Search

International audience; Background: Enhanced Recovery After Surgery (ERAS) is a multimodal, evidence-based, program of care developed to minimize the response to surgical stress, associated with reduced perioperative morbidity and hospital stay. This study presents the specific ERAS Society recommendations for liver transplantation (LT) based on the best available evidence and on expert consensus.Methods: PubMed and ClinicalTrials.gov were searched in April 2019 for published and ongoing RCTs on LT in the last 15 years. Studies were selected by 5 independent reviewers, and were eligible if focusing on each validated ERAS items in the area of adult LT. An e-Delphi method was used with an extended interdisciplinary panel of experts to validate the final recommendations.Results: Forty-three articles were included in the systematic review. Consensus was reached among experts after the second round. Patients should be screened for malnutrition and treated whenever possible. Prophylactic nasogastric intubation and prophylactic abdominal drainage may be omitted, and early extubation should be considered. Early oral intake, mobilization and multimodal-balanced analgesia are recommended.Conclusions: The current ERAS recommendations were elaborated based on the best available evidence and endorsed by the e-Delphi method. Nevertheless, prospective studies need to confirm the clinical use of the suggested protocol.PROSPERO CRD4201913279.

Lactate and glucose sampling frequency and number of insulin infusion rate adjustments in the first 15 hours of postoperative intensive care unit stay. The figure shows a graphical representation of difference in sampling frequency of lactate and glucose and insulin infusion rate adjustments between the dexamethasone and placebo groups during the observation period of the study. Figure S2. Individual measurements of glucose, lactate, and insulin infusion rate in the dexamethasone and placebo groups. The figure shows a graphical representation of unadjusted (individual) measurements of glucose and lactate levels and the actual insulin infusion rate during the observation period of the study. Table S1. Multivariate linear regression model of the effect of dexamethasone on postoperative lactate levels. The table shows the linear regression models of the effect of treatment allocation (to dexamethasone or placebo) and postoperative glucose levels (area under the curve in the first 15 hours of postoperative intensive care unit stay (AUC15) on postoperative lactate levels (AUC15). Table S2. Bivariate correlation matrix of glucose and lactate levels in the first 15 hours of postoperative intensive care unit (ICU) stay. The table shows the bivariate correlation coefficients of glucose and lactate levels at each time point in the first 15 hours of postoperative ICU stay.

BackgroundIntraoperative driving pressure (ΔP) is associated with development of postoperative pulmonary complications (PPC). When tidal volume (VT) is kept constant, ΔP may change according to positive end-expiratory pressure (PEEP)-induced changes in lung aeration. ΔP may decrease if PEEP leads to a recruitment of collapsed lung tissue but will increase if PEEP mainly causes pulmonary overdistension. This study tests the hypothesis that individualized high PEEP, when compared to fixed low PEEP, protects against PPC in patients undergoing open abdominal surgery.MethodsThe “Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery trial” (DESIGNATION) is an international, multicenter, two-group, double-blind randomized clinical superiority trial. A total of 1468 patients will be randomly assigned to one of the two intraoperative ventilation strategies. Investigators screen patients aged ≥ 18 years and with a body mass index ≤ 40 kg/m2, scheduled for open abdominal surgery and at risk for PPC. Patients either receive an intraoperative ventilation strategy with individualized high PEEP with recruitment maneuvers (RM) (“individualized high PEEP”) or one in which PEEP of 5 cm H2O without RM is used (“low PEEP”). In the “individualized high PEEP” group, PEEP is set at the level at which ΔP is lowest. In both groups of the trial, VTis kept at 8 mL/kg predicted body weight. The primary endpoint is the occurrence of PPC, recorded as a collapsed composite of adverse pulmonary events.DiscussionDESIGNATION will be the first randomized clinical trial that is adequately powered to compare the effects of individualized high PEEP with RM versus fixed low PEEP without RM on the occurrence of PPC after open abdominal surgery. The results of DESIGNATION will support anesthesiologists in their decisions regarding PEEP settings during open abdominal surgery.Trial registrationClinicaltrials.gov,NCT03884543. Registered on 21 March 2019.

Additional file 1. Detailed information on constants and calculations and sex-specific model for MES and MEC.

This thesis describes the relation of potassium, glucose and lactate with outcome in critical care and cardiac care and computer-assisted regulation of glucose and potassium in the intensive care. In patient with acute myocardial infarction it is important to identify those who have the highest risk for adverse outcome. Several markers can be used for this purpose. This thesis demonstrates that hyperglycemia predicts short-term prognosis associated with a larger infarct size whereas HbA1c predicts long-term outcome resulting from a higher baseline risk. Managing glucose levels in critically ill patients is part of routine clinical care, also in patients without diabetes. This thesis describes several aspects of glucose control in the intensive care and the implementation of a computer-assisted glucose regulation protocol. Atrial fibrillation is a common complication after cardiac surgery. The GRIP-COMPASS trial compares two potassium targets (both within the normal range) and the effect on post-operative atrial fibrillation in patients after cardiac surgery. There was no difference in the incidence of atrial fibrillation between the two groups. Patients who developed AF/AFL were more likely to develop a cerebral vascular accident (CVA) or to die during hospitalization.

Background: Persulfate salts are potent oxidizing agents in hair bleach products that accelerate the bleaching process. Ammonium and potassium persulfates may cause delayedtype and immediate skin reactions. Also allergic asthma and rhinitis have been described. Objectives: Ammonium and potassium persulfates may cause delayed-type and immediate skin reactions. Also allergic asthma and rhinitis have been described. Methods: Case 1A 36-year-old female hairdresser suffered from contact urticaria after exposure to bleaching agents for ten years. She also experienced asthma and rhinitis when she worked in the hair salon for the same period. Several minutes after accidental contact with bleaching powder she developed an urticarial reaction on the neck, facial angioedema, and dyspnoea. We performed prick-to-prick tests with serial dilutions of freshly prepared persulfates starting with 0.1%. Prick-to-prick tests with ammonium persulfate 1.0% aqua and potassium persulfate 1.0% aqua showed wheals of 8 mm (positive control 6 mm). Ten minutes after the prick-to-prick tests, she suffered from asthmatic complaints which cleared after inhalation of b2-sympathicomimetics. Patch testing with ammonium persulfate 2.5% petrolatum and potassium persulfate 2.5% aqua resulted in wheals at the test site after 20 minutes. Prick tests with ammonium and potassium persulfate 1.0% aqua were negative in four controls.Case 2A 48-year-old woman showed pruritus of the scalp and facial angioedema which started several minutes after application of a hair bleaching product. Forty-five minutes after application she fainted with increased heart rate and low blood pressure. She was treated with clemastine, dexamathasone, and saline and transferred to a hospital. Prick tests with ammonium persulfate 2.0% aqua and potassium persulfate 2.0% aqua showed wheals of 4 mm (positive control 7 mm). Intradermal testing with ammonium persulfate 0.1% aqua and potassium persulfate 0.1% aqua showed wheals of almost 20 mm. Several hours after the intradermal tests, she became increasingly dizzy which cleared after treatment with fexofenadine. Patch tests with ammonium persulfate 2.5% petrolatum and potassium persulfate 2.5% aqua were negative after 20 minutes. Intradermal tests with ammonium and potassium persulfate 0.1% aqua were negative in three controls. Results: We presented two cases of immediate type hypersensitivity to persulfates with an anaphylactic reaction in one patient. These reactions have never been adequately documented. Conclusion: It seems that the reactions are immunologic and based on release of IgE. In patients suspected of allergic reactions to persulfates, prick and patch tests should be performed. Because severe respiratory symptoms and anaphylaxis may occur, we recommend to start with prick-toprick testing.