Summary
Key wordsTotal intravenous unaesthesia. Anaesthetics, intravenous; propofol, ketamine.Ketamine is a powerful analgesic, even in doses insufficient to induce anaesthesia.' It has many of the attributes of the 'ideal' analgesic agent for longer routine operations: a very high margin of safety, no irritation of the veins and no negative influence on ventilation or circulation. Its main disadvantages are that it produces hypertension and precipitates psychomimetic emergence phenomena. These effects can be mitigated by judicious medication, particularly by administering benzodiazepines. The combination of midazolam with ketamine has been recommended previously ror total intravenous anaesthesia in military surgery, general civilian practice and cardiac s~r g e r y .~-~ In this study, the combination of propofol/ketamine was compared to the combination propofol/fentanyl in a double-blind, prospective trial in patients undergolng general anaesthesia for elective surgery. Haemodynamic variables, the time to recovery and patient acceptability were compared.
MethodsA prospective study of 18 patients who underwent noncardiac surgery was performed. Patients gave informed consent to a protocol approved by the medical ethics committee of our hospital. All patients were ASA grade 1 or 2 and scheduled for operations longer than 15 minutes (Table I). Patients received oral oxazepam (0.25-0.3 mg/kg) as premedication 2 hours before surgery and were allocated randomly to one of two groups to receive propofol with ketamine (n = 9) or propofol with fentanyl (n = 9) for total intravenous anaesthesia.Standard lead I1 of the electrocardiogram was monitored and an intravenous cannula inserted on arrival of the patient in the operating theatre. Heart rate was detected by electrocardiogram and calculated electronically on a beatto-beat basis. The pulse rate was timed for at least 30 seconds. One person recorded all arterial pressure measurements by auscultation (diastolic reading as Korotkoff phase V) using an anaeroid sphygomanometer previously calibrated at zero and 150 mmHg against a mercury column. Anaesthesia was induced with propofol (2 mg/kg) and either fentanyl (3 pg/kg) or ketamine (I mg/kg). Vecuronium (0.15 mg/kg) was administered. Anaesthesia was maintained with propofol 12 mg/kg/hour during the first 30 minutes, followed by 9 mg/kg/hour for 30 minutes and then 6 mg/kg/hour combined with fentanyf 1.5 pg/kg/hour or with ketamine 2 mg/kg hour. The patient's lungs were ventilated with oxygen-enriched air with an no2 of 0.35.The postinduction arterial pressure and heart rate were recorded one minute after induction, and direct laryngoscopy with a curved blade was initiated 2 minutes after induction. None of the patients received topical or intravenous lignocaine before laryngoscopy, and tracheal intubation was always accomplished within 20 seconds.
Background
In patients scheduled for colorectal surgery with an enhanced recovery program (ERP), feeding after returning home has been insufficiently investigated. The aim of this study was to measure energy and protein intake during the first month at home.
Methods
Seventy adult patients scheduled for colorectal surgery with ERP were included. Calorie and protein intakes were calculated, and body weight was measured preoperatively and 3, 7, 15, and 30 days after discharge home. Data are mean ± SD or median (interquartile range).
Results
Patient characteristics were age 60.0 ± 15.0 years, BMI = 25.9 ± 5.5 kg/m2, and colon/rectum of 56/14. The duration of hospitalization was 3 (2–5) days. Calorie and protein intakes (21.9 [17.7–28.6] kilocalorie per kilogram of ideal body weight [kcal/kg IBW] and 0.81 [0.61–1.14] g/kg IBW) were significantly reduced (P < .01) by 15% on day 3, compared with preoperative values, and then increased gradually to reach preoperative values after 1 month. Almost 50% of the patients failed to reach the calorie intake target of 25 kcal/kg IBW, and almost no patient reached the protein intake target of 1.5 g/kg IBW 30 days after discharge home. Weight loss after 30 days at home remained at −1.8 ± 2.7 kg.
Conclusions
Colorectal surgery, even in an ERP, is associated with energy and protein intake below the targets recommended for the rehabilitation phase and results in weight loss. Whether nutrition counseling and prolonged administration of protein‐enriched oral supplements could accelerate weight gain needs to be explored.
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