Torakalna epiduralna analgezija za radikalnu cistektomiju pospješuje funkciju crijeva i u tradicionalnoj perioperacijskoj skrbi

Radical cystectomy is associated with significant morbidity and mortality due to complex surgery and comorbidities associated with advanced age of patients. In contrast to the surgery, which is clearly the procedure of choice for patients with invasive bladder cancer, the optimal anesthesiologic method is still under debate. Therefore, we retrospectively analyzed 85 patients having undergone radical cystectomy at our institution, either under combined epidural-general anesthesia (CEG A) or opioid based general anesthesia (GA). The intraoperative blood loss was significantly lower in CEG A group (497.37±354.13) than in GA group (742.31±403.69; p=0.006), due to induced hypotension. Consequently, blood transfusion requirements were lower in CEG A group (107.20±263.92) than in GA group (388.18±321.32; p=0.001). The incidence of postoperative ileus was also lower in CEG A group (p=0.024). There was no difference in analgesic efficacy, but a trend towards lower incidence of venous thrombosis and infection was noticed. The results of our study suggest that epidural anesthesia might have specific advantages in patients undergoing radical cystectomy.Radikalna cistektomija je praćena značajnom smrtnošću i pobolom zbog složenog kirurškog zahvata i komorbiditeta povezanog sa starijom dobi bolesnika. Za razliku od kirurškog zahvata koji je bez dvojbe metoda izbora za invazivni karcinom mokraćnog mjehura, optimalna metoda anestezije još je predmet rasprave. Stoga smo retrospektivno analizirali 85 bolesnika koji su u našoj ustanovi podvrgnuti zahvatu radikalne cistektomije u kombiniranoj torakalnoj epiduralnoj i općoj anesteziji ili u općoj anesteziji baziranoj na opioidima. Intraoperacijski gubitak krvi bio je značajno niži u skupini na kombiniranoj torakalnoj epiduralnoj i općoj anesteziji (497,37±354,13) nego u skupini na općoj anesteziji baziranoj na opioidima (742,31±403,69, p=0,006). Posljedično, količina transfundirane krvi bila je značajno niža u skupini koja je imala torakalnu epiduralnu anesteziju (107,20±263,92) nego u skupini na općoj anesteziji (388,18±321,32, p=0,001). Incidencija poslijeoperacijskog ileusa također je bila niža u skupini na kombiniranoj anesteziji (p=0,024). Nije uočena razlika u analgetskoj učinkovitosti, ali je zabilježen trend prema nižoj incidenciji venske tromboze i poslijeoperacijskih infekcija u skupini na kombiniranoj anesteziji. Rezultati naše studije impliciraju da bi torakalna epiduralna analgezija mogla imati specifične prednosti kod bolesnika podvrgnutih zahvatu radikalne cistektomije

Nonelective surgery at night and in-hospital mortality - Prospective observational data from the European Surgical Outcomes Study

BACKGROUND Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia. OBJECTIVE Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care. DESIGN A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study). SETTING Four hundred and ninety-eight hospitals in 28 European countries. PATIENTS Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure. INTERVENTION None. MAIN OUTCOME MEASURES Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission. RESULTS Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)]. CONCLUSION In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed