When ERAS programme is used for laparoscopic colonic resection, an intrathecal mixture of bupivacaine and morphine was associated with less postoperative opioid consumption, but has no other advantages over systemic opioids.
Intraoperative and postoperative IV infusion of lidocaine in patients undergoing laparoscopic colorectal resection using an ERP had a similar impact on bowel function compared with thoracic epidural analgesia.
BackgroundThe Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting.Methods and FindingsWe undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis.ConclusionIt is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.
At this institution, the majority of ED intubations were performed by residents and no drug was used. In this ED patients were intubated with a high success rate and a low rate of serious complications.
The aim of the present study was to compare the surgical condition between deep neuromuscular blockade (NMB) and moderate NMB.
Multicenter, randomized, parallel intervention trial.
One hundred two patients underwent microscopic endolaryngeal surgery at four university hospitals. The patients were randomized into moderate NMB (train‐of‐four 1‐2) (M group) or deep NMB (post‐tetanic count 1‐2) (D group) with moderate or high doses of rocuronium, respectively. Surgical rating conditions (SRCs) were evaluated during the surgery. Sugammadex was given to the M group at 2 mg/kg and the D group at 4 mg/kg. Perioperative clinical signs and conditions were recorded until discharge from the postanesthesia care unit.
Clinically acceptable SRC was observed in 49 patients (100%) in the D group and 43 patients (89.6%) in the M group (P = .027). The frequency of notable vocal fold movement in the M group was significantly higher than the D group (70.8% vs. 32.7%). The patients in the M group required more additional doses of rocuronium (47.9%) than the D group (20.4%) to maintain full relaxation (P = .005). The median time (interquartile range) from administration of sugammadex to train‐of‐four ratio 0.9 in the D group was shorter than the M group (120 [109–180 minutes] vs. 180 minutes [120–240 minutes], P = .034).
Deep NMB with high doses of rocuronium combined with 4 mg/kg of sugammadex for reversal during endolaryngeal surgery provided better SRC and anesthetic conditions than moderate NMB of rocuronium with 2 mg/kg of sugammadex.
Level of Evidence
1b Laryngoscope, 130:437–441, 2020
The measured outcomes were: length of stay (LOS), complication rate, readmission rate, compliance with ERAS protocol elements and recovery parameters (tolerance of early oral diet, mobilisation and time to first flatus). Results: Group 1 (colon) consisted of 150 patients and Group 2 (rectum) of 82 patients. There was no statistical difference between the two group based on other demographic parameters such as ASA scale, BMI and the stage of cancer. Patients in Group 1 were discharged home earlier than in Group 2-median LOS 4 vs. 5 days respectively (p¼0.046). There was no statistical difference in complication rate (27.3% vs. 36.6%, p¼0.14), severity of complications according to Clavien-Dindo classification (p¼0.58) and readmissions (7.3% vs. 6.1%, p¼0.72). Compliance with the protocol was 86.9% and 82.6% respectively (p¼0.07). However, in Group 1 the following procedures were used less frequently: bowel preparation (24% vs. 78.3%) and postoperative drainage (23.3% vs. 71.0%). There were no differences in recovery parameters between the groups: tolerance of an oral diet on the 1st postoperative day (76.7% vs. 68.3%, p¼0.17), mobilisation of a patient on the day of surgery (90.7% vs. 82.9%, p¼0.09), time to first flatus (1.8 ± 1.4 vs. 2.1 ± 1.9 days respectively, p¼0.64). Univariate logistic regression showed that the type of surgery (OR 1.89, 95% CI 1.10-3.27), drainage (OR 3.42, 95% CI 1.95-5.99), bowel preparation (OR 2.81, 95% CI 1.63-4.86) and stoma creation (OR 2.70, 95% CI 1.38-5.28) prolonged LOS significantly. In a multivariate logistic regression model only a bowel preparation (OR 2.24, 95% CI 1.19-4.20) and drainage (OR 2.85, 95% CI 1.54-5.28) were shown to be significant. Conclusion: Although functional recovery and high compliance with ERAS protocol is possible irrespective of the type of surgery, laparoscopic rectal resections were associated with a longer LOS Disclosure of interest: None declared.
The SPLS is technically feasible with proper patient selection for a variety of applications in colorectal surgery. Improvement in instrumentation and technology is likely to expand the role of SPLS in minimally invasive surgery. It is important to audit outcomes as this novel approach is introduced.
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