Dexmedetomidine as a total intravenous anesthetic agent,”

DEXMEDETOMIDINE is a highly selective ␣ 2 adrenoceptor agonist that has sedative and analgesic properties with associated reduction in opioid and anesthetic requirements. 1-11 One significant advantage of dexmedetomidine is that in the clinical dose range there is no respiratory depression. Case Reports Case 1 A 66-yr-old, 85-kg woman presented with inspiratory stridor and was found to have a severe subglottic stenosis of her trachea. The stenosis was measured to be 1.5 cm below the vocal cords and to have a lumen diameter of 4 mm. Neodymium:yttrium-aluminum-garnet laser destruction of the tracheal stenosis was scheduled emergently. The patient was brought to the operating room and peripheral intravenous and arterial cannulae were inserted and electrocardiogram electrodes and pulse oximetry sensor were applied. A loading dose of dexmedetomidine 1 g/kg was infused over 10 min and then an infusion of 0.7 g·kg Ϫ1 ·h Ϫ1 was delivered but rapidly increased over 10 min to 10 g·kg Ϫ1 ·h Ϫ1 to attain an acceptable level of anesthesia that would allow the airway to be instrumented by direct laryngoscopy. Topical lidocaine was applied to the nasal mucosa, the back of the pharynx, and the upper surface of the glottis. A fiberoptic bronchoscope was passed through the nose and the tracheal stenosis was visualized. No supplemental oxygen was supplied. When the patient was completely unresponsive approximately 20 min after induction the laser was powered and the tracheal stenosis was ablated. The procedure took 30 min and during that time the airway had to be supported with a chin lift. The blood pressure declined from 150/80 mm Hg to 110/60 mm Hg and pulse rate was maintained between 70 and 75 beats/min. (figs. 1 and 2) After 20 min the infusion of dexmedetomidine was reduced to 5 g·kg , but the patient began to exhibit signs of lightening from anesthesia and so the infusion was increased back to 10 g·kg Ϫ1 ·h Ϫ1 . The oxygen saturations were maintained at greater than 90% except when the upper airway was obstructed and a chin lift was necessary. Case 2 A 65-yr-old, 50-kg man was admitted with acute exacerbation of chronic respiratory failure secondary to emphysema. He required mechanical ventilation for 5 days and was then weaned to spontaneous ventilation and the endotracheal tube was removed. While breathing room air, his arterial PaO 2 was 55 mm Hg and PaCO 2 was 60 mm Hg. He was then scheduled to have extensive resections of facial skin cancers with full-thickness skin graft reconstruction. The patient arrived in the operating room tachycardic and hypertensive and vigorously refused local anesthesia. Sedation with dexmedetomidine was attempted with a loading dose of 1 g/kg followed by an infusion of 0.7 g·kg Ϫ1 ·h Ϫ1 . This did not provide adequate anesthesia so the infusion was increased to 5 g·kg Ϫ1 ·h Ϫ1 , and after a further 10 min the patient was anesthetized deeply enough to allow the surgery to take place. No supplemental oxygen was administered because of the close proximity of the electrical cautery. Hemodynamically he became stable with heart rate slowing from 120 beats/minute to 65 beats/minute and blood pressure declining from 220/120 mm Hg to 120/65 mm Hg. Oxygen saturation, measured by a pulse oximeter, was maintained above 90% and respiratory rate declined from 30 breaths/min to 16 breaths/min. At the conclusion of the procedure local anesthesia was infiltrated into the surgical sites. The patient required no analgesia in the postanesthesia recovery unit and remained hemodynamically stable. He was discharged from the unit 2 h postoperatively

Dexmedetomidine as a total intravenous anesthetic agent

DEXMEDETOMIDINE is a highly selective ␣ 2 adrenoceptor agonist that has sedative and analgesic properties with associated reduction in opioid and anesthetic requirements. 1-11 One significant advantage of dexmedetomidine is that in the clinical dose range there is no respiratory depression. Case Reports Case 1 A 66-yr-old, 85-kg woman presented with inspiratory stridor and was found to have a severe subglottic stenosis of her trachea. The stenosis was measured to be 1.5 cm below the vocal cords and to have a lumen diameter of 4 mm. Neodymium:yttrium-aluminum-garnet laser destruction of the tracheal stenosis was scheduled emergently. The patient was brought to the operating room and peripheral intravenous and arterial cannulae were inserted and electrocardiogram electrodes and pulse oximetry sensor were applied. A loading dose of dexmedetomidine 1 g/kg was infused over 10 min and then an infusion of 0.7 g·kg Ϫ1 ·h Ϫ1 was delivered but rapidly increased over 10 min to 10 g·kg Ϫ1 ·h Ϫ1 to attain an acceptable level of anesthesia that would allow the airway to be instrumented by direct laryngoscopy. Topical lidocaine was applied to the nasal mucosa, the back of the pharynx, and the upper surface of the glottis. A fiberoptic bronchoscope was passed through the nose and the tracheal stenosis was visualized. No supplemental oxygen was supplied. When the patient was completely unresponsive approximately 20 min after induction the laser was powered and the tracheal stenosis was ablated. The procedure took 30 min and during that time the airway had to be supported with a chin lift. The blood pressure declined from 150/80 mm Hg to 110/60 mm Hg and pulse rate was maintained between 70 and 75 beats/min. (figs. 1 and 2) After 20 min the infusion of dexmedetomidine was reduced to 5 g·kg , but the patient began to exhibit signs of lightening from anesthesia and so the infusion was increased back to 10 g·kg Ϫ1 ·h Ϫ1 . The oxygen saturations were maintained at greater than 90% except when the upper airway was obstructed and a chin lift was necessary. Case 2 A 65-yr-old, 50-kg man was admitted with acute exacerbation of chronic respiratory failure secondary to emphysema. He required mechanical ventilation for 5 days and was then weaned to spontaneous ventilation and the endotracheal tube was removed. While breathing room air, his arterial PaO 2 was 55 mm Hg and PaCO 2 was 60 mm Hg. He was then scheduled to have extensive resections of facial skin cancers with full-thickness skin graft reconstruction. The patient arrived in the operating room tachycardic and hypertensive and vigorously refused local anesthesia. Sedation with dexmedetomidine was attempted with a loading dose of 1 g/kg followed by an infusion of 0.7 g·kg Ϫ1 ·h Ϫ1 . This did not provide adequate anesthesia so the infusion was increased to 5 g·kg Ϫ1 ·h Ϫ1 , and after a further 10 min the patient was anesthetized deeply enough to allow the surgery to take place. No supplemental oxygen was administered because of the close proximity of the electrical cautery. Hemodynamically he became stable with heart rate slowing from 120 beats/minute to 65 beats/minute and blood pressure declining from 220/120 mm Hg to 120/65 mm Hg. Oxygen saturation, measured by a pulse oximeter, was maintained above 90% and respiratory rate declined from 30 breaths/min to 16 breaths/min. At the conclusion of the procedure local anesthesia was infiltrated into the surgical sites. The patient required no analgesia in the postanesthesia recovery unit and remained hemodynamically stable. He was discharged from the unit 2 h postoperatively

Safety and efficacy of non-steroidal anti-inflammatory drugs to reduce ileus after colorectal surgery

Background: Ileus is common after elective colorectal surgery, and is associated with increased adverse events and prolonged hospital stay. The aim was to assess the role of non-steroidal anti-inflammatory drugs (NSAIDs) for reducing ileus after surgery. Methods: A prospective multicentre cohort study was delivered by an international, student- and trainee-led collaborative group. Adult patients undergoing elective colorectal resection between January and April 2018 were included. The primary outcome was time to gastrointestinal recovery, measured using a composite measure of bowel function and tolerance to oral intake. The impact of NSAIDs was explored using Cox regression analyses, including the results of a centre-specific survey of compliance to enhanced recovery principles. Secondary safety outcomes included anastomotic leak rate and acute kidney injury. Results: A total of 4164 patients were included, with a median age of 68 (i.q.r. 57\u201375) years (54\ub79 per cent men). Some 1153 (27\ub77 per cent) received NSAIDs on postoperative days 1\u20133, of whom 1061 (92\ub70 per cent) received non-selective cyclo-oxygenase inhibitors. After adjustment for baseline differences, the mean time to gastrointestinal recovery did not differ significantly between patients who received NSAIDs and those who did not (4\ub76 versus 4\ub78 days; hazard ratio 1\ub704, 95 per cent c.i. 0\ub796 to 1\ub712; P = 0\ub7360). There were no significant differences in anastomotic leak rate (5\ub74 versus 4\ub76 per cent; P = 0\ub7349) or acute kidney injury (14\ub73 versus 13\ub78 per cent; P = 0\ub7666) between the groups. Significantly fewer patients receiving NSAIDs required strong opioid analgesia (35\ub73 versus 56\ub77 per cent; P < 0\ub7001). Conclusion: NSAIDs did not reduce the time for gastrointestinal recovery after colorectal surgery, but they were safe and associated with reduced postoperative opioid requirement

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research