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Biomedical subjects

H Kehlet

Publications and source records attributed to H Kehlet.

At least 55 records · Page 3Linked to original sources
PubMed2003

Effects of posture on postoperative pulmonary function.

BACKGROUND: Pulmonary morbidity is still a relevant complication to major surgery despite improvements in surgical technique and anaesthetic methods. Postoperative posture may be a pathogenic factor, but the effects of changes in postoperative posture on pulmonary function have not been reviewed. METHODS: Review of controlled, clinical trials evaluating postoperative pulmonary function in patients positioned in the supine vs. the sitting or standing position and patients positioned in the supine vs. the lateral position. Data were obtained from a search in the Medline and Cochrane databases (1966 - August 2002) and manually searched bibliographies of the identified papers. RESULTS: Eighteen papers met the inclusion criteria. Twelve studies evaluated the supine vs. the sitting or standing position and six studies evaluated the supine vs. the lateral position. Six of 12 studies found a positive effect on postoperative pulmonary function in the sitting or standing position compared with the supine. Thus, avoidance of the supine position may improve postoperative pulmonary function. Three of six studies showed a positive effect on postoperative pulmonary function of the lateral side compared with the supine. Thus, the lateral position has limited effects on pulmonary function. CONCLUSION: Changes of postoperative position from supine to sitting or standing are of major importance in the interpretation of postoperative pulmonary outcome studies and in future strategies to improve pulmonary outcome.

Functional Residual Capacity↗
PubMed2002

Chronic postherniorrhaphy pain--a call for uniform assessment.

The reported incidence of chronic postherniorrhaphy pain is estimated to be 10-15% and therefore has considerable socio-economic consequences. Interpretation of available data regarding pathogenesis, relation to surgical techniques, and postoperative pain treatment is hindered by differences in the description and definition of postherniorrhaphy pain. We propose a scheme for uniform assessment of chronic postherniorrhaphy pain in order to facilitate interpretation of future studies.

Chronic Disease↗
PubMed2002

Compensatory fluid administration for preoperative dehydration--does it improve outcome?

BACKGROUND: Preoperative fasting may lead to a fluid deficit of about 1 litre, which may contribute to perioperative discomfort and morbidity. We therefore examined the association between perioperatively administered fluids aiming to correct dehydration and clinical outcome. METHODS: Review of randomized, controlled, clinical trials evaluating clinical outcome, in which fluid versus no fluid was administered pre- or intraoperatively, attempting to correct preoperative fluid deficits. Data were obtained from a Medline search (1966-2001), and references cited in original papers. Seventeen trials met the inclusion criteria. RESULTS: Based on the amount of fluid administered, we divided the studies into two groups. In nine studies, fluid administration was <1 litre, and in eight studies > or =1 litre of fluid was administered. Administration of low-dose fluid reduced preoperative thirst, but the limited data do not allow conclusions on postoperative outcome such as nausea, vomiting, headache and pain. Administration of > or =1 litre fluid generally reduced postoperative drowsiness and dizziness, while the effects on postoperative nausea, vomiting and thirst has not been clarified. CONCLUSION: Fluid administration to compensate preoperative dehydration improves symptoms related to dehydration. Based on the available data, administration of about 1 litre fluid pre- or intraoperatively in patients having fasted for minor surgical procedures seems rational.

Dehydration↗
PubMed2002

Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition.

BACKGROUND: Postoperative organ dysfunction contributes to morbidity, hospital stay and convalescence. Multimodal rehabilitation with epidural analgesia, early oral feeding, mobilization and laxative use after colonic resection has reduced ileus and hospital stay. METHODS: Fourteen patients receiving conventional care (group 1) and 14 patients who had multimodal rehabilitation (group 2) were studied before and 8 days after colonic resection. Outcome measures included postoperative mobilization, body composition by whole-body dual X-ray absorptiometry, cardiovascular response to treadmill exercise, pulmonary function and nocturnal oxygen saturation. RESULTS: Defaecation occurred earlier (median day 1 versus day 4) and hospital stay was shorter (median 2 versus 12 days) in patients who had multimodal treatment. Lean body and fat mass decreased in group 1 but not in group 2. Exercise performance decreased by 44 per cent in group 1 but was unchanged in group 2. A postoperative increase in heart rate (HR) response to exercise was avoided in group 2. Pulmonary function decreased in group 1 but not in group 2. There was less nocturnal postoperative hypoxaemia in group 2. Cardiac demand-supply (HR/oxygen saturation ratio) increased in group 1 but not in group 2. CONCLUSION: Multimodal rehabilitation prevents reduction in lean body mass, pulmonary function, oxygenation and cardiovascular response to exercise after colonic surgery.

Aged↗
PubMed2002

Risk of femoral hernia after inguinal herniorrhaphy.

BACKGROUND: Small case series have suggested an increased risk of femoral hernia after previous inguinal herniorrhaphy, but no large-scale data with complete follow-up are available. METHODS: Data were extracted from the Danish Hernia Database covering the interval from 1 January 1998 to 1 July 2001, and included 34 849 groin hernia repairs. RESULTS: Of 1297 femoral hernia repairs, 71 patients had previously had an operation for inguinal hernia within the observation period. These 71 femoral hernias represented 7.9 per cent of all reoperations for groin hernia recorded in the database. The median time to reoperation for a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 7 months, compared with 10 months for inguinal recurrences. The risk of developing a 'recurrent' femoral hernia after previous inguinal herniorrhaphy was 15 times higher than the rate of femoral hernia repair in the general population. CONCLUSION: This study of 34 849 groin hernia repairs demonstrated a 15-fold greater incidence of femoral hernia after inguinal herniorrhaphy compared with the spontaneous incidence. These femoral recurrences occurred earlier than inguinal recurrences, suggesting that they were possibly femoral hernias overlooked at the primary operation.

Adult↗
PubMed2002

Ranitidine as adjuvant treatment in colorectal cancer.

BACKGROUND: Results from short-term studies of histamine type 2 (H2) receptor antagonists on survival of patients with solid tumours are debatable. In this study the efficacy of the H2-receptor antagonist ranitidine on long-term survival of patients with colorectal cancer was evaluated. METHODS: Patients scheduled for elective resection of primary tumours were consecutively included in a randomized double-blind placebo-controlled clinical study designed to evaluate the effect of ranitidine on survival. Before skin incision ranitidine 100 mg or placebo was given intravenously twice daily followed by oral ranitidine 150 mg or placebo twice daily for 5 years. Adjuvant cytotoxic or radiation therapy was not given. An observer-blinded interim analysis performed after 40 months showed that there was no effect of ranitidine on overall survival, and the study was discontinued in accordance with the protocol. The patient cohort has been followed continuously without loss of any patient, and a final statistical analysis was performed on an intention-to-treat basis after more than 5 years; this included a subgroup analysis of perioperative blood transfusion and postoperative infectious complications. RESULTS: The median observation period of the 740 patients included was 6.8 (range 5.4-7.9) years. A univariate analysis of all 740 patients and of the subgroup of 560 who underwent curative resection showed no significant effect of ranitidine on survival. Furthermore, ranitidine had no survival benefit in curatively resected patients who received a perioperative blood transfusion (n = 358), but it improved the survival of non-transfused patients (n = 202; hazard ratio (HR) 0.6 (95 per cent confidence interval (c.i.) 0.4 to 0.9), P = 0.02) and of non-transfused patients who did not develop postoperative infectious complications (n = 170; HR 0.6 (95 per cent c.i. 0.4 to 0.9), P = 0.01). In multivariate analysis of patients who had a curative resection, including Dukes' stage, age, gender, tumour location, blood transfusion, postoperative infectious complications and treatment, ranitidine still had an independent, beneficial effect on survival (HR 0.6 (95 per cent c.i. 0.4 to 1.0), P = 0.04) within the subgroup of patients who did not receive perioperative blood transfusion and did not develop postoperative infectious complications. CONCLUSION: Ranitidine may prolong the survival of patients who undergo curative resection of colorectal cancer and who do not receive perioperative blood transfusion and do not develop postoperative infectious complications.

Adult↗
PubMed2002

Epidural anaesthesia and analgesia - effects on surgical stress responses and implications for postoperative nutrition.

BACKGROUND: Surgical injury leads to an endocrine-metabolic and inflammatory response with protein catabolism, increased cardiovascular demands, impaired pulmonary function and paralytic ileus, the most important release mechanisms being afferent neural stimuli and inflammatory mediators. RESULTS: Epidural local anaesthetic blockade of afferent stimuli reduces endocrine metabolic responses, and improve postoperative catabolism. Furthermore, dynamic pain relief is achieved with improved pulmonary function and a pronounced reduction of postoperative ileus, thereby providing optimal conditions for improved mobilization and oral nutrition, and preservation of body composition and muscle function. Studies integrating continuous epidural local anaesthetics with enforced early nutrition and mobilization uniformly suggest an improved recovery, decreased hospital stay and convalescence. CONCLUSIONS: Epidural local anaesthetics should be included in a multi-modal rehabilitation programme after major surgical procedures in order to facilitate oral nutrition, improve recovery and reduce morbidity.

Analgesia, Epidural↗
PubMed2002

Comparative effect of paracetamol, NSAIDs or their combination in postoperative pain management: a qualitative review.

BACKGROUND: Quantitative reviews of postoperative pain management have demonstrated that the number of patients needed to treat for one patient to achieve at least 50% pain relief (NNT) is 2.7 for ibuprofen (400 mg) and 4.6 for paracetamol (1000 mg), both compared with placebo. However, direct comparisons between paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) have not been extensively reviewed. The aims of this review are (i) to compare the analgesic and adverse effects of paracetamol with those of other NSAIDs in postoperative pain, (ii) to compare the effects of combined paracetamol and NSAID with those of either drug alone, and (iii) to discuss whether the adverse effects of NSAIDs in short-term use are justified by their analgesic effects, compared with paracetamol. METHODS: Medline (1966 to January 2001) and the Cochrane Library (January 2001) were used to perform a systematic, qualitative review of postoperative pain studies comparing paracetamol (minimum 1000 mg) with NSAID in a double-blind, randomized manner. A quantitative review was not performed as too many studies of high scientific standard (27 out of 41 valid studies, including all major surgery studies) would have been excluded. RESULTS: NSAIDs were clearly more effective in dental surgery, whereas the efficacy of NSAIDs and paracetamol seemed without substantial differences in major and orthopaedic surgery, although firm conclusions could not be made because the number of studies was limited. The addition of an NSAID to paracetamol may confer additional analgesic efficacy compared with paracetamol alone, and the limited data available also suggest that paracetamol may enhance analgesia when added to an NSAID, compared with NSAIDs alone. CONCLUSION: Paracetamol is a viable alternative to the NSAIDs, especially because of the low incidence of adverse effects, and should be the preferred choice in high-risk patients. It may be appropriate to combine paracetamol with NSAIDs, but future studies are required, especially after major surgery, with specific focus on a potential increase in side-effects from their combined use.

Acetaminophen↗
PubMed2002

Ketorolac, diclofenac, and ketoprofen are equally safe for pain relief after major surgery.

BACKGROUND: Ketorolac is approved for the relief of postoperative pain but concerns have been raised over a possible risk of serious adverse effects and death. Two regulatory reviews in Europe on the safety of ketorolac found the data were inconclusive and lacked comparison with other non-steroidal anti-inflammatory drugs. The aim of this study was to compare the risk of serious adverse effects with ketorolac vs diclofenac or ketoprofen in adult patients after elective major surgery. METHODS: This prospective, randomized multicentre trial evaluated the risks of death, increased surgical site bleeding, gastrointestinal bleeding, acute renal failure, and allergic reactions, with ketorolac vs diclofenac or ketoprofen administered according to their approved parenteral and oral dose and duration of treatment. Patients were followed for 30 days after surgery. RESULTS: A total of 11,245 patients completed the trial at 49 European hospitals. Of these, 5634 patients received ketorolac and 5611 patients received one of the comparators. 155 patients (1.38%) had a serious adverse outcome, with 19 deaths (0. 17%), 117 patients with surgical site bleeding (1.04%), 12 patients with allergic reactions (0.12%), 10 patients with acute renal failure (0.09%), and four patients with gastrointestinal bleeding (0.04%). There were no differences between ketorolac and ketoprofen or diclofenac. Postoperative anticoagulants increased the risk of surgical site bleeding equally with ketorolac (odds ratio=2.65, 95% CI=1.51-4.67) and the comparators (odds ratio=3.58, 95% CI=1.93-6.70). Other risk factors for serious adverse outcomes were age, ASA score, and some types of surgery (plastic/ear, nose and throat, gynaecology, and urology). CONCLUSION: We conclude that ketorolac is as safe as ketoprofen and diclofenac for the treatment of pain after major surgery.

Acute Kidney Injury↗
PubMed2002

Prevention of postoperative ileus.

Postoperative ileus (PI) is a major contributor to postoperative morbidity and prolonged convalescence after major surgical procedures. The pathophysiology of PI is multifactorial, including activation of the stress response to surgery, with inhibitory sympathetic visceral reflexes and inflammatory mediators. We update evidence on the advances in the prevention and treatment on PI. As single interventions, continuous thoracic epidural analgesia with local anesthetics and minimally invasive surgery are the most efficient interventions in the reduction of PI. The effects of pharmacological agents have generally been disappointing with the exception of cisapride and the introduction of the new selective peripherally acting m-opioid antagonists. Presently, introduction of a multi-modal rehabilitation programme (including continuous epidural analgesia with local anesthetics, early oral feeding and enforced mobilization) is the most effective technique to reduce PI in abdominal procedures.

Anesthesia↗
PubMed2002

Effect of postoperative epidural analgesia on surgical outcome.

Pain relief allowing sufficient mobilization after major surgical procedures can only be achieved by continuous epidural analgesia with local anesthetics, which also reduces the stress response to surgery. However, the role of postoperative epidural analgesia on postoperative morbidity is controversial. We therefore update the effects of postoperative analgesia on surgical outcome. After major abdominal surgery, postoperative epidural analgesia with local anesthetics significantly reduces postoperative ileus and pulmonary complications while effects on cardiac morbidity are debatable. Continuous epidural analgesia significantly lowers the risk of thromboembolic complications after lower body procedures, while no effect is seen after major abdominal surgery. Unfortunately, many studies have inadequate study design, with use of lumbar epidural analgesia for abdominal procedures, or the epidural regimen does not contain a sufficient amount of local anesthetics. Future evaluation of the effects of epidural analgesia on postoperative outcome also requires integration of epidural analgesia within a multimodal rehabilitation programme.

Analgesia, Epidural↗
PubMed2001

[Convalescence recommendations after hysterectomy. A study of opinions among Danish physicians].

INTRODUCTION: The aim of this study was to describe advice and restrictions given by Danish general practitioners (GPs) and gynaecologists to patients after uncomplicated hysterectomy. MATERIALS AND METHODS: Four hundred and ninety-one randomly selected GPs and 433 gynaecologists received a postal questionnaire in 1998/1999. The questions concerned the length of recommended sick leave, lifting restrictions, and time to resumption of seven defined common activities after hysterectomy. In addition, the gynaecologists were asked about the use of vaginal packaging, bladder catheters, and expected length of hospital stay. RESULTS: The total response rate was 72%. GPs and gynaecologists recommended a median of 4 weeks (1-8 weeks) of convalescence after hysterectomy to patients, whose work did not involve heavy lifting, and a median of six weeks (2-12 weeks) to women, whose work did. Responses concerning the resumption of common activities showed considerable variation, for instance patients were advised to postpone sexual intercourse for a median of four weeks postoperatively (0-12 weeks). Lifting restrictions varied from lifting a maximum of 15 kg for two weeks to a maximum of 2 kg for 12 weeks. CONCLUSION: A considerable variation was found in recommendations and regimens for hysterectomised patients. Evidence-based guidelines do not exist, and until these are available, the national and local boards of physicians need to agree on what restrictions should be given to patients.

Attitude of Health Personnel↗
PubMed2001

[Accelerated course in hip arthroplasty].

INTRODUCTION: The aim of the study was to assess the results of a well-defined rehabilitation programme after hip arthroplasty. METHODS: The effects of a revised, optimised, perioperative care programme with continuous epidural analgesia, oral nutrition, and physiotherapy were assessed in 60 patients before intervention and 60 patients after intervention. RESULTS: The hospital stay was reduced from nine to six days (p < 0.01), there were fewer complications and less need for rehabilitation after discharge (p < 0.05) in the intervention group. CONCLUSION: A clinical programme focusing on pain relief, oral nutrition, and rehabilitation may reduce the stay in hospital and improve recovery after hip arthroplasty.

Aged↗
PubMed2001

Microlaparoscopic vs conventional laparoscopic cholecystectomy: a prospective randomized double-blind trial.

BACKGROUND: Downsizing the port incisions may reduce pain after laparoscopic cholecystectomy. METHODS: In a double-blind controlled study, 60 patients were randomized to undergo either microlaparoscopic cholecystectomy using one 10-mm and three 3.5-mm trocars (3.5-mm LC) or traditional laparoscopic cholecystectomy using two 10-mm and two 5-mm trocars (LC). Incisional pain at each port incision and overall pain were recorded for 1 week after the operation. Fatigue, nausea and vomiting, pulmonary function, and cosmetic results were also measured. RESULTS: Data from 52 patients were analyzed; eight patients were excluded from the study for various reasons. One patient was converted from 3.5-mm LC to LC due to technical problems with the 3.5-mm optic. In the 3.5-mm LC group (n = 25), incisional pain was significantly decreased in the 1st postoperative week as compared with the LC group (n = 27) (p <0.01). In both groups, pain scores at the supraumbilical 10-mm port were significantly higher compared with other port sites (p <0.05). The cosmetic results were significantly better in the 3.5-mm LC group (p <0.01). There were no significant differences in any of the other variables. CONCLUSION: The use of 3.5-mm trocars is feasible in LC, and it both reduces incisional pain and improves the cosmetic result.

Anesthesia↗
PubMed2001

[Gastroesophageal reflux surgery in Denmark 1997-1999].

INTRODUCTION: The incidence and length of postoperative stay in hospital in Denmark after oesophageal reflux surgery has not been described previously. MATERIAL AND METHODS: We examined the national patient hospital register and discharge information from the hospitals for the number of reflux operations carried out, the length of postoperative hospital stay, readmissions, and postoperative complications occurring within 30 days in the period, 1997-1999. RESULTS: Twenty-four departments performed 4.9 operations/100,000 inhabitants per year, corresponding to 788 operations. The postoperative 30-day mortality was 0.4% and 6.6% of the operations were followed by serious surgical complications. The combined primary + readmission hospital stay was 3.7 days in the first postoperative month. DISCUSSION: The small number of oesophageal reflux operations performed in many departments in Denmark is not in agreement with the Danish National Board of Health recommendations from 1996, which say that the operations should be done in only five departments. The spreading of surgery means that only few surgeons can reach sufficient training of surgery and that statistical comparison between the departments of the early results of treatment is not meaningful. Overall, national results are comparable to international results. The incidence of oesophageal reflux surgery is about three times lower than in other Scandinavian countries. On these results, it is recommended that the operation is performed in fewer departments and by fewer surgeons.

Clinical Competence↗