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Purpose: To describe nepafenac use in the Netherlands and Denmark with reference to its approved indications. For context, we also describe the use of ketorolac and diclofenac., Methods: We identified users in the PHARMO Database Network (the Netherlands, 2008-2013) and the Danish national health registers (Denmark, 1994-2014). We described prevalence of cataract surgery and duration of use in patients with cataract surgery with and without diabetes., Results: In the Netherlands, 9530 nepafenac users (mean age, 71 years; 60% women) contributed 12 691 therapy episodes, of which 21% had a recently recorded cataract surgery. Of 2266 episodes in adult non-diabetic patients with cataract surgery, 60% had one bottle dispensed (treatment duration ≤21 days). Of 441 episodes in adult diabetic patients with cataract surgery, 90% had up to two bottles dispensed (≤60 days). Denmark had 60 403 nepafenac users (mean age, 72 years; 58% women) and 73 648 episodes (41% had recorded cataract surgery). Of 26 649 nepafenac episodes in adult non-diabetic patients with cataract surgery, 92% had one bottle dispensed. Of 3801 episodes in adult diabetic patients with cataract surgery, 99.8% had up to two bottles dispensed. Use patterns of nepafenac, ketorolac and diclofenac were roughly similar in the Netherlands, but not in Denmark., Conclusion: Less than half of therapy episodes were related to cataract surgery; around 90% of episodes with surgery were within the approved duration. Underrecording of ophthalmic conditions and procedures was a challenge in this study., (© 2017 The Authors Acta Ophthalmologica published by John Wiley & Sons Ltd on behalf of Acta Ophthalmologica Scandinavica Foundation.)

Background: This is an update of a review last published in Issue 9, 2009, of The Cochrane Library. Pulse oximetry is used extensively in the perioperative period and might improve patient outcomes by enabling early diagnosis and, consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry during anaesthesia and in the recovery room have been performed that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and cognitive dysfunction., Objectives: To study the use of perioperative monitoring with pulse oximetry to clearly identify adverse outcomes that might be prevented or improved by its use.The following hypotheses were tested.1. Use of pulse oximetry is associated with improvement in the detection and treatment of hypoxaemia.2. Early detection and treatment of hypoxaemia reduce morbidity and mortality in the perioperative period.3. Use of pulse oximetry per se reduces morbidity and mortality in the perioperative period.4. Use of pulse oximetry reduces unplanned respiratory admissions to the intensive care unit (ICU), decreases the length of ICU readmission or both., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5), MEDLINE (1966 to June 2013), EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), ISI Web of Science (1956 to June 2013), LILACS (1982 to June 2013) and databases of ongoing trials; we also checked the reference lists of trials and review articles. The original search was performed in January 2005, and a previous update was performed in May 2009., Selection Criteria: We included all controlled trials that randomly assigned participants to pulse oximetry or no pulse oximetry during the perioperative period., Data Collection and Analysis: Two review authors independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period and intraoperative or postoperative mortality., Main Results: The last update of the review identified five eligible studies. The updated search found one study that is awaiting assessment but no additional eligible studies. We considered studies with data from a total of 22,992 participants that were eligible for analysis. These studies gave insufficient detail on the methods used for randomization and allocation concealment. It was impossible for study personnel to be blinded to participant allocation in the study, as they needed to be able to respond to oximetry readings. Appropriate steps were taken to minimize detection bias for hypoxaemia and complication outcomes. Results indicated that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5 to three times less. Postoperative cognitive function was independent of perioperative monitoring with pulse oximetry. A single study in general surgery showed that postoperative complications occurred in 10% of participants in the oximetry group and in 9.4% of those in the control group. No statistically significant differences in cardiovascular, respiratory, neurological or infectious complications were detected in the two groups. The duration of hospital stay was a median of five days in both groups, and equal numbers of in-hospital deaths were reported in the two groups. Continuous pulse oximetry has the potential to increase vigilance and decrease pulmonary complications after cardiothoracic surgery; however, routine continuous monitoring did not reduce transfer to an ICU and did not decrease overall mortality., Authors' Conclusions: These studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we found no evidence that pulse oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective study results, despite an intense methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency. Routine continuous pulse oximetry monitoring did not reduce transfer to the ICU and did not decrease mortality, and it is unclear whether any real benefit was derived from the application of this technology for patients recovering from cardiothoracic surgery in a general care area.

Background: Pulse oximetry is extensively used in the perioperative period and might improve patient outcomes by enabling an early diagnosis and, consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry during anaesthesia and in the recovery room have been performed that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications, and cognitive dysfunction., Objectives: The objective of this review was to assess the effects of perioperative monitoring with pulse oximetry and to clearly identify the adverse outcomes that might be prevented or improved by the use of pulse oximetry., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 2), MEDLINE (1966 to May 2009), EMBASE (1980 to May 2009), CINAHL (1982 to May 2009), ISI Web of Science (1956 to May 2009), LILACS (1982 to May 2009), and databases of ongoing trials; and checked the reference lists of trials and review articles., Selection Criteria: We included all controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period., Data Collection and Analysis: Two authors independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period, and intra- or postoperative mortality., Main Results: Searching identified five reports. We considered the studies with data from a total of 22,992 patients that were eligible for analysis. Results indicated that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5 to three times less. Postoperative cognitive function was independent of perioperative monitoring with pulse oximetry. The one study in general surgery showed that postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group. No statistically significant differences were detected in cardiovascular, respiratory, neurologic, or infectious complications in the two groups. The duration of hospital stay was a median of five days in both groups, and an equal number of in-hospital deaths was registered in the two groups. Continuous pulse oximetry has the potential to increase vigilance and decrease pulmonary complications after cardiothoracic surgery, however routine continuous monitoring did not reduce transfer to an intensive care unit (ICU) or overall mortality., Authors' Conclusions: The studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we have found no evidence that pulse oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective results of the studies, despite an intense methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness, and efficiency. Routine continuous pulse oximetry monitoring did not reduce either transfer to ICU or mortality, and it is unclear if there is any real benefit from the application of this technology in patients who are recovering from cardiothoracic surgery in a general care area.

Introduction: Preoperative smoking intervention programmes reduce post-operative complications in smokers. Little is known about the long-term effect upon smoking cessation., Aim: To discover long-term quit rates and the reasons behind successful cessation., Materials and Methods: 101 one of 120 smokers, randomised to smoking intervention or no intervention before hip and knee surgery, completed questionnaires concerning smoking after 1 year. We selected representative men and women for focus group interviews., Results: Significantly more patients from the intervention group abstained from smoking for 1 year post-operatively [13 in 60 patients (22%) vs 2 in 60 (3%), P < 0.01]. Sex (male), low nicotine dependency, non-smoking spouse and preoperative smoking intervention were related to smoking cessation. All patients gave the same reasons for smoking cessation: improved health and saving money. Follow-up for 5 years showed 17% of the controls and 8% in the intervention group (P = 0.42) had died., Conclusion: The intervention group had a significantly higher quit rate 1 year after a preoperative smoking cessation programme.

Smoking is a risk factor for postoperative complications such as pneumonia, infections and impaired wound healing. These can be reduced by preoperative stop-smoking intervention six to eight weeks before surgery. The aim of this study was to evaluate the costs and benefits of a stop-smoking intervention program by means of cost consequence analysis (CCA). A total of 120 smokers scheduled for hip or knee alloplasty were randomised to either a control group or an intervention group. The intervention group received an intensive stop-smoking intervention six to eight weeks before surgery. The focus of the economic analysis was on direct costs. Diagnosis-related group (DRG) costs were used for estimating the costs of secondary surgery. In all, 64% of the patients in the intervention group stopped smoking before surgery, as opposed to 8% in the control group. In the intervention group, 5.4% of the patients had wound complications, and 3.6% needed secondary surgery. In the control group, 30.8% had wound complications and 15.4% needed secondary surgery. The direct costs were almost the same in the two groups, whereas the overall costs in the intervention group were lower than in the control group. The economic analysis shows that a preoperative smoking intervention program is beneficial to society and the patient alike. Based on these calculations, we recommend that all patients scheduled for hip or knee alloplasty be given preoperative stop-smoking intervention.

Objective: The aim was to examine to what extent lifestyle, education, social support, and comorbidity predict the ability of perioperative smoking cessation, and are associated with the development of important postoperative complications., Design: The design was a randomized clinical trial., Setting: University hospitals in Copenhagen, Denmark, were the settings., Participants and Methods: One hundred twenty patients scheduled for primary elective hip or knee arthroplasty were randomized to either smoking intervention or standard care. Tobacco and alcohol consumption, exercise and eating habits, level of education, matrimonial status, and the presence of social support were registered. The data gathered concerned smoking cessation/reduction and severe postoperative morbidity., Results: Men and patients with a good social network were more likely to successfully quit smoking. Smoking intervention successfully reduced the incidence of postoperative complications, as did weekly exercise exceeding 4 h, and having a high education level., Conclusions: This study emphasizes that smoking intervention programs in health care settings are highly effective in reducing postoperative risks in hip and knee arthroplasty.

Smoking is an important risk factor for the development of postoperative pulmonary complications after major surgical procedures. We studied 811 consecutive patients who had undergone hip or knee arthroplasty, recording current smoking and drinking habits, any history of chronic disease and such intraoperative factors as the type of anaesthesia and the type and duration of surgery. We recorded any postoperative complications occurring before discharge from hospital. There were 232 smokers (28.6%) and 579 non-smokers. We found that smoking was the single most important risk factor for the development of postoperative complications, particularly those relating to wound healing, cardiopulmonary complications, and the requirement of postoperative intensive care. A delay in discharge from hospital was usual for those suffering a complication. In those patients requiring prolonged hospitalisation (>15 days) the proportion of smokers with wound complications was twice that of non-smokers.

Smoking is a risk factor for intra-operative pulmonary complications and a wide range of postoperative pulmonary, cardiovascular, infection and wound-related complications. These may all lead to unplanned postoperative intensive care admission. We tested the hypothesis that smokers have an increased incidence of postoperative intensive care admission and more postoperative complications than nonsmokers in a general and orthopaedic surgical population. The following information was assessed in 6026 surgical patients: age, sex and smoking status (pack-years), history of heart and lung disease, American Society of Anesthesiologists (ASA) physical classification, intensive care admission and postoperative complications. Two thousand five hundred and twenty-six (46%) were smokers but for 620 patients (10.3%) smoking status was not confirmed. Postoperative intensive care admission was required by 319 patients (5.3%). Patients with > 50 pack-years were admitted to the intensive care more frequently than were smokers with < or = 50 pack-years history and nonsmokers (p < 0.001). Ex-smokers with > 50 pack-years history had the same risk of postoperative admission to intensive care as smokers with > 50 pack-years history. Smokers admitted to intensive care with > 50 pack-years history had a higher incidence of chronic lung disease (p < 0.005) and heavy alcohol consumption (p < 0.001). These smokers also had a higher incidence of postoperative pulmonary complications (odds ratio = 3.91, p < 0.01). The mortality rate was 37% in smokers with > 50 pack-years history and 24% in nonsmokers (odds ratio = 2.02, p = 0.08). We conclude long-term tobacco smoking (> 50 pack-years) carries a higher risk of postoperative admission to intensive care, and there seems to be a dose relationship between the amount of tobacco consumed and the risk of postoperative intensive care admission.

Background: Monitoring with pulse oximetry might improve patient outcome by enabling an early diagnosis and consequently, correction of perioperative events that might cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry have been performed during anaesthesia, and in the recovery room which describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and cognitive dysfunction., Objectives: The objective of this review was to assess the effect of perioperative monitoring with pulse oximetry and to clearly identify the adverse outcomes that might be prevented or improved by the use of pulse oximetry., Search Strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2003, issue 1) MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003), and by checking the reference lists of trials and review articles., Selection Criteria: All controlled trials that randomized patients to either pulse oximetry or no pulse oximetry during the perioperative period, including the operating and recovery room., Data Collection and Analysis: Two reviewers independently assessed data in relation to events detectable by pulse oximetry, any serious complications that occurred during anaesthesia or in the postoperative period, intra- or postoperative mortality, and duration of recovery or intensive care stay. Formal statistical synthesis of individual trials was not performed in view of the variety of outcomes studied., Main Results: Searching identified six reports. Four studies with data from a total of 21,773 patients were considered eligible for analysis. Only two studies specifically addressed the outcomes in question, both found no evidence of an effect on the rate of postoperative complications using perioperative pulse oximetry. Two studies used hypoxaemia detectable by pulse oximetry to assess the value of perioperative monitoring, although outcomes were not given. It was found that hypoxaemia was reduced in the pulse oximetry group both in the operating theatre and in the recovery room. During observation in the recovery room, the incidence of hypoxaemia in the pulse oximetry group was 1.5-3 times less. The postoperative cognitive function using the Wechsler memory scale and continuous reaction time was independent of perioperative monitoring with pulse oximetry. The other study showed that postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group. No statistically significant differences were detected in cardiovascular, respiratory, neurologic, or infectious complications in the two groups. The duration of hospital stay was a median of five days in both groups, and an equal number of in-hospital deaths was registered in the two groups., Reviewer's Conclusions: The studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we have found no evidence that pulse oximetry affects the outcome of anaesthesia. The conflicting subjective and objective results of the studies, despite an intense, methodical collection of data from a relatively large population, indicate that the value of perioperative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency.

Background: Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers. Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement., Methods: We did a randomised trial in three hospitals in Denmark. 120 patients were randomly assigned 6-8 weeks before scheduled surgery to either the control (n=60) or smoking intervention (60) group. Smoking intervention was counselling and nicotine replacement therapy, and either smoking cessation or at least 50% smoking reduction. An assessor, who was masked to the intervention, registered the occurrence of cardiopulmonary, renal, neurological, or surgical complications and duration of hospital admittance. The main analysis was by intention to treat., Findings: Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled. Thus, 52 and 56 patients, respectively, were analysed for outcome. The overall complication rate was 18% in the smoking intervention group and 52% in controls (p=0.0003). The most significant effects of intervention were seen for wound-related complications (5% vs 31%, p=0.001), cardiovascular complications (0% vs 10%, p=0.08), and secondary surgery (4% vs 15%, p=0.07). The median length of stay was 11 days (range 7-55) in the intervention group and 13 days (8-65) in the control group., Interpretation: An effective smoking intervention programme 6-8 weeks before surgery reduces postoperative morbidity, and we recommend, on the basis of our results, this programme be adopted.

Background: Smokers have been shown to have increased risk of intraoperative pulmonary complications and of a wide range of postoperative complications, but an increased risk of postoperative intensive care admittance has not yet been described. The aim of this study was to estimate the risk of pulmonary complications and postoperative intensive care admittance in smokers and non-smokers in a general and orthopaedic surgical population., Methods: A total of 4725 surgical patients were assessed. The following information was noted: age, sex and smoking status, history of heart and lung disease, ASA classification, type of anaesthesia, intensive care admittance and postoperative pulmonary or cardiovascular complications. A logistic regression model was used to determine the probability of intensive care admittance and pulmonary complications as a function of smoking status, age, and chronic heart and lung disease., Results: Of the patients, 39.9% were smokers, 45.5% were non-smokers and in 14.6% of the cases smoking status was unspecified. Postoperative intensive care admittance and pulmonary complications were found in 2.0% and 4.3% of the patients, respectively. Non-smokers were more often female (P<0.01), and smokers had a higher incidence of emergency surgical procedures (P<0.05). When applying multiple regression analysis, we found that smoking, age >65 years, and a history of chronic lung disease increased the risk of unplanned intensive care admittance (odds ratio 1.55, 12.52 and 2.73)., Conclusion: Our results indicate a relationship between a history of tobacco smoking and postoperative intensive care admittance.

Background: Smokers have a substantially increased risk of intra and postoperative complications. Preoperative smoking intervention may be effective in decreasing this incidence. The preoperative period may be a well chosen time to offer smoking cessation interventions due to increased patient motivation., Objectives: The objective of this review was to assess the effect of preoperative smoking intervention on smoking cessation in the postoperative period and longer term. We also set out to determine the effect of smoking cessation on the incidence of postoperative complications., Search Strategy: The specialised register of the Tobacco Addiction Group was searched using the free text and keywords (surgery) OR (operation) OR (anaesthesia) or (anesthesia). The databases "EMBASE" and "CINAHL" were also searched, combining tobacco and surgery related terms., Selection Criteria: We considered randomised trials which recruited smokers prior to surgery, offered a smoking cessation intervention, and measured abstinence from smoking in the pre-operative and post-operative periods. We also considered randomised trials of the effect of smoking cessation on the incidence of intra and post-operative complications., Data Collection and Analysis: The reviewers independently assessed studies to determine eligibility. The results were discussed between the reviewers., Main Results: No trial meeting the inclusion criteria was found., Reviewer's Conclusions: We found no evidence to determine the effectiveness of pre-operative interventions in helping people to stop smoking, or of the effectiveness of smoking cessation in reducing peri-operative complications. However, observational evidence suggests benefits in stopping smoking before surgery. Although there is no direct evidence about which interventions work best in patients preparing for surgery, behavioural and pharmacological interventions shown to be effective in other settings should be considered.

About one third of the patients presenting for surgery are smokers. Smoking has acute and chronic effects on the cardiovascular, respiratory and immune systems, microcirculatory function and drug metabolism. Smoking is related to a wide range of per- and postoperative complications. Short term smoking cessation will probably reduce the disadvantageous acute effects of nicotine and carbon monoxide on the cardiovascular system, while the changes in lung function take about eight weeks to improve. Whether the rate of postoperative complications can be reduced by preoperative smoking cessation is unknown. The preoperative period might be a beneficial time for a greater smoking cessation intervention by an interdisciplinary hospital staff team.

Smoking is related to a wide range of intra- and post-operative complications. In relation to the idea of health promoting hospitals, we investigated how Danish departments of anaesthesia dealt with tobacco smoking and the surgical patient. We sent a questionnaire to 44 Danish departments of anaesthesia with seven questions about practical management of tobacco related problems in anaesthetic practice, the information of patients and the state of preventive initiatives. At about half of the departments patients are not asked about their smoking habits and at only seven departments is the patient given oral information about their increased intra- and postoperative risks. Half of the departments advocate smoking abstinence in the six fasting hours. Two departments offer assistance to preoperative smoking cessation within a scientific preventive project. In conclusion, the idea of prevention of intra- and postoperative complications by means of preoperative smoking cessation has not gained interest at Danish departments of anaesthesia so far.

The present study describes risk factors, the incidence of complications and mortality in the anaesthetized patient. The aims were further to identify additional patient-, anaesthesia-, technique-, and surgery-related factors associated with cardiopulmonary complications and mortality, to describe the value of preoperative radionuclide cardiography in patients with cardiopulmonary insufficiency, and to evaluate the importance of perioperative manual evaluation of the response to train-of-four nerve stimulation for the occurrence of residual neuromuscular blockade in the recovery room. Complications attributable to anaesthesia-complications caused mainly by the anaesthetic procedure-occurred in 0.6% (1:170) of the patients, and mortality attributable to anaesthesia was found to be 0.04% (1:2500). An analysis of the patient data suggests that the seriously ill patients (ASA-class > or = 3) were more likely to be affected by errors and a substantial negative outcome such as acute myocardial infarction, irreversible cerebral damage or death, than were more healthy patients (ASA 1-2). One-third of the complications attributable to anaesthesia are judged preventable. Cardiopulmonary complications associated with anaesthesia and surgery and requiring intervention occurred in 1:11 of the anesthetized patients. The cardiopulmonary complications were associated with elderly patients (> or = 70 yr), patients with preoperative clinical signs of ischaemic heart disease and recent myocardial infarction, chronic heart failure, and chronic obstructive lung disease, as well as perioperative and emergency procedures involving major abdominal surgery. In patients with severe cardiovascular or pulmonary insufficiency (high-risk patients) preoperative radionuclide cardiography could distinguish between different levels of cardiopulmonary risk in the anaesthetized patient. Patients with a preoperative left ventricular ejection fraction < 50% or > 70% demonstrated a high incidence of cardiopulmonary complications following anaesthesia (70%). It is recommended that left ventricular ejection fraction be measured in patients referred for major surgery who have an increased risk of cardiopulmonary complications as evidenced clinically by heart failure or severe ischaemic heart disease. Hypotension before anaesthetic induction is associated with a high incidence of cardiopulmonary morbidity and mortality. Postoperative pulmonary complications in comparable groups of patients depend primarily on the type of surgery, as major abdominal surgery was related to the highest incidence of pulmonary complications. Regional anaesthesia may be a superior technique to general anaesthesia, especially in elderly patients with chronic obstructive lung disease admitted to major orthopaedic surgery. Furthermore, in avoidance of postoperative complications such as residual neuromuscular blockade, the choice of muscle relaxant was more decisive than was manual evaluation of the response to train-to-four nerve stimulation.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiac complications occur with an incidence of 2-6% and are a main cause (15-20%) of mortality after non-cardiac surgery. Cardiac risk should be determined and reduced by treatment preoperatively and by an intraoperative and postoperative care that has been adjusted to the increased risk. This review provides recommendations concerning risk evaluation and management.

Hip joint replacement surgery, using acrylic cement for prosthesis fixation, is associated with intraoperative cardiorespiratory dysfunction, and a high frequency of postoperative proximal deep vein thrombosis (DVT). Levels of prothrombin fragments 1+2 (F1+2), tissue plasminogen activator antigen (t-PA), plasminogen activator inhibitor 1 activity (PAI-1), D-dimer and interleukin 6 (IL-6) were measured in arterial (AB) and mixed venous blood (MVB) in five patients during and after total hip replacement operation with acrylic cement prosthesis fixation. Sequential peaks of F1+2, t-PA, PAI-1 and IL-6 appeared, starting with activation of coagulation during preparation of bone, closely followed by activation of fibrinolysis. Later, this was counteracted by an antifibrinolytic response and increase of IL-6. After a fibrinolytic shutdown on the third postoperative day as evidenced by a drop in t-PA and D-dimer concentrations, a second wave of coagulation was seen at the end of the first week. The present model, with frequent sampling of blood entering and leaving the lungs, confirms our earlier findings of the lung as a key organ in promoting coagulation following traumatic activation.

Background: The authors describe the effect of pulse oximetry monitoring on the frequency of unanticipated perioperative events, changes in patient care, and the rate of postoperative complications in a prospective randomized study., Methods: The study included 20,802 surgical patients in Denmark randomly assigned to be monitored or not with pulse oximetry in the operating room (OR) and postanesthesia care unit (PACU)., Results: During anesthesia and in the PACU, significantly more patients in the oximetry group had at least one respiratory event than did the control patients. This was the result of a 19-fold increase in the incidence of diagnosed hypoxemia in the oximetry group than in the control group in both the OR and PACU (P < 0.00001). In the OR, cardiovascular events were observed in a similar number of patients in both groups, except myocardial ischemia (as defined by angina or ST-segment depression), which was detected in 12 patients in the oximetry group and in 26 patients in the control group (P < 0.03). Several changes in PACU care were observed in association with the use of pulse oximetry. These included higher flow rate of supplemental oxygen (P < 0.00001), increased use of supplemental oxygen at discharge (P < 0.00001), and increased use of naloxone (P < 0.02). The rate of changes in patient care as a consequence of the oximetry monitoring increased as the American Society of Anesthesiologists physical status worsened (P < 0.00001). One or more postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group (difference not significant). The two groups did not differ significantly in cardiovascular, respiratory, neurologic, or infectious complications. The duration of hospital stay was a median of 5 days in both groups (difference not significant). An equal number of inhospital deaths were registered in the two groups. Questionnaires, completed by the anesthesiologists at the five participating departments, revealed that 18% of the anesthesiologists had experienced a situation in which a pulse oximeter helped to avoid a serious event or complication and that 80% of the anesthesiologists felt more secure when they used a pulse oximeter., Conclusions: This study demonstrated that pulse oximetry can improve the anesthesiologist's ability to detect hypoxemia and related events in the OR and PACU and that the use of the oximeter was associated with a significant decrease in the rate of myocardial ischemia. Although monitoring with pulse oximetry prompted a number of changes in patient care, a reduction in the overall rate of postoperative complications was not observed.

The aim of this study was to identify risk factors associated with postoperative pulmonary complications. The influence of the anaesthetic technique was evaluated (i.e. general contra regional anaesthesia and long contra intermediately acting muscle relaxants (pancuronium and atracurium)) taking into account the patient's age, the presence or absence of chronic obstructive lung disease (preoperative risk factors), the type of surgery and the duration of anaesthesia (perioperative risk factors). Seven thousand and twenty-nine patients undergoing abdominal, urological, gynaecological or orthopaedic surgery were included in the study. A total of 290 patients (4.1%) suffered from one or more postoperative pulmonary complications. Six thousand and sixty-two patients received general anaesthesia and 4.5% of these had postoperative pulmonary complications. Of the patients admitted to major surgery receiving pancuronium, 12.7% (135/1062) developed postoperative pulmonary complications, compared to only 5.1% (23/449) receiving atracurium (P < 0.05). When stratified for type of surgery and duration of anaesthesia, conventional statistics showed no difference between pancuronium and atracurium as regard postoperative pulmonary complications. However, a logistic regression analysis indicated that long-lasting procedures involving pancuronium entailed a higher risk of postoperative pulmonary complications than did other procedures. In patients having regional anaesthesia, only 1.9% (18/967) developed postoperative pulmonary complications (P < 0.05 compared to general anaesthesia). However, when stratified for type of surgery there was a significantly higher incidence of postoperative pulmonary complications only in patients undergoing major orthopaedic surgery under general anaesthesia, 11.5% compared to 3.6% in patients given a regional anaesthesia.(ABSTRACT TRUNCATED AT 250 WORDS)

In a retrospective investigation at the department of Surgery, Frederiksberg Hospital in 1981, the frequency of operations in patients above 80 years old was 3.4% compared to 1.7% in the general population. The total number of operations in the aged group was 183. The object of this investigation was to determine the postoperative mortality and 5-year survival rate in the patients aged 80 years or more. Furthermore, the ability of the patients to stay in their homes was investigated. The patients were divided into a major surgery group and a minor surgery group depending on the extent of the operation. The postoperative mortality var 5.5%. Compared to an age and sex matched control group, only the major surgery group had a higher rate of mortality during the first six postoperative months. Among the patients who were admitted from home, 85% were discharged directly to their homes. At the end of the study period or at the time of death, the percentage of patients staying in old peoples homes was essentially the same as for the rest of the population. It is concluded that the patients aged 80 years or more tolerated surgical trauma relatively well and, that the number of geriatric operations may be anticipated to increase greatly.

The purpose of this study was to identify factors which will predict the risk of severe postoperative complications in individual patients in a neurosurgical unit. Eleven risk factors were investigated in 363 neurosurgical patients, of whom 40 (11%) developed postoperative complications requiring mechanical ventilation for more than 24 h in an intensive care unit, 16 were found to be severely disabled or in a vegetative state at follow-up 1 month after admission, and 28 patients died. By applying stepwise, logistic regression analysis to the patient's data, we were able to select two significant risk variables, i.e. the Glasgow Coma Scale (GCS) 8 or less preoperatively and emergency anaesthesia. The presence of GCS 8 or less on the consciousness scale was associated with postoperative complications in approximately 40% of the cases. Emergency patients with severe neurological damage had the greatest risk of postoperative complications (93%). Fatal outcome for patients with postoperative complications was seen in 40% of the cases.

The types and frequency of complications attributable solely to anaesthesia, and which caused serious morbidity and substantial negative outcome, were examined in a prospective study of 7306 anaesthetics. The analysis demonstrated that severe complications and mortality attributable to anaesthesia occurred in 0.59% (1:170) and 0.04% (1:2500) of patients respectively. The data suggest that "high-risk' patients are more likely to be affected by errors and a substantial negative outcome than more healthy patients. We judged one-third of the anaesthesia-related morbidity to be preventable. Anaesthetists are faced with an increasing number of patients who are at high risk, and who undergo increasingly extensive surgical interventions. Concomitant with the increasing complexity of care and increasing demands on the anaesthetists may be an expected increase in the incidence of errors. Recognition of the importance of human factors in morbidity and mortality attributable to anaesthesia is a necessary first step.

In a prospective, controlled clinical study prevention of postoperative deep venous thrombosis by low-dose heparin (Heparin Leo 5 000 I.U. subcutaneously twice daily) was compared with graded compression stockings (TED stockings, Kendall Co.). One hundred and twelve patients, admitted during a period of one year for elective major surgery, were allocated to one of the two treatment groups. In order to detect deep venous thrombosis the 99mTc-plasmin test was performed before the operative procedure and again 5 days later. Ninety-seven patients completed the study (45 patients in the heparin group and 52 patients in the stocking group). Venous thromboembolism was detected in 4 patients (8.9%) in the heparin group and in 3 patients (5.8%) in the stocking group (p greater than 0.05). In 6 patients the plasmin test was positive and one patient in the heparin group died following pulmonary embolism. It is concluded that graded compression stockings can be used as an alternative to low-dose heparin for prophylaxis against deep venous thrombosis in elective general surgery.