American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on perioperative fluid management within an enhanced recovery pathway for colorectal surgery

BACKGROUND: Enhanced recovery may be viewed as a comprehensive approach to improving meaningful outcomes in patients undergoing major surgery. Evidence to support enhanced recovery pathways (ERPs) is strong in patients undergoing colorectal surgery. There is some controversy about the adoption of specific elements in enhanced recovery "bundles" because the relative importance of different components of ERPs is hard to discern (a consequence of multiple simultaneous changes in clinical practice when ERPs are initiated). There is evidence that specific approaches to fluid management are better than alternatives in patients undergoing colorectal surgery; however, several specific questions remain. METHODS: In the "Perioperative Quality Initiative (POQI) Fluids" workgroup, we developed a framework broadly applicable to the perioperative management of intravenous fluid therapy in patients undergoing elective colorectal surgery within an ERP. DISCUSSION: We discussed aspects of ERPs that impact fluid management and made recommendations or suggestions on topics such as bowel preparation; preoperative oral hydration; intraoperative fluid therapy with and without devices for goal-directed fluid therapy; and type of fluid

Perioperative nutrition and insulin resistance [Elektronisk resurs]

Surgical trauma induces a catabolic response with development of insulin resistance as a central and well-characterised feature. In insulin resistance, the stimulating effect of insulin on peripheral glucose uptake and the suppressing effect of insulin on endogenous glucose release are decreased, resulting in hyperglycaemia. It is marked the first day after surgery and normalises within two to three weeks. Preoperative treatment with oral carbohydrates instead of traditional fasting and use of epidural anaesthesia reduce postoperative insulin resistance. Both starvation and bed rest are known to induce insulin resistance. In the first study, the effect of traditional post-surgical low caloric feeding and bed rest on insulin sensitivity (hyperinsulinaemic (0.8 mU/kg/min) normoglycaemic (4.5 mM) clamps) and substrate utilisation (indirect calorimetry) were studied in healthy volunteers in a control situation and after three days of low caloric feeding and bed rest. Half of the volunteers underwent a second protocol with identical low caloric feeding but without bed rest. Three days of low caloric feeding induced a decrease in insulin sensitivity by nearly 60 % and caused alterations in substrate utilisation both with and without bed rest. The metabolic effect of low caloric feeding and bed rest was not related to age in the present study. Thus, low caloric feeding might be of importance for development of postoperative insulin resistance. The use of total parenteral nutrition (TPN) in patients undergoing surgery in order to reduce catabolism has been shown to induce hyperglycaemia and increase the complication rate, mainly infectious. However, the effects of TPN have not been investigated in patients treated to proactively minimise development of postoperative insulin resistance. Insulin sensitivity, glucose kinetics (6,62H2-D-glucose) and substrate utilisation were studied before surgery and on the third postoperative day in 13 patients undergoing colorectal resections. Patients were randomised to postoperative hypocaloric glucose or TPN. All received preoperative oral carbohydrate treatment and epidural anaesthesia during and after surgery. Whole-body glucose disposal decreased by only approximately 25 % irrespective of whether or not TPN was given. Low caloric feeding resulted in changes in substrate utilisation and nitrogen balance resembling starvation, while TPN attenuated these changes. Preoperative oral carbohydrate treatment has been used as an evening dose the day before surgery (100 g) and a morning dose (50 g). The aim of study III was to investigate to what extent the two doses, respectively, affected insulin sensitivity at the time of onset of surgery. Insulin sensitivity and substrate utilisation were measured in six healthy volunteers on four occasions in a randomised order (in the overnight fasted state, after the evening dose only, after the morning dose only, and after both doses). Oral carbohydrate treatment given in the morning increased insulin sensitivity three hours later (corresponding to the time of onset of surgery) by approximately 50%. The evening dose did not affect insulin sensitivity the following day. Thus, increased insulin sensitivity at the onset of surgery might, at least in part, explain the positive effects of carbohydrate loading seen on postoperative insulin sensitivity. In paper IV, the effect of preoperative oral carbohydrate treatment on postoperative whole-body protein kinetics was evaluated. Insulin sensitivity, protein (2H5-phenylalanine, 2H2-tyrosine, 2H4-tyrosine) and glucose (6,62H2-D-glucose) kinetics and substrate utilisation were studied before surgery and on the first postoperative day in 12 patients undergoing colorectal resections. Patients were randomised between oral carbohydrate treatment and a placebo drink before surgery. Preoperative carbohydrate treatment improved postoperative whole-body protein balance. The effect of insulin on whole-body protein kinetics was not altered after surgery

Children of Mentally Ill Mothers: Social Situation and Psychometric Testing of Mental Development

Children of mothers who satisfied the Research Diagnostic Criteria of (1) Schizophrenia, (2) Alcoholism or Drug Use Disorder, (3) Major Depressive Disorder including Mania, (4) Unspecified Functional Psychosis, and (5) Other Psychiatric Disorder and children of obstetric controls were studied with regard to subsequent mental and behavioural development and social conditions. 72 index children and 17 children from the comparison group were examined at an approximate age of six years by a child psychologist. More index children than those from the comparison group showed impaired mental and behavioural development. The children of abusing mothers in particular tended to have a worse outcome. One-half of the index children were not living with their mothers at the time of follow-up. </jats:p

The Importance of Blood Loss During Colon Cancer Surgery for Long-Term Survival

OBJECTIVE: This study tested the hypothesis that the amount of blood loss during surgery for colonic cancer influences long-term survival.BACKGROUND: The perioperative blood loss during surgery for colorectal cancer relates to the risk for complications and early mortality.METHODS: All patients who underwent surgery for colon cancer between 1997 and 2003 in the health-care region of Uppsala/Örebro were prospectively registered at the regional oncological center. Data on patients who underwent radical surgery for stages I to III disease were analyzed. Patients who died within 6 months after surgery were excluded. Hazard ratios were calculated with uni- and multivariate Cox proportional hazard regression. Because of covariation, blood loss, blood transfusion, and complications were tested in separate multivariate analyses.RESULTS: Blood loss of 250 mL or more during surgery, male gender, occurrence of complications, age more than 75 years, and stage III disease were risk factors for overall mortality in the uni- and multivariate analyses. Perioperative blood transfusion was shown to be a risk factor in the univariate analysis only.CONCLUSIONS: The results support the hypothesis that degree of blood loss during surgery for colon cancer is a factor that influences long-term survival.</p

Congenital pericardial defect with ruptured acute type A aortic dissection

This paper reports the results of a preliminary cross-evaluation experiment run in the framework of the European research project PF-Star1, with the double aim of evaluating the possibility of exchanging FAP data between the involved sites and assessing the adequacy of the emotional facial gestures performed by talking heads. The results provide initial insights in the way people belonging to various cultures react to natural and synthetic facial expressions produced in different cultural settings, and in the potentials and limits of FAP data exchang