNS to produce IL-8 and the presence of receptors for its action in the CNS.
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Affiliation(s)
- Danny Chuang
- South Auckland Clinical School, University of Auckland, Auckland, New Zealand
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Rubin GJ, Hardy R, Hotopf M. A systematic review and meta-analysis of the incidence and severity of postoperative fatigue. J Psychosom Res 2004; 57:317-26. [PMID: 15507259 DOI: 10.1016/s0022-3999(03)00615-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2003] [Accepted: 10/12/2003] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Postoperative fatigue is common following major abdominal surgery. Less is known about its prevalence in other surgical subgroups, and about its long-term prognosis. A systematic review of prospective cohort studies was conducted to clarify these issues. METHOD Studies were identified from an extensive literature search. Overall estimates of pre- to postoperative change in fatigue severity and the incidence of clinically significant postoperative fatigue were calculated using meta-analyses. RESULTS Eighty-one cohorts were identified. Type of surgery was found to be a possible predictor of fatigue severity, with major abdominal, gynaecological, cardiac and minor surgery apparently associated with greater fatigue than orthopaedic surgery. Limited data were available regarding the long-term persistence of postoperative fatigue. CONCLUSION Postoperative fatigue appears to be an important problem following only certain forms of surgery. Why this is so remains unclear, and further work using better fatigue questionnaires is now required to confirm these differences.
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Affiliation(s)
- G James Rubin
- Section of General Hospital Psychiatry, Division of Psychological Medicine, Guy's, King's and St Thomas' School of Medicine, UK.
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Hayes C, Ambazidis S, Gani JS. Intensive care unit admissions following laparoscopic surgery: what lessons can be learned? THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1996; 66:206-9. [PMID: 8611125 DOI: 10.1111/j.1445-2197.1996.tb01165.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic surgery has been widely embraced, often without adequate data concerning the range and incidence of complications. In the present series, our experience of complications requiring Intensive Care Unit (ICU) admission following laparoscopic surgery is described. METHODS The records of patients requiring ICU admission at John Hunter Hospital (JHH) following laparoscopic surgery over a 39 month period were retrospectively reviewed by an independent multidisciplinary panel. RESULTS Twenty-three ICU admissions were identified. Twenty-one followed general surgical laparoscopic procedures and two followed gynaecological laparoscopies. Ten cases were operated on initially at JHH and 13 were transferred from other hospitals. During the study period, 2444 laparoscopic surgical cases were performed at JHH; 725 general surgical procedures (1.37% admitted to ICU) and 1719 gynaecological procedures (no ICU admissions). Twelve cases suffered surgical complications (including five gastrointestinal tract perforations and three biliary tract injuries) and 11 cases were admitted for non-surgical problems. In 75% of surgical complications there was delay in diagnosis of more than 24 h. The duration of ICU stay for surgical complications (16.4 days) was significantly longer than for the non-surgical group (3.9 days). CONCLUSION There was a greater likelihood of ICU admission following general surgical rather than gynaecological laparoscopy. Fifty-two per cent of the admissions were for surgical complications. Surgical complications are characterized by delay in diagnosis and longer ICU admission periods. Strategies to prevent some of these complications are discussed.
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Affiliation(s)
- C Hayes
- Department of Anaesthesia, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
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