Tom Pedersen

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

BACKGROUNDnSmokers 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.nnnMETHODSnWe 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.nnnFINDINGSnEight 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.nnnINTERPRETATIONnAn 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.

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.

Pulse oximetry for perioperative monitoring

BACKGROUNDnThis is an update of a review last published in Issue 9, 2009, of The Cochrane Library. Pulse oximetry is used extensively in the perioperative period and might improve patient outcomes by enabling early diagnosis and, consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry during anaesthesia and in the recovery room have been performed that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and cognitive dysfunction.nnnOBJECTIVESnTo study the use of perioperative monitoring with pulse oximetry to clearly identify adverse outcomes that might be prevented or improved by its use.The following hypotheses were tested.1. Use of pulse oximetry is associated with improvement in the detection and treatment of hypoxaemia.2. Early detection and treatment of hypoxaemia reduce morbidity and mortality in the perioperative period.3. Use of pulse oximetry per se reduces morbidity and mortality in the perioperative period.4. Use of pulse oximetry reduces unplanned respiratory admissions to the intensive care unit (ICU), decreases the length of ICU readmission or both.nnnSEARCH METHODSnWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5), MEDLINE (1966 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), ISI Web of Science (1956 to June 2013), LILACS (1982 to June 2013) and databases of ongoing trials; we also checked the reference lists of trials and review articles. The original search was performed in January 2005, and a previous update was performed in May 2009.nnnSELECTION CRITERIAnWe included all controlled trials that randomly assigned participants to pulse oximetry or no pulse oximetry during the perioperative period.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period and intraoperative or postoperative mortality.nnnMAIN RESULTSnThe last update of the review identified five eligible studies. The updated search found one study that is awaiting assessment but no additional eligible studies. We considered studies with data from a total of 22,992 participants that were eligible for analysis. These studies gave insufficient detail on the methods used for randomization and allocation concealment. It was impossible for study personnel to be blinded to participant allocation in the study, as they needed to be able to respond to oximetry readings. Appropriate steps were taken to minimize detection bias for hypoxaemia and complication outcomes. Results indicated that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5 to three times less. Postoperative cognitive function was independent of perioperative monitoring with pulse oximetry. A single study in general surgery showed that postoperative complications occurred in 10% of participants in the oximetry group and in 9.4% of those in the control group. No statistically significant differences in cardiovascular, respiratory, neurological or infectious complications were detected in the two groups. The duration of hospital stay was a median of five days in both groups, and equal numbers of in-hospital deaths were reported in the two groups. Continuous pulse oximetry has the potential to increase vigilance and decrease pulmonary complications after cardiothoracic surgery; however, routine continuous monitoring did not reduce transfer to an ICU and did not decrease overall mortality.nnnAUTHORS CONCLUSIONSnThese studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we found no evidence that pulse oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective study results, despite an intense methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency. Routine continuous pulse oximetry monitoring did not reduce transfer to the ICU and did not decrease mortality, and it is unclear whether any real benefit was derived from the application of this technology for patients recovering from cardiothoracic surgery in a general care area.

Prehabilitation and early rehabilitation after spinal surgery: randomized clinical trial

Objective: To evaluate the outcome after spinal surgery when adding prehabilitation to the early rehabilitation. Design: A randomized clinical study. Setting: Orthopaedic surgery department. Subject: Sixty patients scheduled for surgery followed by inpatient rehabilitation for degenerative lumbar disease. Interventions: The patients were computer randomized to prehabilitation and early rehabilitation (28 patients) or to standard care exclusively (32 patients). The intervention began two months prior to the operation. The prehabilitation included an intensive exercise programme and optimization of the analgesic treatment. Protein drinks were given the day before surgery. The early postoperative rehabilitation included balanced pain therapy with self-administered epidural analgesia, doubled intensified mobilization and protein supplements. Main measures: The outcome measurements were postoperative stay, complications, functionality, pain and satisfaction. Results: At operation the intervention group had improved function, assessed by Roland Morris Questionnaire (P = 0.001). After surgery the intervention group reached the recovery milestones faster than the control group (1—6 days versus 3—13, P =0.001), and left hospital earlier (5 (3—9) versus 7 (5—15) days, P =0.007). There was no difference in postoperative complications, adverse events, low back pain and radiating pain, timed up and go, sit-to-stand or in life quality. Patient satisfaction was significantly higher in the intervention group compared with the control group. Conclusion: The integrated programme of prehabilitation and early rehabilitation improved the outcome and shortened the hospital stay — without more complications, pain or dissatisfaction.

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.

Hydroxyethyl starch reduces coagulation competence and increases blood loss during major surgery: results from a randomized controlled trial.

Objective:This study evaluated whether administration of hydroxyethyl starch (HES) 130/0.4 affects coagulation competence and influences the perioperative blood loss. Background:Artificial colloids substitute blood volume during surgery; with the administration of HES 130/0.4 (Voluven, Fresenius Kabi, Uppsala, Sweden) only a minor effect on coagulation competence is expected. Methods:Eighty patients were scanned for enrolment in the study, and 40 patients fulfilled the inclusion criteria. Two patients withdrew their consent to participate in the study, and 5 patients were excluded. Thus, 16 patients were randomized to receive lactated Ringers solution and 17 to receive HES 130/0.4. Results:Among the patients receiving HES 130/0.4, thrombelastography indicated reduced clot strength (P < 0.001) and blinded evaluation of the perioperative blood loss was 2.2 (range 0.5 to 5.0) versus 1.4 (range 0.5 to 2.4) L in the patients who received HES 130/0.4 or lactated Ringer, respectively (P < 0.038). The patients in the lactated Ringers group, however, received more fluid (P < 0.0001) than those in the HES 130/0.4 group. There was no significant difference between the 2 groups with regard to frequency of reoperations or the length of hospital stay, but use of HES 130/0.4 was both more expensive and less efficacious than the use of lactated Ringer. Conclusions:Administration of HES 130/0.4 reduced clot strength and perioperative hemorrhage increased by more than 50%, while administration of lactated Ringers solution provoked an approximately 2.5 times greater positive volume balance at the end of surgery.

Long‐term effects of a preoperative smoking cessation programme

Introduction:u2002 Preoperative smoking intervention programmes reduce post‐operative complications in smokers. Little is known about the long‐term effect upon smoking cessation.

Impact of lifestyle on perioperative smoking cessation and postoperative complication rate.

OBJECTIVEnThe aim was to examine to what extent lifestyle, education, social support, and comorbidity predict the ability of perioperative smoking cessation, and are associated with the development of important postoperative complications.nnnDESIGNnThe design was a randomized clinical trial.nnnSETTINGnUniversity hospitals in Copenhagen, Denmark, were the settings.nnnPARTICIPANTS AND METHODSnOne hundred twenty patients scheduled for primary elective hip or knee arthroplasty were randomized to either smoking intervention or standard care. Tobacco and alcohol consumption, exercise and eating habits, level of education, matrimonial status, and the presence of social support were registered. The data gathered concerned smoking cessation/reduction and severe postoperative morbidity.nnnRESULTSnMen and patients with a good social network were more likely to successfully quit smoking. Smoking intervention successfully reduced the incidence of postoperative complications, as did weekly exercise exceeding 4 h, and having a high education level.nnnCONCLUSIONSnThis study emphasizes that smoking intervention programs in health care settings are highly effective in reducing postoperative risks in hip and knee arthroplasty.

Coagulation competence for predicting perioperative hemorrhage in patients treated with lactated Ringer’s vs. Dextran - a randomized controlled trial

BackgroundPerioperative hemorrhage may depend on coagulation competence and this study evaluated the influence of coagulation competence on blood loss during cystectomy due to bladder cancer.MethodsForty patients undergoing radical cystectomy were included in a randomized controlled trial to receive either lactated Ringer’s solution or Dextran 70 (Macrodex ®) that affects coagulation competence.ResultsBy thrombelastography evaluated coagulation competence, Dextran 70 reduced “maximal amplitude” (MA) by 25xa0% versus a 1xa0% reduction with the administration of lactated Ringer’s solution (P <0.001). Blinded evaluation of the blood loss was similar in the two groups of patients - 2339xa0ml with the use of Dextran 70 and 1822xa0ml in the lactated Ringer’s group (Pu2009=u20090.27). Yet, the blood loss was related to the reduction in MA (ru2009=u2009−0.427, Pu2009=u20090.008) and by multiple regression analysis independently associated with MA (Pu2009=u20090.01). Thus, 11 patients in the dextran group (58xa0%) developed a clinical significant blood loss (>1500xa0ml) compared to only four patients (22xa0%) in the lactated Ringer’s group (Pu2009=u20090.04).ConclusionsWith the use of Dextran 70 vs. lactated Ringer’s solution during cystectomy, a relation between hemorrhage and coagulation competence is demonstrated. Significant bleeding develops based on an about 25xa0% reduction in thrombelastography determined maximal amplitude. A multivariable model including maximal amplitude discriminates patients with severe perioperative bleeding during cystectomy.Trial registrationThe study was accepted on January 7th, 2013 at www.clinicaltrialsregister.eu EudraCT 2012-005040-20.

The mission of the cochrane anesthesia review group: preparing and disseminating systematic reviews of the effect of health care in anesthesiology.

IMPLICATIONSnThis article illustrates the basic principles of evidence-based medicine and the work within the Cochrane Collaboration and the Cochrane Anesthesia Review Group. It describes how important randomized controlled trials and systematic reviews are in providing the best evidence to answer clinically relevant questions.