The combination of advances in microsurgery and the improvement of anesthetic management with increased understanding of the physiology of preoperative and postoperative care has significantly raised the upper age limit for free-flap transfer in elderly patients. Despite pessimistic opinions regarding elderly patients who have poor recovery potential and decreased physiological reserves, the unique feature of free-tissue transfer is that it allows the transfer of well-vascularized tissue to defects in a single-stage procedure, and leads to improved quality of life. In this report, a retrospective analysis of 55 patients aged 50 and older who underwent microsurgical tissue transfer is presented. Hospital and our own records were used to review various parameters. The preoperative medical status of each patient was assessed using the American Society of Anesthesiologists (ASA) Classification of Physical Status. Each patient's preoperative medical records, age, sex, transferred tissue type, and length of operation were outlined. Postoperative recorded parameters were the fate of flaps and the short-term postoperative outcome, including surgical complications, medical morbidity, and death within 30 days of surgery. Fifty-eight microvascular tissue transfers were performed in 55 consecutive patients. The study comprised 38 male and 17 female patients, with a mean age of 64.8 years. ASA classification status was class 1 for 15 patients, class 2 for 26 patients, and class 3 for 14 patients. Twenty-five flaps were used for lower extremity reconstruction, 32 flaps were used for head and neck reconstruction, and 1 was used for breast reconstruction. The average operative time was 5.7 h, ranging between 2-13 h. There were 14 major medical complications, resulting in an overall medical complication rate of 25%. There were 3 deaths within 30 days postoperatively. Thus, the overall surgical mortality rate was 5.4%. The longer operation times were associated with the development of postoperative total medical and surgical complications (P = 0.008). While the relationship between ASA class and medical complications was significant (P = 0.0007), no significant relation was determined between ASA class and surgical complications (P = 0.66). It was revealed that the greater the age group, the greater the occurrence of postoperative medical complications (P = 0.0001). The relationship between postoperative surgical complications and age groups was not significant (P = 0.07). It was also demonstrated that the advanced age of patients was associated with a higher ASA class (P = 0.0017). Eleven flaps required reoperation for vascular compromise. While 10 of these were salvaged with vascular anastomosis revisions, one flap was lost. Thus the overall flap success rate was 98.3%. In conclusion, if a patient's medical problems do not constitute a handicap, age itself should not be considered a barrier to free-flap transfer. It is important to be familiar with preoperative medical problems and possible postoperative medical complications in...
We investigated the anesthetic and analgesic effectiveness of adding dexamethasone to lidocaine for IV regional anesthesia (IVRA). Seventy-five patients undergoing ambulatory hand surgery were randomly assigned to one of three groups: group L received 3 mg/kg lidocaine, group LD received 3 mg/kg lidocaine + 8 mg dexamethasone, and group LDc received 3 mg/kg lidocaine for IVRA and 8 mg dexamethasone IV to the nonsurgical arm. IVRA was established using 40 mL of a solution. Visual analog scale and verbal pain scores were recorded intraoperatively and for 2 h postoperatively. Postoperative pain was treated with oral acetaminophen 500 mg every 4 h when visual analog scale score was more than 3. Time to request for the first analgesic and the total dose in the first 24 h were noted. Times to onset of complete sensory and motor block were similar in the 3 groups. The times to recovery of motor block (L = 8 [5.91-10.08] min, LD = 13 [6.76-20.19] min, LDc = 6 [4.44-8.43] min) and sensory block (L = 7 [5.21-10.30] min, LD = 12 [6.11-19.40] min and LDc = 6 [4.2-8.11] min) were longer in group LD (P < 0.05). Patients in group LD reported significantly lower pain scores and required less acetaminophen in the first 24 h after surgery. In conclusion, the addition of 8 mg dexamethasone to lidocaine for IVRA in patients undergoing hand surgery improves postoperative analgesia during the first postoperative day.
Background: The aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs). Methods: LAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during 'daytime' when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as 'night-time' when induction was between 8:00 PM and 7:59 AM. Results: Of 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P¼0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P¼0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P¼0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09e1.90; P¼0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89e1.90; P¼0.15). Conclusions: Intraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events. Clinical trial registration: NCT01601223.
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