17 Sep 08
Posted in Anesthesia, Pre-operatie evaluation at 12:27 by Laci
By P K Lindenauer, P Pekow, K Wang, D K Mamidi, B Gutierrez and E M Benjamin
NEJM 2005;353:349-361
Despite limited evidence from randomized trials, perioperative treatment with beta-blockers is now widely advocated. We assessed the use of perioperative beta-blockers and their association with in-hospital mortality in routine clinical practice.
Methods
We conducted a retrospective cohort study of patients 18 years of age or older who underwent major noncardiac surgery in 2000 and 2001 at 329 hospitals throughout the United States. We used propensity-score matching to adjust for differences between patients who received perioperative beta-blockers and those who did not receive such therapy and compared in-hospital mortality using multivariable logistic modeling.
Result
Of 782,969 patients, 663,635 (85 percent) had no recorded contraindications to beta-blockers, 122,338 of whom (18 percent) received such treatment during the first two hospital days, including 14 percent of patients with a Revised Cardiac Risk Index (RCRI) score of 0 and 44 percent with a score of 4 or higher. The relationship between perioperative beta-blocker treatment and the risk of death varied directly with cardiac risk; among the 580,665 patients with an RCRI score of 0 or 1, treatment was associated with no benefit and possible harm, whereas among the patients with an RCRI score of 2, 3, or 4 or more, the adjusted odds ratios for death in the hospital were 0.88 (95 percent confidence interval, 0.80 to 0.98), 0.71 (95 percent confidence interval, 0.63 to 0.80), and 0.58 (95 percent confidence interval, 0.50 to 0.67), respectively.
Conclusions
Perioperative beta-blocker therapy is associated with a reduced risk of in-hospital death among high-risk, but not low-risk, patients undergoing major noncardiac surgery. Patient safety may be enhanced by increasing the use of beta-blockers in high-risk patients.
Permalink
15 Sep 08
Posted in General at 15:38 by Laci
By A H Lee, B Afessa
Critical Care Medicine 2007;35:1517-1521
Smokers admitted to the intensive care unit may receive nicotine replacement therapy to prevent withdrawal. However, the safety of nicotine replacement in the critically ill has not been studied. The objective of this study was to determine the impact of nicotine replacement on the outcome of critically ill patients.
Design
Retrospective, case-control.
Setting
The medical intensive care unit of a tertiary academic hospital.
Patients
Patients who were active smokers at admission to the intensive care unit were included in the study. Those who received nicotine replacement therapy were considered as cases, and those who did not receive nicotine replacement were considered as controls.
Interventions
None.
Measurements and Main Results
For each of the 90 cases, one control smoker who did not receive nicotine replacement therapy was selected based on the severity of illness and then age. Outcome was measured by hospital mortality and 28-day intensive care unit-free days, defined as the number of days spent outside of intensive care or without mechanical ventilation by a living patient following admission to intensive care. The mean mortality rate predicted by the Acute Physiology and Chronic Health Evaluation III was 9.2% for the cases compared with 10.3% for the controls (p = .7127). The observed hospital mortality rate was 20% in the cases vs. 7% in the control group (p = .0085). When adjusted for the severity of illness and invasive mechanical ventilation, nicotine replacement therapy was independently associated with increased mortality (odds ratio, 24.6; 95% confidence interval, 3.6-167.6; p = .0011). The mean (sd) 28-day intensive care unit-free days were 20.7 (10.5) in the case group compared with 23.4 (7.1) in the control group (p = .0488).
Conclusions
Our study shows that nicotine replacement therapy is associated with increased hospital mortality in critically ill patients. However, because of the limitations of the study, a future study based on a better case-control design is warranted.
Permalink
14 Sep 08
Posted in Enhanced recovery at 12:39 by Laci
By H Kehlet, D Wilmore
Annals of Surgery 2008;248:189-198
Optimization of postoperative outcome requires the application of evidence-based principles of care carefully integrated into a multimodal rehabilitation program.
Objective
To assess, synthesize, and discuss implementation of “fast-track” recovery programs.
Data Sources
Medline MBASE (January 1966–May 2007) and the Cochrane library (January 1966–May 2007) were searched using the following keywords: fast-track, enhanced recovery, accelerated rehabilitation, and multimodal and perioperative care. In addition, the synthesis on the many specific interventions and organizational and implementation issues were based on data published within the past 5 years from major anesthesiological and surgical journals, using systematic reviews where appropriate instead of multiple references of original work.
Data Synthesis
Based on an increasing amount of multinational, multicenter cohort studies, randomized studies, and meta-analyses, the concept of the “fast-track methodology” has uniformly provided a major enhancement in recovery leading to decreased hospital stay and with an apparent reduction in medical morbidity but unaltered “surgery-specific” morbidity in a variety of procedures. However, despite being based on a combination of evidence-based unimodal principles of care, recent surveys have demonstrated slow adaptation and implementation of the fast-track methodology.
Conclusion
Multimodal evidence-based care within the fast-track methodology significantly enhances postoperative recovery and reduces morbidity, and should therefore be more widely adopted. Further improvement is expected by future integration of minimal invasive surgery, pharmacological stress-reduction, and effective multimodal, nonopioid analgesia.
Permalink
Posted in Enhanced recovery at 12:30 by Laci
By S E Noblett, D S Watson, H Huong, B Davison, P J. Hainsworth and A F Horgan
Colorectal Disease 2006;8:563-569
Surgery induces a catabolic response with stress hormone release and insulin resistance. The aim of this study was to assess the effect of pre-operative carbohydrate administration on grip strength, gastrointestinal function and hospital stay following elective colorectal surgery.
Methods
Thirty-six patients undergoing elective colonic resection were randomized into one of three groups. Group 1 were fasted; Group 2 were given pre-operative oral water, Group 3 received equivalent volumes of a Maltodextrin drink. Time to first flatus, first bowel movement and hospital stay were recorded. Muscle strength was measured pre-operatively, and on alternate days thereafter until discharge using a grip strength dynamometer.
Results
Patients in the carbohydrate group had a median postoperative hospital stay of 7.5 days compared with 13 days in the water group (P > 0.01) and 10 days in the fasted group (P = 0.06). The median time postsurgery to first flatus was 3 days for both the fasted and water groups compared with 1.5 days in the carbohydrate group (P = 0.13). First bowel movement occurred on day 3 in the carbohydrate group, day 4 in the fasting group and day 5 in the water group. The fasted group showed a significant reduction in postoperative grip strength (P < 0.05) with a median drop of 10% at discharge. Neither the water nor the carbohydrate groups showed significant reductions in muscle strength.
Conclusion
We found that pre-operative administration of oral carbohydrate leads to a significantly reduced postoperative hospital stay, and a trend towards earlier return of gut function when compared with fasting or supplementary water.
Permalink