Search

Purpose: Enhanced Recovery After Surgery (ERAS) programs have increasingly attracted the attention of clinicians who are intent on minimizing postoperative morbidity, decreasing variability in surgical care, and containing hospital costs. The purpose of this review is to discuss the relevant pathophysiology of the surgical stress response and its associated mechanisms that regulate important metabolic changes., Principal Findings: The combination of hormonal release and various inflammatory responses inherent in the stress response to surgery contributes to a state of insulin resistance that represents one of the main pathogenic factors modulating perioperative outcome. The consequence of a decrease in insulin sensitivity is a significant change in protein and glucose metabolism characterized by an increase in the production of endogenous hepatic glucose, a decrease in the uptake of peripheral glucose, and an increase in the breakdown of protein. Muscle is the main tissue for uptake of insulin-mediated glucose, and consequent with the reduced activation of a specific glucose transporter protein (GLUT 4), glucose cannot be transported into the muscle cells. Consequently, breakdown of muscle protein, also related to insulin resistance, occurs to supply amino acids for gluconeogenesis, thus leading to the overall loss of lean muscle tissue. Besides the metabolic changes associated with the surgical insult, pain, relative perioperative starvation, and poor mobilization further contribute to a loss of insulin sensitivity and an increased catabolic state. Many of the ERAS elements that are implemented, including perioperative feeding, epidural analgesia, and minimally invasive surgery, modulate the stress response, promote insulin sensitivity, and attenuate the breakdown of protein., Conclusions: The implementation of a targeted ERAS program has been shown to modulate perioperative insulin sensitivity, thus improving postoperative outcomes and accelerating the return of baseline function.

Purpose: Postoperative complications represent a major concern for elderly patients. We report a case of a medically complex and frail 88-yr-old woman with endometrial cancer who was scheduled for a robotic-assisted total abdominal hysterectomy. In addition to her cardiac morbidity she presented with several risk factors for neurocognitive decline, including prior episodes of postoperative delirium., Clinical Features: The patient underwent functional, nutritional, and neuropsychological assessments prior to a three-week prehabilitation home-based program consisting of strength and endurance exercises as well as nutritional optimization. Remarkably, there were no episodes of postoperative confusion, and over the following eight weeks, she continued to show sustained improvement in exercise tolerance (as per the six-minute walk test), cognitive function (as per the Repeatable Battery for the Assessment of Neuropsychological Status), and overall functional capacity (Short Form-36)., Conclusion: This report provides suggestive evidence that a prehabilitation program optimized the health of this elderly patient and may have prevented a further episode of postoperative delirium. Prehabilitation protocols should be evaluated in clinical trials to evaluate their efficacy and the target populations who may benefit and to elucidate the underlying mechanisms responsible for enhanced recovery in the perioperative setting.

Background: Enhanced perioperative care programs have been developed in order to attenuate the impact of surgical stress on organ dysfunction, thereby accelerating hospital discharge and reducing morbidity. The implementation of a fast-track program for laparoscopic colorectal surgery is reported., Methods: We report on a series of patients who entered a coordinated program based on preoperative patient education and counseling, a laparoscopic approach, provision of postoperative epidural analgesia, early food intake and mobilization, and structured surgical and nursing care practices. The program was introduced in September 2006 and adapted to our institutional needs. Outcome measures included length of hospital stay, return of bowel function, incidences of postoperative complications, and rate of readmission to hospital., Results: Twenty-five patients were selected by the surgeons for the accelerated laparoscopic colorectal pathway. The median duration of hospital stay was 3 (95% confidence interval, 3-4) days. Sixteen patients (64%) were discharged from hospital on day 3. Nine patients failed the pathway for various reasons (social indications, poor pain relief, wound infection, anemia, urinary retention) and were discharged later (six patients on day 4, two patients on day 5, and one patient on day 6). Times to recover bowel function and to resume a full diet were all within the first 36 hr from time of surgery. There were two readmissions., Conclusion: This early clinical experience demonstrates the feasibility of a fast-track program for colonic surgery and the requirement for an integrated multidisciplinary approach to perioperative care.

Background: Lidocaine has been shown to inhibit neural conduction and to have anti-inflammatory properties. The purpose of this study was to determine whether intraoperative lidocaine infusion reduces opioid consumption in the postanesthesia care unit (PACU)., Methods: Fifty patients were enrolled in this prospective, randomized and observer-blinded study. At induction of anesthesia the control group (n = 25) received fentanyl 3 microg.kg(-1) while the lidocaine group received fentanyl 1.5 microg.kg(-1) and a bolus of lidocaine 1.5 mg.kg(-1) followed by a continuous infusion of lidocaine 2 mg.kg(-1).hr(-1). General anesthesia included propofol, rocuronium, and desflurane titrated to maintain blood pressure and heart rate within set parameters, and the bispectral index between 35 and 50. No supplemental opioids were given during surgery. All patients received acetaminophen, ketorolac, dexamethasone, droperidol and local anesthetics in the skin incision. Patients received fentanyl and ondansetron in the PACU. The primary outcome variable was the amount of fentanyl required in the PACU to establish and to maintain visual analogue scale pain scores < 3., Results: Most patients received fentanyl for pain relief in the PACU, but the cumulative mean dose was lower in the lidocaine group compared to the control group (98 +/- 54 microg, vs 154 +/- 99 microg, respectively, P = 0.018). Lidocaine infusion reduced by 10% the amount of desflurane required (P = 0.012). White-Song scores > 12 were attained by all patients in both groups within 30 min of their arrival in the PACU. Median time from arrival to the PACU to discharge home was similar in both groups, 167.5 min in the control group vs 180 min in the lidocaine group (P = 0.649)., Conclusion: Intraoperative lidocaine infusion reduces opioid consumption in the PACU and intraoperative requirements of desflurane.

Purpose: A standardized care plan incorporating patient-controlled analgesia with iv morphine and a non-accelerated feeding schedule following colectomy was used to compare return of bowel function and hospital discharge times following surgery done by laparoscopy or laparotomy, Methods: Thirty-eight patients were assigned to undergo either laparoscopic or laparotomy colon resection. Postoperative analgesia was achieved with patient-controlled analgesia with iv morphine. General anesthesia and perioperative care were standardized, and a traditional surgical and nursing care program was implemented. Gastrointestinal function (time from surgery to return of passage of flatus and presence of bowel movements), pain intensity (visual analogue scale) at rest, on coughing and on mobilization, amount of morphine used, and criteria for discharge and length of hospital stay were recorded., Results: Bowel movements resumed earlier in the laparoscopic group (P < 0.05), but not passage of flatus. No significant relationship was found between the amount of morphine used and return of bowel function. Cumulative morphine consumption during the first two postoperative days was similar in both groups. Where a trend towards lower postoperative visual analogue scale scores was observed in the laparoscopic group, visual analogue scale scores on coughing were lower in the laparoscopic vs laparotomy group only during the first 24 hr (P < 0.05). Length of hospital stay was significantly shorter in the laparoscopic group (P < 0.05), although times to meet discharge criteria were similar in both groups., Conclusions: When patient-controlled analgesia with morphine and a traditional perioperative program are used, a laparoscopic approach to colon surgery promotes earlier restoration of bowel function and more rapid hospital discharge in comparison to resection by laparotomy.

Purpose: To illustrate how a patient's previously undiagnosed obstructive sleep apnea was uncovered after administration of a spinal anesthetic with a high sensory blockade, and to discuss possible explanations for this occurrence and anesthetic implications., Clinical Features: A 55-yr-old male presented for osteotomy and open reduction and internal fixation of his left femur secondary to malunion from a previous fracture. Past medical history consisted of hypertension, hypercholesterolemia, bipolar disorder, gastroesophageal reflux disease, and cluster headaches. A combined spinal-epidural technique was chosen. Isobaric bupivacaine 0.5% (15 mg), was provided for the spinal anesthetic, along with 1 mg iv midazolam for procedural sedation and 0.5 mg iv droperidol for mild nausea. Throughout the operation, many apneic events were noted, often with respiratory efforts. The patient was easily arousable during each event and would breathe normally until the next episode. Vital signs remained stable throughout. Postoperative respirology consultation was requested, and a sleep study revealed severe obstructive sleep apnea. The patient was subsequently started on continuous positive airway pressure with marked improvement in symptoms, including the cluster headaches., Conclusion: Recent literature suggests that high spinal blockade can result in altered levels of arousal by producing a de-afferentation of peripheral proprioceptive and sensory stimuli necessary for maintaining an awake state. In patients predisposed to upper airway obstruction, decreasing the level of consciousness can result in airway obstruction as occurs during sleep in these patients. This serves to underline the importance of considering capnography for all cases utilizing a neuraxial anesthetic technique.

Purpose: A human resource planning model for anesthesiology is described., Methods: The model uses 'per capita' expenditure for anesthesiologists in Quebec, as a measure of clinical services provided to different age/gender groups. The future demand for anesthesia services is calculated as the product of 'per capita' expenditure and the population projections to a future date. Future demand was converted into full-time equivalent (FTE) providers required, by dividing by the annual 'units of service' optimally delivered by one FTE anesthesiologist. The pattern of age/gender (demographic) consumption of anesthesia services in Quebec was compared with data from Ontario to validate its use in a planning model. The model was then applied to all provinces and territories., Results: The 'per capita' expenditures on anesthesia services in Quebec and Ontario showed a regular pattern. Using the model, the estimated 1999 demand for FTE anesthesiologists to provide clinical services in Quebec is 546 and 669 for 2016. When non-clinical demands were included, we estimated that Quebec's total demand will increase to approximately 730 FTEs in 2016. Similar estimates are made for all provinces. The population increase anticipated is 17.9% but the increase in FTE demand in Canada is 30.9%., Conclusion: The model showed that the cause of the increased FTE demand for anesthesiologists is a combination of increased population and its demographic composition. The relative impact of each of these factors varies in different provinces. Effective specialty-specific planning models can be designed but they need ongoing committed resources and personnel for their usefulness to be maximized.

Purpose: To examine the supply of physician anesthesia providers necessary to accommodate the previously described clinical and non-clinical service volume needs throughout Canada., Methods: The Canadian Medical Association (CMA) physician database provided baseline specialist anesthesiologists numbers and ages as of January 1, 2000. The Royal College of Physician and Surgeons of Canada (RCPSC) provided annual anesthesia certificant numbers for the period 1971-2000. Combining these data with the separately reported estimates of anesthesia provider needs for the years 1999 and 2016, the matching of anesthesia provider supply and demand during the period 2000-2016 was examined., Results: The CMA database included 2,287 anesthesiologists in Canada on January 1, 2000. The needs assessment (clinical and non-clinical) identified the requirement for 2,495 full time equivalent (FTE) anesthesiologists in 1999 and 3,265 in 2016 (31% increase). Taking into account the ages of current anesthesiologists, the increased future requirements and the current rate of graduation from RCPSC-approved training programs in Canada a deficit of at least 656 FTEs is identified for the period 2000-2016 (average 41 per year)., Conclusions: Canada has a current shortage of anesthesiologists. Based on the assessment of future needs in Quebec and extrapolated to all provinces, this shortage will worsen, unless Canadian training programs are expanded or other steps are taken to augment the numbers of anesthesia practitioners. Ongoing studies in each province are required to validate and update these conclusions.

Purpose: Transport after surgery under spinal anesthesia is associated with cardiovascular changes. The extensively vasodilated patient may be unable to compensate for postural blood flow redistribution. This observational study investigated pre- and post-surgery sensory levels as well as hemodynamic changes during the postoperative transfer period., Methods: One hundred ninety nine women, ASA 1 and 2, undergoing Cesarean section under spinal anesthesia were studied at the end of surgery. Hyperbaric bupivacaine 12-15 mg and morphine 0.25 mg were the agents used. Patients in group A (n = 111) were transferred to the Recovery Room on a stretcher with the upper body flexed 30 degrees head up: patients in group B (n = 88) remained supine during transport., Results: At the end of Cesarean section 95% of patients had upper sensory levels of T4 and higher. In 17.5% the block ascended 2-7 dermatomes compared with the pre-operative level. The incidence of hypotension on arrival in Recovery Room was similar in both groups (group A 10% and group B 9%)., Conclusion: These results draw attention to the persistence of extensive sympathetic block at the end of Cesarean section. Transport to the Recovery Room was associated with the development of considerable hypotension in 10% of patients and this was unaffected by position. We recommend recording the level of sensory block at the end of surgery and increased monitoring during transport to the Recovery Room.

Purpose: To examine the effect of the duration of peritoneal cavity exposure on glucose metabolism after abdominal surgery., Methods: In eight otherwise healthy patients (ASA 1) with uterine myoma, endogenous glucose production (Ra glucose) was measured immediately before and two hours after abdominal hysterectomy by a stable isotope dilution technique using primed continuous infusions of [6,6-2H2]-glucose. Plasma concentrations of glucose, lactate, insulin, glucagon, cortisol, epinephrine and norepinephrine were determined before, during (5 and 60 min after peritoneal incision, skin closure) and two hours after surgery. Pre- and postoperative glucose clearance was calculated as Ra glucose divided by plasma glucose concentration., Results: Ra glucose increased from 11.8 +/- 1.2 to 16.8 +/- 3.2 micromol x kg(-1) x min(-1) two hours after hysterectomy (P < 0.05) with a correlation between the degree of increase and the time of peritoneal cavity exposure (r = 0.859, P = 0.006). Plasma glucose concentration increased after surgery from 4.7 +/- 0.8 to 8.3 +/- 1.9 mmol x l(-1) (P < 0.05), while glucose clearance decreased from 2.6 +/- 0.4 to 2.1 +/- 0.4 ml x kg(-1) x min(-1) (P < 0.05). Plasma concentrations of cortisol and catecholamines increased after hysterectomy (cortisol from 6 +/- 2 to 31 +/- 7 microg x dl(-1), epinephrine from 25 +/- 14 to 205 +/- 132 pg x ml(-1), norepinephrine from 182 +/- 82 to 377 +/- 132 pg x ml(-1), P < 0.05), whereas plasma lactate, insulin and glucagon concentrations remained unchanged., Conclusion: The magnitude of increase of glucose production after abdominal hysterectomy is associated with the duration of peritoneal cavity exposure.

Purpose: To determine the effect of epidural analgesia on biochemical markers of stress, plasma oxytocin concentrations and frequency of uterine contractions during the first stage of labour., Methods: Nine nulliparous women, in spontaneous labour, with a singleton fetus and cervical dilatation < or = 5 cm were enrolled. Epidural bupivacaine 0.25% (range 10-14 ml) was administered and bilateral sensory blockade to ice (T8-L4) achieved. Blood samples were collected before the epidermal block and every 10 min for one hour after the block was achieved for the measurement of plasma beta-endorphin, cortical, glucose, lactate and oxytocin concentrations. No exogenous oxytocin was given. Intensity of pain was assessed at the time of the blood sampling using a 10 cm visual analogue scale (VAS). The frequency of uterine contractions was recorded for 60 min before and after the epidural block., Results: There was a decrease in plasma beta-endorphin and cortisol concentrations after epidural block (P < 0.01). There were no changes in plasma glucose and lactate concentrations. The mean VAS for pain decreased 10 min after epidural block was achieved and remained < 2 throughout the study period (P < 0.001). Mean plasma oxytocin concentrations did not change. The frequency of uterine contractions before and after the epidural block was similar., Conclusions: The metabolic stress response to the pain of labour was attenuated by epidural analgesia. In contrast, plasma oxytocin concentration and frequency of uterine contractions were unaffected by the attenuation of metabolic stress response.

The purpose of this study was to evaluate the effect of core warming on heat redistribution from the core to the periphery as manifested by changes in core, mean skin temperature and mean body heat, investigated in a group of 30 patients undergoing total hip replacement. The control group (n = 10) had no active warming. Core warming was achieved in the humidifier group (n = 10) by using humidified and warmed gases at 40 degrees C, whilst in the oesophageal group (n = 10), an oesophageal heat exchanger was used to achieve active warming. Operating room temperature and relative humidity was standardised. Aural canal and skin temperatures (15 sites) were measured before induction of anaesthesia, at the end of surgery and one hour of recovery after anaesthesia. Mean skin temperatures were calculated for a weighted four and unweighted 15 points, and mean body heat were calculated to quantify the distribution of body heat. Core temperature decreased in the control and the oesophageal groups, but not in the humidifier group at the end of surgery; by mean values +/- SD of 1.9 degrees C +/- 0.6, 1.2 degrees C +/- 0.6 and 0.4 degree C +/- 0.2 degree C, respectively (P < 0.01). Mean skin temperature (MST15) decreased in the control group by 1.0 degree C +/- 1.0, but not in the actively warmed groups where the mean increased by 0.1 degree C +/- 1.4 and 0.2 degree C +/- 0.2 in the oesophageal and humidifier groups, respectively (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Oxygen consumption (VO2), carbon dioxide production (VCO2), end-tidal carbon dioxide partial pressure (PETCO2), mixed venous oxygen saturation (SvO2) and haemodynamic variables were recorded every 30 min for four hours in 15 patients recovering from hypothermic cardiopulmonary bypass (CPB). All patients had been anaesthetised with fentanyl 40 micrograms.kg-1, supplemented with isoflurane, and pancuronium 0.15 mg.kg-1 for muscle relaxation. Three of the 15 patients (20 per cent) shivered, defined as intermittent or continuous, vigorous movements of chest or limb muscles. Patients who shivered had a VO2 of 159 +/- 16.4 ml.min-1.m-2 on arrival in the ICU which rose to a maximum value of 254 +/- 28.3 ml.min-1.m-2 by 150 min post-CPB. In contrast, patients who did not shiver had a significantly lower VO2 of 93.1 +/- 6.9 ml.min-1.m-2 on arrival in the ICU which rose to a maximal value of only 168 +/- 11.5 ml.min-1.m-2 by 180 min post-CPB. Maximal VO2 in both groups was reached when the nasopharyngeal temperature (NPT) was approaching normal. VCO2 paralleled the increase in VO2 in both groups. By four hours there was no significant difference between the two groups; however, the VO2 in both groups (160.5 +/- 21.3 ml.min-1.m-2 and 173.9 +/- 12.3 ml.min-1.m-2 respectively) was approximately twice values commonly measured in anaesthetized patients. Patients who shivered had a significantly higher heart rate and cardiac index and significantly lower SvO2. We conclude that the high VO2 and VCO2 associated with shivering causing increased myocardial work may be detrimental to patients who have impaired cardiac function post-coronary artery surgery (CAS).