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Al-Adwi Y, Gan TJ, Bosma J, Abdulahad W, Atzeni IM, Van der Leij M, Kroesen BJ, Stel AJ, Timens W, Burgess J, Van Goor H, Westra J, Mulder DJ. AB0659 Recruitment and prevalence of mixed phenotype macrophages is prominent in Bronchoalveolar Lavage (BAL) of Systemic Sclerosis (SSc) patients with Interstitial Lung Disease (ILD). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundILD is a major problem in SSc for which no disease-modifying therapies are available. Many observations suggest monocyte/macrophage involvement in SSc and might be a key component in the development of ILD. Macrophages polarize into M1 and M2 phenotypes and thereby orchestrate inflammation and subsequent fibrosis by responding to and producing a vast array of cytokines and chemokines. Differences in the levels of the chemokines might explain variations in the recruitment and activation of macrophages in affected organs. In SSc, monocytes with a mixed phenotype (expressing both M1 and M2 markers) are prominent in peripheral blood. No previous study has investigated the mixed phenotype macrophages locally on the lung level.Objectivesa-to measure macrophage-related chemokines in BAL fluid obtained from SSc-ILD and SSc-no-ILD patients.b-to investigate levels of M1 and M2 macrophage markers in BAL cells obtained from SSc-ILD and SSc-no-ILD patients.MethodsA cross-sectional study in which BAL procedure was performed on 15 treatment-naïve SSc patients divided into two groups according to lung involvement determined by HRCT and lung function tests: SSc-no-ILD group and SSc-ILD group (Table 1). Levels of chemokines (CCL18, CXCL-10 and CCR2) were analysed using ELISA. mRNA expression levels of CD86 (M1; inflammatory macrophage marker) and CD206 (M2; fibrogenic macrophage marker) in cells isolated from BAL were assessed using RT-qPCR. In addition, immunofluorescence studies and flow cytometry analyses were performed to evaluate the expression of M1 (CD86) or M2 (CD206) markers in BAL macrophages.Table 1.Patient characteristicsno ILDILDNumber of patients87Age57 (51-68)60 (53-73)Female75%57%Raynauds phenomenon100%85%Age start of Raynauds36 (22-53)56 (41-66)Age start of non-Raynauds50 (33-60)49 (36-68)Skin thickening50%43%Digital ulcer at this moment0%29%Digital ulcer in the past38%29%Pitting scars38%43%Telangiectasia50%43%Calcinosis13%29%Cardiac25%14%Gastro-intestinal88%43%Kidney0%0%ResultsMacrophages were the predominant immune cell population in BAL of SSc patients (73%). The levels of CCL18, CCR2 and CXCL10 were slightly elevated in the SSc-ILD group compared to the SSc-no-ILD (Figure 1.1). RT-qPCR data showed that CD86 expression was elevated in the SSc-ILD group while no difference was observed in CD206 expression between the two groups (data not shown). The SSc-ILD group had higher proportions of double-positive (CD86+, CD206+) macrophages than SSc-no-ILD which, in contrast, had higher proportions of CD86+, CD206- macrophages (Figure 1.2). These results were supported by fluorescent microscopy images in which the SSc-ILD group had higher CD86 and CD206 expression than the SSc-no-ILD (Figure 1.3). Double staining clearly showed a more prevalent mixed activation of macrophages in the SSc-ILD group.ConclusionIn this pilot study, recruitment and activation of mixed phenotype macrophages was more prominent in SSc-ILD than in SSc-no-ILD. Although levels of chemokines were not profoundly different between both groups, studying extensively the macrophage activation patterns in BAL provided novel findings regarding differences between the two groups. Since SSc is characterised by inflammatory and fibrotic phases, the mixed polarization of macrophages we showed for the first time in SSc-ILD patients on an organ level is a key aspect in such disease and could potentially serve as a target for therapeutics.References[1]Perelas A, Silver RM, Arrossi AV, Highland KB. Systemic sclerosis-associated interstitial lung disease. Lancet Respir Med. 2020;8(3):304-320. doi:10.1016/S2213-2600(19)30480-1[2]Schmidt K, Martinez-Gamboa L, Meier S, et al. Bronchoalveoloar lavage fluid cytokines and chemokines as markers and predictors for the outcome of interstitial lung disease in systemic sclerosis patients. Arthritis Res Ther. 2009;11(4):R111. doi:10.1186/ar2766Disclosure of InterestsYehya Al-Adwi: None declared, Tji-Joong Gan: None declared, Janneke Bosma: None declared, Wayel Abdulahad: None declared, Isabella M. Atzeni: None declared, Marcel Van der Leij: None declared, Bart-Jan Kroesen: None declared, Alja J. Stel: None declared, Wim Timens: None declared, Janette Burgess: None declared, Harry van Goor: None declared, Johanna Westra: None declared, Douwe J Mulder Grant/research support from: Dr. DJ Mulder as an employee of the UMCG received research grants from Sanofi Genzyme which were paid to the UMCG
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Mallipattu SK, Jawa R, Moffitt R, Hajagos J, Fries B, Nachman S, Gan TJ, Saltz M, Saltz J, Kaushansky K, Skopicki H, Abell-Hart K, Chaudhri I, Deng J, Garcia V, Gayen S, Kurc T, Bolotova O, Yoo J, Dhaliwal S, Nataraj N, Sun S, Tsai C, Wang Y, Abbasi S, Abdullah R, Ahmad S, Bai K, Bennett-Guerrero E, Chua A, Gomes C, Griffel M, Kalogeropoulos A, Kiamanesh D, Kim N, Koraishy F, Lingham V, Mansour M, Marcos L, Miller J, Poovathor S, Rubano J, Rutigliano D, Sands M, Santora C, Schwartz J, Shroyer K, Spitzer S, Stopeck A, Talamini M, Tharakan M, Vosswinkel J, Wertheim W, Mallipattu SK, Jawa R, Moffitt R, Hajagos J, Fries B, Nachman S, Gan TJ, Saltz M, Saltz J, Kaushansky K, Skopicki H, Abell-Hart K, Chaudhri I, Deng J, Garcia V, Gayen S, Kurc T, Bolotova O, Yoo J, Dhaliwal S, Nataraj N, Sun S, Tsai C, Wang Y, Abbasi S, Abdullah R, Ahmad S, Bai K, Bennett-Guerrero E, Chua A, Gomes C, Griffel M, Kalogeropoulos A, Kiamanesh D, Kim N, Koraishy F, Lingham V, Mansour M, Marcos L, Miller J, Poovathor S, Rubano J, Rutigliano D, Sands M, Santora C, Schwartz J, Shroyer K, Spitzer S, Stopeck A, Talamini M, Tharakan M, Vosswinkel J, Wertheim W. Geospatial Distribution and Predictors of Mortality in Hospitalized Patients With COVID-19: A Cohort Study. Open Forum Infect Dis 2020; 7:ofaa436. [PMID: 33117852 PMCID: PMC7543608 DOI: 10.1093/ofid/ofaa436] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 09/09/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The global coronavirus disease 2019 (COVID-19) pandemic offers the opportunity to assess how hospitals manage the care of hospitalized patients with varying demographics and clinical presentations. The goal of this study was to demonstrate the impact of densely populated residential areas on hospitalization and to identify predictors of length of stay and mortality in hospitalized patients with COVID-19 in one of the hardest hit counties internationally. METHODS This was a single-center cohort study of 1325 sequentially hospitalized patients with COVID-19 in New York between March 2, 2020, to May 11, 2020. Geospatial distribution of study patients' residences relative to population density in the region were mapped, and data analysis included hospital length of stay, need and duration of invasive mechanical ventilation (IMV), and mortality. Logistic regression models were constructed to predict discharge dispositions in the remaining active study patients. RESULTS The median age of the study cohort (interquartile range [IQR]) was 62 (49-75) years, and more than half were male (57%) with history of hypertension (60%), obesity (41%), and diabetes (42%). Geographic residence of the study patients was disproportionately associated with areas of higher population density (r s = 0.235; P = .004), with noted "hot spots" in the region. Study patients were predominantly hypertensive (MAP > 90 mmHg; 670, 51%) on presentation with lymphopenia (590, 55%), hyponatremia (411, 31%), and kidney dysfunction (estimated glomerular filtration rate < 60 mL/min/1.73 m2; 381, 29%). Of the patients with a disposition (1188/1325), 15% (182/1188) required IMV and 21% (250/1188) developed acute kidney injury. In patients on IMV, the median (IQR) hospital length of stay in survivors (22 [16.5-29.5] days) was significantly longer than that of nonsurvivors (15 [10-23.75] days), but this was not due to prolonged time on the ventilator. The overall mortality in all hospitalized patients was 15%, and in patients receiving IMV it was 48%, which is predicted to minimally rise from 48% to 49% based on logistic regression models constructed to project disposition in the remaining patients on ventilators. Acute kidney injury during hospitalization (odds ratioE, 3.23) was the strongest predictor of mortality in patients requiring IMV. CONCLUSIONS This is the first study to collectively utilize the demographics, clinical characteristics, and hospital course of COVID-19 patients to identify predictors of poor outcomes that can be used for resource allocation in future waves of the pandemic.
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Affiliation(s)
| | - S K Mallipattu
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Jawa
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Moffitt
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Hajagos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - B Fries
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Nachman
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - T J Gan
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Saltz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Saltz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Kaushansky
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - H Skopicki
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Abell-Hart
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - I Chaudhri
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Deng
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - V Garcia
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Gayen
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - T Kurc
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - O Bolotova
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Yoo
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Dhaliwal
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - N Nataraj
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Sun
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Tsai
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - Y Wang
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Abbasi
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Abdullah
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Ahmad
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Bai
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - E Bennett-Guerrero
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Chua
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Gomes
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Griffel
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Kalogeropoulos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - D Kiamanesh
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - N Kim
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - F Koraishy
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - V Lingham
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Mansour
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - L Marcos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Miller
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Poovathor
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Rubano
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - D Rutigliano
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Sands
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Santora
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Schwartz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Shroyer
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Spitzer
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Stopeck
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Talamini
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Tharakan
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Vosswinkel
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - W Wertheim
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S K Mallipattu
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Jawa
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Moffitt
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Hajagos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - B Fries
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Nachman
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - T J Gan
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Saltz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Saltz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Kaushansky
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - H Skopicki
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Abell-Hart
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - I Chaudhri
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Deng
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - V Garcia
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Gayen
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - T Kurc
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - O Bolotova
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Yoo
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Dhaliwal
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - N Nataraj
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Sun
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Tsai
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - Y Wang
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Abbasi
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - R Abdullah
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Ahmad
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Bai
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - E Bennett-Guerrero
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Chua
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Gomes
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Griffel
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Kalogeropoulos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - D Kiamanesh
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - N Kim
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - F Koraishy
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - V Lingham
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Mansour
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - L Marcos
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Miller
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Poovathor
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Rubano
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - D Rutigliano
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Sands
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - C Santora
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Schwartz
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - K Shroyer
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - S Spitzer
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - A Stopeck
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Talamini
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - M Tharakan
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - J Vosswinkel
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
| | - W Wertheim
- Renaissance School of Medicine at Stony Brook University, Stony Brook University, Stony Brook, New York, USA
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Noll E, Gan TJ, Diemunsch P. Postoperative nausea self-reporting in Spanish-speaking children: reducing the grey zone in patient-reported outcomes. Br J Anaesth 2018; 121:1187-1188. [PMID: 30442239 DOI: 10.1016/j.bja.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Accepted: 08/03/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- E Noll
- Anesthesia and Intensive Care Department, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France; Insitut Hospitalo Universitaire 'Image-Guided Surgery', Strasbourg University Hospital, Strasbourg, France.
| | - T J Gan
- Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY, USA
| | - P Diemunsch
- Anesthesia and Intensive Care Department, Hautepierre Hospital, Strasbourg University Hospital, Strasbourg, France; Insitut Hospitalo Universitaire 'Image-Guided Surgery', Strasbourg University Hospital, Strasbourg, France
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Viscusi ER, DeLeon-Casasola O, Gan TJ, Onel E, Boccia G, Chu A, Keller MR, Ottoboni T, Patel SS, Quart B. HTX-011, a Proprietary, Extended-Release Combination of Bupivacaine and Meloxicam, Reduces Acute Postoperative Pain Intensity and Opioid Consumption after Bunionectomy: Results From an Interim Analysis. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.617] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Tien M, Gan TJ, Lacassie HJ, Habib AS. Dexamethasone, blood glucose and CONSORT guidelines - a reply. Anaesthesia 2017; 72:791-792. [PMID: 28654168 DOI: 10.1111/anae.13924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- M Tien
- Mayo Medical School, Rochester, MN, USA
| | - T J Gan
- Stony Brook University Medical Center, Stony Brook, NY, USA
| | - H J Lacassie
- Pontificia Universidad Catolica de Chile , Santiago, Chile
| | - A S Habib
- Duke University Medical Center, Durham, NC, USA
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Tien M, Gan TJ, Dhakal I, White WD, Olufolabi AJ, Fink R, Mishriky BM, Lacassie HJ, Habib AS. The effect of anti-emetic doses of dexamethasone on postoperative blood glucose levels in non-diabetic and diabetic patients: a prospective randomised controlled study. Anaesthesia 2016; 71:1037-43. [DOI: 10.1111/anae.13544] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 01/03/2023]
Affiliation(s)
- M. Tien
- Mayo Medical School; Mayo Clinic College of Medicine; Rochester Minnesota USA
| | - T. J. Gan
- Department of Anesthesiology; Stony Brook University Medical Center; Stony Brook New York USA
| | - I. Dhakal
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina USA
| | - W. D. White
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina USA
| | - A. J. Olufolabi
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina USA
| | - R. Fink
- Oregon Health and Science University; Portland Oregon USA
| | - B. M. Mishriky
- Department of medicine; East Carolina University; Greenville North Carolina USA
| | - H. J. Lacassie
- Pontificia Universidad Catolica de Chile; Facultad de Medicina; Santiago Chile
| | - A. S. Habib
- Department of Anesthesiology; Duke University Medical Center; Durham North Carolina USA
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Feldheiser A, Aziz O, Baldini G, Cox BPBW, Fearon KCH, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytrebø LM, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2: consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016; 60:289-334. [PMID: 26514824 PMCID: PMC5061107 DOI: 10.1111/aas.12651] [Citation(s) in RCA: 364] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 09/23/2015] [Accepted: 09/25/2015] [Indexed: 12/17/2022]
Abstract
Background The present interdisciplinary consensus review proposes clinical considerations and recommendations for anaesthetic practice in patients undergoing gastrointestinal surgery with an Enhanced Recovery after Surgery (ERAS) programme. Methods Studies were selected with particular attention being paid to meta‐analyses, randomized controlled trials and large prospective cohort studies. For each item of the perioperative treatment pathway, available English‐language literature was examined and reviewed. The group reached a consensus recommendation after critical appraisal of the literature. Results This consensus statement demonstrates that anaesthesiologists control several preoperative, intraoperative and postoperative ERAS elements. Further research is needed to verify the strength of these recommendations. Conclusions Based on the evidence available for each element of perioperative care pathways, the Enhanced Recovery After Surgery (ERAS ®) Society presents a comprehensive consensus review, clinical considerations and recommendations for anaesthesia care in patients undergoing gastrointestinal surgery within an ERAS programme. This unified protocol facilitates involvement of anaesthesiologists in the implementation of the ERAS programmes and allows for comparison between centres and it eventually might facilitate the design of multi‐institutional prospective and adequately powered randomized trials.
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Affiliation(s)
- A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - O. Aziz
- St. Mark's Hospital Harrow Middlesex UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - B. P. B. W. Cox
- Department of Anesthesiology and Pain Therapy University Hospital Maastricht (azM) Maastricht The Netherlands
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - R. H. Kennedy
- St. Mark's Hospital/Imperial College Harrow, Middlesex/London UK
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - D. N. Lobo
- Gastrointestinal Surgery National Institute for Health Research Nottingham Digestive Diseases Biomedical Research Unit Nottingham University Hospitals and University of Nottingham Queen's Medical Centre Nottingham UK
| | - T. Miller
- Department of Anesthesiology Duke University Medical Center Durham North Carolina USA
| | - F. F. Radtke
- Department of Anesthesiology and Intensive Care Medicine Campus Charité Mitte and Campus Virchow‐Klinikum Charité University Medicine Berlin Germany
| | - T. Ruiz Garces
- Anestesiologa y Reanimacin Hospital Clinico Lozano Blesa Universidad de Zaragoza Zaragoza Spain
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal Quebec Canada
| | - M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Surrey UK
| | - J. K. Thacker
- Department of Surgery Duke University Medical Center Durham North Carolina USA
| | - L. M. Ytrebø
- Department of Anaesthesiology University Hospital of North Norway Tromso Norway
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal Quebec Canada
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Affiliation(s)
- R. Gupta
- Department of Anaesthesia; Stony Brook University School of Medicine; Stony Brook New York USA
| | - T. J. Gan
- Department of Anaesthesia; Stony Brook University School of Medicine; Stony Brook New York USA
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Scott MJ, Baldini G, Fearon KCH, Feldheiser A, Feldman LS, Gan TJ, Ljungqvist O, Lobo DN, Rockall TA, Schricker T, Carli F. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand 2015; 59:1212-31. [PMID: 26346577 PMCID: PMC5049676 DOI: 10.1111/aas.12601] [Citation(s) in RCA: 221] [Impact Index Per Article: 24.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 06/18/2015] [Accepted: 07/23/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND The present article has been written to convey concepts of anaesthetic care within the context of an Enhanced Recovery After Surgery (ERAS) programme, thus aligning the practice of anaesthesia with the care delivered by the surgical team before, during and after surgery. METHODS The physiological principles supporting the implementation of the ERAS programmes in patients undergoing major abdominal procedures are reviewed using an updated literature search and discussed by a multidisciplinary group composed of anaesthesiologists and surgeons with the aim to improve perioperative care. RESULTS The pathophysiology of some key perioperative elements disturbing the homoeostatic mechanisms such as insulin resistance, ileus and pain is here discussed. CONCLUSIONS Evidence-based strategies aimed at controlling the disruption of homoeostasis need to be evaluated in the context of ERAS programmes. Anaesthesiologists could, therefore, play a crucial role in facilitating the recovery process.
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Affiliation(s)
- M. J. Scott
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - G. Baldini
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - K. C. H. Fearon
- University of Edinburgh The Royal Infirmary Clinical Surgery Edinburgh UK
| | - A. Feldheiser
- Department of Anesthesiology and Intensive Care Medicine Campus Charit Mitte and Campus Virchow‐Klinikum Charit University Medicine Berlin Germany
| | - L. S. Feldman
- Department of Surgery McGill University Health Centre Montreal General Hospital Montreal QC Canada
| | - T. J. Gan
- Department of Anesthesiology Duke University Medical Center Durham NY USA
| | - O. Ljungqvist
- Department of Surgery Faculty of Medicine and Health Orebro University Orebro 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
| | - T. A. Rockall
- Royal Surrey County Hospital NHS Foundation Trust University of Surrey Guildford UK
| | - T. Schricker
- Department of Anesthesia McGill University Health Centre Royal Victoria Hospital Montreal QC Canada
| | - F. Carli
- Department of Anesthesia McGill University Health Centre Montreal General Hospital Montreal QC Canada
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Waldron NH, Jones CA, Gan TJ, Allen TK, Habib AS. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth 2012; 110:191-200. [PMID: 23220857 DOI: 10.1093/bja/aes431] [Citation(s) in RCA: 391] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The analgesic efficacy and adverse effects of a single perioperative dose of dexamethasone are unclear. We performed a systematic review to evaluate the impact of a single i.v. dose of dexamethasone on postoperative pain and explore adverse events associated with this treatment. METHODS MEDLINE, EMBASE, CINAHL, and the Cochrane Register were searched for randomized, controlled studies that compared dexamethasone vs placebo or an antiemetic in adult patients undergoing general anaesthesia and reported pain outcomes. RESULTS Forty-five studies involving 5796 patients receiving dexamethasone 1.25-20 mg were included. Patients receiving dexamethasone had lower pain scores at 2 h {mean difference (MD) -0.49 [95% confidence interval (CI): -0.83, -0.15]} and 24 h [MD -0.48 (95% CI: -0.62, -0.35)] after surgery. Dexamethasone-treated patients used less opioids at 2 h [MD -0.87 mg morphine equivalents (95% CI: -1.40 to -0.33)] and 24 h [MD -2.33 mg morphine equivalents (95% CI: -4.39, -0.26)], required less rescue analgesia for intolerable pain [relative risk 0.80 (95% CI: 0.69, 0.93)], had longer time to first dose of analgesic [MD 12.06 min (95% CI: 0.80, 23.32)], and shorter stays in the post-anaesthesia care unit [MD -5.32 min (95% CI: -10.49 to -0.15)]. There was no dose-response with regard to the opioid-sparing effect. There was no increase in infection or delayed wound healing with dexamethasone, but blood glucose levels were higher at 24 h [MD 0.39 mmol litre(-1) (95% CI: 0.04, 0.74)]. CONCLUSIONS A single i.v. perioperative dose of dexamethasone had small but statistically significant analgesic benefits.
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Affiliation(s)
- N H Waldron
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA
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Chan KS, Chen WH, Gan TJ, Hsieh R, Chen C, Lakshminarayanan M, Revicki DA. Development and validation of a composite score based on clinically meaningful events for the opioid-related symptom distress scale. Qual Life Res 2009; 18:1331-40. [DOI: 10.1007/s11136-009-9547-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2009] [Indexed: 11/30/2022]
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Kranke P, Eberhart LH, Gan TJ, Roewer N, Tramèr MR. Algorithms for the prevention of postoperative nausea and vomiting: an efficacy and efficiency simulation. Eur J Anaesthesiol 2007; 24:856-67. [PMID: 17608963 DOI: 10.1017/s0265021507000713] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [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: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVE A number of algorithms for the prevention of postoperative nausea and vomiting have been proposed. Their efficacy and efficiency remains unclear. METHODS We assumed that four antiemetic interventions were similarly effective and achieved additive effects when combined. We applied published and hypothetical algorithms for the prevention of postoperative nausea and vomiting to patient populations with different baseline risks. As indicators of efficacy and efficiency we computed for each baseline risk and each algorithm the total number of patients receiving prophylaxis, the total number of administered interventions, the cumulative 24 h incidence of postoperative nausea and vomiting, and an Efficiency Index (i.e. the number of administered interventions divided by the achieved absolute risk reduction). This was done for cohorts of 100 patients. RESULTS Ten algorithms were tested in seven populations with different baseline risks. Algorithms were fixed (> or = 1 intervention given to all patients, independent of baseline risk) or risk-adapted (> or = 1 intervention administered depending on the presumed baseline risk). Risk-adapted algorithms were escalating (the greater the baseline risk, the more interventions are given) or dichotomous (a fixed number of interventions is given to high-risk patients only). With some algorithms, when applied to selected patient populations, the average postoperative nausea and vomiting incidence could be decreased below 15%; however, none produced consistent postoperative nausea and vomiting incidences below 20% across all populations. With all, the number of administered antiemetic interventions was the major factor for improved efficacy. Depending on the baseline risk, some algorithms offered potential towards improved efficiency. CONCLUSIONS Despite improved knowledge on risk factors and antiemetic strategies, none of the tested algorithms completely prevents postoperative nausea and vomiting and none is universally applicable. Anesthesiologists should try to identify the most useful antiemetic strategy for a specific setting. That strategy may be prophylactic or therapeutic or a combination of both, and it should consider institutional policies and individual baseline risks.
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Affiliation(s)
- P Kranke
- *University of Würzburg, Department of Anesthesiology, Würzburg, Germany.
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Diemunsch P, Gan TJ, Philip BK, Girao MJ, Eberhart L, Irwin MG, Pueyo J, Chelly JE, Carides AD, Reiss T, Evans JK, Lawson FC. Single-dose aprepitant vs ondansetron for the prevention of postoperative nausea and vomiting: a randomized, double-blind phase III trial in patients undergoing open abdominal surgery. Br J Anaesth 2007; 99:202-11. [PMID: 17540667 DOI: 10.1093/bja/aem133] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.4] [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: 12/30/2022] Open
Abstract
BACKGROUND The neurokinin(1) antagonist aprepitant is effective for prevention of chemotherapy-induced nausea and vomiting. We compared aprepitant with ondansetron for prevention of postoperative nausea and vomiting. METHODS Nine hundred and twenty-two patients receiving general anaesthesia for major abdominal surgery were assigned to receive a single preoperative dose of oral aprepitant 40 mg, oral aprepitant 125 mg, or i.v. ondansetron 4 mg in a randomized, double-blind trial. Vomiting episodes, use of rescue therapy, and nausea severity (verbal rating scale) were documented for 48 h after surgery. Primary efficacy endpoints were complete response (no vomiting and no use of rescue therapy) 0-24 h after surgery and no vomiting 0-24 h after surgery. The secondary endpoint was no vomiting 0-48 h after surgery. RESULTS Aprepitant at both doses was non-inferior to ondansetron for complete response 0-24 h after surgery (64% for aprepitant 40 mg, 63% for aprepitant 125 mg, and 55% for ondansetron, lower bound of 1-sided 95% CI > 0.65), superior to ondansetron for no vomiting 0-24 h after surgery (84% for aprepitant 40 mg, 86% for aprepitant 125 mg, and 71% for ondansetron; P < 0.001), and superior for no vomiting 0-48 h after surgery (82% for aprepitant, 40 mg, 85% for aprepitant, 125 mg, and 66% for ondansetron; P < 0.001). The distribution of peak nausea scores was lower in both aprepitant groups vs ondansetron (P < 0.05). CONCLUSIONS Aprepitant was non-inferior to ondansetron in achieving complete response for 24 h after surgery. Aprepitant was significantly more effective than ondansetron for preventing vomiting at 24 and 48 h after surgery, and in reducing nausea severity in the first 48 h after surgery. Aprepitant was generally well tolerated.
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Affiliation(s)
- P Diemunsch
- Services d'Anesthesiologie-Reanimation Chirurgicale, CHU, Hôpital de Hautepierre, 1 Avenue de Moliere, Strasbourg 67000, France.
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Abstract
We report a case of persistent post-dural puncture headache (PDPH) in a patient despite two epidural blood patches (EBPs). Successful resolution of headache was achieved with a third EBP performed under computed tomography (CT) guidance. A 38-year-old female had a total abdominal hysterectomy under combined spinal-epidural anesthesia with no complications. After surgery, she developed a postural headache consistent with PDPH. The first EBP was performed by injecting autologous blood through the epidural catheter that was in situ. The second EBP was performed under fluoroscopy. The patient continued to have a persistent headache. A computed tomography (CT) myelogram demonstrated cerebrospinal fluid (CSF) leak at L3-4 level. A "directed" CT-guided blood patch was then performed successfully with resolution of the headache.
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Affiliation(s)
- K-Y Ho
- Department of Anaesthesia and Surgical Intensive Care, Singapore General Hospital, Outram Road, Singapore 169608.
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Abstract
BACKGROUND Post-operative nausea and vomiting (PONV) is a common complication of anaesthesia. This study was conducted in 100 German and 100 Turkish patients scheduled for elective surgery under general anaesthesia to assess the amount patients were willing to pay for an anti-emetic that completely prevented PONV. METHODS Post-operatively, using Dixon's up and down method, patients completed an interactive computer questionnaire with a random starting point to determine how much of their own money they were willing to pay for a totally effective anti-emetic treatment. RESULTS On average, participants were willing to pay 65 euro in Germany and 68 euro in Turkey to avoid PONV. However, patients who actually experienced PONV were willing to pay larger amounts: 96 euro in Germany and 99 euro in Turkey. The amount patients were willing to pay was related to female sex, history of motion sickness, non-smoking status and better education. CONCLUSIONS Despite differences in political and cultural origin, health care system and financial background, the amount patients were willing to pay for an effective anti-emetic was similar in both Germany and Turkey to that reported previously for the USA.
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Affiliation(s)
- H Kerger
- Department of Anaesthesiology and Operative Critical Care Medicine, University Hospital of Mannheim, Mannheim, Germany
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Olufolabi AJ, Gan TJ, Lacassie HJ, White WD, Habib AS. A randomized, prospective double-blind comparison of the efficacy of generic propofol (sulphite additive) with Diprivan®. Eur J Anaesthesiol 2006; 23:341-5. [PMID: 16438763 DOI: 10.1017/s0265021505001961] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2005] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE We compared the dose requirement and side effect profile of total intravenous anaesthesia using Diprivan to generic propofol at a specific anaesthetic target level utilizing the bispectral index monitor to determine efficacy differences between the two products. METHODS Sixty women undergoing abdominal hysterectomy were induced with propofol 2 mg kg-1 and maintained with infusion (20-200 microg kg-1 min-1) adjusted to maintain a bispectral index of 50-65. Plasma propofol concentration was measured at 1 and 2 h post induction in 25 patients. RESULTS Mean (SD) drug doses adjusted for weight and time were similar in the Diprivan and generic propofol groups: 90 (30) microg kg-1 min-1 vs. 90 (20) microg kg-1 min-1 respectively. Mean (SD) plasma propofol levels at 1 and 2 h were also similar (3.0 (1.0) microg mL-1 vs. 3.6 (1.4) microg mL-1, P = 0.2 and 3.0 (1.9) microg mL-1 vs. 3.4 (1.6) microg mL-1, P = 0.58). CONCLUSIONS Diprivan and generic propofol have similar efficacy at a specified, bispectral index-defined, depth of anaesthesia.
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Affiliation(s)
- A J Olufolabi
- Duke University Medical Center, Department of Anesthesiology, Division of Women's Anaesthesia Research Group, Durham, NC 27710, USA.
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Stout RG, Gan TJ, Glass PSA, Silverman DG, Brull SJ. The effect of desflurane on rocuronium onset, clinical duration and maintenance requirements. Acta Anaesthesiol Belg 2006; 57:349-53. [PMID: 17236635] [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] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Volatile anesthetics potentiate the effects of non-depolarizing agents. This study investigated the interaction between the inhalational anesthetic desflurane and rocuronium. Forty ASA I and II patients randomly received desflurane/N2O/fentanyl, or propofol/ N2O/fentanyl anesthesia, and rocuronium 0.6 mg/kg. Neuromuscular block was assessed at the adductor pollicis muscle. Block onset and clinical duration times were measured; a rocuronium infusion was started when the first twitch on train-of-four returned to 10% of control (T10%). Maintenance infusion requirements and recovery profiles (spontaneous and after reversal) were recorded until recovery of twitch to 90% of control (T90%). Rocuronium onset was prolonged by 67% (p = 0.034), clinical duration by 30% (p = NS), and infusion requirements were lower in the desflurane group (4.5 vs. 7.1 mg/kg/min, p = 0.003). Recovery times were not statistically different. Desflurane significantly delays the onset of neuromuscular block, potentiates rocuronium during maintenance infusion, but does not affect clinical duration or recovery.
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Affiliation(s)
- R G Stout
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520-8051, USA
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D'Angelo R, Philip B, Gan TJ, Kovac A, Hantler C, Doblar D, Melson T, Minkowitz H, Dalby P, Coop A. A randomized, double-blind, dose-ranging, pilot study of intravenous granisetron in the prevention of postoperative nausea and vomiting in patients undergoing abdominal hysterectomy 1. Eur J Anaesthesiol 2005; 22:774-9. [PMID: 16211739 DOI: 10.1017/s0265021505001286] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Postoperative nausea and vomiting (PONV) is a frequent and unpleasant experience that may increase postoperative complications and costs. For surgical procedures with a high risk of PONV, prevention is preferable to treatment. In this study, the authors explore the dose-response relationship between granisetron administered just prior to the end of surgery and post-operative nausea and vomiting in patients undergoing abdominal hysterectomy. METHODS This was a randomized, double-blind, placebo-controlled, pilot study of post-operative nausea and vomiting prevention. Patients undergoing elective open abdominal hysterectomy requiring general anaesthesia received a single dose of granisetron 0.1, 0.2 or 0.3 mg or placebo administered approximately 15 min prior to the end of surgery. The primary efficacy end-point was the proportion of patients with no vomiting in the 0--6 h interval following medication administration. No inferential statistics were planned. RESULTS The proportion of patients with no vomiting episode in the 0--6 h interval after administration of study medication was higher in each granisetron treatment group (>90%) than in the placebo group (77%). Proportions of patients with no vomiting episodes in the 0--24 h interval were similar across treatment groups. Results of analyses of proportions of patients with no moderate or severe nausea episodes, proportions of those requiring rescue medication and times to first use of rescue medication suggested a treatment effect of granisetron relative to placebo in both the 0--6 and 0--24 h intervals. Similar proportions of patients in each treatment group reported at least one adverse event. CONCLUSIONS Granisetron at doses of 0.1, 0.2 and 0.3 mg administered just prior to the end of surgery suggested a trend of improved efficacy compared to placebo in preventing postoperative nausea and vomiting in the first 6 h after abdominal hysterectomy. This pilot study did not identify a dose-response relationship.
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Gan TJ, Joshi GP, Zhao SZ, Hanna DB, Cheung RY, Chen C. Presurgical intravenous parecoxib sodium and follow-up oral valdecoxib for pain management after laparoscopic cholecystectomy surgery reduces opioid requirements and opioid-related adverse effects. Acta Anaesthesiol Scand 2004; 48:1194-207. [PMID: 15352969 DOI: 10.1111/j.1399-6576.2004.00495.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [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: 02/06/2023]
Abstract
BACKGROUND Opioids are associated with numerous adverse effects. It is unclear if reduced postoperative opioid consumption lowers the incidence and severity of opioid-related adverse effects. This analysis -- from a multicenter, randomized, double-blind trial -- tested if the reduction of opioid consumption among patients who received intravenous preoperative parecoxib 40 mg, followed by oral valdecoxib 40 mg qd postoperatively, in Days 1-4 after outpatient laparoscopic cholecystectomy surgery, reduced opioid-related symptoms. METHODS Patients received intravenous fentanyl for pain before discharge, and oral acetaminophen 500 mg hydrocodone 5 mg q 4-6 h prn postdischarge for up to 7 days postsurgery. Patients also received intravenous parecoxib 40 mg administered 30-45 min preoperatively, and valdecoxib 40 mg qd up to Day 4 and prn Days 5-7 postsurgery, or placebo. Patients completed an opioid-related Symptoms Distress Scale (SDS) questionnaire every 24 h for 7 days. Opioid use was converted to morphine-equivalent doses (MEDs). Clinically meaningful events (CMEs) for 12 opioid-related symptoms were assessed by three ordinal measures: frequency, severity, and bothersomeness. Reduction of CMEs on Day 1 and number of patient-days with CMEs on Days 1-4 were examined. RESULTS Cumulative MEDs on Day 0, Day 1, and Days 1-4 were significantly lower in the parecoxib/valdecoxib group compared with the placebo group (P < 0.001). At the end of Day 1, parecoxib/valdecoxib-treated patients had significantly lower SDS scores (P < 0.02), a significantly reduced incidence of CMEs (P < 0.05), and significantly fewer patient-days with CMEs in Days 1-4 than placebo patients (P < 0.05). Patients in the parecoxib/valdecoxib group were less likely to have CMEs for multiple symptoms than those in the placebo group (P < 0.001). CONCLUSIONS Treatment with parecoxib and valdecoxib significantly reduced the cumulative MED requirements, the incidence of opioid-related adverse effects, and patient-days with CMEs.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
BACKGROUND Optimal treatment for acute pain is a function of an individual's willingness to make trade-offs between treatment side effects and pain control. The objective was to investigate the degree to which patients are willing to make these trade-offs. METHODS Fifty patients undergoing major abdominal surgery were enrolled and completed interviews before and after surgery. Measures included an experience with pain questionnaire and an adaptive conjoint analysis (ACA) interview. RESULTS Percentage of pain relief obtained post-surgery was between 70 and 80%. Eight-two per cent reported at least one moderate or severe side effect. ACA results demonstrated that pain efficacy and side effect type/severity have almost equal 'importance' scores. Patients varied in their willingness to trade-off pain efficacy for different or milder side effects. CONCLUSIONS We conclude that people have different relative preferences for different side effects and are willing to trade-off pain relief for less upsetting and/or less severe side effects but to different degrees. Thus, physicians should consider offering pain medications with fewer side effects than narcotics as a first choice. Our study indicates the need to balance analgesia and side effects in order for patients to achieve optimal pain control.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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Minkowitz H, Joshi G, Gan T, Cheung R, Hubbard R, Chen C, Fort J. Crit Care 2003; 7:P094. [DOI: 10.1186/cc1983] [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: 11/10/2022] Open
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Martin G, Bennett-Guerrero E, Wakeling H, Mythen MG, el-Moalem H, Robertson K, Kucmeroski D, Gan TJ. A prospective, randomized comparison of thromboelastographic coagulation profile in patients receiving lactated Ringer's solution, 6% hetastarch in a balanced-saline vehicle, or 6% hetastarch in saline during major surgery. J Cardiothorac Vasc Anesth 2002; 16:441-6. [PMID: 12154422 DOI: 10.1053/jcan.2002.125146] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.0] [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: 11/11/2022]
Abstract
OBJECTIVES To compare the effects of lactated Ringer's solution (LR), 6% hetastarch in a balanced-saline vehicle (HS-BS), and 6% hetastarch in normal saline (HS-NS) on coagulation using thromboelastography. DESIGN Prospective, randomized double-blinded evaluation of previously published clinical trial. SETTING Tertiary-care medical center. PARTICIPANTS Patients undergoing elective noncardiac surgery with an anticipated blood loss >500 mL. A total of 90 patients were enrolled with 30 patients in each group. INTERVENTIONS Patients received a standardized anesthetic. LR, HS-BS, and HS-NS were administered intraoperatively based on a fluid administration algorithm. Hemodynamic targets included maintenance of arterial blood pressure, heart rate, and urine output within a predefined range. MEASUREMENTS AND MAIN RESULTS Thromboelastography variables for r time, k time, maximum amplitude, and alpha angle (mean +/- SD) were recorded at induction of anesthesia, at the end of surgery, and 24 hours postoperatively. Patients in the LR group showed a state of hypercoagulation at the end of surgery with reductions (p < 0.005) in r time (-3.8 +/- 6.7 mm) and k time (-1.7 +/- 2.5 mm). This state of hypercoagulation continued into the postoperative period. Patients in the HS-NS group showed a state of hypocoagulation with increases (p < 0.05) in r time (+6.2 +/- 8.5 mm) and k time (+1.7 +/- 3.9 mm) and a reduction in maximum amplitude (-8.0 +/- 9.8 mm) at the end of surgery. This state of hypocoagulation was reduced in the postoperative period. Patients in the HS-BS group showed no significant changes in coagulation status at end of surgery, with the smallest changes in r time (-0.3 +/- 4.1 mm), k time (+0.1 +/- 3.1 mm), maximum amplitude (-5.4 +/- 12.3 mm), and alpha angle (0.3 +/- 12.5 degrees ). CONCLUSION LR-treated patients exhibited a hypercoagulative profile that persisted into the postoperative period. HS-BS administration was associated with a lesser change in the coagulation profile compared with HS-NS, which was associated with a hypocoagulative state.
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Affiliation(s)
- G Martin
- Department of Anesthesiology, and Division of Biometry, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
In October 1996, the Food and Drug Administration approved the use of the first anaesthesia effect monitor in the USA: the bispectral index (BIS) monitor (Aspect MS®, Newton, MA). The BIS is a computer-processed electro-encephalography (EEG) variable, which results in a single number, ranging from 0 (isoelectric EEG) to 100 in the awake state. It is derived by combining several different EEG descriptors: the BetaRatio, the SynchFastSlow and a measure of burst suppression (Rampil, 1998).
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Gan TJ, Lubarsky DA. Whose Value is it Anyway? Anesth Analg 2001. [DOI: 10.1213/00000539-200108000-00054] [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: 11/05/2022]
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Gan TJ, Madan R, Alexander R, Jhaveri R, El-Moalem H, Weatherwax K, Glass PS. Duration of action of vecuronium after an intubating dose of rapacuronium, vecuronium, or succinylcholine. Anesth Analg 2001; 92:1199-202. [PMID: 11323346 DOI: 10.1097/00000539-200105000-00022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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: 11/25/2022]
Abstract
UNLABELLED Rapacuronium (RAP) is a new, rapid-onset, short-duration, nondepolarizing neuromuscular blocker. If RAP is used to facilitate endotracheal intubation, what will the duration of a subsequent maintenance dose of vecuronium (VEC) be? We investigated the duration of action of a maintenance dose of VEC after intubation with RAP, VEC, or succinylcholine (SUC). Adult surgical patients under general anesthesia were randomly allocated to receive a tracheal intubating dose of RAP 1.5 mg/kg, VEC 0.1 mg/kg, or SUC 1 mg/kg. The anesthetic was induced with propofol and maintained with propofol, nitrous oxide, and oxygen. Neuromuscular function was monitored with electromyography. Recovery of the intubating dose of neuromuscular blocker was allowed to occur spontaneously until the first twitch of the train-of-four (T1) reached 50% of baseline, and then VEC 0.025 mg/kg (0.5 x 95% effective dose [ED(95)]) was administered. The onset, duration, and recovery to T1 = 25% and 50% were recorded. The durations of action (recovery of T1 25%) after intubating doses of RAP, VEC, and SUC were 13.7 +/- 5.3, 43.2 +/- 13.2, and 9.2 +/- 3.7 min (mean +/- SD), respectively (P < 0.0001). The times to maximum depression of T1 after a maintenance dose of VEC (0.5 x ED(95)) were 5.4 +/- 2.9, 5.1 +/- 2.5, and 5.3 +/- 2.8 min (mean +/- SD) for the RAP, VEC, and SUC groups, respectively. Recoveries to T1 25% after VEC for the RAP, VEC, and SUC groups were 18.9 +/- 11.5, 21.5 +/- 8.03, and 12.8 +/- 8.4 min, and at T1 50% they were 21.5 +/- 9.1, 30.8 +/- 9.5, and 15.5 +/- 9.7 min (mean +/- SD), respectively (P < 0.001, RAP and VEC versus SUC). The duration of action of a maintenance dose of VEC was similar after an intubating dose of RAP or VEC but was shortened when preceded by an intubating dose of SUC. IMPLICATIONS The duration of action of a maintenance dose of vecuronium was longer after an endotracheal intubating dose of rapacuronium compared with succinylcholine.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Durham, NC 27710, USA.
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Abstract
UNLABELLED The cost of a dose of succinylcholine from society's perspective equals the acquisition cost of the drug plus the cost of its adverse outcomes. We hypothesized that although the acquisition cost of succinylcholine is minimal, the true cost would be much larger. We reviewed the medical literature to identify the total cost of a dose of succinylcholine when administered for nonemergency purposes according to manufacturers' guidelines (i.e., to adults only). We found that 88% of the cost per dose of succinylcholine was for the chance of dying or sustaining permanent brain injury from anaphylactic or anaphylactoid reactions to succinylcholine. Consequently, the estimated cost per dose of succinylcholine was sensitive to the incidence of anaphylactic or anaphylactoid reactions to succinylcholine, the risk of severe injury from anaphylactic or anaphylactoid reactions, and the financial value of unforeseen instant death or permanent brain injury. The range for the cost per dose of succinylcholine was thus large, $9 to $93. Our best estimate of the cost per dose was $37. We conclude that the true cost per dose of succinylcholine from society's perspective is more than 20 times the acquisition cost. However, a precise costing requires better knowledge of the incidence and consequences of anaphylactic or anaphylactoid reactions to succinylcholine. IMPLICATIONS The true cost of succinylcholine is more than 20 times the acquisition cost of the drug. The estimated cost is very sensitive to the risk and cost of patients dying or sustaining brain injury from anaphylactic or anaphylactoid reactions to succinylcholine.
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Affiliation(s)
- F Dexter
- Department of Anesthesia, University of Iowa, Iowa City, Iowa 52242, USA.
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Abstract
Hysteroscopy is becoming a more widely used technique. Diagnostic hysteroscopy is replacing conventional dilatation and curettage in the diagnosis of intrauterine pathologies. Transcervical endometrial resection is often the first-line surgical treatment for dysfunctional uterine bleeding and carries less associated morbidity and morality. Overall, the technique is extremely safe, but vigilance is required particularly for intravasation of irrigation media. Complications such as gas embolus and hypo-osmolar hyponatremia require prompt treatment to reduce associated morbidity and morality. Careful monitoring of fluid deficit is paramount in avoiding the latter problem. Regional or general anesthetic techniques can be used and, in the ambulatory or office-based setting, in which these procedures are increasingly performed, the need for "street readiness" can influence the choice of the agents used.
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Affiliation(s)
- J A Murdoch
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Klein SM, Slaughter TF, Vail PT, Ginsberg B, El-Moalem HE, Alexander R, D'Ercole F, Greengrass RA, Perumal TT, Welsby I, Gan TJ. Thromboelastography as a perioperative measure of anticoagulation resulting from low molecular weight heparin: a comparison with anti-Xa concentrations. Anesth Analg 2000; 91:1091-5. [PMID: 11049889 DOI: 10.1097/00000539-200011000-00009] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [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: 11/25/2022]
Abstract
UNLABELLED Low molecular weight heparin (LMWH) is commonly used to prevent postoperative thromboembolism. Currently, there is no convenient test to measure the degree of anticoagulation from LMWH. This prospective study examines the relationship of thromboelastography and serum anti-Xa concentration in patients treated with enoxaparin. Twenty-four adult patients scheduled for orthopedic surgery using epidural anesthesia were enrolled. Epidural catheters were removed the morning after surgery before the commencement of subcutaneous enoxaparin 30 mg twice daily. Venous blood samples were obtained at 1) the induction of anesthesia (baseline), 2) immediately before the third dose of enoxaparin postoperatively (Day 2-trough), 3) 4 h after the third dose postoperatively (Day 2-peak), and 4) immediately before the fifth dose postoperatively (Day 3-trough). Whole blood samples were obtained for thromboelastography, activated clotting time, and anti-Xa level analyses at each of the four time intervals. At the four sample intervals, the r time (mean +/- SEM). (20 +/- 1, 25 +/- 2, 51 +/- 6, 31 +/- 3 mm) and the k time (9 +/- 0. 7, 12 +/- 1, 27 +/- 5, 14 +/- 2 mm) of the thromboelastograph were significantly correlated with the expected peak and trough levels of LMWH and serum anti-Xa levels (P: < 0.05). At the Day 3-trough, thromboelastograph r times exceeded the normal range in 6 of 25 patients (25%). Prolongation of r time and k time on postoperative Day 3 may indicate an exaggerated response to LMWH. Thromboelastography is a test that could potentially correlate with the degree of anticoagulation produced by low molecular weight heparin. IMPLICATIONS Thromboelastography is a test that could potentially correlate with the degree of anticoagulation produced by low molecular weight heparin. The r time from the thromboelastogram correlates with serum anti-Xa concentration.
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Affiliation(s)
- S M Klein
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Fabling JM, Gan TJ, El-Moalem HE, Warner DS, Borel CO. A randomized, double-blinded comparison of ondansetron, droperidol, and placebo for prevention of postoperative nausea and vomiting after supratentorial craniotomy. Anesth Analg 2000; 91:358-61. [PMID: 10910848 DOI: 10.1097/00000539-200008000-00023] [Citation(s) in RCA: 24] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
UNLABELLED Nausea or vomiting occurs frequently after craniotomy. Because of the need for frequent postoperative neurological assessment, an effective antiemetic with minimal sedative side effects is needed. Therefore, we compared ondansetron to droperidol in a randomized, double-blinded, placebo-controlled study. A total of 60 adults requiring elective supratentorial craniotomy received standardized IV anesthesia with 4 mg of ondansetron, 0.625 mg of droperidol, or placebo at skin closure. The incidence of postoperative nausea, emesis, pain and sedation scores, and rescue antiemetic use were recorded at 0, 0.5, 1, 4, 8, 12, 24, and 48 h. All groups were demographically similar. Differences existed for cumulative 8, 12, and 24 h incidences of nausea (24 h, P = 0.03) and emesis (24 h, P = 0.04). Within 4 h, when maximal effect could be expected from treatment, 20% of the ondansetron group, 25% of the droperidol group and 50% of the placebo group received rescue antiemetic (P = 0.12). No differences in pain (P = 0.82) or sedation (P = 0.74) scores were detected. Both ondansetron and droperidol prevent nausea; however, only droperidol reduces emesis after supratentorial craniotomy. The dose of droperidol used was not more sedating than ondansetron. Sustained reduction in nausea and emesis over 24 h indicates a preemptive benefit of prophylactic antiemetic in this surgical population. IMPLICATIONS Nausea and vomiting after brain surgery are particularly troubling, because effective treatment may cause sedation, making postoperative neurological assessment difficult. Our study shows that both ondansetron and droperidol are effective in reducing nausea, and that droperidol is particularly effective in reducing vomiting. Neither drug caused more sedation than placebo.
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Affiliation(s)
- J M Fabling
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
STUDY OBJECTIVES To investigate the use of propofol by anesthesiologists for its antiemetic effect and to compare our findings with published evidence. DESIGN Anonymous survey of U.S. anesthesiologists. SETTING American Society of Anesthesiologists' annual meeting. MEASUREMENTS AND MAIN RESULTS One hundred fifty anesthesiologists were surveyed on how they use propofol to achieve an antiemetic effect. A large majority (84%) of the anesthesiologists surveyed stated they used propofol for its antiemetic effect: 63% of those used propofol for induction only for cases lasting <1 h to achieve an antiemetic effect. In addition 37% used a "sandwich" technique, using propofol at the beginning and end of a case for a similar purpose. There is evidence that the antiemetic effect of propofol is associated with a defined plasma concentration range; mean, 343 ng/mL (10-90% confidence intervals [CI] 200-600 ng/mL). Simulation data demonstrated that after propofol 2 mg/kg, its concentration will drop below 350 ng/mL at 32 min. After 2 mg/kg and 20 mg within 10 min of the end of surgery, its concentration will drop below 350 ng/mL by 7 min after the 20 mg bolus dose. This finding suggests that the plasma concentrations of propofol, when used in these cases, will be below the effective range of antiemetic effect. CONCLUSIONS Many anesthesiologists used propofol for its antiemetic effect. There is strong evidence for its antiemetic efficacy after anesthesia maintained by a propofol infusion and also for its use in the postanesthesia care unit (PACU). However, there is little evidence to support its use purely at induction of anesthesia or as part of a "sandwich" technique in an attempt to reduce postoperative nausea and vomiting. This is especially true in cases lasting longer than a few minutes.
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Affiliation(s)
- A J Soppitt
- Dept. of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Iselin-Chaves IA, El Moalem HE, Gan TJ, Ginsberg B, Glass PS. Changes in the auditory evoked potentials and the bispectral index following propofol or propofol and alfentanil. Anesthesiology 2000; 92:1300-10. [PMID: 10781275 DOI: 10.1097/00000542-200005000-00018] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.7] [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: 11/26/2022]
Abstract
BACKGROUND Midlatency auditory evoked potentials (MLAEP) show graded changes with increasing doses of hypnotics but little change with opioids. The effect of their combination on the MLAEP was evaluated. Also, the bispectral index (BIS) was compared with the ability of MLAEP to correlate with sedation and predict loss of consciousness. METHODS Twenty healthy volunteers were randomly assigned to receive stepped increases in propofol concentration (10 subjects) or propofol plus alfentanil 100 ng/ml (10 subjects). At baseline and at each targeted effect site concentration the mean MLAEP, BIS, measures of sedation, and drug concentration were obtained. The relation among MLAEP, BIS, and sedation score was determined. The prediction probability (Pk) was calculated and compared for BIS and MLAEP. RESULTS The BIS and MLAEP patterns showed significant changes (Pa and Nb decreased in amplitude and increased in latency) with increasing level of sedation (P < 0.0001). The BIS correlated better with sedation scores (0.884) than did the MLAEP (P < 0.05). Pa and Nb latencies showed the best correlation with sedation levels (0.685 and 0.658, respectively). The addition of alfentanil did not affect the relation between MLAEP and loss of consciousness (P > 0.15). The BIS (Pk = 0.952) was a better predictor of loss of consciousness than were Pa and Nb amplitude (P < 0.05) but were comparable to Pa and Nb latency (Pk = 0.869 and 0. 873, respectively). CONCLUSION MLAEP changes, like the BIS, correlate well with increasing sedation produced by propofol, and these changes in the MLAEP are independent of the presence of an opioid. Among all the MLAEP parameters, Pa and Nb latencies are the best predictors of increasing sedation and loss of consciousness.
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Affiliation(s)
- I A Iselin-Chaves
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Hill RP, Lubarsky DA, Phillips-Bute B, Fortney JT, Creed MR, Glass PS, Gan TJ. Cost-effectiveness of prophylactic antiemetic therapy with ondansetron, droperidol, or placebo. Anesthesiology 2000; 92:958-67. [PMID: 10754614 DOI: 10.1097/00000542-200004000-00012] [Citation(s) in RCA: 200] [Impact Index Per Article: 8.3] [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: 11/26/2022]
Abstract
BACKGROUND In an era of growing economic constraints on healthcare delivery, anesthesiologists are increasingly expected to understand cost analysis and evaluate clinical practices. Postoperative nausea and vomiting (PONV) are distressing for patients and may increase costs in an ambulatory surgical unit. The authors compared the cost-effectiveness of four prophylactic intravenous regimens for PONV: 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo. METHODS Adult surgical outpatients at high risk for PONV were studied. Study drugs were administered intravenously within 20 min of induction of nitrous oxide-isoflurane or enflurane anesthesia. A decision-tree analysis was used to group patients into 12 mutually exclusive subgroups based on treatment and outcome. Costs were calculated for the prevention and treatment of PONV. Cost-effectiveness analysis was performed for each group. RESULTS Two thousand sixty-one patients were enrolled. Efficacy data for study drugs have been previously reported, and the database from that study was used for pharmacoeconomic analysis. The mean-median total cost per patient who received prophylactic treatment with 4 mg ondansetron, 0.625 mg droperidol, 1.25 mg droperidol, and placebo were $112 or $16.44, $109 or $0.63, $104 or $0.51, and $164 or $51.20, respectively (P = 0.001, active treatment groups vs. placebo). The use of a prophylactic antiemetic agent significantly increased patient satisfaction (P < 0.05). Personnel costs in managing PONV and unexpected hospital admission constitute major cost components in our analysis. Exclusion of nursing labor costs from the calculation did not alter the overall conclusions regarding the relative costs of antiemetic therapy. CONCLUSION The use of prophylactic antiemetic therapy in high-risk ambulatory surgical patients was more effective in preventing PONV and achieved greater patient satisfaction at a lower cost compared with placebo. The use of 1.25 mg droperidol intravenously was associated with greater effectiveness, lower costs, and similar patient satisfaction compared with 0.625 mg droperidol intravenously and 4 mg ondansetron intravenously.
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Affiliation(s)
- R P Hill
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Soppitt AJ, Glass PS, el-Moalem H, Ginsberg B, Weatherwax K, Gan TJ. Duration and recovery profile of cisatracurium after succinylcholine during propofol or isoflurane anesthesia. J Clin Anesth 1999; 11:652-6. [PMID: 10680107 DOI: 10.1016/s0952-8180(99)00118-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [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: 11/17/2022]
Abstract
STUDY OBJECTIVE To determine the duration and recovery profile of maintenance doses of cisatracurium besylate following succinylcholine, and during propofol or isoflurane anesthesia. DESIGN Randomized, open-label study. SETTING Operating suite of a university-affiliated medical center. PATIENTS Forty ASA physical status I and II adult patients having elective surgery with general anesthesia lasting longer than 90 minutes. INTERVENTIONS Following a standardized induction sequence, a baseline electromyogram (EMG) was obtained. An intubating dose of intravenous (i.v.) succinylcholine 1.0 mg/kg was administered. Ventilation was maintained with a face mask until the first twitch (T1) of the evoked train-of-four (TOF) reached 10% of control when tracheal intubation was performed. Spontaneous recovery from neuromuscular blockade was allowed to occur until the first twitch returned to 25% of control. Patients then were randomized to receive cisatracurium as follows. Group 1: 0.025 mg/kg [0.5 x 95% effective dose (ED95)]; Group 2: 0.05 mg/kg (ED95); Group 3: 0.05 mg/kg (ED95); and Group 4: 0.1 mg/kg (2 x ED95). Anesthesia for Groups 1 and 2 were maintained with isoflurane 1% to 2%, 66% nitrous oxide (N2O) in oxygen (O2), and in Groups 3 and 4, anesthesia was maintained with propofol 80 to 160 micrograms/kg/min, 66% N2O in O2. The TOF-evoked EMG was recorded at 10-second intervals. The time for the evoked EMG to spontaneously return to 25%, 50%, and 75% of the original baseline was recorded. MEASUREMENTS AND MAIN RESULTS There were 10 patients in each of the four groups. The duration of action of cisatracurium 0.05 mg/kg (ED95) after an intubating dose of succinylcholine is 24.5 +/- 10 minutes and 21.3 +/- 9 minutes during anesthesia maintained with isoflurance and propofol, respectively. Doubling the dose of cisatracurium resulted in approximately twice the duration of action (40.2 +/- 7 min) during propofol anesthesia. Following a dose of cisatracurium 0.025 mg/kg (0.5 x ED95), the T1 of the EMG-evoked response did not decrease below 25% in 7 of 10 patients. CONCLUSION Following succinylcholine, the duration of action of a single dose of cisatracurium 0.05 mg/kg is 20 to 25 minutes during anesthesia maintained with propofol or isoflurane. The duration and recovery profile of cisatracurium is dose dependent during propofol and isoflurane anesthetics. Cisatracurium 0.025 mg/kg is an inadequate maintenance dose following recovery from succinylcholine and it fails to provide adequate surgical relaxation.
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Affiliation(s)
- A J Soppitt
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Fleming NW, Chung F, Glass PS, Kitts JB, Kirkegaard-Nielsen H, Gronert GA, Chan V, Gan TJ, Cicutti N, Caldwell JE. Comparison of the intubation conditions provided by rapacuronium (ORG 9487) or succinylcholine in humans during anesthesia with fentanyl and propofol. Anesthesiology 1999; 91:1311-7. [PMID: 10551582 DOI: 10.1097/00000542-199911000-00023] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [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: 11/26/2022]
Abstract
BACKGROUND Currently, the only approved muscle relaxant with a rapid onset and short duration of action is succinylcholine, a drug with some undesirable effects. Rapacuronium is an investigational nondepolarizing relaxant that also has a rapid onset and short duration and consequently should be compared with succinylcholine in its ability to facilitate rapid tracheal intubation. METHODS This prospective, randomized clinical trial involved 336 patients. Anesthesia was induced with fentanyl and propofol and either 1.5 mg/kg rapacuronium or 1.0 mg/kg succinylcholine. The goal was to accomplish tracheal intubation by 60 s after administration of the neuromuscular blocking drug. Endotracheal intubation was performed, and conditions were graded by a blinded investigator. Recovery of neuromuscular function was assessed by electromyography. RESULTS Intubation conditions were evaluated in 236 patients. Intubation by 60 s after drug administration occurred in 100% of patients with rapacuronium and in 98% with succinylcholine. Intubation conditions were excellent or good in 87% of patients with rapacuronium and in 95% with succinylcholine (P < 0.05). The time (median and range) to the first recovery of the train-of-four response was 8.0 (2.8-20.0) min with rapacuronium and 5.7 (1.8-17.7) min with succinylcholine (P < 0.05). The overall incidence of adverse effects was similar with both drugs. CONCLUSIONS A 1.5-mg/kg dose of rapacuronium effectively facilitates rapid tracheal intubation. It can be considered a valid alternative to 1.0 mg/kg succinylcholine for this purpose.
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Affiliation(s)
- N W Fleming
- Department of Anesthesiology, University of California, Davis, USA
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Abstract
BACKGROUND The role of propofol for the management of postoperative nausea and vomiting (PONV) is not well established. This study determines the efficacy of small doses of propofol administered by patient-controlled device for the treatment of PONV. METHODS Patients presenting for ambulatory surgery received a standardized general anesthetic. Those who experienced significant nausea or emesis within 1 h of arrival in the recovery room were randomized to receive repeated doses of propofol 20 mg (P-20), propofol 40 mg (P-40), or intralipid (placebo) on demand. Study medications (in equal volumes) were administered with a patient-controlled delivery device for 2 h. A lockout interval of 5 min between doses was used. The following parameters were assessed: nausea, vomiting, rescue antiemetic use, recovery profile, study drug administration history, and satisfaction with treatment. RESULTS Sixty-nine patients participated in the study. Patient demographics were similar. The average nausea score for a patient in the P-20 and P-40 groups was 25% and 29% less, respectively, compared with placebo during the study period (P < 0.05). This difference was apparent 15 min after initiation of therapy. More placebo patients vomited (P-20, 12%; P-40, 23%; placebo, 56%; P = 0.003) and needed rescue antiemetics (P-20, 17%; P-40, 23%; placebo, 70%; P = 0.001) compared with treatment groups. Sedation scores were similar between groups. Propofol-treated patients had shorter stays in the post-anesthesia care unit (PACU; P-20, 131+/-35 min [mean +/- SD]; P-40, 141+/-34 min; placebo, 191+/-92 min; P = 0.005) and higher satisfaction with their control of PONV than placebo (P < 0.01). CONCLUSIONS Propofol is effective in managing PONV with shorter PACU stay and great degree of patient satisfaction. There were two episodes of oversedation in the P-40 group. Hence, propofol at a demand dose of 20 mg seems more appropriate.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Gan TJ, Bennett-Guerrero E, Phillips-Bute B, Wakeling H, Moskowitz DM, Olufolabi Y, Konstadt SN, Bradford C, Glass PSA, Machin SJ, Mythen MG. Hextend[registered sign], a Physiologically Balanced Plasma Expander for Large Volume Use in Major Surgery. Anesth Analg 1999. [DOI: 10.1213/00000539-199905000-00005] [Citation(s) in RCA: 170] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gan TJ, Bennett-Guerrero E, Phillips-Bute B, Wakeling H, Moskowitz DM, Olufolabi Y, Konstadt SN, Bradford C, Glass PS, Machin SJ, Mythen MG. Hextend, a physiologically balanced plasma expander for large volume use in major surgery: a randomized phase III clinical trial. Hextend Study Group. Anesth Analg 1999; 88:992-8. [PMID: 10320157 DOI: 10.1097/00000539-199905000-00005] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [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: 11/26/2022]
Abstract
UNLABELLED Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and physiological levels of glucose. In preclinical studies, its use in shock models was associated with an improvement in outcome compared with alternatives, such as albumin or 6% hetastarch in saline. In a prospective, randomized, two-center study (n = 120), we compared the efficacy and safety of Hextend versus 6% hetastarch in saline (HES) for the treatment of hypovolemia during major surgery. Patients at one center had a blood sample drawn at the beginning and the end of surgery for thromboelastographic (TEG) analysis. Hextend was as effective as HES for the treatment of hypovolemia. Patients received an average of 1596 mL of Hextend: 42% received >20 mL/kg up to a total of 5000 mL. No patient received albumin. Hextend-treated patients required less intraoperative calcium (4 vs 220 mg; P < 0.05). In a subset analysis of patients receiving red blood cell transfusions (n = 56; 47%), Hextend-treated patients had a lower mean estimated blood loss (956 mL less; P = 0.02) and were less likely to receive calcium supplementation (P = 0.04). Patients receiving HES demonstrated significant prolongation of time to onset of clot formation (based on TEG) not seen in the Hextend patients (P < 0.05). No Hextend patient experienced a related serious adverse event, and there was no difference in the total number of adverse events between the two groups. The results of this study demonstrate that Hextend, with its novel buffered, balanced electrolyte formulation, is as effective as 6% hetastarch in saline for the treatment of hypovolemia and may be a safe alternative even when used in volumes up to 5 L. IMPLICATIONS Hextend (BioTime, Inc., Berkeley, CA) is a new plasma volume expander containing 6% hetastarch, balanced electrolytes, a lactate buffer, and a physiological level of glucose. It is as effective as 6% hetastarch in saline for the treatment of hypovolemia but has a more favorable side effects profile in volumes of up to 5 L compared with 6% hetastarch in saline.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Gan TJ, Glass PS, Sigl J, Sebel P, Payne F, Rosow C, Embree P. Women emerge from general anesthesia with propofol/alfentanil/nitrous oxide faster than men. Anesthesiology 1999; 90:1283-7. [PMID: 10319774 DOI: 10.1097/00000542-199905000-00010] [Citation(s) in RCA: 107] [Impact Index Per Article: 4.3] [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: 01/17/2023]
Abstract
BACKGROUND Recovery from general anesthesia is governed by pharmacodynamic and pharmacokinetic factors. Gender has not previously been recognized as a factor influencing the time to emergence from general anesthesia. METHODS This multicenter study was originally designed to measure the effects of the bispectral index on intraoperative anesthetic management and patient recovery. We compared the wake-up and recovery times of 274 adults after propofol/alfentanil/nitrous oxide anesthesia. Patients were randomly assigned to have the titration of propofol performed with or without the use of bispectral index monitoring. Specific guidelines were given for the titration of drugs. The aim in all cases was to provide a safe anesthetic with the fastest possible recovery. RESULTS There was a significant reduction in propofol dose, time to eye opening, and response to verbal command when the anesthetic was titrated using the bispectral index. Unexpectedly, gender proved to be a highly significant independent predictor for recovery time. Women woke significantly faster than men: the time from end of anesthesia to eye opening was 7.05 versus 11.22 min, P < 0.05, and response to verbal command was 8.12 versus 11.67 min, P < 0.05. These differences were significant at all four study sites and in each treatment group. Men consistently had prolonged recovery times compared to women, P < 0.001. There was no difference in the dose of anesthetic used between gender. CONCLUSIONS Gender appears to be an important variable in recovery from general anesthesia. These findings may explain the increased reported incidence of awareness in women (three times more frequent) and support the need to include gender as a variable in pharmacokinetic and pharmacodynamic studies of anesthetic drugs.
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Affiliation(s)
- T J Gan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Gan TJ, Lubarsky DA. Cost effectiveness ratio: an often misunderstood term. Anesth Analg 1999; 88:1191-2. [PMID: 10320202 DOI: 10.1097/00000539-199905000-00052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Iselin-Chaves IA, Flaishon R, Sebel PS, Howell S, Gan TJ, Sigl J, Ginsberg B, Glass PS. The effect of the interaction of propofol and alfentanil on recall, loss of consciousness, and the Bispectral Index. Anesth Analg 1998; 87:949-55. [PMID: 9768800 DOI: 10.1097/00000539-199810000-00038] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [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: 11/25/2022]
Abstract
UNLABELLED The Bispectral Index (BIS) correlates well with the level of consciousness with single anesthetic drugs. We studied the effect of the interaction of propofol with alfentanil on propofol concentration and BIS associated with 50% probability of loss of consciousness and lack of recall (Cp50 and BIS50, respectively). We studied 40 consenting volunteers at two institutions who were randomly assigned to receive stepped increases of propofol (10 subjects at each site), propofol plus alfentanil 50 ng/mL (10 subjects at Emory site), or propofol plus alfentanil 100 ng/mL (10 subjects at Duke site) by using a target-controlled infusion device. Measures of sedation, BIS, deltaBIS (absolute change of BIS after a painful stimulus), memory, and drug concentration were obtained at each target drug concentration. The relation among BIS, measured drug concentration, sedation score, and presence or absence of recall was determined by linear and logistic regression for different drug regimens, and the prediction probability (Pk) was calculated. The addition of alfentanil in increasing doses did not significantly affect the BIS50 and propofol Cp50 values for loss of consciousness and lack of recall. DeltaBIS was significantly decreased by both an increase in the concentration of propofol and the presence of alfentanil. The Pk for BIS was >0.93 with all drug regimens, better than those of the target and measured propofol concentrations. We conclude that BIS correlated well with the hypnotic component of anesthesia independent of the presence of an opioid. Moreover, the level of consciousness, and, therefore, the BIS index, is affected by a painful stimulus, and this response is ablated either by opioids or increasing propofol concentration. IMPLICATIONS In volunteers, the sedation and changes in memory function produced by propofol correlated well with changes in the Bispectral Index. This relationship was not altered by the addition of an analgesic (alfentanil). However, in moderately sedated patients who received a painful stimulus, the Bispectral Index increased, but this response was blocked by the analgesic or increasing propofol concentrations.
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Affiliation(s)
- I A Iselin-Chaves
- Department of Anesthesiology, Duke University, Durham, North Carolina, USA
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Gan TJ, Rogers S. Informed Use of Buccal Oximetry. Anesth Analg 1998. [DOI: 10.1097/00000539-199808000-00053] [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: 11/25/2022]
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Gan TJ, Rogers S. Informed Use of Buccal Oximetry. Anesth Analg 1998. [DOI: 10.1213/00000539-199808000-00053] [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: 11/05/2022]
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Arrowsmith JE, Alexander R, Dear GL, Gan TJ, Hill RP, Olufolabi A, Sanderson IC, Soppitt AJ. Audit commission tackles anaesthetic services. Anaesthesia should remain physician based service. BMJ 1998; 316:1827. [PMID: 9624086 PMCID: PMC1113331 DOI: 10.1136/bmj.316.7147.1827a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Chari RS, Gan TJ, Robertson KM, Bass K, Camargo CA, Greig PD, Clavien PA. Venovenous bypass in adult orthotopic liver transplantation: routine or selective use? J Am Coll Surg 1998; 186:683-90. [PMID: 9632158 DOI: 10.1016/s1072-7515(98)00101-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [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: 02/06/2023]
Abstract
BACKGROUND The role of venovenous bypass (VVB) during orthotopic liver transplantation (OLT) remains controversial. The aims of this study were to evaluate the current role of VVB at all major centers in North America, to examine the results of OLT and complications of VVB between two periods with a strict policy for routine versus selective use of VVB, and to review the literature. STUDY DESIGN A survey of 50 major liver transplant centers was conducted using mailed questionnaires. A retrospective chart review was performed for 547 OLT patients having transplantation during two distinct periods with a strict policy for routine versus selective use of VVB at the University of Toronto, Canada, and at Duke University Medical Center, Durham, North Carolina. The literature was reviewed with a focus on the benefits and indications for routine versus selective use of VVB. RESULTS Thirty-eight (76%) of 50 centers responded. Sixteen (42%) of them used VVB routinely, with a reported complication rate of 10-30%. Lymphocele and hematoma were the most common complications, but patients having major vascular injury, air embolism, and death were reported. A recent change to selective use of VVB was reported in 30% of the centers (11 of 38). In the Duke-Toronto series, the complication rates were similar between the two periods, at 13.4% and 18.8%, respectively. The outcome of OLT was not influenced by the policy of routine or selective use of VVB. CONCLUSIONS There is a trend away from the routine use of VVB during OLT. Intraoperative hemodynamic instability during the hepatectomy and a failed trial of hepatic venous occlusion were the most important criteria for using VVB. We conclude that VVB should be used selectively to avoid associated complications and to decrease operative time and costs.
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Affiliation(s)
- R S Chari
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Fortney JT, Gan TJ, Graczyk S, Wetchler B, Melson T, Khalil S, McKenzie R, Parrillo S, Glass PS, Moote C, Wermeling D, Parasuraman TV, Duncan B, Creed MR. A comparison of the efficacy, safety, and patient satisfaction of ondansetron versus droperidol as antiemetics for elective outpatient surgical procedures. S3A-409 and S3A-410 Study Groups. Anesth Analg 1998; 86:731-8. [PMID: 9539593 DOI: 10.1097/00000539-199804000-00011] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [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: 02/07/2023]
Abstract
UNLABELLED Two identical, randomized, double-blind, placebo-controlled studies enrolled 2061 adult surgical outpatients at high risk of postoperative nausea and vomiting (PONV) to compare i.v. ondansetron 4 mg with droperidol 0.625 mg and droperidol 1.25 mg for the prevention of PONV. The antiemetic drugs or placebo were administered i.v. 20 min before the induction of anesthesia with a barbiturate compound, followed by maintenance with N2O/isoflurane/enflurane. Nausea, emetic episodes, adverse events, and patient satisfaction were analyzed for the 0 to 2 h and 0 to 24 h postoperative periods. In the 0 to 2 h postoperative period, there was a complete response (no emesis or rescue antiemetic) in 46% of subjects given placebo (P < 0.05 versus antiemetic groups), in 62% given ondansetron, in 63% given droperidol 0.625 mg, and in 69% given droperidol 1.25 mg (P < 0.05 versus ondansetron). In the 0 to 24-h postoperative period, there were no significant differences in complete response between the ondansetron and droperidol 0.625 or 1.25 mg groups; all groups remained superior to placebo. The proportion of patients without nausea during the 0 to 24 h postoperative period was greater in the antiemetic groups compared with the placebo group; however, droperidol 1.25 mg was more effective than ondansetron 4 mg or droperidol 0.625 mg (43% vs 29% or 29%, respectively). Headache incidence was higher in the ondansetron group compared with either droperidol group. Patient satisfaction scores did not differ significantly among antiemetic treatment groups, although all were superior to placebo. In conclusion, all antiemetic treatment regimens were superior to placebo for the prevention of PONV in the immediate postoperative period; however, droperidol 1.25 mg was more efficacious than ondansetron during the early recovery period (0-2 h). There were no significant differences between ondansetron and either droperidol dose for emesis prevention during the 0 to 24 h postoperative period. IMPLICATIONS More than 2000 patients at high risk of postoperative nausea and vomiting were given either placebo, ondansetron 4 mg, or droperidol 0.625 mg or 1.25 mg i.v. before the administration of general anesthesia. After surgery, the incidence of nausea, vomiting, medication side effects, and patient satisfaction were evaluated for 24 h. Droperidol 0.625 or 1.25 mg i.v. compared favorably with ondansetron 4 mg i.v. for the prevention of postoperative nausea and vomiting after ambulatory surgery.
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Affiliation(s)
- J T Fortney
- Department of Anesthesiology, Duke University, Durham, North Carolina 27710, USA
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