Ann Merete Møller

Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial

BACKGROUND Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers. Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement. METHODS We did a randomised trial in three hospitals in Denmark. 120 patients were randomly assigned 6-8 weeks before scheduled surgery to either the control (n=60) or smoking intervention (60) group. Smoking intervention was counselling and nicotine replacement therapy, and either smoking cessation or at least 50% smoking reduction. An assessor, who was masked to the intervention, registered the occurrence of cardiopulmonary, renal, neurological, or surgical complications and duration of hospital admittance. The main analysis was by intention to treat. FINDINGS Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled. Thus, 52 and 56 patients, respectively, were analysed for outcome. The overall complication rate was 18% in the smoking intervention group and 52% in controls (p=0.0003). The most significant effects of intervention were seen for wound-related complications (5% vs 31%, p=0.001), cardiovascular complications (0% vs 10%, p=0.08), and secondary surgery (4% vs 15%, p=0.07). The median length of stay was 11 days (range 7-55) in the intervention group and 13 days (8-65) in the control group. INTERPRETATION An effective smoking intervention programme 6-8 weeks before surgery reduces postoperative morbidity, and we recommend, on the basis of our results, this programme be adopted.

Cost‐analysis of robotic‐assisted laparoscopic hysterectomy versus total abdominal hysterectomy for women with endometrial cancer and atypical complex hyperplasia

The aim of this study was to analyse the hospital cost of treatment with robotic‐assisted laparoscopic hysterectomy and total abdominal hysterectomy for women with endometrial cancer or atypical complex hyperplasia and to identify differences in resource use and cost.

Effect of smoking on early complications after elective orthopaedic surgery

Smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. We studied 811 consecutive patients who had undergone hip or knee arthroplasty, recording current smoking and drinking habits, any history of chronic disease and such intraoperative factors as the type of anaesthesia and the type and duration of surgery. We recorded any postoperative complications occurring before discharge from hospital. There were 232 smokers (28.6%) and 579 non-smokers. We found that smoking was the single most important risk factor for the development of postoperative complications, particularly those relating to wound healing, cardiopulmonary complications, and the requirement of postoperative intensive care. A delay in discharge from hospital was usual for those suffering a complication. In those patients requiring prolonged hospitalisation (>15 days) the proportion of smokers with wound complications was twice that of non-smokers.

Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation

The aim of this study was to examine the effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation itself.

Smoking and alcohol intervention before surgery: evidence for best practice

Smoking and hazardous drinking are common and important risk factors for an increased rate of complications after surgery. The underlying pathophysiological mechanisms include organic dysfunctions that can recover with abstinence. Abstinence starting 3-8 weeks before surgery will significantly reduce the incidence of several serious postoperative complications, such as wound and cardiopulmonary complications and infections. However, this intervention must be intensive to obtain sufficient effect on surgical complications. All patients presenting for surgery should be questioned regarding smoking and hazardous drinking, and interventions appropriate for the surgical setting applied.

High body mass index is a weak predictor for difficult and failed tracheal intubation: a cohort study of 91,332 consecutive patients scheduled for direct laryngoscopy registered in the Danish Anesthesia Database.

Background:Previous studies have failed to detect high body mass index (BMI) as a risk factor for difficult tracheal intubation (DTI). BMI was investigated as a risk factor for DTI in patients planned for direct laryngoscopy. Methods:A cohort of 91,332 consecutive patients planned for intubation by direct laryngoscopy was retrieved from the Danish Anesthesia Database. A four-point scale to grade the tracheal intubation was used. Age, sex, American Society of Anesthesiologists physical status classification, priority of surgery, history of previous DTI, modified Mallampati-score, use of neuromuscular blocker, and BMI were retrived. Logistic regression to assess whether BMI was associated with DTI was performed. Results:The frequency of DTI was 5.2% (95% confidence interval [CI] 5.0–5.3). In multivariate analyses adjusted for other significant covariates, BMI of 35 or more was a risk for DTI with an odds ratio of 1.34 (95% CI 1.19–1.51, P < 0.0001). As a stand alone test, BMI of 35 or more predicted DTI with a sensitivity of 7.5% (95% CI 7.3–7.7%) and with a predictive value of a positive test of 6.4% (95% CI 6.3–6.6%). BMI as a continuous covariate was a risk for failed intubation with an odds ratio of 1.031 (95% CI 1.002–1.061, P < 0.04). Conclusions:High BMI is a weak but statistically significant predictor of difficult and failed intubation and may be more appropriate than weight in multivariate models of prediction of DTI.

Avoidance of neuromuscular blocking agents may increase the risk of difficult tracheal intubation: a cohort study of 103 812 consecutive adult patients recorded in the Danish Anaesthesia Database

BACKGROUND Previous studies indicate that avoiding neuromuscular blocking agents (NMBAs) may be a risk factor for difficult tracheal intubation (DTI). We investigated whether avoiding NMBA was associated with DTI. METHODS A cohort of 103,812 consecutive patients planned for tracheal intubation by direct laryngoscopy was retrieved from the Danish Anaesthesia Database. We used an intubation score based upon the number of attempts, change from direct laryngoscopy to a more advanced technique, or intubation by a different operator. We retrieved data on age, sex, ASA physical status classification, priority of surgery, time of surgery, previous DTI, modified Mallampati score, BMI, and the use of NMBA. Using logistic regression, we assessed whether avoiding NMBA was associated with DTI. RESULTS The frequency of DTI was 5.1 [95% confidence interval (CI): 5.0-5.3]%. In a univariate analysis, avoiding NMBA was associated with DTI, odds ratio (OR) 1.52 (95% CI: 1.43-1.61)%, P<0.0001. Using multivariate analysis, avoiding NMBA was associated with DTI, OR 1.48 (95% CI: 1.39-1.58), P<0.0001. Among patients intubated using NMBA, a multivariate analysis identified patients anaesthetized with only non-depolarizing NMBA to be more at risk for DTI than those anaesthetized with depolarizing NMBA alone. CONCLUSIONS Avoiding NMBA may increase the risk of DTI. However, confounding by indication may be a problem in this observational study and systematic reviews with meta-analysis or more randomized clinical trials are needed.

Inhaled nitric oxide for acute respiratory distress syndrome and acute lung injury in adults and children: a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: Acute hypoxemic respiratory failure, defined as acute lung injury and acute respiratory distress syndrome, are critical conditions associated with frequent mortality and morbidity in all ages. Inhaled nitric oxide (iNO) has been used to improve oxygenation, but its role remains controversial. We performed a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials (RCTs). We searched CENTRAL, Medline, Embase, International Web of Science, LILACS, the Chinese Biomedical Literature Database, and CINHAL (up to January 31, 2010). Additionally, we hand-searched reference lists, contacted authors and experts, and searched registers of ongoing trials. Two reviewers independently selected all parallel group RCTs comparing iNO with placebo or no intervention and extracted data related to study methods, interventions, outcomes, bias risk, and adverse events. All trials, irrespective of blinding or language status were included. Retrieved trials were evaluated with Cochrane methodology. Disagreements were resolved by discussion. Our primary outcome measure was all-cause mortality. We performed subgroup and sensitivity analyses to assess the effect of iNO in adults and children and on various clinical and physiological outcomes. We assessed the risk of bias through assessment of trial methodological components. We assessed the risk of random error by applying trial sequential analysis. RESULTS: We included 14 RCTs with a total of 1303 participants; 10 of these trials had a high risk of bias. iNO showed no statistically significant effect on overall mortality (40.2%versus 38.6%) (relative risks [RR] 1.06, 95% confidence interval [CI] 0.93 to 1.22; I2 = 0) and in several subgroup and sensitivity analyses, indicating robust results. Limited data demonstrated a statistically insignificant effect of iNO on duration of ventilation, ventilator-free days, and length of stay in the intensive care unit and hospital. We found a statistically significant but transient improvement in oxygenation in the first 24 hours, expressed as the ratio of PO2 to fraction of inspired oxygen (mean difference [MD] 15.91, 95% CI 8.25 to 23.56; I2 = 25%). However, iNO appears to increase the risk of renal impairment among adults (RR 1.59, 95% CI 1.17 to 2.16; I2 = 0) but not the risk of bleeding or methemoglobin or nitrogen dioxide formation. CONCLUSION: iNO cannot be recommended for patients with acute hypoxemic respiratory failure. iNO results in a transient improvement in oxygenation but does not reduce mortality and may be harmful.

Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.

Background:Anesthesia is associated with complications, and some of them may be fatal. The authors investigated the circumstances under which deaths were associated with anesthesia. In Denmark, the specialty anesthesiology encompasses emergency medicine, chronic and acute pain medicine, anesthetic procedures, perioperative care medicine, and intensive care medicine. Methods:The authors retrospectively investigated anesthesia related deaths registered by the Danish Patient Insurance Association. Results:From 1996 to 2004, 27,971 claims were made by the Danish Patient Insurance Association covering all medical specialties, of which 1,256 files (4.5%) were related to anesthesia. In 24 cases, the patient’s death was considered to result from the anesthetic procedure: 4 deaths were related to airway management, 2 to ventilation management, 4 to central venous catheter placement, 4 as a result of medication errors, 4 from infusion pump problems, and 4 after complications from regional blockades. Severe hemorrhage caused 1 death, and in 1 case the cause was uncertain. Conclusions:Several of the 24 deaths could potentially have been avoided by more extended use of airway algorithm, thorough preoperative evaluation, training, education, and use of protocols for diagnosis and treatment.

Pulse oximetry for perioperative monitoring: Systematic review of randomized, controlled trials

Monitoring with pulse oximetry might improve patient outcome by enabling an early diagnosis and, consequently, correction of perioperative events that might otherwise cause postoperative complications or even death. The aim of the study was to clarify the effect of perioperative monitoring with pulse oximetry and to identify the adverse outcomes that might be prevented or improved by its use. Trials were identified by computerized searches of the Cochrane Library, MEDLINE, EMBASE, and by checking the reference lists of trials and review articles. All controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period, including in the operating and recovery room, were included in the study. The search identified six reports. Of these 6 reports, 4 studies with data from 21,773 patients were considered eligible for analysis. Two studies specifically addressed the outcomes in question; both found no effect on the rate of postoperative complications using perioperative pulse oximetry. Hypoxemia was reduced in the pulse oximetry group both in the operating room and in the recovery room. During observation in the recovery room, the incidence of hypoxemia in the pulse oximetry group was 1.5–3 times less. There were postoperative complications in 10% of the patients in the oximetry group and in 9.4% in the control group. The duration of hospital stay was a median of 5 days in both groups, and an equal number of in-hospital deaths was registered in both groups. The studies confirmed that pulse oximetry could detect hypoxemia and related events. However, given the relatively small number of patients studied and the rare events being sought, the studies were not able to show an improvement in various outcomes.