Postoperative delirium:A tragedy for elderly cancer patients

In this editorial,we comment on the article by Hu et al entitled“Predictive modeling for postoperative delirium in elderly patients with abdominal malignancies using synthetic minority oversampling technique”.We wanted to draw attention to the general features of postoperative delirium(POD)as well as the areas where there are uncertainties and contradictions.POD can be defined as acute neurocognitive dysfunction that occurs in the first week after surgery.It is a severe postoperative complication,especially for elderly oncology patients.Although the underlying pathophysiological mechanism is not fully understood,various neuroinflammatory mechanisms and neurotransmitters are thought to be involved.Various assessment scales and diagnostic methods have been proposed for the early diagnosis of POD.As delirium is considered a preventable clinical entity in about half of the cases,various early prediction models developed with the support of machine learning have recently become a hot scientific topic.Unfortunately,a model with high sensitivity and specificity for the prediction of POD has not yet been reported.This situation reveals that all health personnel who provide health care services to elderly patients should approach patients with a high level of awareness in the perioperative period regarding POD.

Portal vein arterialization in 25 liver transplant recipients:A Latin American single-center experience

BACKGROUND Portal vein arterialization(PVA)has been used in liver transplantation(LT)to maximize oxygen delivery when arterial circulation is compromised or has been used as an alternative reperfusion technique for complex portal vein thrombosis(PVT).The effect of PVA on portal perfusion and primary graft dysfunction(PGD)has not been assessed.All patients receiving PVA and LT at the Fundacion Santa Fe de Bogota between 2011 and 2022 were analyzed.To account for the time-sensitive effects of graft perfusion,patients were classified into two groups:prereperfusion(pre-PVA),if the arterioportal anastomosis was performed before graft revascularization,and postreperfusion(post-PVA),if PVA was performed afterward.The pre-PVA rationale contemplated poor portal hemodynamics,severe vascular steal,or PVT.Post-PVA was considered if graft hypoperfusion became evident.Conservative interventions were attempted before PVA.

Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients-results after three years of practice

AIM To evaluate the potential benefits and risks of the use of epidural anaesthesia within an enhanced recovery protocol in this specific subpopulation.METHODS A retrospective review was conducted, including all cirrhotic patients who underwent open liver resection between January 2013 and December 2015 at Bologna University Hospital. Patients with an abnormal coagulation profile contraindicating the placement of an epidural catheter were excluded from the analysis. The control group was composed by patients refusing epidural anaesthesia. RESULTS Of the 183 cirrhotic patients undergoing open liver resections, 57 had contraindications to the placement of an epidural catheter; of the remaining 126, 86 patients received general anaesthesia and 40 combined anaesthesia. The two groups presented homogeneous characteristics. Intraoperatively the metabolic data did not differ between the two groups, whilst the epidural group had a lower mean arterial pressure(P = 0.041) and received more colloid infusions(P = 0.007). Postoperative liver and kidney function did not differ significantly.Length of mechanical ventilation(P = 0.003) and hospital stay(P = 0.032) were significantly lower in the epidural group. No complications related to the epidural catheter placement or removal was recorded.CONCLUSION The use of Epidural Anaesthesia within a fast track protocol for cirrhotic patients undergoing liver resections had a positive impact on the patient's outcomes and comfort as demonstrated by a significantly lower length of mechanical ventilation and hospital stay in the epidural group. The technique appears to be safely manageable in this fragile population even though these results need confirmation in larger studies.

Variability of platelet aggregation in patients with clopidogrel treatment and hip fracture: A retrospective case-control study on 112 patients

AIM: To identify the rate of non-responders to clopidogrel treatment in hip fracture patients and study how non-responders differ from controls.METHODS: In a retrospective case-control study we included 28 cases of acute proximal femoral fracture with clopidogrel treatment 2011 to 2013. Eighty-four controls from the same time period were included. Data collected included response to clopidogrel measured with multiple electrode aggregometry(MEA), intraoperative bleeding, erythrocyte transfusion, time to surgery and the incidence of adverse events up to 3 mo after surgery. RESULTS: Eight(29%) of the 28 cases were nonresponders. The median intraoperative bleeding was 300 mL(range, 0-1500), and was lower for non-responders(50 m L) but did not reach statistical significance. Erythrocyte transfusions did not differ between responders, non-responders and controls. Forty-five(40%) of 112 patients had adverse events postoperatively but the rate did not differ between patients with and without clopidogrel treatment.CONCLUSION: Almost one-third of patients withclopidogrel treatment and an acute proximal femoral fracture are non-responders to antiplatelet therapy and can be operated without delay.

Comparison between surgical outcomes of colorectal cancer in younger and elderly patients

AIM:To compare the outcome of surgical treatment of colorectal adenocarcinoma in elderly and younger patients.METHODS:The outcomes of 122 patients with colorectal adenocarcinoma who underwent surgical treatment between January 2004 and June 2009 were analyzed.The clinicopathological and blood biochemistry data of the younger group(<75 years) and the elderly group (≥75 years) were compared.RESULTS:There were no significant differences between the two groups in operation time,intraoperative blood loss,hospital stay,time to resumption of oral intake,or morbidity.The elderly group had a significantly higher rate of hypertension and cardiovascular disease.The perioperative serum total protein and albumin levels were significantly lower in the elderly than in the younger group.The serum carcinoembryonic antigen level was lower in the elderly than in the younger group,and there was a significant decreasing trend after the operation in the elderly group.CONCLUSION:The short-term outcomes of surgical treatment in elderly patients with colorectal adenocarcinoma were acceptable.Surgical treatment in elderly patients was considered a selectively effective approach.

Anesthetic management and associated complications of peroral endoscopic myotomy:A case series

AIM To investigate the anesthetic management of peroral endoscopic myotomy(POEM) and its associated complications.METHODS This study was a single-center,retrospective,observational study comprising a case series of all patients who underwent POEM in our hospital from April 2015 to November 2016.We collected data regarding patient characteristics,anesthetic methods,surgical factors,and complications using an electronic chart.RESULTS There were 86 patients who underwent POEM in our hospital during the study period.Preoperatively,patients were maintained on a low residue diet for 48 h prior to the procedure.They were fasted of solids for 24 h before surgery.There was one case of aspiration(1.2%).During POEM,patients were positioned supine with the upper abdomen covered by a clear drape so that pneumoperitoneum could be timeously identified.In three cases,the peak airway pressure exceeded 35 cm H2 O during volume controlled ventilation with tidal volumes of 6-8 m L/kg and subsequent impairment of ventilation.These cases had been diagnosed with spastic esophageal disorders(SEDs) and the length of the muscular incision on the esophageal side was longer than normal.CONCLUSION In the anesthetic management of POEM,it is important to prevent aspiration during induction of anesthesia and to identify and treat complications associated with CO_2 insufflation.

Epidural Blood Patch for Treatment of Postdural Puncture Headache in a Patient with Spinal Fusion and Recent Implantation of Intrathecal Pain Pump

We present an interesting case report of a 49-year-old female who presented with symptoms of post-dural puncture headache following implantation of an intrathecal pain pump. Her history was complicated by previous multi-level spinal fusion with hardware. The patient was evaluated and felt to be a candidate for epidural blood patch, which she elected to proceed with. Under fluoroscopic guidance epidural blood patch was successfully performed. Immediately following the procedure the patient noted significant improvement in the headache and six hours following the procedure was headache free and remained so at follow up three weeks later.

The Addition of Midazolam Reduces the Incidence of Early Postoperative Nausea and Vomiting in Short Time Gynecological Procedures

Background: If untreated, one third of patients who undergo surgery develop postoperative nausea and/or vomiting (PONV). The prevention of postoperative nausea and vomiting can improve satisfaction among vulnerable patients. We hypothesized that preoperative anxiety may increase the incidence of PONV. The objective was to assess whether administration of a benzodiazepine prior to surgery would reduce the incidence of PONV. Methods: 130 women (ASA I and II) scheduled to undergo dilatation and curettage comprised the study group. The women were allocated randomly to two study groups according to the type of anesthesia administered (with and without midazolam). Results: Sixty-eight women received midazolam and 62 did not. Patients treated with midazolam were feeling more comfortable (“friendliness”, p = 0.005 and “elation”, p = 0.01) and had less postoperative fatigue (p = 0.04) than non-midazolam-treated group. Patients treated with midazolam had significantly fewer emetic episodes during the first 4 hours after surgery than those without midazolam (0.1 ± 0.2 vs 0.3 ± 0.6, respectively, p = 0.003). Conclusions: Midazolam reduces the incidence of PONV and improves patient’s comfort. We suggest that midazolam has to be routinely included in the anesthesia protocol for short-term gynecological procedures (dilatation and curettage).

Analysis of Mad Honey (Grayanotoksin) Cases Admitted to Duzce University School of Medicine Emergency Department

Background: Mad honey is the type of honey made by bees that are nourished from the plants of Rhododendron (Rh.) family, and it contains grayanotoksin (GTX). The most significant types of Rh family, which contain GTX, are Rh. The purpose of this study was to analyze the cases which came to the emergency room because of GTX intoxication in detail in order to help diagnosis, treatment, follow-up and prognosis in daily emergency medicine practice. A total of 36 patients with the symptoms and diagnosis of intoxication after consuming mad honey, were included in the study. Ten healthy individuals who did not have a history of taking mad honey were included in the control group. The study is designed as a prospective case control study. The average GTX level of the group who ate mad honey (studygroup) was 7.88 ng/ml (min: 0.00/max: 30.47). At control group, GTX level was 0 ng/ml. There was no statistically significant relationship between the symptoms (dizziness, nausea, vomiting, weakness, deterioration, angina) and blood GTX level in the study group. Also statistic value reflects relationship between kidney function tests, troponin and control troponin levels in case group. The patients who have absolute decrease in blood pressure and pulse should be questioned by emergency medicine doctors about consuming mad honey. Further studies are needed to demonstrate the relationship between symptoms and GTX poisoning.

Changes in Health Consciousness of Nursing Students in Japan after Acquiring Medical Care Knowledge from a Nursing School

Background: Health consciousness in daily life is very important because lifestyle habits, such as dietary and exercise habits, sleep, and smoking, are involved in the development and progression of lifestyle-related diseases, such as cancer, heart diseases, stroke, liver diseases, kidney diseases, and diabetes. Purpose: In this study, we surveyed to see if the health consciousness increased and what behaviors in daily life changed in students of a nursing school (Seiwa Nursing College, Tokyo, Japan) after they learned medical care knowledge required to become a nurse. Results: After learning medical care knowledge for 3 years, the students were found to have a higher level of health consciousness in the third year than they did in the first year. They applied the medical care knowledge they learned in daily life. All data were collected in 2019. Conclusions: The medical care knowledge learned in a nursing school was demonstrated to serve as information to increase the health consciousness.

Post reperfusion syndrome during liver transplantation:From pathophysiology to therapy and preventive strategies

This review aims at evaluating the existing evidence regarding post reperfusion syndrome, providing a description of the pathophysiologic mechanisms involved and possible management and preventive strategies. A Pub Med search was conducted using the Me SH database, "Reperfusion" AND "liver transplantation" were the combined Me SH headings; EMBASE and the Cochrane library were also searched using the same terms. 52 relevant studies and one ongoing trial were found. The concept of post reperfusion syndrome has evolved through years to a multisystemic disorder. The implications of the main organ, recipient and procedure related factors in the genesis of this complex syndrome are discussed in the text as the novel pharmacologic and technical approaches to reduce its incidence. However the available evidence about risk factors, physiopathology and preventive measures is still confusing, the presence of two main definitions and the numerosity of possible confounding factors greatly complicates the interpretation of the studies.

Portopulmonary hypertension and hepatopulmonary syndrome

Portopulmonary hypertension (POPH) and hepatopulmonary syndrome (HPS) are two frequent complications of liver disease, with prevalence among liver transplant candidates of 6% and 10%, respectively. Both conditions result from a lack of hepatic clearance of vasoactive substances produced in the splanchnic territory. Subsequently, these substances cause mainly pulmonary vascular remodeling and some degree of vasoconstriction in POPH with resulting elevated pulmonary pressure and right ventricular dysfunction. In HPS the vasoactive mediators cause intrapulmonary shunts with hypoxemia. Medical treatment is disappointing overall. Whereas liver transplantation (LT) results in the disappearance of HPS within six to twelve months, its effect on POPH is highly unpredictable. Modern strategies in managing HPS and POPH rely on a thorough screening and grading of the disease&#x02019;s severity, in order to tailor the appropriate therapy and select only the patients who will benefit from LT. The anesthesiologist plays a central role in managing these high-risk patients. Indeed, the important hemodynamic and respiratory modifications of the perioperative period must be avoided through continuation of the preoperatively initiated drugs, appropriate intraoperative monitoring and proper hemodynamic and respiratory therapies.

Thoracic epidural anesthesia:Effects on splanchnic circulation and implications in Anesthesia and Intensive care

AIM: To evaluate the currently available evidence on thoracic epidural anesthesia effects on splanchnic macro and microcirculation, in physiologic and pathologic conditions.METHODS:A Pub Med search was conducted using the Me SH database.Anesthesia,Epidural was always the first MeS H heading and was combined by boolean operator AND with the following headings:Circulation,Splanchnic;Intestines;Pancreas and Pancreatitis;LiverFunction Tests.EMBASE,Cochrane library,ClinicalT rials.gov and clinicaltrialsregister.eu were also searched using the same terms.RESULTS:Twenty-seven relevant studies and four ongoing trials were found.The data regarding the effects of epidural anesthesia on splanchnic perfusion are conflicting.The studies focusing on regional macro-hemodynamics in healthy animals and humans undergoing elective surgery,demonstrated no influence or worsening of regional perfusion in patients receiving thoracic epidural anesthesia(TEA).On the other hand most of the studies focusing on micro-hemodynamics,especially in pathologic low flow conditions,suggested that TEA could foster microcirculation.CONCLUSION:The available studies in this field are heterogeneous and the results conflicting,thus it is difficult to draw decisive conclusions.However there is increasing evidence deriving from animal studies,that thoracic epidural blockade could have an important role in modifying tissue microperfusion and protecting microcirculatory weak units from ischemic damage,regardless of the effects on macro-hemodynamics.

Perioperative blood transfusion decreases long-term survival in pediatric living donor liver transplantation

BACKGROUND The impact of perioperative blood transfusion on short-and long-term outcomes in pediatric living donor liver transplantation(PLDLT)must still be ascertained,mainly among young children.Clinical and surgical postoperative complications related to perioperative blood transfusion are well described up to three months after adult liver transplantation.AIM To determine whether transfusion is associated with early and late postoperative complications and mortality in small patients undergoing PLDLT.METHODS We evaluated the effects of perioperative transfusion on postoperative complications in recipients up to 20 kg of body weight,submitted to PLDLT.A total of 240 patients were retrospectively allocated into two groups according to postoperative complications:Minor complications(n=109)and major complications(n=131).Multiple logistic regression analysis identified the volume of perioperative packed red blood cells(RBC)transfusion as the only independent risk factor for major postoperative complications.The receiver operating characteristic curve was drawn to identify the optimal volume of the perioperative RBC transfusion related to the presence of major postoperative complications,defining a cutoff point of 27.5 mL/kg.Subsequently,patients were reallocated to a low-volume transfusion group(LTr;n=103,RBC≤27.5 mL/kg)and a high-volume transfusion group(HTr;n=137,RBC>27.5 mL/kg)so that the outcome could be analyzed.RESULTS High-volume transfusion was associated with an increased number of major complications and mortality during hospitalization up to a 10-year follow-up period.During a short-term period,the HTr showed an increase in major infectious,cardiovascular,respiratory,and bleeding complications,with a decrease in rejection complications compared to the LTr.Over a long-term period,the HTr showed an increase in major infectious,cardiovascular,respiratory,and minor neoplastic complications,with a decrease in rejection complications.Additionally,Cox hazard regression found that high-volume RBC transfusion increased the mortality risk by 3.031-fold compared to low-volume transfusion.The Kaplan-Meier survival curves of the studied groups were compared using log-rank tests and the analysis showed significantly decreased graft survival,but with no impact in patient survival related to major complications.On the other hand,there was a significant decrease in both graft and patient survival,with high-volume RBC transfusion.CONCLUSION Transfusion of RBC volume higher than 27.5 mL/kg during the perioperative period is associated with a significant increase in short-and long-term postoperative morbidity and mortality after PLDLT.

Ventilator associated pneumonia following liver transplantation:Etiology,risk factors and outcome

AIM: To determine the incidence, etiology, risk factors and outcome of ventilator-associated pneumonia(VAP) in patients undergoing orthotopic liver transplantation(OLT).METHODS: This retrospective study considered 242 patients undergoing deceased donor OLT. VAP was diagnosed according to clinical and microbiological criteria. RESULTS: VAP occurred in 18(7.4%) patients, with an incidence of 10 per 1000 d of mechanical ventilation(MV). Isolated bacterial etiologic agents were mainly Enterobacteriaceae(79%). Univariate logistic analysis showed that model for end-stage liver disease(MELD) score, pre-operative hospitalization, treatment with terlipressin, Child-Turcotte-Pugh score, days of MV and red cell transfusion were risk factors for VAP. Multivariateanalysis, considering significant risk factors in univariate analysis, demonstrated that pneumonia was strongly associated with terlipressin usage, pre-operative hospitalization, days of MV and red cell transfusion. Mortality rate was 22% in the VAP group vs 4% in the group without VAP. CONCLUSION: Our data suggest that VAP is an important cause of nosocomial infection during postoperative period in OLT patients. MELD score was a significant risk factor in univariate analysis. Multiple transfusions, treatment with terlipressin, preoperative hospitalization rather than called to the hospital while at home and days of MV constitute important risk factors for VAP development.

Acute Urinary Retention among Adult Men at Bobo-Dioulasso University Teaching Hospital: Epidemiology, Aetiologies and Initial Management

We conducted a cross-sectional study between February 1st, 2012 and September 30, 2012 at Bobo-Dioulasso University Teaching hospital. The target population was all patients seen at the emergency services for acute urinary retention. Among the 155 patients admitted for urological emergencies, 104 (67.1%) had acute urinary retention. The average age of patients was 65 years, ranging from 23 to 89 years and the majority was more than 60 years old (77.8%) and lived in rural areas (64.4%). Prostate tumor pathology and urethral stricture were the most frequent diagnosis, and the renal function was impaired in 33.7% of cases. Urethrovesical drainage, cystocatheterism, and suprapubic cystostomy were the treatment approach in 56.0%, 28.0% and 15.2% of the cases. Acute urinary retention is the most common urological emergency and many complications are associated with urethrovesical sounding. These complications should therefore be prevented by improving acute urinary care.

An Unusual Intravesical Foreign Body for Abortion Attempt. About a Case Report at Bobo Dioulasso University Teaching Hospital (Burkina Faso) and Literature Review

We reported a case of an intravesical foreign body in a 16 years old teenager for abortion attempt. During laparotomy for suspected pelvic appendicitis, we incidentally discovered an intravesical foreign body. From this first observation in our urology division, we reviewed the literature on the nature and circumstance of self introduction in bladder of foreign body and their surgical ablation. We emphasized the importance of endoscopy as a support of diagnosis and therapeutic of intravesical foreign body. This observation also highlighted the lack of information in our teenagers about reproductive and sexual health.

Extended Antiepileptic Drug Prophylaxis and Late Onset Seizures in Aneurysmal Subarachnoid Hemorrhage

Background: The indication and optimal duration of antiepileptic drug (AED) prophylaxis after aneurysmal subarachnoid hemorrhage (SAH) remains controversial. Our institution practices routine seizure prophylaxis for variable durations at the discretion of the neurosurgeon and neuro-intensivist. Given the propensity of late onset seizures to progress to chronic epilepsy, we sought to investigate the efficacy of extended AED prophylaxis in reducing the risk of late seizures. Methods: This retrospective study analyzed 36 patients who were admitted to our neurosurgical intensive care unit (NICU) over a 2-year period (1st November 2015 to 31st October 2017). All hospital admissions records, electronic medication records as well as outpatient visits up to 1 year were reviewed. Late onset seizures were defined as seizures occurring more than 7 days post-intervention (or presentation if no intervention was performed) up to 1 year of follow-up. Results: Majority of the patients received Levetiracetam (94%) as seizure prophylaxis and late onset seizures occurred in 6 (17%) of the patients. Those patients who received a greater proportion of in-patient stay with AED prophylaxis had a statistically significant lower risk of developing late seizures (OR = 0.964, 95%, p = 0.02). Although the value tended towards benefit (OR = 0.382) for AED > 21 days in-hospital, the result was not statistically significant (p = 0.307). Conclusion: An extended duration of AED prophylaxis, in particular Levetiracetam, may confer some benefit in reducing risk of developing late seizures. However, the optimal duration of therapy is yet to be determined and further large multi-centered randomized studies are necessary.

Anesthesia for ambulatory surgery in a child with hyposensitivity to pain

Congenital hyposensitivity to pain is a condition with predisposition to injury. In these patients, knowledge regarding anesthetic requirements and complications derives from individual case reports, or small case series. Different categories have been described. In patients with hyposensitivity to pain, preventing and treating anxiety as well as insuring immobilization, avoidance of triggering of autonomic reflexes, and sedation are integral aspects for a safe and adequate anesthetic management.

Impaired Hypothalamic Regulation of Sympathetic Outflow in Primary Hypertension

The hypothalamic paraventricular nucleus(PVN) is a crucial region involved in maintaining homeostasis through the regulation of cardiovascular, neuroendocrine, and other functions. The PVN provides a dominant source of excitatory drive to the sympathetic outflow through innervation of the brainstem and spinal cord in hypertension. We discuss current findings on the role of the PVN in the regulation of sympathetic output in both normotensive and hypertensive conditions. The PVN seems to play a major role in generating the elevated sympathetic vasomotor activity that is characteristic of multiple forms of hypertension, including primary hypertension in humans. Recent studies in the spontaneously hypertensive rat model have revealed an imbalance of inhibitory and excitatory synaptic inputs to PVN presympathetic neurons as indicated by impaired inhibitory and enhanced excitatory synaptic inputs in hypertension.This imbalance of inhibitory and excitatory synaptic inputs in the PVN forms the basis for elevated sympathetic outflow in hypertension. In this review, we discuss the disruption of balance between glutamatergic and GABAergic inputs and the associated cellular and molecular alterations as mechanisms underlying the hyperactivity of PVN pre-sympathetic neurons in hypertension.