Cardiac troponin I assessment and late cardiac complications after carotid stenting or endarterectomy

PurposeWhen compared with carotid endarterectomy (CEA), percutaneous carotid angioplasty with stent replacement (CAS) is a less invasive technique in the treatment of carotid stenosis. However, periprocedural hemodynamic instability still remains a challenge. This instability might lead to myocardial damage, which is now measured accurately by using cardiac troponin I (CTnI).MethodsThis study was designed to compare the periprocedural variation of CTnI in 150 consecutive patients scheduled to undergo CEA (n = 75) or CAS (n = 75). The levels of CTnI were measured until the third postoperative day in all patients. Short-term (1 month) and long-term (up to 5 years) postoperative cardiac outcome were assessed by means of chart review, regular follow-ups, and telephone calls.ResultsThere was not any statistically significant difference between the 2 groups regarding the demographic characteristics and preprocedural medical status. The incidence of increase of CTnI (>0.5 ng/mL) was significantly higher in the CEA group (13%) compared with that in the CAS group (1%; P = .001). During the acute postprocedural period, the CAS group was significantly more prone to hypotension, requiring vasopressor therapy, whereas the CEA group had more hypertension, necessitating hypotensive medications (P < .001). At 5 years, the overall incidence of major cardiac complications (nonfatal myocardial infarction and death related to cardiac origin) was significantly more frequent in the CEA group (20% vs 5%, P < .01).ConclusionThe results of our study suggest that CAS yielded less myocardial damage in the short and long term when compared with CEA. Larger randomized multicenter trials with long-term outcomes are necessary to confirm our findings

Intracuff Pressure and Tracheal Morbidity Influence of Filling Cuff with Saline during Nitrous Oxide Anesthesia

Background: Diffusion of nitrous oxide into the cuff of the endotracheal tube results in an increase in cuff pressure. Excessive endotracheal tube cuff pressure may impair tracheal mucosal perfusion and cause tracheal damage and sore throat. Filling the cuff of the endotracheal tube with saline instead of air prevents the increase in cuff pressure due to nitrous oxide diffusion. This method was used to test whether tracheal morbidity is related to excess in tracheal cuff pressure during balanced anesthesia. Methods: Fifty patients with American Society of Anesthesiologists physical status I or II were randomly allocated to two groups with endotracheal tube cuffs initially inflated to 20 -30 cm H 2 O with either air (group A) or saline (group S). Anesthesia was maintained with isoflurane and nitrous oxide. At the time of extubation, a fiberoptic examination of the trachea was performed by an independent observer, and abnormalities of tracheal mucosa at the level of the cuff contact area were scored. Patients assessed their symptoms (sore throat, dysphagia, and hoarseness) at the time of discharge from the postanesthesia care unit and 24 h after extubation on a 101-point numerical rating scale. Results: Cuff pressure increased gradually during anesthesia in group A but remained stable in group S. The incidence of sore throat was greater in group A than in group S in the postanesthesia care unit (76 vs. 20%) and 24 h after extubation (42 vs. 12%; P &lt; 0.05). Tracheal lesions at time of extubation were seen in all patients of group A and in eight patients (32%) of group S (P &lt; 0.05). Conclusion: Excess in endotracheal tube cuff pressure during balanced anesthesia due to nitrous oxide diffusion into this closed gas space causes sore throat that is related to tracheal mucosal erosion

Sugammadex in Emergency Situations

Sugammadex may be required or used in multiple emergency situations. Moderate and high doses of this compound can be used inside and outside the operating room setting. In this communication, recent developments in the use of sugammadex for the immediate reversal of rocuronium-induced neuromuscular blockade were assessed. In emergency surgery and other clinical situations necessitating rapid sequence intubation, the tendency to use rocuronium followed by sugammadex instead of succinylcholine has been increasing. In other emergency situations such as anaphylactic shock caused by rocuronium or if intubation or ventilation is not possible, priority should be given to resuming ventilation maintaining hemodynamic stability, in accordance with the traditional guidelines. If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue

Incidence of Severe Hypothermia and Its Impact on Postoperative Surgical Complications and Time Delay to Adjunct Treatments in Breast Surgery Cancer Patients: A Case-Controlled Study

Introduction: Unintended postoperative hypothermia frequently occurs upon arrival in the post anesthesia care unit (PACU). As part of our quality assurance program in anesthesia, we regularly monitor the incidence of this complication through our anesthesia information management system (AIMS). In this case-controlled retrospective study, our goal was to detect the incidence of unintended severe hypothermia in our breast surgery cancer patients, and subsequently to analyze the consequence of this complication in terms postoperative cutaneous infection, as well as its impact on further complementary treatment, such as radiotherapy and chemotherapy. Methods: This study was a retrospective analysis conducted through our AIMS system from 2015 through 2019, with extraction criteria based on year, type of surgery (breast), and temperature upon arrival in PACU. A tympanic temperature of less than 36 °C was considered to indicate hypothermia. Severe hypothermia was considered for patients having a temperature lower than 35.2 °C (hypothermic) (n = 80), who were paired using a propensity score analysis with a control group (normothermic) (n = 80) of other breast cancer surgery patients. Extracted data included time of surgery, sex, age, ASA status, and type and duration of the intervention. Results: The mean incidence of hypothermia was 21% from 2015 through 2019. The body mass index (BMI) was significantly lower in the hypothermia group before matching, 23.5 ± 4.1 vs. 26.4 ± 6.1 kg/m2 in normothermic patients (p &lt; 0.05). The hypothermia group also had significantly fewer monitoring and active warming devices. No difference was noted for wound complications. Time to complementary chemotherapy and or radiotherapy did not differ between groups (52 ± 21 days in group hypothermia vs 49 ± 22 days in the control group). Conclusion: Severe intraoperative hypothermia remains an important quality assurance issue in our breast surgery cancer patients, but we could not detect any long-term effect of hypothermia

Comparison of the Time to Extubation and Length of Stay in the PACU after Sugammadex and Neostigmine Use in Two Types of Surgery: A Monocentric Retrospective Analysis

Sugammadex provides a rapid pharmacological reversal of aminosteroid, as well as fewer pulmonary complications, a better physiological recovery, and shorter stays in the postanesthetic recovery unit (PACU). This retrospective analysis of our Centricity anesthesia database in 2017–2019 assessed the efficiency of sugammadex in real-life situations in two groups of surgical cancer patients (breast and abdominal surgery) based on the extubation time, operating room exit time, and length of PACU stay. Overall, 382 anesthesia records (131 breast and 251 abdominal surgeries) were extracted for the pharmacological reversal of neuromuscular blockades by neostigmine or sugammadex. Sugammadex was used for reversal in 91 breast and 204 abdominal surgeries. Sugammadex use did not affect the extubation time, operating room exit time, or length of PACU stay. However, the time to reach a 90% train of four (TOF) recovery was significantly faster in sugammadex patients: 2 min (1.5–8) in breast surgery and 2 min (1.5–7) in abdominal surgery versus 10 (6–20) and 9 min (5–20), respectively, for neostigmine (p &lt; 0.05). Most patients who were reversed with sugammadex (91%) reached a TOF ratio of at least 90%, while 54% of neostigmine patients had a 90% TOF ratio recorded (p &lt; 0.05). Factors other than pharmacological reversal probably influence the extubation time, operating room exit time, or PACU stay; however, sugammadex reliably shortened the time so as to reach a 90% TOF ratio with a better level of reversal

Comparison of the Time to Extubation and Length of Stay in the PACU after Sugammadex and Neostigmine Use in Two Types of Surgery: A Monocentric Retrospective Analysis

Sugammadex provides a rapid pharmacological reversal of aminosteroid, as well as fewer pulmonary complications, a better physiological recovery, and shorter stays in the postanesthetic recovery unit (PACU). This retrospective analysis of our Centricity anesthesia database in 2017–2019 assessed the efficiency of sugammadex in real-life situations in two groups of surgical cancer patients (breast and abdominal surgery) based on the extubation time, operating room exit time, and length of PACU stay. Overall, 382 anesthesia records (131 breast and 251 abdominal surgeries) were extracted for the pharmacological reversal of neuromuscular blockades by neostigmine or sugammadex. Sugammadex was used for reversal in 91 breast and 204 abdominal surgeries. Sugammadex use did not affect the extubation time, operating room exit time, or length of PACU stay. However, the time to reach a 90% train of four (TOF) recovery was significantly faster in sugammadex patients: 2 min (1.5–8) in breast surgery and 2 min (1.5–7) in abdominal surgery versus 10 (6–20) and 9 min (5–20), respectively, for neostigmine (p p < 0.05). Factors other than pharmacological reversal probably influence the extubation time, operating room exit time, or PACU stay; however, sugammadex reliably shortened the time so as to reach a 90% TOF ratio with a better level of reversal

Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients&rsquo; characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation &lt; 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses

Opioid Reduced Anesthesia in Major Oncologic Cervicofacial Surgery: A Retrospective Study

International audienceOpioid sparing is one of the new challenges in anesthesia and perioperative medicine. Opioid reduced anesthesia (ORA) is part of this approach, and it consists of a multimodal analgesiaassociating non-opioid analgesic regional anesthesia to reduce intraoperative opioid requirements. Major cervicofacial oncologic surgery could specifically benefit from ORA, since it is known to generate intense and prolonged postoperative pain, with a high risk of pulmonary complications. Methods: This is a retrospective case-controlled study of 172 patients with major cervicofacial oncologic surgery. Group ORA (dexmedetomidine and lidocaine), n = 86, was compared to patients treated with standard opioid based anesthesia, Group control, n = 86. The main endpoint was to study perioperative opioid consumption and postoperative pain scores, and the secondary endpoint was to observe opioid related side effects. Results: The ORA group received 6.2 ± 3.1 mg morphine titration at the end of surgery, while the control group received 10.1 ± 3.7 mg p < 0.0001; there was no significant difference in post-operative analgesia requirements and pain scores between the groups. Intraoperatively, the ORA protocol yielded bradycardia in 4 persons, while in the control group, only 2 persons had bradycardia necessitating intervention, p < 0.05. Postoperatively, episodes of hypoxemia (50%) and the need for additional pressure-assisted ventilation (6%), was significantly different in the ORA group than in the control group (70% and 19%), p < 0.05. There was no difference between the two groups for the incidence of nausea and vomiting, ileus, or postoperative delirium. Discussion: ORA was not associated with a decrease in postoperative pain and opioid requirement, but possibly reduced the incidence of hypoxemia and the use of additional pressureassisted ventilation, although we cannot rule out confounding factors. The possible benefits of ORA remain to be demonstrated by prospective studies

Serum Albumin Kinetics in Major Ovarian, Gastrointestinal, and Cervico Facial Cancer Surgery

Hypoalbuminemia in major cancer surgery can lead to postoperative short and long-term complications. Our study was designed to detect albumin variations in three major cancer surgeries: ovarian debulking (DBK), major abdominal gastrointestinal surgery (ABD), and major cervico-facial, or ear, nose and throat cancer surgery (ENT). Single-center prospective study inclusion criteria were non-emergency procedures scheduled to last at least five hours. We performed hourly perioperative monitoring of the patients&rsquo; albuminemia and hemoglobinemia. Electronic charts were followed for at least five years for survival analysis. Sixty-three patients were analyzed: 30 in the DBK group, 13 in the ABD group, and 20 in the ENT group. There was a significant difference in albumin decrease between the ENT group and the two others (&minus;19% at six hours in the ENT group versus -49% in the debulking group and &minus;31% in the ABD group (p &lt; 0.05). There was no significant difference between the DBK and ABD groups. The decrease in hemoglobin was not significantly different between the groups, and no significant difference was observed in long-term survival. DBK and ABD surgery yielded significant hypoalbuminemia. Therefore, the extent of decrease in serum albumin is probably not the only etiology of the specific postoperative complications of these major surgeries. No significant difference was noticed in five-year mortality, and no correlation was found in relation to the degree of intraoperative albumin kinetics