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Anaesthesiology Intensive Therapy 2015Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma,... (Review)
Review
Blood loss and subsequent transfusions are associated with major morbidity and mortality. The use of antifibrinolytics can reduce blood loss in cardiac surgery, trauma, orthopedic surgery, liver surgery and solid organ transplantation, obstetrics and gynecology, neurosurgery and non-surgical diseases. The evidence of their efficacy has been mounting for years. Tranexamic acid (TXA), a synthetic lysine-analogue antifibrinolytic, was first patented in 1957 and its use has been increasing in contrast to aprotinin, a serine protease inhibitor antifibrinolytic. This review aims to help acute care physicians navigate through the clinical evidence available for TXA therapy, develop appropriate dose regimens whilst minimizing harm, as well as understand its broadening scope of applications. Many questions remain unanswered regarding other clinical effects of TXA such as anti-inflammatory response to cardiopulmonary bypass, the risk of thromboembolic events, adverse neurological effects such as seizures, and its morbidity and mortality, all of which necessitate further clinical trials on its usage and safety in various clinical settings.
Topics: Antifibrinolytic Agents; Blood Loss, Surgical; General Surgery; Humans; Tranexamic Acid
PubMed: 25797505
DOI: 10.5603/AIT.a2015.0011 -
Anesthesiology Aug 2019The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities,... (Review)
Review
The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety.
Topics: Anesthesiology; Checklist; Humans; Medical Errors; Operating Rooms; Patient Care Team; Patient Safety; Surgical Procedures, Operative; World Health Organization
PubMed: 31090552
DOI: 10.1097/ALN.0000000000002674 -
Current Opinion in Infectious Diseases Apr 2015Surgical site infection (SSI) is a common healthcare-associated infection and complicates up to 10-20% of operations with considerable strain on healthcare resources.... (Review)
Review
PURPOSE OF REVIEW
Surgical site infection (SSI) is a common healthcare-associated infection and complicates up to 10-20% of operations with considerable strain on healthcare resources. Apart from the widely adopted use of appropriate hair removal, antibiotic prophylaxis, avoidance of hypothermia and perioperative glycaemic control to reduce SSIs, this review has considered new research and systematic reviews, and whether their findings should be included in guidelines.
RECENT FINDINGS
The efficacy of preoperative bathing/showering, antibiotic prophylaxis for clean surgery and perioperative oxygen supplementation to reduce the risk of SSI is still in doubt. By contrast, the use of 2% chlorhexidine in alcohol skin preparation, postoperative negative pressure wound therapy and antiseptic surgical dressings do show promise. Antimicrobial sutures in independent meta-analyses were found to reduce the risk of SSI after all classes of surgery (except dirty) whereas the use of wound guards, or diathermy skin incision (compared with scalpel incision), did not.
SUMMARY
The incidence of SSI after surgery is not falling. Based on this review of published trials and evidence-based systematic reviews some advances might be included into these care bundles. More research is needed together with improved compliance with care bundles.
Topics: Humans; Incidence; Infection Control; Perioperative Care; Surgical Procedures, Operative; Surgical Wound Infection
PubMed: 25692267
DOI: 10.1097/QCO.0000000000000144 -
Anesthesiology Dec 2015Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including... (Review)
Review
Surgery represents a major stressor that disrupts homeostasis and can lead to loss of body cell mass. Integrated, multidisciplinary medical strategies, including enhanced recovery programs and perioperative nutrition support, can mitigate the surgically induced metabolic response, promoting optimal patient recovery following major surgery. Clinical therapies should identify those who are poorly nourished before surgery and aim to attenuate catabolism while preserving the processes that promote recovery and immunoprotection after surgery. This review will address the impact of surgery on intermediary metabolism and describe the clinical consequences that ensue. It will also focus on the role of perioperative nutrition, including preoperative nutrition risk, carbohydrate loading, and early initiation of oral feeding (centered on macronutrients) in modulating surgical stress, as well as highlight the contribution of the anesthesiologist to nutritional care. Emerging therapeutic concepts such as preoperative glycemic control and prehabilitation will be discussed.
Topics: Humans; Nutritional Status; Nutritional Support; Perioperative Care; Postoperative Complications; Preoperative Care; Surgical Procedures, Operative
PubMed: 26248016
DOI: 10.1097/ALN.0000000000000795 -
Clinical Nutrition (Edinburgh, Scotland) Nov 2020Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on... (Review)
Review
BACKGROUND & AIMS
Malnutrition has been recognized as a major risk factor for adverse postoperative outcomes. The ESPEN Symposium on perioperative nutrition was held in Nottingham, UK, on 14-15 October 2018 and the aims of this document were to highlight the scientific basis for the nutritional and metabolic management of surgical patients.
METHODS
This paper represents the opinion of experts in this multidisciplinary field and those of a patient and caregiver, based on current evidence. It highlights the current state of the art.
RESULTS
Surgical patients may present with varying degrees of malnutrition, sarcopenia, cachexia, obesity and myosteatosis. Preoperative optimization can help improve outcomes. Perioperative fluid therapy should aim at keeping the patient in as near zero fluid and electrolyte balance as possible. Similarly, glycemic control is especially important in those patients with poorly controlled diabetes, with a stepwise increase in the risk of infectious complications and mortality per increasing HbA1c. Immobilization can induce a decline in basal energy expenditure, reduced insulin sensitivity, anabolic resistance to protein nutrition and muscle strength, all of which impair clinical outcomes. There is a role for pharmaconutrition, pre-, pro- and syn-biotics, with the evidence being stronger in those undergoing surgery for gastrointestinal cancer.
CONCLUSIONS
Nutritional assessment of the surgical patient together with the appropriate interventions to restore the energy deficit, avoid weight loss, preserve the gut microbiome and improve functional performance are all necessary components of the nutritional, metabolic and functional conditioning of the surgical patient.
Topics: Congresses as Topic; Europe; Fluid Therapy; Humans; Malnutrition; Nutrition Therapy; Perioperative Care; Practice Guidelines as Topic; Societies, Medical; Surgical Procedures, Operative; Water-Electrolyte Imbalance
PubMed: 32362485
DOI: 10.1016/j.clnu.2020.03.038 -
Clinical Interventions in Aging 2018Improving trends in global health care have resulted in a steady increase in the geriatric population. However, as the population ages, surgery is being performed more... (Review)
Review
Improving trends in global health care have resulted in a steady increase in the geriatric population. However, as the population ages, surgery is being performed more frequently in progressively older patients and those with higher prevalence of comorbidities. A significant percentage of elderly patients experience transient postoperative delirium following surgery or long-term postoperative cognitive dysfunction (POCD). Increasing age, educational level, pre-existing mental health, and comorbidities are contributory factors. Comprehensive geriatric assessment provides an objective evaluation on overall medical, social, mental, and functional well-being with scope for preoperative optimization. Preventive strategies for POCD target the surgical and patient-related factors as well as the utilization of the concept of stress-free anesthesia and surgery, that is, Enhanced Recovery After Surgery. This includes care bundles and protocols for the perioperative period which improves outcomes in the elderly. Research on biomarkers of neural injury in POCD is gaining momentum. Pharmacologic agents such as acetylcholine esterase inhibitors promise to have a vital role in the management of POCD but exhibit undesired side effects. Interventions to reduce oxidative stress and neuroinflammation could prove beneficial. Preventive strategies, early recognition, and management of perioperative risk factors seems to be, by far, the best modality to deal with POCD till further progress in therapeutic interventions evolve.
Topics: Aged; Cognitive Dysfunction; Comorbidity; Delirium; Geriatric Assessment; Humans; Postoperative Complications; Risk Factors; Surgical Procedures, Operative
PubMed: 30519008
DOI: 10.2147/CIA.S133896 -
World Journal of Emergency Surgery :... 2018Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are... (Review)
Review
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group.
BACKGROUND
Adhesive small bowel obstruction (ASBO) is a common surgical emergency, causing high morbidity and even some mortality. The adhesions causing such bowel obstructions are typically the footprints of previous abdominal surgical procedures. The present paper presents a revised version of the Bologna guidelines to evidence-based diagnosis and treatment of ASBO. The working group has added paragraphs on prevention of ASBO and special patient groups.
METHODS
The guideline was written under the auspices of the World Society of Emergency Surgery by the ASBO working group. A systematic literature search was performed prior to the update of the guidelines to identify relevant new papers on epidemiology, diagnosis, and treatment of ASBO. Literature was critically appraised according to an evidence-based guideline development method. Final recommendations were approved by the workgroup, taking into account the level of evidence of the conclusion.
RECOMMENDATIONS
Adhesion formation might be reduced by minimally invasive surgical techniques and the use of adhesion barriers. Non-operative treatment is effective in most patients with ASBO. Contraindications for non-operative treatment include peritonitis, strangulation, and ischemia. When the adhesive etiology of obstruction is unsure, or when contraindications for non-operative management might be present, CT is the diagnostic technique of choice. The principles of non-operative treatment are per os, naso-gastric, or long-tube decompression, and intravenous supplementation with fluids and electrolytes. When operative treatment is required, a laparoscopic approach may be beneficial for selected cases of simple ASBO.Younger patients have a higher lifetime risk for recurrent ASBO and might therefore benefit from application of adhesion barriers as both primary and secondary prevention.
DISCUSSION
This guideline presents recommendations that can be used by surgeons who treat patients with ASBO. Scientific evidence for some aspects of ASBO management is scarce, in particular aspects relating to special patient groups. Results of a randomized trial of laparoscopic versus open surgery for ASBO are awaited.
Topics: Disease Management; General Surgery; Guidelines as Topic; Humans; Intestinal Obstruction; Tissue Adhesions; Treatment Outcome
PubMed: 29946347
DOI: 10.1186/s13017-018-0185-2 -
Minerva Anestesiologica Jan 2015Surgical site infections (SSIs) are a frequent cause of morbidity following surgical procedures. Gram-positive cocci, particularly staphylococci, cause many of these... (Review)
Review
Surgical site infections (SSIs) are a frequent cause of morbidity following surgical procedures. Gram-positive cocci, particularly staphylococci, cause many of these infections, although Gram-negative organisms are also frequently involved. The risk of developing a SSI is associated with a number of factors, including aspects of the operative procedure itself, such as wound classification, and patient-related variables, such as preexisting medical conditions. Antimicrobial prophylaxis (AP) plays an important role in reducing SSIs, especially if patient-related risk factors for SSIs are present. The main components of antimicrobial prophylaxis are: timing, selection of drugs and patients, duration and costs. Compliance with these generally accepted preventive principles may lead to overall decreases in the incidence of these infections. Ideally the administration of the prophylactic agent should start within 30 minutes from the surgical incision. The duration of the AP should not exceed 24 hours for the majority of surgical procedures. The shortest effective period of prophylactic antimicrobial administration is not known and studies have demonstrated that post-surgical antibiotic administration is unnecessary. Furthermore, there were no proven benefits in multiple dose regimens when compared to single-dose regimens. The choice of an appropriate prophylactic antimicrobial agent should be based primarily on efficacy and safety. Broad spectrum antibiotics should be avoided due to the risk of promoting bacterial resistance. Cephalosporins are the most commonly used antibiotics in surgical prophylaxis; specifically, cefazolin or cefuroxime are mainly used in the prophylaxis regimens for cardio-thoracic surgery, vascular surgery, hip or knee arthroplasty surgery, neurosurgical procedures and gynecologic and obstetric procedures. A review of the prophylactic regimens regarding the main surgical procedures is presented.
Topics: Anti-Infective Agents; Antibiotic Prophylaxis; Humans; Surgical Procedures, Operative; Surgical Wound Infection
PubMed: 24561611
DOI: No ID Found -
International Journal of Surgery... Sep 2019It is human nature to make mistakes, all people in all works make errors, but an amputation of the wrong leg or an inadvertently retained needle in the abdominal cavity... (Review)
Review
It is human nature to make mistakes, all people in all works make errors, but an amputation of the wrong leg or an inadvertently retained needle in the abdominal cavity are unanticipated incidents, that no physician in the world wants to experience. Such catastrophic events, except for the consequences on the patient's health and the physician's career, have severe financial implications on the healthcare system. Human nature, apart from making mistakes, is also able to find solutions to minimize adverse incidents. A systematic time-out in the operating room just before incision has been introduced the last two decades to help prevent wrong site surgeries and other surgical never events. Despite its effectiveness in increasing patient safety, compliance issues remain a major problem in its implementation and gaps in its daily use still occur. The current review presents patterns of wrong time-out procedures, emphasizes the problem of poor compliance and reviews the suggested strategies to increase compliance for safer operating rooms.
Topics: Checklist; Humans; Medical Errors; Patient Safety; Practice Guidelines as Topic; Surgical Procedures, Operative; World Health Organization
PubMed: 31310820
DOI: 10.1016/j.ijsu.2019.07.006 -
Medicina (Kaunas, Lithuania) Feb 2020Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization,... (Observational Study)
Observational Study
Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization, and improves the quality of the postoperative period. The aim of the study was to assess the effectiveness of pain management in patients after surgery. The study included 216 patients operated on in the following surgical wards: the Department of Cardiosurgery and the Department of General and Endocrine Surgery. Patients were hospitalized on average for 6 ± 4.5 days. Patients were randomly selected for the study using a questionnaire technique with a numerical rating scale. Immediately after surgery, pre-emptive analgesia, multimodal analgesia, and analgosedation were used significantly more frequently than other methods ( < 0.001). In the subsequent postoperative days, the method of administering drugs on demand was used most often. Patients with confirmed complications during postoperative wound healing required significantly more frequent use of drugs from Steps 2 and 3 of the World Health Organization (WHO) analgesic ladder compared with patients without complications. The mode of patient admission for surgery significantly affected the level of pain perception. Different pain management methods were used and not every method was effective.
Topics: Analgesia; Analgesics; Analgesics, Opioid; Cardiac Surgical Procedures; Endocrine Surgical Procedures; Female; Humans; Length of Stay; Male; Middle Aged; Pain Management; Pain, Postoperative; Surgical Procedures, Operative; Wound Healing
PubMed: 32046199
DOI: 10.3390/medicina56020065