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Objective: To investigate the relationship between the preoperative HbA1c levels and the complications and mortality rates in the postoperative period in patients with diabetes undergoing a major surgical treatment. Study Design: Descriptive study Place and Duration of Study: Deparment of Internal Medicine, Adana Numune Research and Training Hospital, Turkey, from January 2015 to December 2016. Methodology: Diabetic patients, who underwent major surgery (a large resection) having preoperative HbA1c levels, were considered. A total of 1,013 patients, whose file data were completely accessed, were included in the study. Preoperative HbA1c levels of the patients and complications seen within the first 7 and first 30 days postoperatively were recorded. Results: Fourty-nine (4.8%) of the patients were exitus in the hospital, while 964 (95.2%) of the patients were discharged. Preoperative HbA1c levels of the patients were found to be predictive marker of mortality and complications in the first 7 and 30 days postoperatively (p

Background: In many immune-related diseases, inflammatory responses and several clinical outcomes are related to increased NF-&kappa, B activity. We aimed to evaluate whether SNPs related to the NF-&kappa, B signaling pathway are associated with higher susceptibility to infection, septic shock, and septic-shock-related death in European patients who underwent major surgery. Methods: We performed a case-control study on 184 patients with septic shock and 212 with systemic inflammatory response syndrome, and a longitudinal substudy on septic shock patients. Thirty-three SNPs within genes belonging to or regulating the NF-&kappa, B signaling pathway were genotyped by Agena Bioscience&rsquo, s MassARRAY platform. Results: No significant results were found for susceptibility to infection and septic shock in the multivariate analysis after adjusting for multiple comparisons. Regarding septic-shock-related death, patients with TNFAIP3 rs6920220 AA, TNIP1 rs73272842 AA, TNIP1 rs3792783 GG, and TNIP1 rs7708392 CC genotypes had the highest risk of septic-shock-related death in the first 28 and 90 days. Also, the MyD88 rs7744 GG genotype was associated with a higher risk of death during the first 90 days. Haplotype analysis shows us that patients with the TNIP1 GAG haplotype (composed of rs73272842, rs3792783, and rs7708392) had a lower risk of death in the first 28 days and the TNIP1 AGC haplotype was associated with a higher risk of death in the first 90 days. Conclusions: The SNPs in the genes TNFAIP3, TNIP1, and MyD88 were linked to the risk of septic-shock-related death in patients who underwent major surgery.

To non-invasively predict fluid responsiveness, respiration-induced pulse amplitude variation (PAV) in the photoplethysmographic (PPG) signal has been proposed as an alternative to pulse pressure variation (PPV) in the arterial blood pressure (ABP) signal. However, it is still unclear how the performance of the PPG-derived PAV is site-dependent during surgery. The aim of this study is to compare finger- and forehead-PPG derived PAV in their ability to approach the value and trend of ABP-derived PPV. Furthermore, this study investigates four potential confounding factors, (1) baseline variation, (2) PPV, (3) ratio of respiration and heart rate, and (4) perfusion index, which might affect the agreement between PPV and PAV. In this work, ABP, finger PPG, and forehead PPG were continuously recorded in 29 patients undergoing major surgery in the operating room. A total of 91.2 h data were used for analysis, from which PAV and PPV were calculated and compared. We analyzed the impact of the four factors using a multiple linear regression (MLR) analysis. The results show that compared with the ABP-derived PPV, finger-derived PAV had an agreement of 3.2 ± 5.1%, whereas forehead-PAV had an agreement of 12.0 ± 9.1%. From the MLR analysis, we found that baseline variation was a factor significantly affecting the agreement between PPV and PAV. After correcting for respiration-induced baseline variation, the agreements for finger- and forehead-derived PAV were improved to reach an agreement of − 1.2 ± 3.8% and 3.3 ± 4.8%, respectively. To conclude, finger-derived PAV showed better agreement with ABP-derived PPV compared to forehead-derived PAV. Baseline variation was a factor that significantly affected the agreement between PPV and PAV. By correcting for the baseline variation, improved agreements were obtained for both the finger and forehead, and the difference between these two agreements was diminished. The tracking abilities for both finger- and forehead-derived PAV still warrant improvement for wide use in clinical practice. Overall, our results show that baseline-corrected finger- and forehead-derived PAV may provide a non-invasive alternative for PPV.

Almost half of patients treated on intensive care unit (ICU) experience moderate to severe pain. Managing pain in the critically ill patient is challenging, as their pain is complex with multiple causes. Pharmacological treatment often focuses on opioids, and over a prolonged admission this can represent high cumulative doses which risk opioid dependence at discharge. Despite analgesia the incidence of chronic pain after treatment on ICU is high ranging from 33–73%. Measures need to be taken to prevent the transition from acute to chronic pain, whilst avoiding opioid overuse. This narrative review discusses preventive measures for the development of chronic pain in ICU patients. It considers a number of strategies that can be employed including non-opioid analgesics, regional analgesia, and non-pharmacological methods. We reason that individualized pain management plans should become the cornerstone for critically ill patients to facilitate physical and psychological well being after discharge from critical care and hospital.

Bakgrund: Akut postoperativ smärta är en vanlig men också förväntad konsekvens efter kirurgiska ingrepp som ger negativ påverkan på den efterföljande postoperativa återhämtningen. Syfte: Syftet med studien var att undersöka genomsnittlig självskattad smärtintensitet som gav vuxna patienter problem med att vila, sova och röra sig under det första postoperativa dygnet samt om det hos män/kvinnor, yngre/äldre och kirurgi/ortopedpatienter förekom olika hanterbara smärtnivåer i förhållande till vila och aktivitet under tidig postoperativ återhämtning. Metod: En kvantitativ empirisk deskriptiv studie genomfördes av ett datamaterial från 479 elektiva kirurg- och ortopedpatienter. Resultat: Resultatet visade att ortopedpatienterna i genomsnitt skattade högre värden av smärta jämfört med kirurgpatienterna men att kirurgpatienterna redan vid låga smärtnivåer fick problem med vila, sömn och rörelse. Slutsats: Resultatet understryker att smärta är en subjektiv upplevelse och att smärtbehandlingen i hög grad behöver individualiseras för att därigenom minska smärtans negativa effekter, förbättra den tidiga postoperativa återhämtningen och därmed öka patientsäkerheten. Background: Acute postoperative pain is a common but also expected consequence after surgery that gives negative impact on the following postoperative recovery. Study objectives: The purpose was to investigate the average level of self-assessed intensity of pain that gave adult patients problem to rest, sleep or mobilize during the first postoperative day and if men/women, younger/older and surgical or orthopedic patients had different manageable levels of pain related to rest, sleep and mobilization during the early postoperative recovery. Design: A quantitative empirical descriptive study was performed from datasets from 479 elective surgical and orthopedic patients. Results: The result showed that the orthopedic patients self-assessed higher levels of postoperative pain than the surgical patients, but also that the surgical patients earlier got problems with recovery at low pain levels. Conclusions: The result underlines that pain is a subjective experience and that the pain treatment has to be individualized just to prevent the negative impact of pain but also to enhance the postoperative recovery and improve patient safety.

Despite the increasing number of elderly patients requiring treatment for head and neck cancer, there is insufficient available evidence about the oncological results of treatment and its tolerability in such patients. Owing to comorbidities, elderly patients often need complex evaluation and pretreatment management, which often results in their exclusion from clinical trials. The question of which patients constitute the highest-risk groups regarding treatment-related morbidity and mortality, and who can tolerate and benefit from aggressive treatment, has not been adequately studied. Biologic rather than chronologic age should be a more important factor in treatment protocols. Age-specific prospective clinical studies are needed on the treatment of head and neck cancer in elderly patients.

Yu-Feng Lin,1,2 Tao-Min Huang,2,3 Shuei-Liong Lin,2,4 Vin-Cent Wu,2 Kwan-Dun Wu2 1Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; 2Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; 3Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan; 4Graduate Institute of Physiology, National Taiwan University College of Medicine, Taipei, Taiwan Objective: Prompt assessment of perioperative complications is critical for the comprehensive care of surgical patients. Acute kidney injury requiring dialysis (AKI-D) is associated with high mortality, yet little is known about how long-term outcomes of patients have evolved. The association of AKI-D with postsurgical outcomes has not been well studied.Methods: We investigated patients from the National Health Insurance Research Database and validated by the multicenter Clinical Trial Consortium for Renal Diseases cohort. All patients with AKI-D 18 years or older undergoing four major surgeries (cardiothoracic, esophagus, intestine, and liver) were retrospectively investigated (N=106,573). Patient demographics, surgery type, comorbidities before admission, and postsurgical outcomes, including the in-hospital, 30-day, and long-term mortality together with dialysis dependence were collected.Results: AKI-D is the top risk factor for 30-day and long-term mortality after major surgery. Of 1,664 individuals with AKI-D and 6,656 matched controls, AKI-D during the hospital stay was associated with in-hospital (adjusted hazard ratio [aHR]=3.04, 95% CI 2.79–3.31), 30-day (aHR=3.65, 95% CI 3.37–3.94), and long-term (aHR=3.22, 95% CI 3.01–3.44) mortality. Patients undergoing cardiothoracic surgery (CTS) showed less in-hospital (aHR=0.85, 95% CI 0.75–0.97), 30-day (aHR=0.79, 95% CI 0.70–0.89), and long-term (aHR=0.80, 95% CI 0.72–0.90) mortality compared with non-CTS patients with AKI-D. CTS patients had a high risk of 30-day dialysis dependence (subhazard ratio [sHR]=1.67, 95% CI 1.18–2.38), but the risk of long-term dialysis dependence was similar (sHR=1.38, 95% CI 0.96–2.00) after AKI-D by taking mortality as a competing risk. Non-CTS patients had more comorbidities of sepsis, azotemia, hypoalbuminemia, and metabolic acidosis compared with CTS patients.Conclusion: AKI exhibits paramount effects on postsurgical outcomes that extend well beyond discharge from the hospital. The goal of the perioperative assessment should include the reassurance of enhancing renal function recovery among different surgeries, and optimized follow-up is warranted in attenuating the complications after postsurgical AKI has occurred. Keywords: major surgery, acute kidney injury, postsurgical complication, dialysis dependence, mortality

Background Anxiety during the preoperative period is the most common problem with a number of postoperative complications such as an increase in postoperative pain, delay of healing and prolong the hospital stay. Further, patients with a high level of preoperative anxiety require higher doses of anesthetic agents and recover poorly. Despite its serious health complications, its magnitude and associated factors have been poorly explored in Ethiopia particularly in the selected study areas. Objective To assess preoperative anxiety and associated factors among adult surgical patients in Debre Markos and Felege Hiwot Referral Hospitals, Northwest Ethiopia. Method An institution based cross-sectional study was conducted on 353 patients scheduled for surgery using a systematic random sampling technique. The data were collected using the state version of the state-trait anxiety inventory scale. All collected data were entered into Epi-Data version 3.1 and analysis was done by using SPSS version 20 software. Binary logistic regression was performed to assess the effect of independent variables on the dependent variable. A p-value

Jan Máca,1 Matúš Peteja,2 Petr Reimer,1 Ondřej Jor,1 Věra Šeděnková,1 Lucie Panáčková,1 Peter Ihnát,2 Michal Burda,3 Pavel Ševčík1 1Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, Ostrava, Czech Republic; 2The Clinic of Surgery, University Hospital Ostrava, Ostrava, Czech Republic; 3Institute for Research and Applications of Fuzzy Modeling, Centre of Excellence IT4Innovations, University of Ostrava, Ostrava, Czech Republic Background: Major abdominal surgery (MAS) is high-risk intervention usually accompanied by tissue injury leading to a release of signaling danger molecules called alarmins. This study evaluates the surgical injury caused by two fundamental types of gastrointestinal surgical procedures (open surgery and laparoscopy) in relation to the inflammation elicited by alarmins. Patients and methods: Patients undergoing MAS were divided into a mixed laparoscopy group (LPS) and an open surgery group (LPT). Serum levels of alarmins (S100A8, S100A12, HMGB1, and HSP70) and biomarkers (leukocytes, C-reactive protein [CRP], and interleukin-6 [IL-6]) were analyzed between the groups. The secondary objectives were to compare LPT and LPS cancer subgroups and to find the relationship between procedure and outcome (intensive care unit length of stay [ICU-LOS] and hospital length of stay [H-LOS]). Results: A total of 82 patients were analyzed. No significant difference was found in alarmin levels between the mixed LPS and LPT groups. IL-6 was higher in the LPS group on day 2 (p=0.03) and day 3 (p=0.04). Significantly higher S100A8 protein levels on day 1 (p=0.02) and day 2 (p=0.01) and higher S100A12 protein levels on day 2 (p=0.03) were obtained in the LPS cancer subgroup. ICU-LOS and H-LOS were longer in the LPS cancer subgroup. Conclusion: The degree of surgical injury elicited by open MAS as reflected by alarmins is similar to that of laparoscopic procedures. Nevertheless, an early biomarker of inflammation (IL-6) was higher in the laparoscopy group, suggesting a greater inflammatory response. Moreover, the levels of S100A8 and S100A12 were higher with a longer ICU-LOS and H-LOS in the LPS cancer subgroup. Keywords: open surgery, laparoscopy, gastrointestinal surgery, alarmins, surgical injury, major surgery

Background Morphine is worldwide the analgesic of first choice after cardiac surgery in children. Morphine has unwanted hemodynamic and respiratory side effects. Therefore, post–cardiac surgery patients may potentially benefit from a non-opioid drug for pain relief. A previous study has shown that intravenous (IV) paracetamol is effective and opioid-sparing in children after major non-cardiac surgery. The aim of the study is to test the hypothesis that intermittent IV paracetamol administration in children after cardiac surgery will result in a reduction of at least 30% of the cumulative morphine requirement. Methods This is a prospective, multi-center, randomized controlled trial at four level-3 pediatric intensive care units (ICUs) in the Netherlands and Belgium. Children who are 0–36 months old will be randomly assigned to receive either intermittent IV paracetamol or continuous IV morphine up to 48 h post-operatively. Morphine will be available as rescue medication for both groups. Validated pain and sedation assessment tools will be used to monitor patients. The sample size (n = 208, 104 per arm) was calculated in order to detect a 30% reduction in morphine dose; two-sided significance level was 5% and power was 95%. Discussion This study will focus on the reduction, or replacement, of morphine by IV paracetamol in children (0–36 months old) after cardiac surgery. The results of this study will form the basis of a new pain management algorithm and will be implemented at the participating ICUs, resulting in an evidence-based guideline on post-operative pain after cardiac surgery in infants who are 0–36 months old. Trial registration Dutch Trial Registry (www.trialregister.nl): NTR5448 on September 1, 2015. Institutional review board approval (MEC2015–646), current protocol version: July 3, 2017 Electronic supplementary material The online version of this article (10.1186/s13063-018-2705-5) contains supplementary material, which is available to authorized users.

Background Pulmonary embolism (PE) is a life-threatening condition common after major surgery. Although the high incidence (0.3–30%) and mortality rate (16.9–31%) of PE in patients undergoing major surgical procedures is apparent from findings of contemporary observational studies, there is a lack of a summary and meta-analysis data on the epidemiology of postoperative PE in this same regard. Hence, we propose to conduct the first systematic review to summarise existing data on the global incidence, determinants and case fatality rate of PE following major surgery. Methods Electronic databases including MEDLINE, EMBASE, SCOPUS, WHO global health library (including LILACS), Web of Science and Google scholar from inception to April 30, 2017, will be searched for cohort studies reporting on the incidence, determinants and case fatality rate of PE occurring after major surgery. Data from grey literature will also be assessed. Two investigators will independently perform study selection and data extraction. Included studies will be evaluated for risk of bias. Appropriate meta-analytic methods will be used to pool incidence and case fatality rate estimates from studies with identical features, globally and by subgroups of major surgical procedures. Random-effects and risk ratio with 95% confidence interval will be used to summarise determinants and predictors of mortality of PE in patients undergoing major surgery. Discussion This systematic review and meta-analysis will provide the most up-to-date epidemiology of PE in patients undergoing major surgery to inform health authorities and identify further research topics based on the remaining knowledge gaps. Systematic review registration PROSPERO CRD42017065126 Electronic supplementary material The online version of this article (10.1186/s13643-017-0647-8) contains supplementary material, which is available to authorized users.

OBJECTIVE: To test postoperative serum albumin drop (ΔAlb) as a marker of surgical stress response and early predictor of clinical outcomes. DESIGN: Prospective cohort study (NCT02356484). Albumin was prospectively measured in 138 patients undergoing major abdominal surgery. Blood samples were collected before surgery and on postoperative days 0, 1 2 and 3. ΔAlb was compared to the modified estimation of physiologic ability and surgical stress (mE-PASS) score and correlated to the performances of C reactive protein (CRP), procalcitonin (PCT) and lactate (LCT). Postoperative outcomes were postoperative complications according to Clavien classification and Comprehensive Complication Index (CCI), and length of hospital stay (LoS). SETTING: Department of abdominal surgery in a European tertiary centre. PARTICIPANTS: Adult patients undergoing elective major abdominal surgery, with anticipated duration ≥2 hours. Patients on immunosuppressive or antibiotic treatments before surgery were excluded. RESULTS: The level of serum albumin rapidly dropped after surgery. ΔAlb correlated to the mE-PASS score (r=0.275, p=0.01) and to CRP increase (r=0.536, p{\textless}0.001). ΔAlb also correlated to overall complications (r=0.485, p{\textless}0.001), CCI (r=0.383, p{\textless}0.001) and LoS (r=0.468, p{\textless}0.001). A ΔAlb ≥10 g/L yielded a sensitivity of 77.1\% and a specificity of 67.2\% (AUC: 78.3\%) to predict complications. Patients with ΔAlb ≥10 g/L on POD 1 showed a threefold increased risk of overall postoperative complications. CONCLUSIONS: Early postoperative decrease of serum albumin correlated with the extent of surgery, its metabolic response and with adverse outcomes such as complications and length of stay. A decreased concentration of serum albumin ≥10 g/L on POD 1 was associated with a threefold increased risk of overall postoperative complications and may thus be used to identify patients at risk.

Summary Pre-operative anaemia in patients undergoing major surgical procedures has been linked to poor outcomes. Therefore, early detection and treatment of pre-operative anaemia is recommended. However, to effectively implement a pre-operative anaemia management protocol, an estimation of its prevalence and main causes is needed. We analysed data from 3342 patients (44.5% female) scheduled for either: elective orthopaedic surgery (n = 1286); cardiac surgery (n = 691); colorectal cancer resection (n = 735); radical prostatectomy (n = 362); gynaecological surgery (n = 203) or resection of liver metastases (n = 122). For both sexes, anaemia was defined by a haemoglobin level 5 mg.l−1); iron sequestration by transferrin saturation 100 ng.ml−1; and low iron stores by transferrin saturation > 20% and ferritin 30–100 ng.ml−1. The overall prevalence of anaemia was 36%, with differences according to the type of surgery. Laboratory parameters allowing classification of iron status were available for 2884 patients. Among those with anaemia (n = 986), 677 (69%) were women, 608 (62%) presented with absolute iron deficiency, 101 (10%) with iron sequestration; and 150 (5%) with low iron stores. Iron status alterations were similar in women with haemoglobin < 130 g.l−1 or < 120 g.l−1. For those who were not anaemic (n = 1898), corresponding figures were 656 (35%), 621 (33%), 165 (9%) and 518 (27%), respectively. Anaemia was present in one-third of patients undergoing major elective procedures. Over two-thirds of anaemic patients presented with absolute iron deficiency or iron sequestration. Over half of non-anaemic patients presented with absolute iron deficiency or low iron stores. We consider these data useful for planning pre-operative management of patients scheduled for major elective surgery.

Zielsetzung: Ausgedehnte operative Eingriffe gehen mit einer ausgeprägten Immunreaktion einher, welche sich häufig in einem postoperativen Systemic Inflammatory Response Syndrom (SIRS) äußert. Es gibt Hinweise, dass das Ausmaß der perioperativen Immunreaktion mit einer erhöhten Inzidenz an Organversagen und einer gesteigerten Mortalität assoziiert ist. Ziel dieser Studie war es Einflüsse auf die Immunreaktion zu eruieren, sowie den Einfluss dieser auf die postoperative Langzeitmortalität zu betrachten. Methodik: Die Daten wurden im Rahmen einer randomisierten, doppelblinden Studie erhoben, in die Patientinnen zur Zytoreduktionsoperation bei primär metastasiertem Ovarialkarzinom eingeschlossen wurden. Die intraoperative Volumentherapie erfolgte nach einem zielgerichteten Hämodynamikprotokoll mit balancierter kristalloider oder kolloidaler Lösung. Blutproben wurden präoperativ, intraoperativ sowie postoperativ am ersten und dritten Tag zur Analyse von Interleukin 6 (IL-6), Interleukin 10 (IL-10), C reaktivem Protein (CrP) und Leukozytenzahl gewonnen. Ergebnisse: Die Plasmaspiegel von IL-6, IL-10, CrP und Leukozytenzahl wiesen jeweils einen postoperativen Anstieg auf und nahmen damit einen signifikant charakteristischen Verlauf über den Beobachtungszeitraum (p, Introduction: Major surgery is associated with an intense inflammatory response, which could evolve into a systemic inflammatory response syndrome (SIRS) in the postoperative course. There is evidence that the extent of the immune response influences the outcome and is correlated with multi organ failure and mortality rate. The aim of this study was to investigate influences on immune response in non-cardiac surgery and to evaluate effects on long term survival. Methods: In a double-blinded randomized study data was obtained from patients with ovarian cancer undergoing cytoreductive surgery. Intraoperative fluids were administered according to a goal-directed hemodynamic algorithm with balanced crystalloid or starch solutions. Serum concentration of Interleukin 6 (IL-6), Interleukin 10 (IL-10), C reactive protein (CrP) and white blood cell count were measured before, 2 hours after onset, 1 and 6 hours after operation and at day 1 and 3 following operation. Results: Levels of IL-6, IL-10, CrP and white blood cell count showed a distinct postoperative course (p

Producción Científica, Background: Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection, being the primary cause of death from infection, especially if not recognized and treated promptly. The aim of this study was to analyze whether IL-6 rs1800795 polymorphism is associated with septic shock-related death in European white patients who underwent major surgery. Methods: We performed a retrospective study on 202 septic shock patients who underwent major cardiac or abdominal surgery. The septic shock was established according to the international septic shock definition. The primary outcome variable was the death within 90 days after diagnosis of septic shock. The IL-6 rs1800795 polymorphism was genotyped by Sequenom’s MassARRAY platform. Results: The median age of the patients was 73 years, 63.4% were male, and more than 40% of patients had heart disease and hypertension. Overall, the survival analysis showed that 111 (55%) patients died with a survival median of 39 days (95% CI 30.7; 47.2). The genetic analysis association with survival was performed under a recessive genetic model (CC vs. GG/CG). Patients with IL-6 rs1800795 CC genotype had higher mortality rate than the IL-6 rs1800795 GG/CG genotype at days 7 [31.6% (6/19) vs. 10.4% (19/183); log-rank test (p = 0.005)] and 28 [57.9% (11/19) vs. 33.3% (61/183); log-rank test (p = 0.009)], and 90 [68.4% (13/19) vs. 53.5% (98/183); log-rank test (p = 0.006)]. The IL-6 rs1800795 CC genotype was associated with higher risk of septic shock-related death during the first 7 days [adjusted hazard ratio (aHR 4.65; p = 0.002), 28 days (aHR 2.50; p = 0.006), and 90 days (aHR 2.28; p = 0.006)] with septic shock. When patients were stratified by type of surgery, those with IL-6 rs1800795 CC genotype who underwent cardiac surgery had higher risk of death during the first 7 days (aHR 18.39; p = 0.001) and 28 days (aHR 6.1; p = 0.025) than IL-6 rs1800795 GG/GC carrier, whereas patients with IL-6 rs1800795 CC genotype who underwent abdominal surgery had higher risk of death during all follow-up (aHR 1.98; p = 0.050) than IL-6 rs1800795 GG/GC carrier. Conclusions: The presence of IL-6 rs1800795 CC genotype was associated with higher risk of septic shock-related death in patients who underwent major cardiac or abdominal surgery. These findings need robust validation in bigger independent cohorts., Instituto de Salud Carlos III (grants PI15/01451, CD13/00013, CD14/00002, and CP14CIII/00010), Junta de Castilla y Leon (grants 463/A/10 and 773/A/13), PFIZER (grant CT25-ESP01-01)

PURPOSE OF REVIEW: Advances in medical care have led to an increasing elderly population. Elderly individuals should be able to participate in society as long as possible. However, with an increasing age their adaptive capacity gradually decreases, specially before and after major life events (like hospitalization and surgery) making them vulnerable to reduced functioning and societal participation. Therapeutic exercise before and after surgery might augment the postoperative outcomes by improving functional status and reducing the complication and mortality rate. RECENT FINDINGS: There is high quality evidence that preoperative exercise in patients scheduled for cardiovascular surgery is well tolerated and effective. Moreover, there is circumstantial evidence suggesting preoperative exercise for thoracic, abdominal and major joint replacement surgery is effective, provided that this is offered to the high-risk patients. Postoperative exercise should be initiated as soon as possible after surgery according to fast-track or enhanced recovery after surgery principles. SUMMARY: The perioperative exercise training protocol known under the name 'Better in, Better out' could be implemented in clinical care for the vulnerable group of patients scheduled for major elective surgery who are at risk for prolonged hospitalization, complications and/or death. Future research should aim to include this at-risk group, evaluate perioperative high-intensity exercise interventions and conduct adequately powered trials. © 2014 Wolter Kluwer Health | Lippincott Williams & Wilkins.

本研究の目的は,侵襲の大きい手術を受けた高齢者の術後移行期における自己の創造を明らかにすることである。侵襲の大きい手術を受けた入院中の高齢者5名(冠動脈バイパス術等・65～80歳・男性4名女性1名)を対象に看護援助を実施し,援助記録をデータとして収集した。分析は質的統合法(KJ法)を用い,個別分析と全体分析を行った。その結果,侵襲の大きい手術を受けた高齢者は,【術後の痛みや大変さに耐え,医療者に応じ,身体を休める】ことにより,【管理された身体への探究と確認】を行い,【入院生活の中で,身体の変化や扱い方を身をもって知っていく】。【不安と期待が交錯し,精神的にばらばらなことを心許せる他者にこぼす】ことを通して,【痛みや疲れやすさがある身体状態に応じて,手を借り,試行錯誤しながら自立していく】,【身体の回復に伴い,他者との交流が広がっていく】,【自分にしかわからない壮絶な体験を語ることで,過去と未来がつながっていく】。結果から,高齢者の術後移行期における自己の創造は,身体の変化への探求に始まり,その中で生じたゆらぎを言語化することでゆとりと多面的視点を得て,手術に伴う経験を統合し,行動の広がりを表すものである。そして,術後移行期にある高齢者を支えようとする他者の存在によって,自己の創造がなされていた。自己の創造は,術後移行期の高齢者の内面の世界に入り込み,支援していく際の有用な視点である。, The purpose of this study was to clarify the creation of the self in elderly patients during the postoperativerecovery phase after major surgery. Study subjects comprised five elderly patients undergoing either cardiac or aorticsurgery. Data were collected from patient records documenting the care offered by the primary nurse(who was alsothe researcher). The Qualitative Synthesis Method(KJ Method) was used within and across cases to analyze thestructure of creation of the self. This structure was found to consist of seven characteristics occurring in the followingsequence:“ Resting while coping with difficulties and postoperative pain by accepting help from medical professionals"leads to“ Inquiry and confirmation of body control" and“ Exploring and establishing body control and understandingbodily changes resulting from the hospitalization"; followed by“ Confiding in others one's thoughts, expectations, andfeelings such as confusion and anxiety", which leads to elderly patients“ Gradually standing with assistance due to bodypain and weakness", “Establishing communication with others as part of the recovery process" and“ Linking the pastand future through descriptions of the hospitalization experience". The results of this study show that creation of theself during the postoperative recovery phase starts with the inquiry into how the postoperative body is and, by talkingabout the conflicts that arise from this process, brings the addition of various viewpoints and implications. This actsboth to unify their recovery experiences and to develop their behavior. Creation of the self is realized by the existence ofother people trying to support them. These indicators can be utilized in the nursing care for elderly patients during thepostoperative recovery phase.

Despite advances in surgical and anesthetic techniques in the past decades, complications are common after major surgery. The negative impact of postoperative complications on outcome is of significant concern to patients and their clinicians. The pathophysiological mechanisms of complications after surgery, however, are largely unknown. This thesis described the relation between two possible determinants of adverse events after major surgery: perioperative inflammation and hypotension. The association of systemic inflammation and outcome was assessed in major abdominal and cardiac surgery. The development of the systemic inflammatory response syndrome (SIRS) in 121 patients undergoing transapical transcatheter aortic valve implantation (TAVI) was associated with an independently increased risk of any adverse event (adjusted odds ratio (AOR) 4.0, 95% confidence interval (CI); 1.6 - 9.6). In a subsequent exploratory analysis, an association between perioperative tissue hypoperfusion (a potential cause of tissue/reperfusion injury) and SIRS was not observed. In 135 patients undergoing major abdominal surgery, an interleukin-6 (IL-6) level of >432 pg/ml was an independent predictor of postoperative complications (AOR 3.3, 95% CI; 1.3 – 8.5). The diagnostic accuracy of IL-6 on day one (area under the curve (AUC) 0.67) was comparable to the diagnostic accuracy of CRP on day three (AUC 0.73). In patients undergoing cardiac surgery preoperative statin therapy was associated with a 67% reduced risk of infectious complications (AOR 0.3, 95% CI; 0.2 - 0.6). The association of intraoperative hypotension (IOH) and postoperative renal function was studied in patients undergoing major abdominal surgery and coronary artery bypass grafting (CABG). None of the investigated IOH definitions (i.e. several absolute and relative mean arterial pressure (MAP) thresholds and the AUC below several absolute MAP thresholds) were associated with a change in the estimated glomerular filtration rate (eGFR) after major abdominal surgery. In patients undergoing CABG none of the IOH definitions investigated were associated with AKI. In conclusion, perioperative systemic inflammation after major surgery is commonly observed an important factor in the development of adverse outcome. Perioperative inflammation may be used as a predictive marker for postoperative complications. In addition, it can be used as a therapeutic target for improving outcome. The role of IOH in the development of AKI after major surgery seems limited.