Anesthesie en Outcome na Majeure Abdominale Heelkunde<br />Kan het peroperatieve anesthesiebeleid tijdens majeure (niet-va...
PostoperativeMorbidity and Mortality and the Surgical Procedure<br />Vascularsurgery<br />Myocardialinfarction<br />Total ...
Major AbdominalSurgery (MAS):PostoperativeMorbidity<br />Pulmonarycomplications<br />Cardiovascularcomplications<br />Prol...
Anesthesiafor MAS<br />Induction of anesthesia<br />Anesthetictechnique<br />Intraoperativefluid management<br />Optimalpe...
Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor...
Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor...
Major AbdominalSurgery (MAS) and <br />EpiduralAnesthesia and Analgesia (EAA):<br />What are the benefits?<br />
MAS and EAA: PostoperativeEffects(1)<br />Epiduralanalgesia provides superior postoperativeanalgesia<br />Localanesthetic ...
Meta-analysis of 16 prospectiveRCTs (1985-2005) comparingpostoperativeepiduralanalgesia and parenteralopioidanalgesiaafter...
Marret et al., Br J Surg (2007; 94: 665-73<br />
Marret et al., Br J Surg (2007; 94: 665-73<br />
MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativem...
Meta-analysis of RTCs<br />Randomisation to intraoperativeneuraxialblockadeornot<br />141 trials (1971-1995)<br />9559 pat...
Remarks<br />General anesthesiaorneuraxialanesthesia<br />Effect of avoidance of generalanesthesia?<br />LMWH is now more ...
Meta-analyses of 65 RTCs (1966-1995)<br />Significantlyreducedincidence of atalectasiswithepiduralopioidscompared to syste...
MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativem...
Ballantyne et al., J ClinAnesth (2005); 17:  382-91<br />
MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativem...
Multicentre trial (15)<br />1021 patients<br />Intraabdominalsurgery<br />Aortic (37 %), gastric, biliaryorcolon<br />Rand...
Significantlybetterpostoperative pain control in the epiduralgroup<br />No significant difference in overall physical perf...
Overall, no significant difference in major complications<br />Nonaorticsurgery:  no significant difference<br />Aorticsur...
<ul><li>Multicentre (25 hospitals, 6 countries)</li></ul>915 high-riskpatients (at least 1 of 9 comorbidstates)<br />Major...
No significant differences in allocation<br />Rigg et al., Lancet (2002); 359<br />
71.3%<br />No significant differences in allocation<br />No significant differences in allocation<br />Rigg et al., Lancet...
Epiduralanalgesia was associatedwithlower pain scores during the first 3 postoperativedays<br />No significant difference ...
Selectednumber of predeterminedsubgroup analyses of Rigg et al. trial:<br /><ul><li>Increased risk of respiratorycomplicat...
Increased risk of cardiaccomplications
Aorticsurgery</li></li></ul><li>The only significant differencebetweenepidural and controlgroups was respiratoryfailure.<b...
70 ASA I or II patients > 70 y<br />Meanageapproximately 76 y forbothgroups<br />Elective major abdominal(cancer) surgery<...
Pain relief was significantlybetterduring 5 postoperativedays in the epiduralgroup, at rest and aftercoughing<br />Mental ...
MAS and EAA: PostoperativeEffects(3)<br />Recently:<br />Positive effect onlong-term survival aftercancersurgery?<br />Int...
MAS and EAA: PostoperativeEffects(3)<br />Recently:<br />Positive effect onlong-term survival aftercancersurgery?<br />Sid...
MAS and EAA:Conclusions(1)<br />EAA for MAS consistentlyresults in superior postoperativeanalgesia and improvedrecovery of...
Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor...
MAS and EAA:Conclusions(2)<br /><ul><li>Epiduralanesthesia/analgesiafor major abdominalsurgery has is important in terms o...
However, sincean effect of epiduralanesthesia/analgesiaonmortality and major morbidityafter major abdominalsurgeryremainsu...
Anesthesia and Hypothermia<br />Anesthesia-relatedthermoregulatoryimpairment<br />Initially:  internal core to peripheralr...
Hypothermia and PerioperativeComplications(1)<br />Increasedblood loss and transfusionrequirement<br />Coagulopathy<br />I...
<ul><li>15 prospectiveRCTs (1966-2006) comparingnormothermicpatientswithpatientswho had mild (34-36 °C) intraoperativehypo...
Rajagopalan et al., Anesthesiology (2008); 108:  71-7<br />
Rajagopalan et al., Anesthesiology (2008); 108:  71-7<br />
Blood loss: estimated 16 % lower average fornormothermicvshypothermicpatients<br />Rajagopalan et al., Anesthesiology (200...
Transfusion: normothermia is associatedwith 22 % less risk thanhypothermia<br />Rajagopalan et al., Anesthesiology (2008);...
Hypothermia and PerioperativeComplications(2)<br />Increasedblood loss and transfusionrequirement<br />Surgicalwoundinfect...
Double blinded RCT<br />200 patients<br />Colorectalsurgery<br />All patients:  cefamandole, metronidazole<br />Randomyass...
Kurz et al.,  NEJM (1996); 334:  1209-15<br />
Intraoperative core temperaturesapproximately 2 °C belownormalduringcolorectalsurgery:triplethe incidence of woundinfectio...
Hypothermia and PerioperativeComplications(3)<br />Cardiaccomplications<br />Prolongedrecovery<br />Prolongedhospitalizati...
PerioperativeMaintenance of NormothermiaReduces the Incidence of MorbidCardiacEvents.Frank et al., JAMA (1997); 277:  1127...
Hypothermia was an independent predictor of morbidcardiacevents:  there was approxiamtely 55 % reduction in risk ifnormoth...
Mild IntraoperativeHypothermia: Conclusion<br />Even mild inadvertentintraoperativehypothermia<br />shouldbeavoided<br />
Intraoperativesupplementaloxygenadministration:Is thereanoptimalconcentration? <br />
PerioperativeSupplementalOxygenConcentration<br />Preoxygenation<br />FiO2 1.0:  development of (mild) atelectasis is a co...
Edmark et al., Anesthsiology (2003); 98:  28-33<br />
Intraoperative High FiO2:  Risks(1)<br />Resorptionatelectasis<br />Airwayobstruction:  absorption of trapped gas <br />Ev...
Benoit et al., AnesthAnalg (2002); 95:  1777-81<br />
Intraoperative High FiO2:  Risks(2)<br />Ischemicreperfusioninjury<br />Free radicaldamage<br />Mainlyanimal studies, nola...
Intraoperative High FiO2:  Benefits(1)<br />Reducedincidence of woundinfection?<br />Yes<br />Greif et al., N Engl J Med (...
SurgicalWoundInfection and Oxygen<br />Wounds are hypoxiccompared to normal tissue due to a disruptedvascularsupply (injur...
Greif et al., NEJM (2000); 342:  161-7<br />
Intraoperative High FiO2:  Benefits(2)<br />Reducedincidence of nausea and vomiting?  <br />Controversialclinical data<br ...
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Anesthesie en Outcome na Abdominale Heelkunde

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Anesthesie en Outcome na Abdominale Heelkunde

  1. 1. Anesthesie en Outcome na Majeure Abdominale Heelkunde<br />Kan het peroperatieve anesthesiebeleid tijdens majeure (niet-vasculaire) abdominale heelkunde de postoperatieve outcome beïnvloeden?<br />M. Verhaegen<br />Vrijdagochtendkrans 05-09-2008<br />
  2. 2. PostoperativeMorbidity and Mortality and the Surgical Procedure<br />Vascularsurgery<br />Myocardialinfarction<br />Total hip orkneereplacement<br />Pulmonaryembolism<br />Thoracicor upper abdominalsurgery<br />Pneumonia<br />
  3. 3. Major AbdominalSurgery (MAS):PostoperativeMorbidity<br />Pulmonarycomplications<br />Cardiovascularcomplications<br />Prolongedileus<br />Anastomoticleaks<br />Fistulae<br />Peritonitis<br />Surgicalwoundinfections<br />Colonsurgery: 10 – 30 %<br />Prolongedhospitalization (5 – 20 days)<br />Increasedcost<br />Nausea and vomiting<br />Pain<br />
  4. 4. Anesthesiafor MAS<br />Induction of anesthesia<br />Anesthetictechnique<br />Intraoperativefluid management<br />Optimalperioperativeoxygenconcentration<br />Musclerelaxation / antagonism<br />Bloodtransfusion<br />Body temperature<br />Postoperativeanalgesia<br />
  5. 5. Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor morbidity<br />Side effects<br />Economicbenefits<br />
  6. 6. Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor morbidity<br />Side effects<br />Economicbenefits<br />Confidentialenquiryintoperioperativedeaths (Lancet 1987)<br />
  7. 7. Major AbdominalSurgery (MAS) and <br />EpiduralAnesthesia and Analgesia (EAA):<br />What are the benefits?<br />
  8. 8. MAS and EAA: PostoperativeEffects(1)<br />Epiduralanalgesia provides superior postoperativeanalgesia<br />Localanesthetic ± opioidcompared to systemicopioids<br />For up to 72 h postoperatively<br />Especiallyduringmovement, coughing<br />Part of multimodalpostoperativerehabilitation programmes<br />Improvedexercisecapacity and vitalityfor 6 w postoperatively<br />Fasterrecovery of bowelfunction<br />Thoracicepiduralwithlocalanestheticslasting > 24 h, compared to postoperativeanalgesiawithsystemicopioids<br />No increasedincidence of anastomoticleaks<br />
  9. 9.
  10. 10. Meta-analysis of 16 prospectiveRCTs (1985-2005) comparingpostoperativeepiduralanalgesia and parenteralopioidanalgesiaaftercolorectalsurgery<br />EA: Epiduralanalgesia (localanesthetic±opioid): n = 406<br />Control: Parenteral (non)opioidanalgesia: n = 400<br />Primaryoutcome: length of hospitalstay<br />Secondaryoutcomes<br />Postoperative pain (VAS score at 24 and 48 h)<br />Recovery of bowelfunction<br />Anastomoticleakage<br />Cardiaccomplications<br />Respiratorycomplications<br />Nausea and vomiting<br />Sedation<br />Pruritus<br />Urinaryretention<br />Hypotension<br />Marret et al., Br J Surg (2007); 94: 665-73<br />
  11. 11. Marret et al., Br J Surg (2007; 94: 665-73<br />
  12. 12. Marret et al., Br J Surg (2007; 94: 665-73<br />
  13. 13. MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativemorbidity<br />Inconsistent results of manyRCTs<br />Meta-analyses<br />
  14. 14.
  15. 15. Meta-analysis of RTCs<br />Randomisation to intraoperativeneuraxialblockadeornot<br />141 trials (1971-1995)<br />9559 patients (NB: 4871, no NB: 4688)<br />Outcomemeasures<br />Mortality<br />Morbidity<br />Neuraxialblockade<br />Reduction of overall mortalityby 1/3<br />Reduction of major morbidityby 40 – 60 %<br />Deepveinthrombosis<br />Pulmonaryembolism<br />Perioperativeblood loss<br />Postoperativeblood loss requiringtransfusion<br />Pneumonia<br />Respiratorydepression<br />Renalfailure<br />CORTRA, Rodgers et al., Br Med J (2000); 321: 1-12<br />
  16. 16. Remarks<br />General anesthesiaorneuraxialanesthesia<br />Effect of avoidance of generalanesthesia?<br />LMWH is now more commonlyused<br />Improvedsurgical and anesthetictechniques<br />Improveddiagnostictechniques<br />Pulmonaryatelectasis<br />CT scan > chestX-ray<br />Myocardialdamage<br />Troponin Ic<br />CORTRA, Rodgers et al., Br Med J (2000); 321: 1-12<br />
  17. 17.
  18. 18. Meta-analyses of 65 RTCs (1966-1995)<br />Significantlyreducedincidence of atalectasiswithepiduralopioidscompared to systemicopioids<br />11 trials (1975-1995)<br />Abdominal and thoracicsurgery<br />769 patients<br />Significantlyreduced the incidence of pulmonaryinfectionorpulmonarycomplications in generalwithepidurallocalanesthetics<br />Pulmonaryinfection: 5 trials (1971-1987), n = 215<br />Pulmonarycomplications: 6 trials (1974-1987), n = 247<br />Ballantyne et al., AnesthAnalg (1998); 86: 598-612<br />
  19. 19. MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativemorbidity<br />Inconsistent results of manyRCTs<br />Meta-analyses: problems<br />Older studies, not relevant to present-daypractices, included<br />Excessiveheterogeneity (oversimplification of complex issues)<br />Publication bias: tendency to publishonlypositiveresults<br />Difficultqualityassessment<br />Definition of endpoints<br />
  20. 20.
  21. 21. Ballantyne et al., J ClinAnesth (2005); 17: 382-91<br />
  22. 22. MAS and EAA: PostoperativeEffects(2)<br />No reduction of postoperativemortality<br />No reduction of major postoperativemorbidity<br />Inconsistent results<br />Meta-analyses<br />Studies investigating majorabdominalsurgery do not support an effect on major morbidity<br />Lack of power?<br />
  23. 23.
  24. 24. Multicentre trial (15)<br />1021 patients<br />Intraabdominalsurgery<br />Aortic (37 %), gastric, biliaryorcolon<br />Randomised to 1 of 2 groups<br />Control: generalanesth. + postoperativeivorimopioids (PCA) (n = 507)<br />General / epiduralanesth. (localanesthetic ± morphine) + postoperativeepiduralanalgesia (morphine) (n = 514)<br />Primaryendpoints<br />Deathwithin 30 days<br />Major postsurgicalmorbiditywithin 30 days<br />Major cardiac, pulmonary, cerebrovascularorrenalcomplications<br />Park et al., Ann Surg (2001); 234: 560-71<br />
  25. 25. Significantlybetterpostoperative pain control in the epiduralgroup<br />No significant difference in overall physical performance (7 d)<br />No significant difference in 30 daymortality<br />Park et al., Ann Surg (2001); 234: 560-71<br />
  26. 26. Overall, no significant difference in major complications<br />Nonaorticsurgery: no significant difference<br />Aorticsurgery<br />Decreasedincidence of myocardialinfarction, respiratoryfailure, and stroke<br />Epiduralpatientswereextubated 13 h earlier (p = 0.01)<br />Park et al., Ann Surg (2001); 234: 560-71<br />
  27. 27.
  28. 28. <ul><li>Multicentre (25 hospitals, 6 countries)</li></ul>915 high-riskpatients (at least 1 of 9 comorbidstates)<br />Major abdominalorthoracicsurgery<br />Elective, non-laparoscopic, lasting > 1 h<br />No cardiacorpulmonary procedures<br />Randomised to 1 of 2 groups<br />Control: generalanesth. + postoperativeivopioids (PCA) and NSAIDs (n = 441)<br />General / epiduralanesthesia + postoperativeepiduralanalgesia (72 h, localanesthetic + opioid) (n = 447)<br />Primaryendpoints<br />Deathwithin 30 days<br />Major postsurgicalmorbidity<br />Rigg et al., Lancet (2002); 359<br />
  29. 29. No significant differences in allocation<br />Rigg et al., Lancet (2002); 359<br />
  30. 30. 71.3%<br />No significant differences in allocation<br />No significant differences in allocation<br />Rigg et al., Lancet (2002); 359<br />
  31. 31. Epiduralanalgesia was associatedwithlower pain scores during the first 3 postoperativedays<br />No significant difference in mortality at 30 days<br />Controlgroup: 4.3 %<br />Epiduralgroup: 5.1 %<br />No overalldifference in major postoperativemorbidity<br />Patientswho had at leastonemorbidendpoint: 60.5 % in the controlgroupvs 56.6 % in the epiduralgroup (p = 0.26)<br />Onlyrespiratoryfailureoccurredlessfrequently in patientsmanagedwithepiduraltechniques: 23.3 % vs 30.2 % (p = 0.02)<br />Rigg et al., Lancet (2002); 359<br />
  32. 32. Selectednumber of predeterminedsubgroup analyses of Rigg et al. trial:<br /><ul><li>Increased risk of respiratorycomplications
  33. 33. Increased risk of cardiaccomplications
  34. 34. Aorticsurgery</li></li></ul><li>The only significant differencebetweenepidural and controlgroups was respiratoryfailure.<br />Respiratory failure = Need for ventilation > 1 h after surgery, or reintubation of PaO2 ≤ 50 mmHg or <br /> PaCO2 ≥ 50 mmHg on room air<br />Peyton et al., AnesthAnalg (2003); 96: 548-54<br />
  35. 35.
  36. 36.
  37. 37. 70 ASA I or II patients > 70 y<br />Meanageapproximately 76 y forbothgroups<br />Elective major abdominal(cancer) surgery<br />Randomlyassigned to<br />General / epiduralanesthesia + postoperativeepiduralanalgesia (localanesthetic + opioid) (n = 35)<br />General anesthesia + postoperativeiv PCA (morphine) (n = 35)<br />Endpoints<br />Pain intensity (VAS score)<br />Mental status<br />Patientssatisfaction score<br />Cardiacfunction<br />Respiratoryfunction<br />Gastrointestinalfunction<br />Mann et al., Anesthesiology (2000); 92: 433-41 <br />
  38. 38. Pain relief was significantlybetterduring 5 postoperativedays in the epiduralgroup, at rest and aftercoughing<br />Mental status scores weresignificantlybetteronpostoperativedays 4 and 5 in the epiduralgroup (although, foreachdayonlyonce out of twodailymeasurements)<br />The incidence of postoperative delirium was similar in bothgroups<br />Bowelfunctionrecoveredfaster in the epiduralgroup<br />Cardiopulmonarycomplicationsweresimilar in bothgroups<br />Mann et al., Anesthesiology (2000); 92: 433-41 <br />
  39. 39. MAS and EAA: PostoperativeEffects(3)<br />Recently:<br />Positive effect onlong-term survival aftercancersurgery?<br />Intraoperativegeneralanesthesia + epiduralanesthesia/analgesia<br />
  40. 40.
  41. 41. MAS and EAA: PostoperativeEffects(3)<br />Recently:<br />Positive effect onlong-term survival aftercancersurgery?<br />Side effects and complications<br />Pruritus (epiduralopioids)<br />Urinaryretention<br />Low incidence of severecomplicationsifcontraindications are respected<br />Epiduralhematoma<br />Epiduralabcess<br />Neurologicinjury (temporary, permanent)<br />
  42. 42.
  43. 43.
  44. 44. MAS and EAA:Conclusions(1)<br />EAA for MAS consistentlyresults in superior postoperativeanalgesia and improvedrecovery of bowelfunction<br />There is insufficientevidencethat EAA for MAS affectsmortality and major postoperativemorbidity<br />EAA techniques are associatedwith minor sideeffects<br />Major complicationsdue to EAA are rare ifcontraindications are heeded<br />
  45. 45. Surgery, Anesthesia and Outcome<br />Patientsafety<br />Mortality<br />Major morbidity<br />Patientsatisfaction<br />Minor morbidity<br />Side effects<br />Economicbenefits<br />
  46. 46. MAS and EAA:Conclusions(2)<br /><ul><li>Epiduralanesthesia/analgesiafor major abdominalsurgery has is important in terms of patient-orientedoutcomes and patientsatisfaction
  47. 47. However, sincean effect of epiduralanesthesia/analgesiaonmortality and major morbidityafter major abdominalsurgeryremainsunproven, the prevention of severecomplications of neuraxialtechniques is absolutelyindicated</li></li></ul><li>Is mild hypothermiaclinically important? <br />
  48. 48. Anesthesia and Hypothermia<br />Anesthesia-relatedthermoregulatoryimpairment<br />Initially: internal core to peripheralredistribution of body heat<br />Subsequently: heat loss exceedingmetabolic heat production<br />Inadvertentperioperativehypothermia: core body temperature ≤ 36.0 °C<br />Incidence ≈ 20 %?<br />Poorcompliance to guidelines<br />Mistaken belief thatforced air warming increases risk of infection<br />Surgeons’ complaint of discomfort<br />Inconsistent monitoring<br />Inadequate knowledge of the consequences<br />
  49. 49. Hypothermia and PerioperativeComplications(1)<br />Increasedblood loss and transfusionrequirement<br />Coagulopathy<br />Impairedplateletfunction<br />Impairedfunction of enzymes of the coagulation cascade<br />
  50. 50.
  51. 51. <ul><li>15 prospectiveRCTs (1966-2006) comparingnormothermicpatientswithpatientswho had mild (34-36 °C) intraoperativehypothermia</li></ul>14 reportingblood loss (1219 patients)<br />10 reportingtransfusionrequirements (985 patients)<br />Median (quartiles) of the meantemperaturesreported in the blood loss trials<br />Normothermic: 36.6 °C (36.4 °C, 36.7 °C)<br />Hypothermic: 35.6 °C (35.4 °C, 35.8 °C)<br />Significant variabilityamong studies<br />Blood loss: estimated 16 % lower average blood loss fornormothermicvshypothermicpatients (P = 0.009)<br />Transfusion: normothermia is associatedwith 22 % less risk of transfusionthanhypothermia (P = 0.027)<br />Rajagopalan et al., Anesthesiology (2008); 108: 71-7<br />
  52. 52. Rajagopalan et al., Anesthesiology (2008); 108: 71-7<br />
  53. 53. Rajagopalan et al., Anesthesiology (2008); 108: 71-7<br />
  54. 54. Blood loss: estimated 16 % lower average fornormothermicvshypothermicpatients<br />Rajagopalan et al., Anesthesiology (2008); 108: 71-7<br />
  55. 55. Transfusion: normothermia is associatedwith 22 % less risk thanhypothermia<br />Rajagopalan et al., Anesthesiology (2008); 108: 71-7<br />
  56. 56. Hypothermia and PerioperativeComplications(2)<br />Increasedblood loss and transfusionrequirement<br />Surgicalwoundinfection<br />Vasoconstrictionwithimpairedsubcutaneousoxygentension<br />Neutrophils: impairedoxidativekilling<br />Reduceddeposition of collagen<br />Impaired immune function<br />
  57. 57.
  58. 58. Double blinded RCT<br />200 patients<br />Colorectalsurgery<br />All patients: cefamandole, metronidazole<br />Randomyassigned to<br />Hypothermia: routine intraoperativethermal care (n = 96)<br />Normothermia: additional warming (n = 104)<br />Warmedfluids, farced air warming<br />Dailywoundinspectionbysurgeonsuntil discharge and after 2 weeks<br />Culture-positive pus = infected<br />Patientcharacteristicsweresimilarfor the 2 groups<br />Kurz et al., NEJM (1996); 334: 1209-15<br />
  59. 59. Kurz et al., NEJM (1996); 334: 1209-15<br />
  60. 60. Intraoperative core temperaturesapproximately 2 °C belownormalduringcolorectalsurgery:triplethe incidence of woundinfection and prolong hospitalizationbyabout 20 %.<br />X 3<br />+ 20 %<br />Kurz et al., NEJM (1996); 334: 1209-15<br />
  61. 61. Hypothermia and PerioperativeComplications(3)<br />Cardiaccomplications<br />Prolongedrecovery<br />Prolongedhospitalization<br />Negativenitrogenbalance<br />Patient discomfort<br />
  62. 62. PerioperativeMaintenance of NormothermiaReduces the Incidence of MorbidCardiacEvents.Frank et al., JAMA (1997); 277: 1127-34<br />RCT comparing routine thermal care (hypothermia) to additional warming care (normothermia)<br />300 patientswithcoronaryarterydiseaseor at high risk forcoronarydisease<br />Surgery: abdominal, thoracic, orvascular<br />Cardiacevents<br />Unstable angina<br />Ischemia<br />Cardiac arrest<br />Myocardialinfarction<br />
  63. 63. Hypothermia was an independent predictor of morbidcardiacevents: there was approxiamtely 55 % reduction in risk ifnormothermia was maintained<br />Postoperativeventriculartachycardiaoccurredlessfrequently in the normothermicgroupthan in the hypothermicgroup<br />Frank et al., JAMA (1997); 277: 1127-34<br />
  64. 64. Mild IntraoperativeHypothermia: Conclusion<br />Even mild inadvertentintraoperativehypothermia<br />shouldbeavoided<br />
  65. 65. Intraoperativesupplementaloxygenadministration:Is thereanoptimalconcentration? <br />
  66. 66. PerioperativeSupplementalOxygenConcentration<br />Preoxygenation<br />FiO2 1.0: development of (mild) atelectasis is a consistent finding<br />And we do thiseveryday…<br />FiO2 0.8: minimal atelectasis<br />Significantlyfasterdesaturationcomparedwith 100 % O2<br />Intraoperativeinspiredoxygenconcentration<br />Postoperativesupplementaloxygenadministration<br />Does everypatientneedit? Howmuch? For how long?<br />Hemodynamicbenefits? Clinicalsignificance?<br />
  67. 67.
  68. 68. Edmark et al., Anesthsiology (2003); 98: 28-33<br />
  69. 69. Intraoperative High FiO2: Risks(1)<br />Resorptionatelectasis<br />Airwayobstruction: absorption of trapped gas <br />Even after a few breaths of 100 % oxygen<br />Reversiblewithpositivepressure<br />No airwayobstruction: if VA/Q is low, absorptionof oxygeninto the capillariesmayexceeding the inspired gas flow<br />Afterlongerduration of exposure?<br />
  70. 70.
  71. 71. Benoit et al., AnesthAnalg (2002); 95: 1777-81<br />
  72. 72. Intraoperative High FiO2: Risks(2)<br />Ischemicreperfusioninjury<br />Free radicaldamage<br />Mainlyanimal studies, nolarge RCT in humans<br />Oxygentoxicity<br />Prolongedexposure<br />FiO2 0.8 < 24 h: safe?<br />FiO21.0 at 1 atmfor 6 d: irreversibledamage<br />Pulmonaryintersititaledema<br />Pulmonaryfibrosis<br />
  73. 73. Intraoperative High FiO2: Benefits(1)<br />Reducedincidence of woundinfection?<br />Yes<br />Greif et al., N Engl J Med (2000); 342: 161-7<br />Sessler and Akca, ClinInfect Dis (2002); 35: 1397-404<br />Belda et al., JAMA (2005); 294; 2035-2042<br />No<br />Pryor et al., JAMA (2004); 291: 79-87<br />(Retrospective, underpowered?, treatmentgroupswerenothomogenous, variables possiblyincreasinfinfection risk werenotcontrolled)<br />
  74. 74. SurgicalWoundInfection and Oxygen<br />Wounds are hypoxiccompared to normal tissue due to a disruptedvascularsupply (injury, vesselthrombosis)<br />Resistance to infectiondependsonwound PO2<br />Oxidativekillingbyneutrophiles<br />Wound tissue PO2predicts the risk of woundinfection in surgicalpatients<br />Oxygen is important for tissue repair and woundhealing<br />Collagensynthesis is PO2-dependent<br />Oxygen is a cellsignalinteractingwithgrowth factors<br />
  75. 75.
  76. 76. Greif et al., NEJM (2000); 342: 161-7<br />
  77. 77. Intraoperative High FiO2: Benefits(2)<br />Reducedincidence of nausea and vomiting? <br />Controversialclinical data<br />Yes<br />Greif et al., Anesthesiology (1999); 91: 1246-52 (colorectalsurgery)<br />Goll et al., AnesthAnalg (2001); 92: 112-17 (gynecologicallaparoscopy)<br />No<br />Purhonen et al., AnesthAnalg (2003); 96: 91-6 (ambulatorygynecologicallaparoscopy)<br />Joris et al., Br J Anaesth (2003); 91: 857-61 (thyroidectomy)<br />Treschan et al., Anesthesiology (2005); 103: 6-10<br />Gastrointestinalischemia (abdominalsurgery)<br />Dopaminerelease fromcarotidbodies is inverselyrelated to bloodPO2<br />
  78. 78.
  79. 79. ?<br />Is thereanoptimalintraoperative FiO2?<br />Intraoperative FiO2 0.8 mayreduce the incidence of postoperativewoundinfections<br />High intraoperative FiO2 is not a reliabletreatment to reducepostoperativenausea and vomiting<br />The risks of intraoperative high inspiredoxygenconcentrations are notclear<br />We need data evaluating more moderate oxygenconcentrations<br />OptimalIntraoperative FiO2: Conclusions<br />
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