Federica Scavonetto

Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis.

Background:Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end–expiratory pressure (PEEP) level and occurrence of PPC. Methods:Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression. Results:Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose–response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08). Conclusions:These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.

Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data.

BACKGROUND Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications. METHODS We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma). FINDINGS We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006). INTERPRETATION In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings. FUNDING None.

Anesthesia and Duchenne or Becker muscular dystrophy: review of 117 anesthetic exposures.

Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are associated with life‐threatening perioperative complications, including rhabdomyolysis, hyperkalemia, and hyperthermia. Current recommendations contraindicate use of succinylcholine and volatile anesthetics; however, the latter recommendation remains controversial.

Perioperative allogeneic nonleukoreduced blood transfusion and prostate cancer outcomes after radical prostatectomy

Allogeneic blood transfusion induces immunosuppression, and concern has been raised that it may increase propensity for cancer recurrence; however, these effects have not been confirmed. We examined the association of perioperative transfusion of allogeneic blood long‐term oncologic outcomes in patients with prostate cancer who underwent prostatectomy.

Outcomes after radical prostatectomy for cancer: a comparison between general anesthesia and epidural anesthesia with fentanyl analgesia: a matched cohort study.

BACKGROUND:The use of regional anesthesia for cancer surgery has been associated with improved oncologic outcomes. One of the proposed mechanisms is a reduction in the use of systemic opioids that may cause immunosuppression. We used a retrospective matched cohort design to compare long-term oncologic outcomes after prostatectomy for cancer performed under general anesthesia with systemic opioids or with epidural anesthesia with epidural fentanyl analgesia. Since epidural fentanyl is quickly reabsorbed systemically, we hypothesized that there would be no difference in long-term oncological outcomes between the 2 groups. METHODS:There were 486 men who underwent prostatectomy performed under epidural anesthesia between January 1, 1991, and January 31, 1996. They were 1:1 matched based on age (±5 years), surgical year (±1 year), and baseline prostate cancer pathology to patients who had general anesthesia with systemic opioids. Long-term cancer outcomes and all-cause mortality were examined. Analyses were performed using stratified proportional hazards regression models, with hazard ratios >1 indicating worse outcome for general anesthesia only compared with epidural anesthesia and fentanyl analgesia. RESULTS:After adjusting for positive surgical margins and adjuvant therapies, patients in the general anesthesia group were found not to be at increased risk of prostate cancer recurrence (hazard ratio [HR] = 0.79, 95% confidence interval [CI], 0.60–1.04], systemic tumor progression (HR = 0.92, 95% CI, 0.46–1.84), cancer-specific mortality (HR = 0.53, 95% CI, 0.18–1.58), or overall mortality (HR = 1.23, 95% CI 0.93–1.63) when compared with patients who received epidural anesthesia. CONCLUSIONS:Compared with general anesthesia with systemic opioids, epidural anesthesia and analgesia with fentanyl were not associated with improvement in oncologic outcomes in patients undergoing radical prostatectomy for cancer.

Anesthesia and cor triatriatum

AIMS AND OBJECTIVES Cor triatriatum sinistrum (CTS) and cor triatriatum dextrum (CTD) are rare congenital anomalies characterized by the presence of a perforated septum which divides the respective atrium into a proximal and distal chamber. This report reviews the perioperative course of patients with uncorrected cor triatriatum (CT) undergoing procedures requiring anesthesia. In addition, we performed a literature search that examines the experience of others regarding the peri-operative course of patients with CT. MATERIALS AND METHODS A computerized search of a medical record database was conducted to identify patients with a clinical diagnosis of uncorrected CTD and CTS undergoing surgical procedures. Descriptive statistics were used. RESULTS We identified 12 adult patients with asymptomatic CTS (n = 7) and CTD (n = 5) who underwent 23 anesthetics. There were no perioperative complications which could be attributed directly to the anatomy of CT. CONCLUSIONS Our observation and review of the literature suggest that patients with asymptomatic CT typically tolerate anesthesia and surgical procedures well.

Management of delayed hemorrhage after partial vocal cord cordectomy

A patient developed brisk airway bleeding after being discharged earlier that day following an uneventful partial vocal cord cordectomy. This emergent complication required management by the team of anesthesiologists and otorhinolaryngologists. A plausible explanation for the occurrence of this complication was the presence of aberrant arterial blood supply in the area of the vocal cords where the surgery was performed.

Interaction between peri-operative blood transfusion, tidal volume, airway pressure and postoperative ARDS: an individual patient data meta-analysis

Background Transfusion of blood products and mechanical ventilation with injurious settings are considered risk factors for postoperative lung injury in surgical Patients. Methods A systematic review and individual patient data meta-analysis was done to determine the independent effects of peri-operative transfusion of blood products, intra-operative tidal volume and airway pressure in adult patients undergoing mechanical ventilation for general surgery, as well as their interactions on the occurrence of postoperative acute respiratory distress syndrome (ARDS). Observational studies and randomized trials were identified by a systematic search of MEDLINE, CINAHL, Web of Science, and CENTRAL and screened for inclusion into a meta-analysis. Individual patient data were obtained from the corresponding authors. Patients were stratified according to whether they received transfusion in the peri-operative period [red blood cell concentrates (RBC) and/or fresh frozen plasma (FFP)], tidal volume size [≤7 mL/kg predicted body weight (PBW), 7-10 and >10 mL/kg PBW] and airway pressure level used during surgery (≤15, 15-20 and >20 cmH2O). The primary outcome was development of postoperative ARDS. Results Seventeen investigations were included (3,659 patients). Postoperative ARDS occurred in 40 (7.2%) patients who received at least one blood product compared to 40 patients (2.5%) who did not [adjusted hazard ratio (HR), 2.32; 95% confidence interval (CI), 1.25-4.33; P=0.008]. Incidence of postoperative ARDS was highest in patients ventilated with tidal volumes of >10 mL/kg PBW and having airway pressures of >20 cmH2O receiving both RBC and FFP, and lowest in patients ventilated with tidal volume of ≤7 mL/kg PBW and having airway pressures of ≤15 cmH2O with no transfusion. There was a significant interaction between transfusion and airway pressure level (P=0.002) on the risk of postoperative ARDS. Conclusions Peri-operative transfusion of blood products is associated with an increased risk of postoperative ARDS, which seems more dependent on airway pressure than tidal volume size.

Where Did All the Sugar Go

This case discusses the potentiation of hypoglycemic effect with the coadministration of levofloxacin and glyburide.