09 Jan 12
Posted in Anesthesia, Neuraxial block at 1:41 by Laci
By A Gupta, A Björnsson, M Fredriksson, O Hallböök and C Eintrei
Br. J. Anaesth 2011;107:164-170
There is some evidence that epidural analgesia (EDA) reduces tumour recurrence after breast and prostatic cancer surgery. We assessed whether EDA reduces long-term mortality after colorectal cancer surgery.
Methods
All patients having colorectal cancer surgery between January 2004 and January 2008 at Linköping and Örebro were included. Exclusion criteria were: emergency operations, laparoscopic-assisted colorectal resection, and stage 4 cancer. Statistical information was obtained from the Swedish National Register for Deaths. Patients were analysed in two groups: EDA group or patient-controlled analgesia (PCA group) as the primary method of analgesia.
Results
A total of 655 patients could be included. All-cause mortality for colorectal cancer (stages 1–3) was 22.7% (colon: 20%, rectal: 26%) after 1–5 yr of surgery. Multivariate regression analysis identified the following statistically significant factors for death after colon cancer (P<0.05): age (>72 yr) and cancer stage 3 (compared with stage 1). A similar model for rectal cancer found that age (>72 yr) and the use of PCA rather than EDA and cancer stages 2 and 3 (compared with stage 1) were associated with a higher risk for death. No significant risk of death was found for colon cancer when comparing EDA with PCA (P=0.23), but a significantly increased risk of death was seen after rectal cancer when PCA was used compared with EDA (P=0.049) [hazards ratio: 0.52 (0.27–1.00)].
Conclusions
We found a reduction in all-cause mortality after rectal but not colon cancer in patients having EDA compared with PCA technique.
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08 Jan 12
Posted in Pre-operatie evaluation at 11:41 by Laci
By X. Zuidema, R. C. Tromp Meesters, I. Siccama and P. L. Houweling
Br. J. Anaesth. 2011;107:180-185
In order to improve the consistency of anaesthetic risk scoring, we have developed an automated method for the calculation of ASA (cASA) scores using decision logic programming. We investigated whether ASA scoring by anaesthetic caregivers could be matched or closely approximated by a cASA.
Methods
We used a web-based preoperative assessment system to present a structured questionnaire comprising 22 questions. These were designed to score and identify conditions that are known, from the literature and expert opinion, to be risk factors. The answers from 14 349 cases were processed using decision logic to provide a variety of risk scores including a computed overall anaesthetic risk (cASA), which was then compared with the ASA score estimated by anaesthesia caregivers (eASA).
Results
We found a close agreement between the two measures in almost all cases. In 159 cases (1.1%), there was an underestimation of cASA, in comparison with the eASA, which appeared to be a result predominantly of incorrect or incomplete answers, or an overestimation of the ASA score by the human classifier (43%).
Conclusion
We showed that ASA scores estimated by a heterogeneous group of anaesthesia caregivers (anaesthetists, anaesthesia trainees, and physician assistants) could be mimicked by the cASA computed by our preoperative assessment system.
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06 Jan 12
Posted in Fluid management at 4:58 by Laci
By B Guidet, N Soni, G D Rocca, S Kozek, B Vallet, D Annane and M James
Critical Care 2010;14:325
The electronic version of this article is the complete one and can be found online at: http://ccforum.com/content/14/5/325
The present review of fluid therapy studies using balanced solutions versus isotonic saline fluids (both crystalloids and colloids) aims to address recent controversy in this topic. The change to the acid-base equilibrium based on fluid selection is described. Key terms such as dilutional-hyperchloraemic acidosis (correctly used instead of dilutional acidosis or hyperchloraemic metabolic acidosis to account for both the Henderson-Hasselbalch and Stewart equations), isotonic saline and balanced solutions are defined. The review concludes that dilutional-hyperchloraemic acidosis is a side effect, mainly observed after the administration of large volumes of isotonic saline as a crystalloid. Its effect is moderate and relatively transient, and is minimised by limiting crystalloid administration through the use of colloids (in any carrier). Convincing evidence for clinically relevant adverse effects of dilutional-hyperchloraemic acidosis on renal function, coagulation, blood loss, the need for transfusion, gastrointestinal function or mortality cannot be found. In view of the long-term use of isotonic saline either as a crystalloid or as a colloid carrier, the paucity of data documenting detrimental effects of dilutional-hyperchloraemic acidosis and the limited published information on the effects of balanced solutions on outcome, we cannot currently recommend changing fluid therapy to the use of a balanced colloid preparation.
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05 Jan 12
Posted in Fluid management at 21:58 by Laci
By S Kozek-Langenecker
Best Practice & Research Clinical Anaesthesiology 2009;23:225-236
Haemostatic alterations associated with the use of fluids are related to non-specific dilutional effects and colloid-specific effects, such as acquired von Willebrand syndrome, inhibition of platelet function and fibrin polymerization. Judging by currently available evidence, dextran, hetastarch and pentastarch have a more pronounced impact than tetrastarch, gelatin and albumin. In patients with hypocoagulability, tetrastarch appears to be a suitable volume expander due to its high safety index and volume efficacy. Gelatins have lower inhibitory effects on clot strength compared with tetrastarch, but their volume efficacy is also lower. Dextrans are potent anticoagulants with a high risk for adverse reactions. Albumin has negligible effects on haemostasis, but low volume efficacy and costs limit the use of a blood product as a routine volume replacement fluid. To avoid potential acidosis-induced changes in haemostasis, plasma-adapted carrier solutions may be used instead of saline-based solutions.Haemostatic alterations associated with the use of fluids are related to non-specific dilutional effects and colloid-specific effects, such as acquired von Willebrand syndrome, inhibition of platelet function and fibrin polymerization. Judging by currently available evidence, dextran, hetastarch and pentastarch have a more pronounced impact than tetrastarch, gelatin and albumin. In patients with hypocoagulability, tetrastarch appears to be a suitable volume expander due to its high safety index and volume efficacy. Gelatins have lower inhibitory effects on clot strength compared with tetrastarch, but their volume efficacy is also lower. Dextrans are potent anticoagulants with a high risk for adverse reactions. Albumin has negligible effects on haemostasis, but low volume efficacy and costs limit the use of a blood product as a routine volume replacement fluid. To avoid potential acidosis-induced changes in haemostasis, plasma-adapted carrier solutions may be used instead of saline-based solutions.
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