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Gaba F, Blyuss O, Chandrasekaran D, Osman M, Goyal S, Gan C, Izatt L, Tripathi V, Esteban I, McNicol L, Ragupathy K, Crawford R, Evans DG, Legood R, Menon U, Manchanda R. Attitudes towards risk-reducing early salpingectomy with delayed oophorectomy for ovarian cancer prevention: a cohort study. BJOG 2020; 128:714-726. [PMID: 32803845 DOI: 10.1111/1471-0528.16424] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To determine risk-reducing early salpingectomy and delayed oophorectomy (RRESDO) acceptability and effect of surgical prevention on menopausal sequelae/satisfaction/regret in women at increased ovarian cancer (OC) risk. DESIGN Multicentre, cohort, questionnaire study (IRSCTN:12310993). SETTING United Kingdom (UK). POPULATION UK women without OC ≥18 years, at increased OC risk, with/without previous RRSO, ascertained through specialist familial cancer/genetic clinics and BRCA support groups. METHODS Participants completed a 39-item questionnaire. Baseline characteristics were described using descriptive statistics. Logistic/linear regression models analysed the impact of variables on RRESDO acceptability and health outcomes. MAIN OUTCOMES RRESDO acceptability, menopausal sequelae, satisfaction/regret. RESULTS In all, 346 of 683 participants underwent risk-reducing salpingo-oophorectomy (RRSO). Of premenopausal women who had not undergone RRSO, 69.1% (181/262) found it acceptable to participate in a research study offering RRESDO. Premenopausal women concerned about sexual dysfunction were more likely to find RRESDO acceptable (odds ratio [OR] = 2.9, 95% CI 1.2-7.7, P = 0.025). Women experiencing sexual dysfunction after premenopausal RRSO were more likely to find RRESDO acceptable in retrospect (OR = 5.3, 95% CI 1.2-27.5, P < 0.031). In all, 88.8% (143/161) premenopausal and 95.2% (80/84) postmenopausal women who underwent RRSO, respectively, were satisfied with their decision, whereas 9.4% (15/160) premenopausal and 1.2% (1/81) postmenopausal women who underwent RRSO regretted their decision. HRT uptake in premenopausal individuals without breast cancer (BC) was 74.1% (80/108). HRT use did not significantly affect satisfaction/regret levels but did reduce symptoms of vaginal dryness (OR = 0.4, 95% CI 0.2-0.9, P = 0.025). CONCLUSION Data show high RRESDO acceptability, particularly in women concerned about sexual dysfunction. Although RRSO satisfaction remains high, regret rates are much higher for premenopausal women than for postmenopausal women. HRT use following premenopausal RRSO does not increase satisfaction but does reduce vaginal dryness. TWEETABLE ABSTRACT RRESDO has high acceptability among premenopausal women at increased ovarian cancer risk, particularly those concerned about sexual dysfunction.
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Affiliation(s)
- F Gaba
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - O Blyuss
- School of Physics, Astronomy and Mathematics, University of Hertfordshire, Hatfield, UK.,Department of Paediatrics and Paediatric Infectious Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Applied Mathematics, Lobachevsky State University of Nizhny Novgorod, Nizhny Novgorod, Russia
| | - D Chandrasekaran
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - M Osman
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - S Goyal
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK
| | - C Gan
- Department of Gynaecological Oncology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - L Izatt
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - V Tripathi
- Department of Clinical Genetics, Guy's Hospital, London, UK
| | - I Esteban
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | - L McNicol
- Ninewells Hospital, NHS Tayside, Dundee, UK
| | | | - R Crawford
- Department of Gynaecological Oncology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - D G Evans
- Manchester Centre for Genomic Medicine, MAHSC, Division of Evolution and Genomic Sciences, University of Manchester, Manchester, UK
| | - R Legood
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - U Menon
- MRC Clinical Trials Unit, University College London, London, UK
| | - R Manchanda
- Wolfson Institute of Preventive Medicine, Cancer Research UK, Barts Centre, Queen Mary University of London, Charterhouse Square, London, UK.,Department of Gynaecological Oncology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK.,MRC Clinical Trials Unit, University College London, London, UK
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Affiliation(s)
- P T McAleer
- Chair, Australian and New Zealand Anaesthetic Allergy Group Chair, Anaesthetic Allergy Subcommittee of the ANZCA Safety & Quality Committee
| | - L McNicol
- Chair, Mortality Subcommittee of ANZCA Safety & Quality Committee Chair, Victorian Consultative Council on Anaesthetic Mortality and Morbidity
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Weinberg L, Rachbuch C, Ting S, Howard W, Yeomans M, Gordon I, McNicol L, James K, Story D, Christophi C. A randomised controlled trial of peri-operative lidocaine infusions for open radical prostatectomy. Anaesthesia 2016; 71:405-10. [PMID: 26749026 PMCID: PMC4849200 DOI: 10.1111/anae.13368] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2015] [Indexed: 12/02/2022]
Abstract
We allocated 76 men scheduled for radical retropubic prostatectomy to peri‐operative lidocaine 2% or saline 0.9%: a pre‐operative 0.075 ml.kg−1 intravenous bolus; an intra‐operative intravenous infusion at 0.075 ml.kg−1.h−1; and 24 hours' postoperative subcutaneous infusion at 0.075 ml.kg−1.h−1. Lidocaine reduced the postoperative hospital stay by a mean (95% CI) of 1.3 (0.3–2.4) days, p = 0.017, from a mean (SD) of 4.6 (3.2) days with saline. Lidocaine reduced pain at rest during the first 24 postoperative hours by a mean (95% CI) of 1.8 (0.7–2.9) mm.h−1, p = 0.001. Lidocaine reduced 24‐h morphine consumption by a mean (95% CI) of 13.9 (2.2–25.7) mg, p = 0.021, from a mean (SD) of 52.3 (26.9) mg with saline. There were no differences in other outcomes.
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Affiliation(s)
- L Weinberg
- Anaesthesia, Peri-operative and Pain Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - C Rachbuch
- Department of Anaesthesia, Eastern Health, Box Hill, Victoria, Australia
| | - S Ting
- Department of Anaesthesia, Monash Health, Clayton, Victoria, Australia
| | - W Howard
- Acute Pain Service, Austin Hospital, Heidelberg, Victoria, Australia.,Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - M Yeomans
- Acute Pain Service, Austin Hospital, Heidelberg, Victoria, Australia
| | - I Gordon
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Victoria, Australia
| | - L McNicol
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - K James
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia
| | - D Story
- Anaesthesia, Peri-operative and Pain Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - C Christophi
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
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Weinberg L, Pearce B, Sullivan R, Siu L, Scurrah N, Tan C, Backstrom M, Nikfarjam M, McNicol L, Story D, Christophi C, Bellomo R. The effects of plasmalyte-148 vs. Hartmann's solution during major liver resection: a multicentre, double-blind, randomized controlled trial. Minerva Anestesiol 2015; 81:1288-1297. [PMID: 25407026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The acid-base, biochemical and hematological effects of crystalloid solutions have not been comprehensively evaluated in patients with liver resection. DESIGN multicenter, prospective, double-blind randomized controlled trial investigating the biochemical effects of Hartmann's solution (HS) or Plasmalyte-148 (PL) in 60 patients undergoing major liver resection. PRIMARY OUTCOME base excess immediately after surgery. SECONDARY OUTCOMES changes in blood biochemistry and hematology. RESULTS At completion of surgery, patients receiving HS had equivalent mean standard base excess (-1.7±2.2 vs. -0.9±2.3 meq/L; P=0.17) to those treated with PL. However, patients treated with HS were more hyperchloremic (difference 1.7 mmol/L, 95% CI: 0.2 to 3.2, P=0.03) and hyperlactatemic (difference 0.8 mmol/L, 95% CI: 0.2 to 1.3; P=0.01). In contrast, patients receiving PL had higher mean plasma magnesium levels and lower ionized calcium levels. There were no significant differences in pH, bicarbonate, albumin and phosphate levels. Immediately after surgery, mean PT and aPTT were significantly lower in the PL group. Intraoperatively, the median (IQR) blood loss in the PL group was 300 mL (200:413) vs. 500 mL (300:638) in the HS group (P=0.03). Correspondingly, the postoperative hemoglobin was higher in the PL group. Total complications were more frequent in the HS Group (56% vs. 20%, relative risk 2.8; 95% CI: 1.3 to 6.1; P=0.007). CONCLUSION In liver resection patients, HS and PL led to similar base excess values but different post operative plasma biochemistry and hematology values. Understanding of these effects may help clinicians individualize fluid therapy in these patients.
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Affiliation(s)
- L Weinberg
- Department of Anesthesia, Austin Hospital, Heidelberg, Victoria, Australia -
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Lipcsey M, McNicol L, Parker F, Poustie S, Liu G, Uchino S, Kattula A, Bellomo R. Effect of perfusion pressure on the splanchnic circulation after CPB: a pilot study. Minerva Anestesiol 2015; 81:752-764. [PMID: 25357214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The impact of different blood pressure targets is unknown for post cardiac surgery patient in the intensive care unit. We, therefore, investigated the effects of a mean arterial pressure (MAP) target of 65 or 85 mmHg on splanchnic oxygenation, metabolic function, cytokine regulation and gastric tonometry after cardiopulmonary bypass. METHODS Sixteen patients were randomized to the HLH group (high-low-high) where MAP of 85-65-85 mmHg was targeted or the LHL group where MAP 65-85-65 mmHg was targeted with norepinephrine infusion. RESULTS MAP targets were achieved in all patients at all timepoints (64 ± 3, 84 ± 4; 65 ± 5, LHL group; vs. 84 ± 3; 66 ± 2; 85 ± 5 mmHg, HLH group). At corresponding timepoints, hepatic venous saturation was 41 ± 15%; 58 ± 24%; 56 ± 21% in the LHL group vs. 50 ± 19%; 43 ± 20%; 41 ± 18% in the HLH group (P<0.05). No changes were observed in cardiac output, global or trans-splanchnic lactate levels and cytokine levels or in gastric tonometry CO2. CONCLUSION Achieving a MAP target of 85 mmHg by means of norepinephrine infusion after CPB appears safe for the splanchnic circulation.
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Affiliation(s)
- M Lipcsey
- Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden -
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Weinberg L, Tay S, Aykanat V, Segal R, Tan CO, Peyton P, McNicol L, Story DA. Changing patterns in volatile anaesthetic agent consumption over seven years in Victorian public hospitals. Anaesth Intensive Care 2014; 42:579-83. [PMID: 25233170 DOI: 10.1177/0310057x1404200506] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evidence-based choices of volatile agents can increase health cost efficiencies. In this pharmaco-economic study, we evaluated the trends and costs of volatile agent use in Australian public hospitals. The total number of volatile agent (isoflurane, sevoflurane and desflurane) bottles ordered and inflation-adjusted costs were collected from 65 Victorian public hospitals from 2005 to 2011. Environmental costs were measured through the 100-year global warming potential index as carbon dioxide equivalents. During this time period, the aggregate inflation-adjusted expenditure was $39,209,878. Time series analysis showed that bottles of isoflurane ordered decreased by 419/year (99% confidence interval (CI): -603 to -235); costs decreased by $56,017/year (99% CI: -$93,243 to -$18,791). Bottles of sevoflurane increased by 1,330/year (99% CI: 1141 to 1,519); costs decreased by $423,3573/year (99% CI: -$720,030 to -112,783). Bottles of desflurane increased by 726/year (99% CI: 288 to 1,164); costs increased by $171,578/year (99% CI: $136,951 to $206,205). The amount of calculated greenhouse gas emissions released into the atmosphere over this period was 37,000 tonnes of carbon dioxide equivalents, with isoflurane contributing 6%, sevoflurane 17%, and desflurane 77% of this total. In conclusion, isoflurane is no longer being used in the majority of Victorian public hospitals, with sevoflurane and desflurane remaining as the primary volatile agents, utilised respectively at a ratio of 2.2 to 1, and costs at 0.8 to 1.
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Affiliation(s)
- L Weinberg
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria
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McNicol L, Lipcsey M, Bellomo R, Parker F, Poustie S, Liu G, Uchino S, Kattula A. Effects of perfusion pressure on the splanchnic circulation after cardiopulmonary bypass: a randomized double cross-over study. Crit Care 2014. [PMCID: PMC4068628 DOI: 10.1186/cc13376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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McNicol L, Lipcsey M, Bellomo R, Parker F, Poustie S, Liu G, Kattula A. Pilot alternating treatment design study of the splanchnic metabolic effects of two mean arterial pressure targets during cardiopulmonary bypass. Br J Anaesth 2013; 110:721-728. [DOI: 10.1093/bja/aes493] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Weinberg L, Scurrah N, Parker FC, Dauer R, Marshall J, McCall P, Story D, Smith C, McNicol L. Markers of coagulation activation after hepatic resection for cancer: evidence of sustained upregulation of coagulation. Anaesth Intensive Care 2011; 39:847-53. [PMID: 21970128 DOI: 10.1177/0310057x1103900508] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We investigated the possibility that despite postoperative derangements of routine laboratory coagulation tests, markers of coagulation activation and thrombin generation would be normal or increased in patients undergoing hepatic resection for cancer In addition to the conventional coagulation tests prothrombin time and activated partial thromboplastin time, we measured select markers of coagulation activation prothrombin fragments 1 and 2 (PF1 + 2), thrombin-antithrombin complexes and plasma von Willebrand Factor antigen in 21 patients undergoing hepatic resection. The impact of hepatic resection on coagulation and fibrinolysis was studied with thromboelastography. Preoperatively, routine laboratory coagulation and liver function tests were normal in all patients. On the first postoperative day, prothrombin time was prolonged (range 16 to 22 seconds) in eight patients (38%). For these patients, thromboelastography was normal in six (75%), PF1 + 2 was elevated in four (50%), and thrombin-antithrombin complexes and von Willebrand Factor antigen were elevated in all, which was evidence of acute phase reaction, sustained coagulation factor turnover and activation. By the fifth postoperative day, despite normalisation of prothrombin time, markers of increased coagulation activity remained greater than 85% of baseline values. The findings indicate that in patients undergoing liver resection for cancer, there is significant and prolonged postoperative activation of the haemostatic system despite routine coagulation tests being normal or even prolonged. Before considering therapeutic interventions an integrated approach to interpreting haematological data with clinical correlation is essential.
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Affiliation(s)
- L Weinberg
- Department of Anaesthesia, Austin Hospital, Heidelberg, Victoria, Australia.
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Weinberg L, Scurrah N, Parker F, Story D, McNicol L. A reply. Anaesthesia 2010. [DOI: 10.1111/j.1365-2044.2010.06578.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weinberg L, Story D, Nam J, McNicol L. Pharmacoeconomics of Volatile Inhalational Anaesthetic Agents: An 11-Year Retrospective Analysis. Anaesth Intensive Care 2010; 38:849-54. [DOI: 10.1177/0310057x1003800507] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
With continuously increasing expenditure on health care resources, various cost containment strategies have been suggested in regard to controlling the cost of inhalational anaesthetic agents. We performed a cost identification analysis assessing inhalational anaesthetic agent expenditure at a tertiary level hospital, along with an evaluation of strategies to contain the cost of these agents. The number of bottles of isoflurane, sevoflurane and desflurane used during the financial years 1997 to 2007 was retrospectively determined and the acquisition costs and cumulative drug expenditure calculated. Pharmacoeconomic modelling using low fresh gas flow anaesthesia was performed to evaluate practical methods of cost reduction. The use of isoflurane decreased from 384 bottles during 1997 to 204 in 2007. In contrast, use of sevoflurane increased from 226 bottles during 1998 to 875 during 2007. Desflurane use increased from 34 bottles per year during 2002 (its year of introduction) to 163 bottles per year in 2007. While the inflation-adjusted cumulative expenditure for these inhalational agents (Australian dollars) increased from $132,000 in 1997 to over $326,000 in 2007, an increase of 168%, patient workload over the same period increased by only 11%. Pharmacoeconomic modelling demonstrated that sevoflurane at 2 l/minute costs 19 times more than isoflurane at 0.5 l/minute. For the financial years 1997 to 2007, we found a progressive shift from the cheaper isoflurane to the more expensive agents, sevoflurane and desflurane, a shift associated with marked increases in costs. Low flow anaesthesia with isoflurane is one strategy to reduce costs.
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Affiliation(s)
- L. Weinberg
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
- Staff Anaesthetist, Department of Anaesthesia and Senior Fellow, Department of Surgery, University of Melbourne, Austin Hospital
| | - D. Story
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
- Head of Research, Department of Anaesthesia and Associate Professor, Department of Surgery, University of Melbourne, Austin Hospital
| | - J. Nam
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
| | - L. McNicol
- Department of Anaesthesia, Austin Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia; Medical Director, Anaesthesia, Perioperative and Intensive Care, Clinical Services Unit and Associate Professor, Department of Surgery, University of Melbourne, Austin Hospital
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Abstract
This report involves a review of 736 cases of anaesthesia-related morbidity reported from 1990 to 2005 by the Victorian Consultative Council on Anaesthetic Mortality and Morbidity. Using a combination of an established classification system, emerging categorisation definitions and appropriate keywords, an analysis of the clinical issues and contributory factors was undertaken. Airway-related morbidity, respiratory complications and drug-related adverse events are the most commonly reported. Organisational issues are increasingly implicated in adverse anaesthesia outcomes.
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Affiliation(s)
- L. McNicol
- Victorian Consultative Council on Anaesthetic Mortality and Morbidity, Melbourne, Victoria, Australia
- Chairman, Victorian Consultative Council on Anaesthetic Mortality and Morbidity, Director of Anaesthesia, Austin Health
| | - P. Mackay
- Victorian Consultative Council on Anaesthetic Mortality and Morbidity, Melbourne, Victoria, Australia
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Abstract
SUMMARY We performed a prospective randomised trial to evaluate the analgesic efficacy of interpleural analgesia in patients undergoing hepatic resection. The control group (n = 25) received multimodal analgesia with intravenous morphine patient-controlled analgesia; in addition, the interventional group (n = 25) received interpleural analgesia with a 20-ml loading dose of levo bupivacaine 0.5% followed by a continuous infusion of levobupivacaine 0.125%. Outcome measures included pain intensity on movement using a visual analogue scale over 24 h, cumulative morphine and rescue analgesia requirements, patient satisfaction, hospital stay and all adverse events. Patients in the interpleural group were less sedated and none required treatment for respiratory depression compared to 6 (24%) in the control group (p< 0.01). Patients in the interpleural group also had lower pain scores during movement in the first 24 h. Patients' satisfaction, opioid requirements and duration of hospital stay were similar. We conclude that continuous interpleural analgesia augments intravenous morphine analgesia, decreases postoperative sedation and reduces respiratory depression after hepatic resection.
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Affiliation(s)
- L Weinberg
- Department of Surgery, University of Melbourne, Austin Hospital, Heidelberg, Victoria, Australia.
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Weinberg L, Scurrah N, Gunning K, McNicol L. Postoperative changes in prothrombin time following hepatic resection: implications for perioperative analgesia. Anaesth Intensive Care 2006; 34:438-43. [PMID: 16913338 DOI: 10.1177/0310057x0603400405] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Disorders of coagulation may occur after uncomplicated hepatic resection in patients who have normal preoperative coagulation profiles and liver function tests. We present a retrospective study performed in a tertiary care university teaching hospital examining changes in liver function tests and coagulation profiles in patients undergoing hepatic resection. Data were obtained for 124 patients. When compared to the preoperative values, prothrombin times were significantly increased throughout the postoperative period. Prolongation of the prothrombin time was related to both duration of surgery and hepatic resection weight. There was no relationship between prothrombin time and patient age. Disorders of coagulation occur after hepatic resection even in patients who have normal preoperative coagulation and liver function tests. This has implications for anaesthetic practice, particularly when considering the use of an indwelling epidural catheter in patients undergoing hepatic resection.
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Affiliation(s)
- L Weinberg
- Department of Anaesthesia, Austin Health, Victoria, Australia
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Abstract
OBJECTIVE The role of the splanchnic circulation in the development of the metabolic acidosis of cardiopulmonary bypass (CPB) is not fully understood. New quantitative methods of acid-base balance now offer the ability to define this phenomenon more accurately. Accordingly, we studied acid-base changes across the splanchnic circulation during CPB and defined and quantified the factors that contributed to acid-base balance. DESIGN Prospective cohort study. SETTING Tertiary institution. PATIENTS Ten patients undergoing CPB for coronary artery bypass surgery. INTERVENTIONS Sampling of arterial and hepatic venous blood at four time intervals: postinduction, on CPB during cooling and rewarming, and at skin closure. MEASUREMENTS Measurement of serum Na+, K+, Mg++, Ca++, Cl-, HCO3-, and phosphate concentrations, arterial and hepatic venous blood gases and serum albumin, and lactate and pyruvate concentrations at each collection point. Analysis of findings according to quantitative physicochemical principles. MAIN RESULTS All patients developed a mild metabolic acidosis with a decrease in median serum bicarbonate concentration from 24.97 mEq/L after induction to 22.29 mEq/L at cooling and 22.23 mEq/L at rewarming (p < .05). Before CPB, the pH decreased by 0.0275 (p < .05) across the splanchnic circulation, representing an increase of 2.26 nmol/L of hydrogen ions. Nevertheless, the splanchnic circulation induced a metabolic alkalosis, with a median transsplanchnic increase in the base excess of 1.50 mEq/L (p < .05). This change was largely due to a decrease in serum chloride and lactate concentration across the splanchnic circulation (p < .05). The acidifying effect of the splanchnic circulation was therefore the result of cell respiration with a median increase in carbon dioxide tension of 5.75 mm Hg (p < .05), causing the strong ion difference effective to increase by 1.94 mEq/L (p < .05). There were no other anions or acids added to the circulation by splanchnic organs (no change in strong ion gap). During and after CPB the splanchnic metabolic alkalinizing effect continued and the respiratory acidifying effect was reduced. This caused the splanchnic circulation to be pH neutral at these times. CONCLUSIONS Using quantitative biophysical methods it can be demonstrated that the splanchnic circulation does not contribute to the metabolic acidosis of CPB, and that it continues to have a metabolic alkalinizing effect involving significant lactate extraction. However, its respiratory acidifying effect continues, although at a reduced rate.
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Affiliation(s)
- M Hayhoe
- Department of Intensive Care Medicine, Austin and Repatriation Medical Centre, Heidelberg, Austria
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Hayhoe M, Bellomo R, Liu G, McNicol L, Buxton B. The aetiology and pathogenesis of cardiopulmonary bypass-associated metabolic acidosis using polygeline pump prime. Intensive Care Med 1999; 25:680-5. [PMID: 10470571 DOI: 10.1007/s001340050930] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The pathogenesis of the metabolic acidosis of cardiopulmonary bypass (CPB) is not fully understood. New quantitative methods of acid-base balance now make it possible to describe it more clearly. Accordingly, we studied acid-base changes during CPB with polygeline pump prime and defined and quantified the factors which contribute to metabolic acidosis. DESIGN Prospective cohort study. SETTING Tertiary institution. PARTICIPANTS 10 cardiac bypass graft surgery patients. INTERVENTIONS Sampling of arterial blood at four time intervals: post-induction, on CPB during cooling and rewarming, and at skin closure. Measurement of serum Na+, K+, Mg++, Ca++, Cl-, bicarbonate, and phosphate concentrations, arterial blood gases, and serum albumin, lactate, and pyruvate concentrations at each collection point. Analysis of findings according to quantitative physicochemical principles, including calculation of the strong ion difference apparent, the strong ion difference effective, and the strong ion gap (SIG). MEASUREMENTS AND MAIN RESULTS All patients developed a mild metabolic acidosis. The median serum standard bicarbonate concentration decreased from 25.0 mEq/l post-induction to 22.3 mEq/l at cooling and 22.2 mEq/l at rewarming (p < 0.05). The standard base excess decreased from a median of 1.55 mEq/l prior to CPB, to -2.50 mEq/l at cooling, -1.65 mEq/l at rewarming and, -0.85 mEq/l at skin closure (p < 0.001). This mild metabolic acidosis occurred despite a decrease in the median serum lactate concentration from 3.20 mEq/l post-induction to 1.83, 1.80, and 1.58 mEq/l at the three other time points. The increase in the median serum chloride concentration from 104.9 mEq/l post induction to 111.0, 111.1, and 110.0 mEq/l at the subsequent time points (p < 0.0001) was the main cause of the acidosis. There was also a significant increase in the SIG of 3.8 mEq/l at cooling and rewarming (p < 0.0001), suggesting a role for other unmeasured anions (polygeline) in the genesis of this acidosis. CONCLUSIONS Using quantitative biophysical methods, it can be demonstrated that, in patients receiving a pump prime rich in chloride and polygeline, the metabolic acidosis of CPB is mostly due to iatrogenic increases in serum chloride concentration and unmeasured strong anions (SIG). Its development is partially attenuated by iatrogenic hypoalbuminaemia. Changes in lactate concentrations did not play a role in the development of metabolic acidosis in our patients.
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Affiliation(s)
- M Hayhoe
- Department of Intensive Care Medicine, Austin and Repatriation Medical Centre, Heidelberg, Australia
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McNicol L, Andersen LW, Liu G, Doolan L, Baek L. Markers of splanchnic perfusion and intestinal translocation of endotoxins during cardiopulmonary bypass: effects of dopamine and milrinone. J Cardiothorac Vasc Anesth 1999; 13:292-8. [PMID: 10392680 DOI: 10.1016/s1053-0770(99)90266-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate markers of splanchnic perfusion and the extent of endotoxemia during cardiopulmonary bypass (CPB) and to compare the effects of dopamine and milrinone on both splanchnic perfusion and endotoxemia. DESIGN Prospective, randomized, blinded study. SETTING University teaching hospital. PARTICIPANTS Twenty-four patients scheduled for elective coronary artery bypass graft surgery (CABG). INTERVENTIONS Patients were allocated to receive placebo (eight patients), dopamine (eight patients), or milrinone (eight patients) during CPB, and at seven times intraoperatively assays were performed of arterial and hepatic venous endotoxin levels, as well as measurements and/or calculations of intramucosal gastric pH (pHi), arterial and hepatic venous lactate-pyruvate ratio (lac/pyr), and hepatic venous oxygen saturation (S(HV)O2). MEASUREMENTS AND MAIN RESULTS Both splanchnic and systemic endotoxin levels increased significantly, and this was unaffected by either dopamine or milrinone. Gastric pHi did not change, and there were only modest increases in lac/pyr, which remained within the normal range of less than 10 in both splanchnic and systemic blood. In the placebo group, S(HV)O2 decreased at the onset of CPB and also significantly decreased during rewarming and at the end of CPB and surgery. In the dopamine-treated patients, S(HV)O2 was greater compared with placebo and milrinone during both hypothermic and rewarming phases. CONCLUSION Endotoxemia occurs during routine CPB. Neither pHi nor lac/pyr values showed adverse change, but hepatic venous oximetry may be a more sensitive indicator of splanchnic dysoxia in that S(HV)O2 was reduced during rewarming. Whether dopamine or milrinone confer protection against splanchnic ischemia remains uncertain.
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Affiliation(s)
- L McNicol
- Department of Anaesthesia, Austin and Repatriation Medical Centre, Melbourne, Australia
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McNicol L, Liu G, Hurley J, Hardy KJ, Jones RM. Endotoxin and tumor necrosis factor levels and hemodynamics during human liver transplantation. Transplant Proc 1993; 25:1828-9. [PMID: 8470184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- L McNicol
- Department of Anesthesiology, Austin Hospital, Heidelberg, Victoria, Australia
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Tancharoen S, Jones RM, Angus PW, Michell ID, McNicol L, Hardy KJ. Prostaglandin E1 therapy in orthotopic liver transplantation recipients: indications and outcome. Transplant Proc 1992; 24:2248-9. [PMID: 1413043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- S Tancharoen
- National Liver Transplant Unit, Austin Hospital, Heidelberg, Victoria
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Abstract
A case of gastric rupture and tension pneumonperitoneum following cardiac resuscitation is presented. Respiratory embarrassment necessitated emergency decompression by needle puncture of the peritoneal cavity, followed by laparotomy and repair of the gastric tear. The post-operative course has been satisfactory. The aetiology of the gastric rupture is discussed and recommendations are made for the prevention and treatment of this unusual complication of combined mouth to mouth respiration and external cardiac massage.
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