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Resumenes de la semana del 13 al 19 de Junio,2002-06-12
The Prevention of Emesis in Plastic Surgery: A Randomized,
Prospective Study
Jeffrey R. Marcus, M.D.; Julius W. Few, M.D.; Jerome D. Chao, M.D.; Neil A. Fine, M.D.; Thomas A. Mustoe,
M.D.
Chicago, Ill.
From the Division of Plastic and Reconstructive Surgery, Northwestern University Medical School.
Presented at the 45th Annual Meeting of the Plastic Surgery Research Council, in Seattle, Washington, in May of
2000; and at the 69th Annual Meeting of the American Society of Plastic Surgeons, in Los Angeles, California,
October 14 through 18, 2000.
PLASTIC AND RECONSTRUCTIVE SURGERY 2002;109:2487-2494
Perhaps the most unpleasant experience following outpatient plastic surgery procedures is postoperative nausea
and vomiting. Postoperative nausea and vomiting often results in delayed recovery time and unintended admission,
and it can be a contributing factor to the formation of hematoma following rhytidectomy. Ondansetron (Zofran) has
proven benefit in preventing postoperative nausea and vomiting if given before general anesthesia in a variety of
surgical procedures. Its utility in cases performed under conscious sedation has not been determined. The purpose
of this study was (1) to test the ability of prophylactic ondansetron to prevent postoperative nausea and vomiting in
plastic surgery cases performed under conscious sedation, and (2) to determine relative risk factors for
postoperative nausea and vomiting and a selection policy for the administration of antiemetic prophylaxis. This
was a prospective, randomized, double-blind study. One hundred twenty patients were enrolled after giving
informed consent. Patients received a single dose of either placebo or ondansetron (4 mg intravenously) before
administration of sedation. Sedation administration followed a standardized institutional protocol, using midazolam
and fentanyl. Data were recorded from a series of three questionnaires: preoperatively, immediately
postoperatively, and at the time of the first office return. Data were confirmed by means of telephone interview,
chart analysis, and nursing documentation. Multivariate analysis was conducted. Nausea and emesis occurred with
an overall frequency of 33 percent and 22 percent, respectively. Postoperative nausea and vomiting was associated
with statistically longer recovery periods. The incidence of emesis was statistically higher among women, among
those undergoing facial rejuvenation, and among those with a history of opioid-induced emesis or postoperative
nausea and vomiting following a previous operation (p < 0.05). The incidence of postoperative nausea and
vomiting paralleled increases in case duration; the incidence of emesis was zero in cases less than 90 minutes in
duration. Ondansetron significantly reduced the incidence of emesis overall (placebo, 30 percent; ondansetron, 13
percent; p < 0.05). Postoperative perception of nausea was significantly lower among those who had received
ondansetron (p < 0.05). These results confirm the efficacy of ondansetron for the prevention of postoperative
nausea and vomiting in plastic surgery cases under conscious sedation. In those who are at increased risk,
prophylaxis should be considered. Such risks include female gender, facial rejuvenation procedures, and a patient
history of opioid-induced emesis or postoperative nausea and vomiting following a prior operation. The zero
incidence of emesis in cases less than 90 minutes does not support the routine use of prophylaxis in such cases.
Patient satisfaction in plastic surgery is derived from the overall subjective experience of the event as much as by
the final result. By remaining attentive to patient concerns and optimizing perioperative care, we can improve the
subjective experience for our patients.
Perioperative risk factors for posterior ischemic optic neuropathy 1
Stephan Dunker a, Hugo Y. Hsu a, Jerry Sebag a and Alfredo A. Sadun aA
Los Angeles, CA 90033 USA[a]Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los
Angeles, CA USA
A Correspondence address: Alfredo A Sadun, MD, PhD, Doheny Eye Institute, 1450 San Pablo St,
Manuscript received 1 November 2001 Revised 29 January 2002 Accepted 30 January 2002;
Journal of the American College of Surgeons Volume 194Issue6 (June 2002)Pages705-710
Background:
Infarction of the optic nerve posterior to the lamina cribrosa, called posterior ischemic optic neuropathy
(PION), is a condition that can result in profound bilateral blindness. Cases of PION treated at this institution
and those described in the literature were analyzed to identify clinical features that profile those individuals at
risk of PION in an attempt to identify major contributing factors that could be addressed prophylactically to
enable effective prevention.
Study Design:
Salient clinical features in seven cases of PION diagnosed at the Doheny Eye Institute between 1989 and
1998 are compared with 46 cases of PION reported in the literature.
Results:
In the Doheny series there were six men and one woman aged 12 to 66 years (mean, 47 years). Five
patients were status-post spine surgery, one was status-post knee surgery, and one had a bleeding stomach
ulcer. Vision loss was simultaneously bilateral in six of seven patients (85.7%) and was apparent immediately
after surgery. There were no abnormal retinal or choroidal findings including diabetic retinopathy, in any of
the patients. Notable contributing factors were blood loss in all seven patients, ranging from 2,000 to 16,000
mL, with a drop in hematocrit of 9.5% to 19% (mean, 14%), and intraoperative systemic hypotension in all
patients. Facial edema was a factor in three of six spine surgery patients (50%). Patients reported in the
literature had a mean age of 50 years and were also predominantly men (34 of 46, 74%) who underwent
spine surgery (30 of 46, 65.2%).
Conclusions:
Middle-aged men undergoing spine surgery with prolonged intraoperative hypotension and postoperative
anemia and facial swelling are at risk of developing PION from hypovolemic hypotension. Avoiding or
immediately correcting these contributory factors can reduce the incidence of PION.
Predictors of mortality in adult trauma patients: the Physiologic Trauma Score is
equivalent to the Trauma and Injury Severity Score 1
Abstract presented at the American College of Surgeons 86th Annual Clinical Congress, Surgical Forum, Chicago, IL,
October 2000.
Deborah A. Kuhls a, Debra L. Malone a,b a,b, Robert J. McCarter d and Lena M. Napolitano b,c b,cA
Baltimore, MD 21201 USA[a]Department of Surgery, University of Nevada School of Medicine, Las Vegas, Nevada (Kuhls)
USA[b]The R Adams Cowley Shock Trauma Center (Malone, Napolitano), University of Maryland School of Medicine,
Baltimore, MD USA[c]Department of Surgery (Malone, Napolitano), University of Maryland School of Medicine, Baltimore, MD
USA[d]Department of Epidemiology (McCarter), University of Maryland School of Medicine, Baltimore, MD USA
A Correspondence address: Lena M Napolitano, MD, Department of Surgery, University of Maryland School of Medicine, 10
North Greene St,
Manuscript received 8 March 2001 Revised 14 December 2001 Accepted 12 February 2002;
Journal of the American College of Surgeons 194Issue6 (June 2002 ) Pages 695-704
Background:
Several statistical models (Trauma and Injury Severity Score [TRISS], New Injury Severity Score [NISS], and
the International Classification of Disease, Ninth Revision-based Injury Severity Score [ICISS]) have been
developed over the recent decades in an attempt to accurately predict outcomes in trauma patients. The
anatomic portion of these models makes them difficult to use when performing a rapid initial trauma
assessment. We sought to determine if a Physiologic Trauma Score, using the systemic inflammatory
response syndrome (SIRS) score in combination with other commonly used indices, could accurately predict
mortality in trauma.
Study Design:
Prospective data were analyzed in 9,539 trauma patients evaluated at a Level I Trauma Center over a 30month period (January 1997 to July 1999). A SIRS score (1 to 4) was calculated on admission (1 point for
each: temperature >38°C or <36°C, heart rate >90 beats per minute, respiratory rate >20 breaths per minute,
neutrophil count > 12,000 or < 4,000. SIRS score, Injury Severity Score (ISS), Revised Trauma Score (RTS),
TRISS, Glasgow Coma Score, age, gender, and race were used in logistic regression models to predict
trauma patients' risk of death. The area under the receiver-operating characteristic curves of sensitivity
versus 1-specificity was used to assess the predictive ability of the models.
Results:
The study cohort of 9,539 trauma patients (of which 7,602 patients had complete data for trauma score
calculations) had a mean ISS of 9 ± 9 (SD) and mean age of 37 ± 17 years. SIRS (SIRS score 2) was
present in 2,165 of 7,602 patients (28.5%). In single-variable models, TRISS and ISS were most predictive of
outcomes. A multiple-variable model, Physiologic Trauma Score combining SIRS score with Glasgow Coma
Score and age (Hosmer-Lemenshow CHI-SQUARE = 4.74) was similar to TRISS and superior to ISS in
predicting mortality. The addition of ISS to this model did not significantly improve its predictive ability.
Conclusions:
A new statistical model (Physiologic Trauma Score), including only physiologic variables (admission SIRS
score combined with Glasgow Coma Score and age) and easily calculated at the patient bedside, accurately
predicts mortality in trauma patients. The predictive ability of this model is comparable to other complex
models that use both anatomic and physiologic data (TRISS, ISS, and ICISS).
Der Anaesthesist Volume 51 Issue 6 (2002) pp 457-462
Does intraoperative hyperventilation improve neurological functions of
older patients after general anaesthesia?
U. Linstedt (1), O. Meyer (1), A. Berkau (2), P. Kropp (3), M. Zenz (1), C. Maier (4)
(1) Klinik für Anästhesiologie, Intensiv- und Schmerztherapie, BG Kliniken Bergmannsheil, Ruhr-Universität
Bochum
(2) Klinik für Anästhesiologie und Intensivmedizin, Christian-Albrechts-Universität zu Kiel
(3) Institut für Medizinische Psychologie, Christian-Albrechts-Universität zu Kiel
(4) Abteilung für Schmerztherapie, BG Kliniken Bergmannsheil, Ruhr-Universität Bochum
Summary. The purpose of the study was to investigate the effect of intraoperative hyperventilation on
postoperative cognitive functions.
Methods. A total of 120 patients (60 older and 60 younger than 65 years old) were allocated randomly to group I
"hyperventilation" (petCO2=30 mmHg) or group II "normoventilation" (petCO2 =45 mmHg). Before the operation
and on days 1, 3 and 6 after the operation, a battery of neuropsychological tests was performed (concentration
endurance test d2, number connection test, digit symbol test). A decline of 20% in at least one test was regarded as
postoperative cognitive deficit (POCD). Anaesthesia was maintained with isoflurane in nitrous oxide/oxygen
supplemented with fentanyl.
Results. In all patients pooled, POCD was present in 26 patients (22%). In patients older than 65 years, POCD was
present in 3 cases after hyperventilation and 13 cases after normoventilation (p <0.01). In younger subjects, 5 cases
of POCD were diagnosed in each ventilation group. Furthermore, POCD was more severely pronounced in older
patients after normoventilation.
Conclusion. In older patients, POCD occurred more frequently after intraoperative normoventilation. We assume
that a reduced amount of noxious substances reach the brain after hyperventilation, because hyperventilation
reduces the cerebral blood flow.
Keywords Intraoperative hyperventilation · Older patients · POCD · Postoperative cognitive deficit
BMJ 2002;324:1386-1389 ( 8 June )
Education and debate
Quality improvement report
Effect of a scoring system and protocol for sedation on duration of
patients' need for ventilator support in a surgical intensive care unit
Guttorm Brattebø, consultant anaesthetist a, Dag Hofoss, professor b, Hans Flaatten, consultant anaesthetist
a
, Anne Kristine Muri, registered nurse a, Stig Gjerde, consultant anaesthetist a, Paul E Plsek, consultant c.
a
Department of Anaesthesia and Intensive Care, Haukeland University Hospital, N-5021 Bergen, Norway, b HELTEF, Foundation for
Health Services Research, PO Box 55, N-1474 Nordbyhagen, Norway, c Paul E Plsek & Associates, 1005 Allenbrook Lane, Roswell, GA
30075, USA
Correspondence to: G Brattebø [email protected]
Abstract
Problem: Need for improved sedation strategy for adults receiving ventilator support.
Design: Observational study of effect of introduction of guidelines to improve the doctors' and nurses'
performance. The project was a prospective improvement and was part of a national quality improvement
collaborative.
Background and setting: A general mixed surgical intensive care unit in a university hospital; all doctors and
nurses in the unit; all adult patients (>18 years) treated by intermittent positive pressure ventilation for more than
24 hours.
Key measures for improvement: Reduction in patients' mean time on a ventilator and length of stay in intensive
care over a period of 11 months; anonymous reporting of critical incidents; staff perceptions of ease and of
consequences of changes.
Strategies for change: Multiple measures (protocol development, educational presentations, written guidelines,
posters, flyers, emails, personal discussions, and continuous feedback) were tested, rapidly assessed, and adopted if
beneficial.
Effects of change: Mean ventilator time decreased by 2.1 days (95% confidence interval 0.7 to 3.6 days) from
7.4 days before intervention to 5.3 days after. Mean stay decreased by 1.0 day (-0.9 to 2.9 days) from 9.3 days to
8.3 days. No accidental extubations or other incidents were identified.
Lessons learnt: Relatively simple changes in sedation practice had significant effects on length of ventilator
support. The change process was well received by the staff and increased their interest in identifying other areas for
improvement.
Acta Anaesthesiologica Scandinavica
Volume 46 Issue 6 Page 625 - July 2002 Small-volume resuscitation: from experimental evidence to clinical
routine. Advantages and disadvantages of hypertonic solutionsU. Kreimeier1,2 and K. Messmer2
Background: The concept of small-volume resuscitatioin (SVR) using hypertonic solutions encompasses the rapid
infusion of a small dose (4 ml per kg body weight, i.e. approximately 250 ml in an adult patient) of 7.2-7.5%
NaCl/colloid solution. Originally, SVR was aimed for initial therapy of severe hypovolemia and shock associated
with trauma.
Methods: The present review focusses on the findings concerning the working mechanisms responsible for the
rapid onset of the circulatory effect, the impact of the colloid component on microcirculatory resuscitation, and
describes the indications for its application in the preclinical scenario as well as perioperatively and in intensive
care medicine.
Results: With respect to the actual data base of clinical trials SVR seems to be superior to conventional volume
therapy with regard to faster normalization of microvascular perfusion during shock phases and early resumption
of organ function. Particularly patients with head trauma in association with systemic hypotension appear to
benefit. Besides, potential indications for this concept include cardiac and cardiovascular surgery (attenuation of
reperfusion injury during declamping phase) and burn injury. The review also describes disadvantaages and
potential adverse effects of SVR:
Conclusion: Small-volume resuscitation by means of hypertonic NaCl/colloid solutions stands for one of the most
innovative concepts for primary resuscitation from trauma and shock established in the past decade. Today the
spectrum of potential indications envolves not only prehospital trauma care, but also perioperative and intensive
care therapy.
Acta Anaesthesiologica Scandinavica
Volume 46 Issue 6 Page 674 - July 2002 Improved long-lasting postoperative analgesia, recovery function and
patient satisfaction after inguinal hernia repair with inguinal field block compared with general anesthesiaV.
Aasbø1, A. Thuen2 and J. Ræder3
Background: Inguinal hernia repair is a common surgical procedure, and different types of anesthetic techniques
are in use. We wanted to test if preoperative inguinal field block (IFB) with ropivacaine would provide benefits in
the postoperative period compared with general anesthesia and wound infiltration.
Methods: Sixty patients scheduled for inguinal hernia repair were randomized to receive general anesthesia with
wound infiltration postoperatively, or inguinal field block (IFB) before surgery, with no or only light sedation
intraoperatively. General anesthesia was induced with midazolam, fentanyl and propofol, maintained with propofol
and alfentanil, and supplemented with nitrous oxide in oxygen through a laryngeal mask. The IFB was performed
by an anesthesiologist, with 50-60ml ropivacaine and 5mg/ml with a dedicated technique.
Results: All significant differences were in favor of the IFB group: less pain (visual analog scale, verbal pain
score) postoperatively and until day 7, faster mobilization with less pain, lower analgesic consumption, and higher
patient satisfaction.
Conclusion: Preoperative inguinal field block for hernia repair provides benefits for patients in terms of faster
recovery, less pain, better mobilization and higher satisfaction throughout the whole first postoperative week.
Paediatric Anaesthesia
Volume 12 Issue 5 Page 411 - June 2002 Airway management in spontaneously breathing anaesthetized children:
comparison of the Laryngeal Mask Airway
with the cuffed oropharyngeal airwayBIRUTA MAMAYA
Background: The efficacy and safety of the smallest size of the cuffed oropharyngeal airway (COPA) for school
age, spontaneously breathing children was investigated and compared with the Laryngeal Mask Airway (LMA ).
Methods:Seventy children of school age (7-16years) were divided into two groups: the COPA (n=35) and the
LMA (n =35). Induction was with propofol i.v. or halothane, nitrous oxide, oxygen and fentanyl. After depression
of laryngopharyngeal reflexes, a COPA size 8 cm or an LMA was inserted. Ventilation was manually assisted until
spontaneous breathing was established. For maintenance, propofol i.v. and fentanyl or halothane with nitrous oxide
were used. Local anaesthesia or peripheral blocks were also used.
Results: Both extratracheal airways had a highly successful insertion rate, but more positional manoeuvres to
achieve a satisfactory airway were required with the COPA, 28.6 versus LMA 2.9 . The need to change the
method of airway management was higher (8.6 ) in the COPA group. After induction, the need for assisted
ventilation was higher in the LMA group 54.3 versus 20 in the COPA group. Airway reaction to cuff inflation
was higher in the LMA group 14.3 versus COPA 5.7 . Problems during surgery were similar, except continuous
chin support to establish an effective airway was more frequent (11.4 ) in the COPA group. In the postoperative
period, blood on the device and incidence of sore throat were detected less in the COPA group.
Conclusions: The COPA is a good extratracheal airway that provides new possibilities for airway management in
school age children with an adequate and well sealed airway, during spontaneous breathing or during short-term
assisted manual ventilation.
Paediatric Anaesthesia
Volume 12 Issue 5 Page 438 - June 2002 The reliability of endtidal CO2 in spontaneously breathing children during
anaesthesia with Laryngeal Mask AirwayTM, low flow, sevoflurane and caudal epiduralPer AASHEIM MD,
SIGURD FASTING MD, Ulf MOSTAD MD & PETTER AADAHL MD, PhD
Background: Noninvasive devices for monitoring endtidal CO2 (PECO2 ) are in common use in paediatric
anaesthesia. Questions have been raised concerning the reliability of these devices in spontaneous breathing
children during surgery. Our anaesthetic technique for elective infraumbilical surgery consists of spontaneous
breathing through a Laryngeal Mask Airway (LMATM), low fresh gas flow, sevoflurane and a caudal epidural. We
wanted to compare PECO2 and arterial CO2 (PaCO2) during surgery.
Methods: Twenty children, aged 1-6years, scheduled for infraumbilical surgery, were studied and one arterial
sample was taken 45min after induction of anaesthesia. PECO2, inspiratory PCO2 , oxygen saturation, heart rate,
respiratory rate, mean arterial blood pressure and expiratory sevoflurane concentration were measured every 5min.
The respiratory and circulatory parameters were stable during surgery.
Results: The mean PaCO2 -PECO2 difference was 0.15 (0.16)kPa [1.1 (1.2mmHg)].
Conclusions: PECO2 is a good indicator of PaCO2 in our anaesthetic setting.
Successful determination of lower inflection point and maximal
compliance in a population of patients with acute respiratory distress
syndrome*
Nicholas S. Ward, MD ; Dennis Y. Lin, MD; David L. Nelson, BA; Jeane Houtchens, MS; William A. Schwartz,
BA, RRT; James R. Klinger, MD; Nicholas S. Hill, MD; Mitchell M. Levy, MD
From Brown University School of Medicine, Division of Pulmonary and Critical Care Medicine, Rhode Island Hospital, Providence, RI.
CRITICAL CARE MEDICINE 2002;30:963-968
Objective: To compare the ease and efficacy of two commonly used methods for choosing optimal positive endexpiratory pressure (PEEP) in patients with acute respiratory distress syndrome: a static pressure-volume curve to
determine the lower inflection point (Pflex) and the “best PEEP” (PEEPbest) as determined by the maximal
compliance curve.
Design: Prospective study.
Setting: Medical and respiratory intensive care units of university-associated tertiary care hospital.
Patients: Twenty-eight patients on mechanical ventilation with acute respiratory distress syndrome.
Interventions: A critical care attending physician or fellow and an experienced respiratory therapist attempted to
obtain both static pressure-volume curves and maximal compliance curves on 28 patients with acute respiratory
distress syndrome by using established methods that were practical to everyday use. The curves then were used to
determine both Pflex and PEEPbest, and the results were compared.
Measurement and Main results: Our results showed at least one value for optimal PEEP was obtained in 26 of 28
patients (93%). Pflex was determined in 19 (68%), a PEEPbest in 24 (86%), and both values in 17 (61%). In patients
who had both Pflex and PEEPbest determined, there was a close concordance (±3 cm H2O) in 60%. When the values
of Pflex and PEEPbest were interpreted by two additional investigators, there was unanimous agreement on the Pflex
(±3) only 64% of the time. There was agreement on the value of PEEPbest 93% of the time.
Conclusions: Our data show that optimal PEEP, as determined by a pressure-volume curve and a maximal
compliance curve, are sometimes unobtainable by practical means but, when obtained, often correspond. A
maximal compliance is more often identified, has less interobserver variability, and poses less risk to the patient.
We conclude that determining optimal PEEP by maximal static compliance may be easier to measure and more
frequently obtained at the bedside than by using a static pressure-volume curve.
Key Words: positive end-expiratory pressure; acute respiratory distress syndrome; mechanical ventilation;
pressure-volume curves; optimal positive end-expiratory pressure; lower inflection point; static compliance