Obesity and Anesthesia Management

The prevalence of obesity is rapidly increasing throughout the world. Correspondingly, anesthetic procedures in obese patients are also increasing due to both treatment of obesity and other surgical problems of obese patients. Anesthesia-related complications are also seen in obese patients than in normal-weighted population. The importance of anesthetic applications in obese patients originates from physiological and pharmacokinetic alterations. Inhalation of these patients via mask or intubation during general anesthesia may be difficult or even impossible. Determination of extubation time after awakening from anesthesia is also a critical decision. Sleep apnea syndrome and postoperative atelectasis are more common in obese patients than in normal-weighted population. Another vital complication that should be emphasized is thromboembolism, whose incidence and severity may be decreased by pharmacological and functional preventive modalities. This patient population has elevated risk of perioperative mortality and morbidity. Prior to any elective surgical procedure, an obese patient should be thoroughly evaluated to check medical conditions that may increase perioperative mortality risk. Since anesthesiologists will gradually encounter more obese patients, they need a better comprehending of the difficulties of obesity during anesthetic procedures and taking more preventive measures for their patients to avoid complications, or rendering them less traumatic, if any

Compare the effects of intrathecal three different doses of bupivacain application combined with opioids in transuretral resection

Transüretral rezeksiyon geçirecek hastalara spinal anestezi uygulamasında üç farklı dozda bupivakainin opioid ile kombinasyonunda hemodinamik parametreler, anestezi kalitesi, motor ve duyusal blok oluşturma özellikleri ve postoperatif analjezik etkinliklerini değerlendirilmesi amaçlandı. Çalışmamızda TUR operasyonu geçirecek 55 yaş ve üzeri, 60 hasta 5.0 mg (Grup I, n=20), 7,5 mg (Grup II, n=20), 10 mg (Grup III, n=20) bupivakain grupları olarak rastgele 3 gruba ayrıldı. Gruplara toplam volüm 3 mL olacak şekilde 100 µg morfin eklendi. Hemodinamik parametreler, duyusal ve motor blok özellikleri, ilk analjezik ihtiyacı, spinal anestezi uygulamasında gözlenen intraoperatif ve postoperatif yan etkiler kaydedildi. Maksimum duyusal blok seviyesi gruplarda sırayla T10, T8 ve T6 olarak bulundu. Ancak duyusal blok seviyesinin zaman içerisindeki seyri izlendiğinde Grup I ve Grup II&#8217;de stabil seyrettiği fakat Grup III&#8217;te zamanla yükseldiği görüldü ve buna bağlı gelişen hemodinamik değişikliklerinde bununla orantılı olduğu saptandı. Gruplar arasında hipotansiyon yönünden anlamlı farklılık olup Grup I&#8217;e göre Grup II ve Grup III&#8217;te hipotansiyon daha sık görüldü (p=0,047 ve p<0,001). Grup II ile Grup III arasında hipotansiyon sıklığında fark saptanmadı (p=0,102). Bradikardi Grup I&#8217;de sadece 1 hastada (%5), Grup II&#8217;de 4 hastada (%20), Grup III&#8217;te 10 hastada (%50) gözlendi. T10&#8217;a ulaşma süresi grup Grup I&#8217;e göre Grup II ve Grup III&#8217;te daha kısa süredeydi. Grup II ve Grup III&#8217;e göre Grup I&#8217;de iki segment gerileme zamanı daha kısa idi. Ayrıca, Grup III&#8217;e göre Grup II&#8217;de de iki segment gerileme zamanı daha kısa idi. Her üç grupta demografik özellikler, duyusal bloğun maksimum düzeye ulaşma zamanı, maksimum motor blok oluşma zamanları benzerdi. Gruplar arasında cerrahi memnuniyet yönünden anlamlı fark olup Grup I ve Grup II&#8217;ye göre Grup III&#8217;te cerrahi memnuniyet daha yüksekti. Gruplar arasında hasta memnuniyeti yönünden de fark olup Grup I ve Grup II&#8217;ye göre Grup III&#8217;te hasta memnuniyeti daha yüksekti. İleri yaş ve yandaş hastalıkları olan hastaların spinal anestezisinde düşük dozda lokal anesteziğin eklenen intratekal morfin ile birlikte kullanımının transüretral rezeksiyon operasyonlarında uygun bir seçenek olduğu sonucuna varıldı.In this study, we aimed to compare the effects of three different doses of bupivacain application combined with opioids on postoperative analgesia, motor and sensory blockade and anesthesia quality in patients undergoing transurethral resection of the prostate (TUR-P) under spinal anesthesia . 60 patients all above the age of 55 undergoing transurethral resection of the prostate (TUR-P) were randomly divided into 3 groups recieving 5.0 mg (Group I, n=20), 7,5 mg (Group II, n=20), 10 mg (Group III, n=20) of bupivacaine. In each group ,100 µg of morphine was added to application in order to complete the final volume of adminstration to 3 cc. Hemodinamic parameters, motor and sensorial blockade, the time of first postoperative analgesia requirement, intra and postoperative adverse effects of spinal anesthesia were then recorded. Maximum sensorial blockade levels in order of groups revealed to be T10, T8 and T6 respectively. As the sensorial block levels of the groups evaluated during the procedure, a higher level was detected in group III , although it was observed stable in the groups I and II. Changes in hemodinamic parameters were found to be corralated. There was sıgnıfıcant difference in terms of hypotension between the groups. In groups II and III hypotension was detected to be more frequently compared to group I. (p=0,047 and p<0,001). There were no statistically significant differences between groups II and III in hypotension frequency. (p=0,102). Bradycardia was detected in 1 patient in Group I (%5), 4 patients in Group II (%20) and 10 patients in Group III (%50). The time to reach T10 dermatome blockade was shorter in Group II and III than in Group I. Two dermatome regression time of sensory block was shorter in Group I when compared to Groups II and III. Besides, regression time of sensory block for two dermatoms in Group II was shorter than in Group III. There were no statistically significant differencies among the groups regarding demographic charachteristics, sensory and motor block onset times. Patient and surgeon satisfaction revealed to be significantly higher in Group III than Groups II and I. In conclusion, for transurethral prostate surgery of elderly patients with morbid diseases, low dose local anestehetic in addition with intratechal morphine can provide stable hemodynamic profile, patient and surgeon satisfaction and effective sensorial and motor blockade in spinal anaesthesia

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (&gt; 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72&nbsp;h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

Acute kidney disease beyond day 7 after major surgery: a secondary analysis of the EPIS-AKI trial

Purpose: Acute kidney disease (AKD) is a significant health care burden worldwide. However, little is known about this complication after major surgery. Methods: We conducted an international prospective, observational, multi-center study among patients undergoing major surgery. The primary study endpoint was the incidence of AKD (defined as new onset of estimated glomerular filtration rate (eCFR) &lt; 60&nbsp;ml/min/1.73&nbsp;m2 present on day 7 or later) among survivors. Secondary endpoints included the relationship between early postoperative acute kidney injury (AKI) (within 72&nbsp;h after major surgery) and subsequent AKD, the identification of risk factors for AKD, and the rate of chronic kidney disease (CKD) progression in patients with pre-existing CKD. Results: We studied 9510 patients without pre-existing CKD. Of these, 940 (9.9%) developed AKD after 7&nbsp;days of whom 34.1% experiencing an episode of early postoperative-AKI. Rates of AKD after 7&nbsp;days significantly increased with the severity (19.1% Kidney Disease Improving Global Outcomes [KDIGO] 1, 24.5% KDIGO2, 34.3% KDIGO3; P &lt; 0.001) and duration (15.5% transient vs 38.3% persistent AKI; P &lt; 0.001) of early postoperative-AKI. Independent risk factors for AKD included early postoperative-AKI, exposure to perioperative nephrotoxic agents, and postoperative pneumonia. Early postoperative-AKI carried an independent odds ratio for AKD of 2.64 (95% confidence interval [CI] 2.21-3.15). Of 663 patients with pre-existing CKD, 42 (6.3%) had worsening CKD at day 90. In patients with CKD and an episode of early AKI, CKD progression occurred in 11.6%. Conclusion: One in ten major surgery patients developed AKD beyond 7&nbsp;days after surgery, in most cases without an episode of early postoperative-AKI. However, early postoperative-AKI severity and duration were associated with an increased rate of AKD and early postoperative-AKI was strongly associated with AKD independent of all other potential risk factors