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Porhomayon J, Pourafkari L, El-Solh A, Nader ND. Novel therapies for perioperative respiratory complications. J Cardiovasc Thorac Res 2017; 9:121-126. [PMID: 29118943 PMCID: PMC5670332 DOI: 10.15171/jcvtr.2017.21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Accepted: 08/06/2017] [Indexed: 12/14/2022] Open
Abstract
Postoperative respiratory complications are of paramount clinical importance as they prolong the hospitalization, increase the costs of treatment and contribute to the perioperative mortality. Obesity, preexisting pulmonary disease and advanced age are known risk factors for developing postoperative respiratory complications, which affect exceeding number of patients. Hereby, we present a review on the pathogenesis of post-operative respiratory complications particularly in obese and older patients. We further focus on the standard management and emerging therapies for the post-operative respiratory complications.
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Affiliation(s)
- Jahan Porhomayon
- Clinical Professor of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Buffalo, NY, USA.,State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Leili Pourafkari
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ali El-Solh
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Nader D Nader
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
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Emanuelli E, Milanese L, Rossetto M, Cazzador D, d'Avella E, Volo T, Baro V, Denaro L, Gioffrè G, Borsetto D, Martini A. The endoscopic endonasal approach for cerebrospinal fluid leak repair in the elderly. Clin Neurol Neurosurg 2015; 132:21-5. [PMID: 25746317 DOI: 10.1016/j.clineuro.2015.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant morbidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. METHODS Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. RESULTS 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. CONCLUSION Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
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Affiliation(s)
- Enzo Emanuelli
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Laura Milanese
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy.
| | - Marta Rossetto
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Diego Cazzador
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Elena d'Avella
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Tiziana Volo
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Valentina Baro
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Luca Denaro
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Giorgio Gioffrè
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Daniele Borsetto
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Alessandro Martini
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Praticò C, Quattrone D, Lucanto T, Amato A, Penna O, Roscitano C, Fodale V. Drugs of anesthesia acting on central cholinergic system may cause post-operative cognitive dysfunction and delirium. Med Hypotheses 2005; 65:972-82. [PMID: 16043305 DOI: 10.1016/j.mehy.2005.05.037] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Accepted: 05/19/2005] [Indexed: 11/30/2022]
Abstract
Given the progressive and constant increase of average life expectancy, an increasing number of elderly patients undergo surgery. After surgery, elderly patients often exhibit a transient reversible state of cerebral cognitive alterations. Among these cognitive dysfunctions, a state of delirium may develop. Delirium is an aetiologically non-specific syndrome characterised by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour and the sleep-wake cycle. Delirium appears to occur in 10-26% of general medical patients over 65, and is frequently associated with a significant increase in morbidity and mortality. During hospitalization, mortality rates have been estimated to be 10-26% of patients who developed post-operative delirium, and 22-76% during the following months. Over the last few decades, post-operative delirium has been associated with several pre-operative predictor factors, as well as age (50 years and older), alcohol abuse, poor cognitive and functional status, electrolyses or glucose abnormalities, and type of surgery. The uncertain pathogenesis of post-operative cognitive dysfunctions and delirium has not permitted a causal approach to developing an effective treatment. General anesthesia affects brain function at all levels, including neuronal membranes, receptors, ion channels, neurotransmitters, cerebral blood flow and metabolism. The functional equivalents of these impairments involve mood, memory, and motor function behavioural changes. These dysfunctions are much more evident in the occurrence of stress-regulating transmission and in the alteration of intra-cellular signal transduction systems. In addition, more essential cellular processes, that play an important role in neurotransmitter synthesis and release, such as intra-neuronal signal transduction and second messenger system, may be altered. Keeping in mind the functions of the central muscarinic cholinergic system and its multiple interactions with drugs of anesthesia, it seems possible to hypothesize that the inhibition of muscarinic cholinergic receptors could have a pivotal role in the pathogenesis not only of post-operative delirium but also the more complex phenomena of post-operative cognitive dysfunction.
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Affiliation(s)
- C Praticò
- Department of Neuroscience, Psychiatric and Anesthesiological Sciences, University of Messina, School of Medicine, Policlinico Universitario G. Martino, via C.Valeria, 98125 Messina, Italy
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Abstract
OBJECTIVE To identify the relationship of age, sex, and type of procedure to extubation outcome (< or = 8 hours or > 8 hours), and to identify barriers to extubation after heart surgery. DESIGN Quasi-experimental, prospective study. SETTING Ten-bed cardiothoracic intensive care unit. SAMPLE Sixty-two consecutive patients undergoing heart surgery. OUTCOME MEASURES Early (< or = 8 hours) versus delayed (> 8 hours) extubation. RESULTS Patients in the delayed extubation group were older (69.1 +/- 11.3 years) than the patients in the early extubation group (59.6 +/- 8.0 years, p = 0.01). Univariate logistic regression comparing age (< 70 or > or = 70 years), sex, and procedure (coronary artery bypass graft or other procedure) identified only age 70 years or older as a predictor of delayed extubation. The unadjusted odds ratio of delayed extubation in patients 70 years or older was 11.25. CONCLUSIONS Age is a powerful predictor of delayed extubation after heart surgery. Only postoperative somnolence distinguished barriers to extubation in younger and older patients.
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Affiliation(s)
- L V Doering
- University of California, Los Angeles, School of Nursing 90095-6918, USA
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