Author Archives: Hannah

Balanced crystalloids vs saline in adult ICU patients

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One discussion this week included the question of balanced crystalloids vs saline in ICU and non-ICU patients.

Reference: Semler MW, et al. Balanced crystalloids versus saline in critically ill adults. NEJM. 2018 Mar 1;378:829-839. doi:10.1056/NEJMoa1711584

Summary: Although both saline and balanced crystalloids have been administered to patients in clinical practice for decades, few trials have addressed the effects of crystalloid composition on clinical outcomes.

The authors conducted an unblinded, cluster-randomized, multiple-crossover trial in which the use of balanced crystalloids was compared with saline for intravenous fluid administration among critically ill adults admitted to five ICUs at Vanderbilt University Medical Center between June 1, 2015, and April 30, 2017. A total of 15,802 patients were enrolled. The median age was 58, and 57.6% of patients were men.

The primary outcome was the proportion of patients who met one or more criteria for a major adverse kidney event within 30 days — the composite of death, new receipt of renal-replacement therapy, or persistent renal dysfunction (defined as a final inpatient creatinine value ≥200% of the baseline value) — all censored at hospital discharge or 30 days after enrollment, whichever came first.

Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60).

In this trial of critically ill adults, the intravenous administration of balanced crystalloids rather than saline had a favorable effect on the composite outcome of death, new renal-replacement therapy, or persistent renal dysfunction.

Additional Reading: Hammond DA, et al. Balanced crystalloids versus saline in critically ill adults: a systematic review and meta-analysis. Annals of Pharmacotherapy. 2019 Jul 31:1060028019866420. doi: 10.1177/1060028019866420.

What is the impact of abdominal binder on seroma formation?

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One discussion this week included the impact of abdominal binder on seroma formation.

Reference: Christoffersen MW, Olsen BH, Rosenberg J, Bisgaard T. Randomized clinical trial on the postoperative use of an abdominal binder after laparoscopic umbilical and epigastric hernia repair. Hernia. 2015 Feb;19(1):147-153. doi:10.1007/s10029-014-1289-6

Summary: Application of an abdominal binder is often part of a standard postoperative regimen after ventral hernia repair to reduce pain and seroma formation. However, there is lack of evidence of the clinical effects.

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Intraoperative cardiac arrest: Resuscitation and Management

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One discussion this week included intraoperative cardiac arrest.

Reference: Moitra VK, et al. Cardiac arrest in the operating room: resuscitation and management for the anesthesiologist: part 1. Anesthesia & Analgesia. 2018 Mar;126(3):876-888. doi: 10.1213/ANE.0000000000002596.

Summary: Cardiac arrest in the operating room and procedural areas has a different spectrum of causes (ie, hypovolemia, gas embolism, and hyperkalemia), and rapid and appropriate evaluation and management of these causes require modification of traditional cardiac arrest algorithms. There is a small but growing body of literature describing the incidence, causes, treatments, and outcomes of circulatory crisis and perioperative cardiac arrest. These events are almost always witnessed, frequently known, and involve rescuer providers with knowledge of the patient and their procedure.

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Surgeon’s choice: TEP or TAPP for recurrent inguinal hernia repair?

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One discussion involved the comparison of outcomes for TEP and TAPP for hernia repair.

Reference: Kockerling F, et al. TEP or TAPP for recurrent inguinal hernia repair-registered-based comparison of the outcome. Surgical Endoscopy. 2017 Oct;31(10):3872-3882. doi: 10.1007/s00464-017-5416-1

Summary: To date, no randomized trials have been conducted to compare the TEP vs TAPP outcome for recurrent inguinal hernia repair. Between September 1, 2009 and August 31, 2013 data were entered into the Herniamed Registry on a total of 2246 patients with recurrent inguinal hernia repair following previous open primary operation in either TAPP (n = 1,464) or TEP technique (n = 782).

  • TAPP group: recurrent repair was performed for n=974/1,464 (66.5%) patients after suture and n=490/1,464 (33.5%) after mesh repair.
  • TEP group: recurrent repair was performed for n=554/782 (70.8%) patients following previous suture repair and for n=228/782 (29.2%) after mesh repair.

No significant differences were found between the recurrent operations in TEP vs TAPP technique with regard to the intraoperative complications, complication-related reoperations, re-recurrence rates, rates of pain at rest, pain on exertion, or chronic pain requiring treatment. Unfavorable results were identified only with regard to the higher seroma rates associated with TAPP; these responded to conservative treatment.

In summary, both TEP and TAPP can be recommended as effective techniques for treatment of recurrent inguinal hernia following previous open primary operation. The decision to use one or the other technique should be based solely on the surgeon’s expertise. The registry study presented here thus confirms the recommendations in the guidelines on laparo-endoscopic treatment of recurrent inguinal hernia following previous open primary operation.

 

What is the effect of abdominal insufflation on deep vein flow?

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One discussion this week involved the effect of abdominal insufflation on deep vein flow.

Reference: Yang C, Zhu L. Coagulation and deep vein flow changes following laparascopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study. Surgical Endoscopy. 2019 Feb 11. doi: 10.1007/s00464-019-06700-6.

Summary: The authors observed morphologic change of the iliac vein during TEP procedure. The iliac vein was almost completely collapsed, which not only impaired venous return from the lower extremities but also caused vein distention. The acute distention caused vessel wall damage due to mechanical disruption of the endothelial lining. Vessel wall damage is one of Virchow’s triad in the pathogenesis of thrombosis.

In this study, activated coagulation and impaired deep venous flow implied that the TEP procedure had a certain degree of potential risk for DVT during the early postoperative period.

What is the risk of rupture for type II endoleaks?

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One discussion last week included the risk of rupture with type II endoleaks.

Reference: Brown A, et al. Type II endoleaks: challenges and solutions. Vascular Health Risk Management. 2016;12:53-63.

Summary:  Although type II endoleak appears to be associated with sac expansion (volume changes), the significance of this expansion on risk of aneurysm rupture remains unclear.

Wyss et al found a significant association between sac expansion and rupture.Twenty-seven ruptures occurred in an EVAR population of 848 patients, with an average follow-up of 4.8 years. Sixty-three percent of these ruptures occurred more than 30 days post-repair and were associated with prior complications detected on follow-up imaging. Five of these 17 ruptures demonstrated evidence of type II endoleak with associated sac expansion (four were isolated type II endoleaks and one was associated with a concomitant type Ib endoleak).

Conversely, other authors have shown no correlation. Van Marrewijk et al demonstrated that sac expansion was significantly associated with type II endoleaks; however, there was no correlation with rupture or increase in aneurysm-associated mortality. A recent systematic review reported a low incidence of rupture in patients with isolated type II endoleaks (under 1%) of which 57% were associated with sac expansion.

Sac expansion may therefore be a poor marker of risk in this population of patients; however, we do not currently have a more sensitive way of monitoring risk of rupture. As such, some authors suggest that consideration should be given to prevention of/or treatment for type II endoleak.