Peter Steffen

Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway

BACKGROUND Fast track programs, multimodal therapy strategies, have been introduced in many surgical fields to minimize postoperative morbidity and mortality. In terms of lung resections no randomized controlled trials exist to evaluate such patient care programs. METHODS In a prospective, randomized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared. Main differences between the two groups consisted in preoperative fasting (6h vs 2h) and analgesia (patient controlled analgesia vs patient controlled epidural analgesia). Study endpoints were pulmonary complications (pneumonia, atelectasis, prolonged air leak), overall morbidity and mortality. Analysis was performed in an intention to treat. RESULTS Both study groups were similar in terms of age, sex, preoperative forced expiratory volume in one second (FEV(1)), American Society of Anesthesiologists score and operations performed. The rate of postoperative pulmonary complications was 35% in the conservative and 6.6% in the fast track group (p=0.009). A subgroup of patients with reduced preoperative FEV(1) (<75% of predicted value) experienced less pulmonary complications in the fast track group (55% vs 7%, p=0.023). Overall morbidity was not significantly different (46% vs 26%, p=0.172), mortality was comparable in both groups (4% vs 3%). CONCLUSION We evaluated an optimized patient care program for patients undergoing lung resections in a prospective randomized pilot study. Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery.

Prophylactic use of epidural mepivacaine/morphine, systemic diclofenac, and metamizole reduces postoperative morphine consumption after major abdominal surgery

Background Surgical trauma induces nociceptive sensitization leading to amplification and prolongation of postoperative pain. While preemptive analgesic treatment with numerous agents has been successful in experimental animals, results of human studies remain conflicting. The authors used a multimodal approach for preemptive analgesia before abdominal surgery: diclofenac and metamizole inhibit prostaglandin synthesis, thus influencing peripheral sensitization; epidural local anesthetics induce conduction block, epidural opioids inhibit nociceptive synaptic transmission, and metamizole induces descending inhibition. The interaction of these drugs might suppress spinal nociceptive sensitization and postoperative analgesic demand. Methods One hundred forty-two patients scheduled for major abdominal surgery were randomly assigned to one of three groups and studied prospectively. Epidural catheters in groups 1 and 2 were placed at interspaces T8-T10, the position of the catheter was confirmed by epidurography, and sensory testing after administration of 5 ml mepivacaine 1%. Group 1 received 75 mg intramuscular diclofenac, 1000 mg intravenous metamizole, 5.3+/-1 mg epidural morphine, and 15-20 ml mepivacaine 1% 85+/-41 min before skin incision. Epidural analgesia was maintained by injections of 0.1 ml *symbol* kg sup -1 *symbol* h sup -1 mepivacaine 1%. Group 2 patients received the balanced analgesia regimen before wound closure (221+/-86 min after skin incision). Group 3 patients did not receive any study substances. General anesthesia was induced with 5 mg/kg thiopental and 2 micro gram/kg fentanyl and maintained with enflurane and nitrous oxide. Postoperative analgesia consisted of patient-controlled intravenous morphine over 5 days. Results Median visual analog scale pain intensities were < 3 cm and did not differ among the groups. Morphine consumption per hour on postoperative day 2 was 0.8+/-0.1 mg/h (group 1) < 1.2+/- 0.1 mg/h (group 2) = 1.1+/-0.1 mg/h (group 3) and cumulative morphine consumption (in mg) on the morning of day 5 was 95+/-9 (group 1) < 111+/-11 (group 2) < 137+/-10 (group 3). Conclusions A significant reduction of patient-controlled analgesia requirements could be achieved by our preincisional balanced analgesia regimen compared to application before wound closure. The more distinct difference between patients receiving balanced analgesia and those in the control group is based on the analgesic action of the study substances, which lasted about 14 h.

The effects of thoracic epidural anesthesia on hepatic blood flow in patients under general anesthesia.

BACKGROUND: Hepatic hypoperfusion is regarded as an important factor in the pathophysiology of perioperative liver injury. Although epidural anesthesia (EDA) is a widely used technique, no data are available about the effects on hepatic blood flow of thoracic EDA with blockade restricted to thoracic segments in humans. METHODS: In 20 patients under general anesthesia, we assessed hepatic blood flow index in the right and middle hepatic vein by use of multiplane transesophageal echocardiography before and after induction of EDA. The epidural catheter was inserted at TH7-9, and mepivacaine 1% with a median (range) dose of 10 (8–16) mL was injected. Norepinephrine (NE) was continuously administered to patients who demonstrated a decrease in mean arterial blood pressure below 60 mm Hg after induction of EDA (EDA-NE group). The other patients did not receive any catecholamine during the study period (EDA group). A further 10 patients without EDA served as controls (control group). RESULTS: In five patients, administration of NE was necessary to avoid a decrease in mean arterial blood pressure below 60 mm Hg. Thus, the EDA-NE group consisted of five patients and the EDA group of 15. In the EDA group, EDA was associated with a median decrease in hepatic blood flow index of 24% in both hepatic veins (P < 0.01). In the EDA-NE group, all five patients showed a decrease in the blood flow index of the right (median decrease 39 [11–45] %) and middle hepatic vein (median decrease 32 [7–49] %). Patients in the control group showed a constant blood flow index in both hepatic veins. Reduction in blood flow index in the EDA group and the EDA-NE group was significant in comparison with the control group (P < 0.05). In contrast to hepatic blood flow, cardiac output was not affected by EDA. CONCLUSIONS: We conclude that, in humans, thoracic EDA is associated with a decrease in hepatic blood flow. Thoracic EDA combined with continuous infusion of NE seems to result in a further decrease in hepatic blood flow.

Epidural bolus clonidine/morphine versus epidural patient-controlled bupivacaine/sufentanil: quality of postoperative analgesia and cost-identification analysis.

We compared the costs, quality of analgesia, and side effects of postoperative patient-controlled epidural analgesia (PCEA) with bupivacaine/sufentanil versus an epidural bolus (BOLUS) of clonidine/morphine in 68 patients with pancreatic surgery. Postoperative pain treatment was performed over 4 days: the PCEA pump was filled with bupivacaine 0.25% and sufentanil 2 micro g/mL and set to 3-mL bolus and 10-min lockout time. BOLUS patients received injections of clonidine 150 micro g plus morphine 2 mg on demand. Visual analog scale (VAS) score at rest and during coughing, heart rate (HR), systolic arterial pressure (SAP), incidence of postoperative nausea and vomiting, pruritus, duration of intestinal paralysis, hospital treatment, and costs for personnel and material were recorded. VAS scores during coughing (3 +/- 2.5 vs 5 +/- 3, P <0.001) was higher, and HR (79 +/- 13 vs 89 +/- 15, P <0.001), and SAP (110 +/- 18 vs 124 +/- 23, P <0.001) were lower, in the BOLUS compared with the PCEA group. The incidence of hypotension (SAP <80 mm Hg) was greater (6 vs 0, P <0.001) in the BOLUS group. The incidence of all other side effects was comparable. The costs of personnel (

Reduktion des postoperativen Opioidbedarfs durch die perioperative Gabe von Naproxen

204 +/-

Reduced postoperative analgesic demand after inhaled anesthesia in comparison to combined epidural-inhaled anesthesia in patients undergoing abdominal surgery.

40 vs

[Combined intravenous administration of diclofenac and apazone for postoperative analgesia A randomized study of 112 patients with access to i. v. on-demand analgesia after minor orthopaedic operations.].

166 +/-

Performance characteristics of a novel reusable intermediate–volume low–pressure cuffed endotracheal tube

38, P <0.001) were higher in the BOLUS group, but the costs of material (

[Reduced postoperative opioid requirement with perioperative administration of naproxen. A randomized study in 86 patients with intravenous on-demand analgesia after orthopaedic surgery.].

51 +/-

Postoperative analgesia with rofecoxib. How effective is the preoperative application of a 25 mg dose

17 vs