Critical Care - Research Publications
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ItemHigh Frequency, Low Background Rate Extrapleural Programmed Intermittent Bolus Ropivacaine Provides Superior Analgesia Compared with Continuous Infusion for Acute Pain Management Following Thoracic Surgery: A Retrospective Cohort Study.(Briefland, 2019-10)BACKGROUND: Thoracic surgery often results in severe postoperative pain. Regional analgesia via surgically placed extrapleural local anaesthetic (LA) and continuous infusion (CI) is an effective technique, however usually requires supplemental opioid to achieve satisfactory patient analgesia. We hypothesized that high frequency, low background rate extrapleural programmed intermittent boluses (PIB) of LA by could achieve superior patient analgesia and reduced oral morphine equivalent daily dosage (OMEDD) requirements for up to 3 days after thoracic surgery vs. CI. METHODS: We retrospectively analysed data from 84 adult patients receiving extrapleural analgesia after thoracic surgery in a single tertiary teaching hospital. The primary outcome measure was the effect of PIB vs. CI on maximum daily 11-point numerical rating scale (NRS-11) ratings as determined by multivariate linear regression analysis, corrected for OMEDD use, total daily LA dose, surgery type, age, opioid type, and use of ketamine analgesia. Secondary outcome measures were the effect on OMEDD use, the effect of total 'rescue' LA boluses, and univariate analyses of the above outcomes and variables. RESULTS: PIB on day 0, and a higher proportion of LA given as rescue boluses on day 1 were associated with reduced maximum NRS-11 ratings [standardized/ [unstandardized] beta coefficient -0.34/ [-0.92 NRS-11 if PIB] (P = 0.007); and -0.26/ [-0.029 NRS-11 per mg/kg extrapleural ropivacaine] (P = 0.03)], respectively. Only patient age was associated with reduced OMEDD use [day 0: -0.58/ [-4.4 OMEDDs per year of age] (P ≤ 0.005); day 1: -0.49/ [-3.56 OMEDDs per year of age] (P ≤ 0.005); day 2: -0.32/ [-1.9 OMEDDs per year of age] (P = 0.04)]. OMEDD use on day 2, however, was associated with slightly higher maximum NRS-11 ratings [+0.28/ +0.006 NRS-11 per mg OMEDD (P = 0.036)]. On univariate analysis, PIB patients achieved the largest difference in OMEDD use [-98 mg (95% CI -73 to -123 mg)] and NRS-11 ratings [-1.1 (-0.4 to -1.8)] against CI patients on day 3. CONCLUSIONS: Use of high frequency, low background rate PIB extrapleural LA after thoracic surgery appears to have a modest beneficial effect on acute pain, but not OMEDD use, over CI when adjusted for patient, surgical and other analgesic factors after thoracic surgery. Further work is required to elucidate the potential magnitude of effect that extrapleural LA given by PIB over CI can achieve.
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ItemThe impact of fluid intervention on complications and length of hospital stay after pancreaticoduodenectomy (Whipple's procedure)(BIOMED CENTRAL LTD, 2014-05-14)BACKGROUND: There is limited information on the impact on perioperative fluid intervention on complications and length of hospital stay following pancreaticoduodenectomy. Therefore, we conducted a detailed analysis of fluid intervention in patients undergoing pancreaticoduodenectomy at a university teaching hospital to test the hypothesis that a restrictive intravenous fluid regime and/or a neutral or negative cumulative fluid balance, would impact on perioperative complications and length of hospital stay. METHODS: We retrospectively obtained demographic, operative details, detailed fluid prescription, complications and outcomes data for 150 consecutive patients undergoing pancreaticoduodenectomy in a university teaching hospital. Prognostic predictors for length of hospital stay and complications were determined. RESULTS: One hundred and fifty consecutive patients undergoing pancreaticoduodenectomy were evaluated between 2006 and 2012. The majority of patients were, middle-aged, overweight and ASA class III. Postoperative complications were frequent and occurred in 86 patients (57%). The majority of complications were graded as Clavien-Dindo Class 2 and 3. Postoperative pancreatic fistula occurred in 13 patients (9%), and delayed gastric emptying occurred in 25 patients (17%). Other postoperative surgical complications included sepsis (22%), bile leak (4%), and postoperative bleeding (2%). Serious medical complications included pulmonary edema (6%), myocardial infarction (8%), cardiac arrhythmias (13%), respiratory failure (8%), and renal failure (7%). Patients with complications received a higher median volume of intravenous therapy and had higher cumulative positive fluid balances. Postoperative length of stay was significantly longer in patients with complications (median 25 days vs. 10 days; p < 0.001). After adjustment for covariates, a fluid balance of less than 1 litre on postoperative day 1 and surgeon caseloads were associated with the development of complications. CONCLUSIONS: In the context of pancreaticoduodenectomy, restrictive perioperative fluid intervention and negative cumulative fluid balance were associated with fewer complications and shorter length of hospital stay. These findings provide good opportunities to evaluate strategies aimed at improving perioperative care.
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ItemPostoperative wristwatch-induced compressive neuropathy of the hand: a case report.(Springer Science and Business Media LLC, 2015-06-16)INTRODUCTION: Postoperative peripheral nerve injuries are well-recognised complications of both surgery and anaesthesia and a leading cause of litigation claims. We present a rare cause of compressive sensory and motor neuropraxia of the median, ulnar and radial nerves of the right hand resulting from a wristwatch that was worn on the first postoperative night following minor surgery. Mechanisms of this compressive neuropathy are discussed, with specific recommendations made regarding the wearing of wristwatches, jewellery and constrictive clothing in the immediate postoperative period. CASE PRESENTATION: A 12-year-old white boy presented with a complete glove and stocking sensory and motor neuropathy involving his right hand from a wristwatch that was worn on the first postoperative night following uneventful surgery for a minor procedure. Over the following 12 hours the oedema and erythema resolved with complete return of motor function. After 18 hours, the sensory deficit completely resolved. CONCLUSIONS: Postoperative neuropraxia is often preventable. Paediatric patients, especially if thin, may be particularly susceptible to a compression neuropathy from constrictive clothing or jewellery, in particular circumferential varieties such as wristwatches. These items should not be worn in the immediate postoperative period as pressure on peripheral nerves can result in severe and debilitating nerve injury. Education should be given to all medical staff, carers or parents of children undergoing surgery on the avoidance of wearing wristwatches, jewellery or constrictive clothing in the immediate postoperative period. Early medical evaluation of any postoperative nerve injury is of paramount importance.
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ItemPlasma-Lyte 148: A clinical review.(Baishideng Publishing Group Inc., 2016-11-04)AIM: To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative medicine. METHODS: We performed an electronic literature search from Medline and PubMed (via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: "surgery", "anaesthesia", "anesthesia", "anesthesiology", "anaesthesiology", "fluids", "fluid therapy", "crystalloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "ringers" "acetate", "gluconate", "malate", "lactate". All relevant articles were accessed in full. We summarized the data and reported the data in tables and text. RESULTS: We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and text. CONCLUSION: Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of Plasma-Lyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.
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ItemThe effects of intravenous lignocaine on depth of anaesthesia and intraoperative haemodynamics during open radical prostatectomy.(Springer Science and Business Media LLC, 2017-07-06)BACKGROUND: Lignocaine is a local anaesthetic agent, which is also commonly used as a perioperative analgesic adjunct to accelerate rehabilitation and enhance recovery after surgery. Lignocaine's systemic effects on intraoperative haemodynamics and volatile anaesthetic requirements are not well explored. Therefore, we evaluated the effects of intravenous lignocaine on intraoperative volatile agent requirements and haemodynamics in patients undergoing major abdominal surgery. METHODS: We performed an analysis of 76 participants who underwent elective open radical retropubic prostatectomy. Patients received lignocaine (1.5 mg/kg loading dose) followed by an infusion (1.5 mg/kg/h) for the duration of surgery, or saline at an equivalent rate. The aims of the study were to evaluate the end-tidal sevoflurane concentration required to maintain a bispectral index of between 40 and 60. Measurements included intraoperative blood pressure, heart rate, and the volume of intravenous fluids and dosage of vasoactive medications administered. RESULTS: The average end-tidal sevoflurane concentration was lower in the Lignocaine group compared to saline [1.49% (SD: 0.32) vs. 1.89% (SD: 0.29); 95% CI 0.26-0.5, p < 0.001]. In the Lignocaine group, the average mean arterial pressure was 80.3 mmHg (SD: 4.9) compared to 85.1 mmHg (SD: 5.4) in the Saline group (95% CI 2.4-7.1, p < 0.001). Systolic blood pressure was also lower in the Lignocaine group: 121.7 mmHg (SD: 6.1) vs. 128.0 mmHg (SD: 6.4) in the Saline group; 95% CI 3.5-9.2, p < 0.001, as was the mean heart rate [Lignocaine group: 74.9 beats/min (SD: 1.8) vs. 81.5 beats/min (SD: 1.7) in the Saline group, 95% CI 4.1-9.1, p < 0.001]. Maintenance fluid requirements were higher in the Lignocaine group: 3281.1 mL (SD: 1094.6) vs. 2552.6 mL (SD: 1173.5) in the Saline group, 95% CI 206-1251, p = 0.007. There were no differences in the use of vasoactive drugs. CONCLUSIONS: Intravenous lignocaine reduces volatile anaesthetic requirements and lowers blood pressure and heart rate in patients undergoing open radical prostatectomy.