Journal Reading Post Operative Effects: Anesthesia

Nama: Nur Afiqah Binti Jasmi NIM: 11-2013-031 Dokter Pembimbing: r! Nur "#amsiani "$! An

ABSTRACT
Anesthesia -% metabo&i' an en o'rine res$onses (on)entiona& *is om: Anestheti' te'hnique -% &itt&e &ong-term effe't on $atient out'omes! +)i en'e: Anestheti' management -% &ongerterm effe'ts in $osto$erati)e out'ome! ,e)ie* the most to$i'a& as$e'ts of anaestheti' management *hi'h ma# $otentia&&# inf&uen'e &ater $osto$erati)e out'omes! -o* in'i en'e of $ost-o$ 'om$&i'ations -% Insuffi'ient e)i en'e to 'onfirm the abi&it# of $osto$erati)e out'omes! .e#*or s: Anesthesia; Postoperative outcome

INTRODUCTION
Two main techniques: 1.General anesthesia -% 'entra& neuro&ogi' e$ression/ 2.Regional anesthesia -% s$ina& 'or or ner)es -% &o'a&&# b&o'k afferent 0 efferent ner)e

After surger#: the risk life threatening events in'rease se)era& fo& s! 1 D23/ $u&monar# embo&ism/ MI/ rena& fai&ure/ $neumonia4 Debate: Anesthesia has substanti)e effe't on these risks!

METHOD
Type s anesthesia an! postoperative outcomes -% Me &ine/ Pubme / +mbase an the (o'hrane &ibrar# Arti'&es are restri'te to the +ng&ish &anguage! A manua& sear'h for $a$ers that ma# $ertinent to the stu # *as a&so $erforme ! (onsi ere an re&e)ant $a$ers *ere in'&u e ! Pa$ers from the same unit or hos$ita& *ere in'&u e on&# on'e Prioriti5e e)i en'e from *e&& esigne ran omi5e 'ontro&&e tria&s

CANCER RECURRENCE
"urger# is the most effi'ient treatment of man# t#$es of 'an'er/ but resi!ual micrometastases are ine)itab&e! "alance bet*een host immune efen'e an tumour sur)i)a& an gro*th -% Minima& resi ua& "urger# an anesthesia -% meta#olic an! en!ocrine res$onses -% immunosuppresion state -% $osto$erati)e septic 'om$&i'ations 6 tumor metastasis formation Posto$erati)e pain -% fa'i&itate metastatic s$rea of 'an'er $pioi! ana&gesia -% inhi#its cellular immune fun'tion 6 $romotes breast tumour gro*th

CANCER RECURRENCE
Regional anaesthesia an! analgesia -% $re)enting the neuroen o'rine surgi'a& stress res$onse -% genera& anaesthesia an minimi5ing o$ioi requirement General anaesthesia plus epi!ural analgesia -% 789 &o*er risk of re'urren'e 'om$are *ith genera& anaesthesia 6 o$ioi ana&gesia ,egiona& anaesthesia an o$timum $osto$erati)e ana&gesia re u'es the metastati' bur en in anima&s stu # %itrous o&i!e -% re u'es DNA an $urine s#nthesis an su$$resses neutro$hi& 'hemota:is -% fa'i&itating 'an'er s$rea ! 20; $atients un ergoing 'o&on rese'tion for bo*e& 'an'er -% nitrous o:i e or air -% no statistically significant !ifference in 'an'er re'urren'e rates

Cardovascular Effects
Near&# ha&f of the $atients un ergo non'ar ia' o$eration are estimate to ha)e 'ar ia' risk fa'tors 'ar!iac mor#i!ity is the $rimar# 'ause of eath after anesthesia an surger# *ith re$orte in'i en'es ranging from 2( to 1)( in high ris* surgical $o$u&ation

<#$er'oagu&abi&it# -% formation of ee$ 2enous 3hrombosis 1D234 an $otentia&&# fata& Pu&monar# +mbo&ism 1P+4! +$i ura& anaesthesia -% $re)ents $erio$erati)e )enous stasis

"tress -% a'ti)ation of the s#m$atheti' ner)ous s#stem -% $artia&&# res$onsib&e for $erio$erati)e 'ar ia' e)ents! B&o'ka e of 'ar ia' s#m$atheti' inner)ation 131-374 b# thora'i' e$i ura& &o'a& anaestheti's -% re u'e m#o'ar ia& o:#gen eman / is'hemia an 'oronar# )esse& 'onstri'tion =

+$i ura& anaesthesia an ana&gesia -% high&# signifi'ant e'rease in in'i en'e of 'ar io)as'u&ar fai&ure +$i ura& anaesthesia uring 'ar ia' surger# -% re u'es $osto$erati)e su$ra)entri'u&ar arrh#thmias an res$irator# 'om$&i'ations

PULMONARY OUTCOMES
,es$irator# 'om$&i'ations ma# 'ause at &east 709 more 'osts than 'ar ia' 'om$&i'ations 3he re u'tion of &ung inf&ation is one of the basi' me'hanisms of $osto$erati)e $u&monar# 'om$&i'ations! 3he bo # $osition 'hange from u$right to su$ine itse&f re u'es resting &ung )o&ume b# aroun 1 &itre Most of the genera& anestheti's/ e:'e$t for ketamine/ $ro u'e a further re u'tion of >un'tiona,esi ua& (a$a'it# 1>,(4 -% 'ontributes to the e)e&o$ment of ate&e'tasis an h#$o:emia!

De'rease in $hreni' ner)e -% e'rease in ia$hragmati' fun'tion an in'rease in inter'osta& an ab omina& mus'&e tone! After institution of 3+A *ith &o'a& anestheti's -% >,( in'rease b# 289! +AA ma# $reser)e $hreni' ner)e a'ti)it#

 +AA is use in thora'otom# or ab omina&-% im$ro)ement in $u&monar# fun'tion tests out'ome / require &ess )enti&ator su$$ort / s$en &ess time in I(? In $atients *ith rea'ti)e air*a# isease/ en otra'hea& intubation in'reases the risk of bron'hos$asm!

ASTROINTESTINAL E!!ECTS
Posto$erati)e i&eus is an im$ortant morbi it# an morta&it# fa'tor! -% @09 after ab omina& surger# Primar# me'hanisms: 1!neurogeni' 1s$ina&/ su$ras$ina& a renergi' $ath*a#s4 2! inf&ammator# 1&o'a& inf&ammator# res$onses initiate neurogeni' inhibitor# $ath*a#s4 3!$harma'o&ogi' 1e!g!/ o$ioi s4 3he $re)entions : a)oi an'e of o$ioi s/ use of e$i ura& b&o'k/ use of a nasogastri' tube/ an 'orre'tion of e&e'tro&#te imba&an'e

+$i ura& ana&gesia *ith &o'a& anestheti' shortens time of intestina& $ara&#sis -% in'reases the strength of 'o&oni' 'ontra'tions/ an oes not im$air anastomoti' hea&ing or in'rease risk of anastomoti' &eakage

A"aest#esa a"d Posto$eratve Co%"tve D&sfu"cto" Posto$erati)e (ogniti)e D#sfun'tion 1PA(D4 -% usua&&# e& er&# e:$erien'e a )ar#ing egree of 'ogniti)e #sfun'tion $osto$erati)e&# *hi'h is es'ribe a range of abnorma&ities/ one of *hi'h is Posto$erati)e De&irium 1PAD4!

Isof&urane-% a'ti)ate the membrane-boun IP3 re'e$tor -% $ro u'ing e:'essi)e 'a&'ium re&ease-% triggering a$o$tosis in 'e&&s -% s#na$ti' #sfun'tion an neuro egeneration

Pros$e'ti)e obser)ationa& stu # of 80 $atients o)er B0 #ears of age un ergoing e&e'ti)e non'ar ia' surger# measure e$th of anaesthesia using a 'erebra& state monitor an 'om$are the measure (erebra& state in e: 1("I4 to the $erforman'e of the $atients on neuro$s#'ho&ogi'a& testing 1 *eek after surger# 4! No signifi'ant 'orre&ation *as foun bet*een the mean ("I an risk of PA(D! Persistent 'ogniti)e e'&ine -% un er&#ing un iagnose neuro&ogi'a& isease or other 'omorbi ities

Posto$erat've Nausea a"d (o)'t'"%

Nausea an )omiting that e)e&o$s *ithin 2; hours $ost o$erationis kno*n as Posto$erati)e Nausea an 2omiting 1PAN24 "e'on most 'ommon 'om$&aint after $ain 309 in a&& $atients/ that in'reases to 809 in high risk $atients (hi& ren are affe'te t*i'e as often 'om$are to a u&ts PAN2 morbi it# : as$iration $neumonia/ air*a# obstru'tion/ eh# ration/ an suture tightening or ru$ture

Patient+specific ris* factors: fema&e se:/ nonsmoking status/ histor# of PAN2Cmotion si'kness! Anesthetic ris* factors: use of )o&ati&e anestheti's/ nitrous o:i e/ use of intrao$erati)e an $osto$erati)e o$ioi s! ,urgical ris* factors : uration of surger# 1ea'h 30min in'rease in uration in'reases PAN2 risk b# B094 an t#$e of surger# 1&a$aros'o$#/ &a$arotom#/ breast/ strabismus/ $&asti' surger#/ ma:i&&ofa'ia&/ g#ne'o&ogi'a&/ ab omina&/ neuro&ogi'/ o$htha&mo&ogi'/uro&ogi'4

 A$fe& s'oring s#stem

,egiona& anesthesia for mo erate to high risk $atients/ i If genera& anesthesia is ne'essar# -% in u'tion shou& be *ith $ro$ofo& ,isk grou$ $ro$h#&a:is : 7-<33 re'e$tor antagonists/ steroi s/ $henothia5ines/ e$he rine/ butro$henones/ antihistamine or anti'ho&inergi's! ; mg on ansetron/ 1!27 mg ro$eri o& an ; mg e:amethasone % re u'e the in'i en'e of PA2N b# 279

1! A)oi an'e of genera& anesthesia 2! ?se of $ro$ofo& for in u'tion an maintenan'e of anesthesia 3! A)oi an'e of nitrous o:i e ;!A)oi an'e of )o&ati&e anestheti's 7!Minimi5ation of intrao$erati)e an $osto$erati)e o$ioi s B! Minimi5ation of neostigmine 8!A a equate h# ration

A)oi Nitrous o:i e/ inha&ation agents an emetogeni' in u'tion agents su'h as etomi ate an ketamine Maintenan'e of anesthesia-% $ro$ofo& an 3I2A 13ota& Intra)enous Anesthesia *ith $ro$ofo&4 Ana&gesia -% N"AID an &o'a& anesthesia! A)oi high oses of anti'ho&inesterases 1 neostigmine 4-% ma: 2!7 mg!

(ombination thera$# is su$erior to monothera$# for PAN2 $ro$h#&a:is! >irst-generation serotonin re'e$tor antagonists are on ansetron/ granisetron/ o&asetron/ an tro$isetron! 12!7 mg as the minimum effe'ti)e ose De:amethasone a$$ears to be most effe'ti)e *hen a ministere before the in u'tion of anesthesia rather than at the en ! 2!7-7mg -% minimum effe'ti)e ose

A$re$itant 1 Neurokinin-1 1N.-14 re'e$tor antagonist4 -% b&o'ks N.1 re'e$tors in the 'entra& an $eri$hera& ner)ous s#stems -% $re)enting emesis! "'o$o&amine is )er# effe'ti)e for $re)ention of PAN2 in the first 2; hours after surger#! A s'o$o&amine $at'h 13rans erma& "'o$o&amine-3D"4 shou& be a$$&ie the night before surger# or before in u'tion of anesthesia

A'u$un'ture/ a'u$ressure/ trans'utaneous e&e'tri'a& ner)e stimu&ation/ or a'u$oint stimu&ation/ an aromathera$# -% antiemeti' effi'a'# *hen use before <#$nosis has been foun to be effe'ti)e *hen 'om$are *ith $&a'ebo

CONCLUSION
3here is a''umu&ating e)i en'e that anaesthetic management may in!ee! e&ert a num#er of influences on longer term postoperative outcomes! >urther $ros$e'ti)e/ ran omi5e / &arge s'a&e/ human tria&s *ith &ong- term fo&&o*-u$ are require to '&arif# the asso'iation