Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome

Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - An observational study in 29 countries

BACKGROUND Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients. OBJECTIVES To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs. DESIGN This was a prospective international 1-week observational study using the ‘Assess Respiratory Risk in Surgical Patients in Catalonia risk score’ (ARISCAT score) for PPC for risk stratification. PATIENTS AND SETTING Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries. MAIN OUTCOME MEASURES The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes. RESULTS A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (V T) size was 500 ml, or 7 to 9 ml kg−1 predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P ˂ 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P ˂ 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure. CONCLUSION The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high V T and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome.</p

Sex difference and intra-operative tidal volume: Insights from the LAS VEGAS study

BACKGROUND: One key element of lung-protective ventilation is the use of a low tidal volume (VT). A sex difference in use of low tidal volume ventilation (LTVV) has been described in critically ill ICU patients.OBJECTIVES: The aim of this study was to determine whether a sex difference in use of LTVV also exists in operating room patients, and if present what factors drive this difference.DESIGN, PATIENTS AND SETTING: This is a posthoc analysis of LAS VEGAS, a 1-week worldwide observational study in adults requiring intra-operative ventilation during general anaesthesia for surgery in 146 hospitals in 29 countries.MAIN OUTCOME MEASURES: Women and men were compared with respect to use of LTVV, defined as VT of 8 ml kg-1 or less predicted bodyweight (PBW). A VT was deemed 'default' if the set VT was a round number. A mediation analysis assessed which factors may explain the sex difference in use of LTVV during intra-operative ventilation.RESULTS: This analysis includes 9864 patients, of whom 5425 (55%) were women. A default VT was often set, both in women and men; mode VT was 500 ml. Median [IQR] VT was higher in women than in men (8.6 [7.7 to 9.6] vs. 7.6 [6.8 to 8.4] ml kg-1 PBW, P &lt; 0.001). Compared with men, women were twice as likely not to receive LTVV [68.8 vs. 36.0%; relative risk ratio 2.1 (95% CI 1.9 to 2.1), P &lt; 0.001]. In the mediation analysis, patients' height and actual body weight (ABW) explained 81 and 18% of the sex difference in use of LTVV, respectively; it was not explained by the use of a default VT.CONCLUSION: In this worldwide cohort of patients receiving intra-operative ventilation during general anaesthesia for surgery, women received a higher VT than men during intra-operative ventilation. The risk for a female not to receive LTVV during surgery was double that of males. Height and ABW were the two mediators of the sex difference in use of LTVV.TRIAL REGISTRATION: The study was registered at Clinicaltrials.gov, NCT01601223

Simulated gastrointestinal digestion and in vitro colonic fermentation of carob polyphenols: Bioaccessibility and bioactivity

Carob is a well-known tree for its nutritional and health-promoting edible pods due to its high phenolic contents. It was aimed to investigate: 1) carob phenolic profiles; soluble free, soluble conjugated and bound, 2) bioaccesibility of those phenolics during simulated gastrointestinal digestions, plus in vitro fecal fermentations, 3) their antioxidant properties, also 4) α-amylase and α-glucosidase inhibitory activities. Ten phenolic acids and six flavonoids were detected in soluble (free and conjugated) and insoluble fractions of undigested carob. After in vitro gastrointestinal digestions, the most bioaccessible phenolic acids and flavonoids were gallic acid (647.4%), chlorogenic acid (485.4%), (+)-catechin (558.3%) and rutin (267.2%). Myricetin (79.5%) and gallic acid (20.0%) were the most abundant metabolites of residual fraction of carob phenolics after fecal fermentations. Antioxidant capacity of digested carob has increased significantly (p < 0.05); DPPH (107 mg GAE/g), ABTS (399 mg TE/g) and ORAC (415 μmol TE/g). Both undigested carob and its digested fractions showed a positive dose-dependent inhibition of α-amylase activity (0.3–1.0 mg/mL). The findings from this study showed first time report on carob phenolic profiles (soluble and insoluble) and their bioaccessibility during digestions and fecal fermentations. Carob phenolic might influence glucose metabolism by inhibiting carbohydrate digestion

Revisiting the Relationship Between the Submandibular Duct, Lingual Nerve and Hypoglossal Nerve

Background: The aim of the study was to evaluate the relations between submandibular duct, lingual nerve and hypoglossal nerve for making a reassessment of this area in fresh frozen specimens. Also, the distance between the angle of the mandible and the vertical line drawn from the point where submandibular duct crossed lingual nerve to the base of the mandible was measured to determine a new landmark for neck surgeons. Materials and methods: Fourteen fresh frozen head and neck specimens were dissected and evaluated. A marginal mandibular incision was made from the mastoid process to the chin. Results: In 8 cases, lingual nerve was crossing the submandibular duct superiorly; in 5 cases, lingual nerve was crossing the duct infero-medially and in 1 case it was parallel to the duct. In 1 case, lingual nerve subdivided into anterior and posterior branches. In 2 cases, 2 parallel submandibular ducts were found and the lingual nerve was crossing the upper duct from superior. In 1 case, lingual nerve was crossing the duct infero-medially and then it was subdividing into branches superior to mylohyoid. In 12 cases, the course of hypoglossal nerve was classical. In 1 case, hypoglossal nerve crossed the submandibular duct medially and coursed parallel to the tendon of posterior belly of digastric. And in another case, hypoglossal nerve crossed the inferior branch of submandibular duct medially. The other structures in this area were as usual. Conclusions: The main factor for reducing nerve damage during surgery is the understanding of the anatomy of this area.WoSScopu

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The influence of epidural volume extension on spinal block with hyperbaric or plain bupivacaine for Caesarean delivery

PubMedID: 17888192Background and objective: Epidural volume extension via a combined spinal-epidural is the enhancement of a small-dose intrathecal block by an epidural injection of physiological saline solution. We evaluated the effect of epidural volume extension on the combined spinal-epidural technique of providing spinal anaesthesia for Caesarean section with hyperbaric or plain 0.5% bupivacaine. Methods: Patients (n = 240) with height >163 cm received 9 mg and patients <163 cm received 8 mg of bupivacaine. Each study drug was combined with 20 µg fentanyl. Using the combined spinal-epidural technique, Group A (n = 60) received hyperbaric bupivacaine, and Group B (n = 60) received hyperbaric bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. Group C (n = 60) received plain bupivacaine and Group D (n = 60) received plain bupivacaine and 10 mL saline epidurally 5 min after subarachnoid injection. An anaesthetist blinded to the anaesthetic solution injected examined the level of analgesia by the pinprick method and motor block with the modified Bromage scale for 30 min after subarachnoid injection, during the intraoperative period and subsequently every 15 min for 135 min during the recovery period. Results: Time to reach a sensory block at T4 was significantly shorter in Groups C and D than in Groups A (P = 0.003 and 0.017) and B (P = 0.006 and 0.048), respectively. During the intraoperative period, sensory block levels were significantly higher in Group C than in Group A. Recovery was similar in all groups; only onset was faster in Groups C and D. Conclusion: There was no effect of epidural volume extension on the profile of spinal anaesthesia with the combined spinal-epidural technique for Caesarean section using hyperbaric or plain bupivacaine. © 2007 European Society of Anaesthesiology

Antioxidant activity of alkylresorcinols from rye bran and their protective effects on cell viability of PC-12 AC cells

Alkylresorcinols (ARs) are phenolic lipids that are present in high amounts in the bran layer of different cereals. Rye samples, cultivar Hazlet, and a white rye genotype, RT202, were analyzed for their antioxidant properties and AR content and composition, based on six fractions of the bran, where 1 was the outermost fraction and 6 was the bran fraction closest to the endosperm. Gas chromatography-mass spectrometry (GC-MS) analysis demonstrated that the most commonly found AR homologue in Hazlet rye is C19:0 and that the total amount of ARs decreases from the outermost to innermost fractions. The antioxidant activity using oxygen radical absorbance capacity (ORAC) for both white rye genotype RT202 and Hazlet brans was determined to decrease from the outermost fraction (136.05 μmol TE/g for Hazlet fraction 1 and 186.57 μmol TE/g for white rye genotype RT202 fraction 1) to the innermost fraction (9.84 μmol TE/g for Hazlet fraction 6 and 78.75 μmol TE/g for white rye genotype RT202 fraction 2). A positive relationship was seen with GC-MS results. Treatment of PC-12 AC cells with Hazlet fraction 1 increased mitochondrial biogenesis as determined using mitochondrial fluorescent dyes. In the presence of a prooxidant (AAPH), PC-12 AC cells were better protected from free radical attack when treated with Hazlet fraction 1 than with all other bran fractions. The results suggest that higher AR content in bran fractions confers antioxidant protection against free radical damage

Impact of supercritical CO2 and traditional solvent extraction systems on the extractability of alkylresorcinols, phenolic profile and their antioxidant activity in wheat bran

SC-CO2 and traditional solvent methods were used to extract alkylresorcinols (ARs) in wheat bran (WB) cultivars. WB soluble free, soluble conjugated and bound phenolics were separated by alkaline hydrolysis. Also, the effects of extraction solvents on antioxidant activity were investigated by using three different solvents. The HPLC results showed that the AR content was higher in acetone extracts compared to the SC-CO2. Using ethanol as a co-solvent yielded higher ARs, especially in collector-2 for hard red WB (HRWB) (57.8 mg/100g) and soft red WB (SRWB) (37.8 mg/100g). Ten phenolic acids and six flavonoids were detected in phenolic fractions which ferulic acid was the predominant and mostly found in bound fractions. Two-way ANOVA showed that cultivar, solvent and their interactions had significantly (P < 0.05) different effects on TPC, DPPH, and ORAC values. The best solvents for ORAC, DPPH, and TPC assays were acidified ethanol, 100% acetone, and 50% acetone, respectively