Preoperative Vancomycin Administration for Surgical Site Prophylaxis: Plasma and Soft-Tissue Concentrations in Pediatric Neurosurgical and Orthopedic Patients.
- 作者列表："Brooks Peterson M","Cohen MN","O'Neill BR","Garg S","Child J","Henthorn TK","Galinkin JG
BACKGROUND:Vancomycin is used for antibiotic prophylaxis in pediatric surgical patients without a complete understanding of plasma and soft-tissue pharmacokinetics. Guidelines recommend incision within 60 minutes after administration; however, tissue vancomycin concentrations at that early time may not be therapeutic. We conducted a study of plasma and skin concentrations in pediatric neurosurgical and orthopedic patients to characterize intraoperative vancomycin pharmacokinetics. METHODS:Patients (0.1-18.8 years of age) undergoing posterior spinal fusion (n = 30) or ventriculoperitoneal shunt placement (n = 30) received intravenous vancomycin 15 mg/kg (maximum 1000 mg) over 1 hour. Skin was biopsied at incision and skin closure. Blood samples were collected at incision, at 2 and 4 hours intraoperatively, and at closure. Population pharmacokinetic analysis was performed to characterize pharmacokinetic parameter estimates and to develop a model of intraoperative plasma and skin vancomycin concentrations versus time. RESULTS:Pharmacokinetic analysis included data from 59 subjects, 130 plasma samples, and 107 skin samples. A 2-compartment model, volume of the central (Vc) and volume of the peripheral compartment (V2), proved to have the best fit. Stepwise covariate selection yielded a significant relationship for body surface area on elimination clearance and body weight on V2. Skin vancomycin concentrations rose continuously during surgery. Modeling predicted that equilibration of skin and plasma vancomycin concentrations took ≥5 hours. CONCLUSIONS:Skin vancomycin concentrations immediately after a preoperative dose are relatively low compared with concentrations at the end of surgery. It may be advisable to extend the time between dose and incision if higher skin concentrations are desired at the start of surgery.
背景: 万古霉素用于儿科手术患者的抗生素预防，但对血浆和软组织药代动力学没有完全了解。指南建议在给药后 60 分钟内切开; 然而，早期的组织万古霉素浓度可能不是治疗性的。我们对小儿神经外科和骨科患者的血浆和皮肤浓度进行了研究，以表征万古霉素的术中药代动力学。 方法: 接受后路脊柱融合术 (n = 30) 或脑室腹腔分流术 (n = 30) 的患者 (0.1-18.8 岁) 在 1 小时内静脉注射万古霉素 15 mg/kg (最多 1000 mg)。在切口和皮肤闭合处进行皮肤活检。在切口处、术中 2 和 4 小时以及闭合时采集血液样本。进行群体药代动力学分析，表征药代动力学参数估计值，并建立术中血浆和皮肤万古霉素浓度随时间变化的模型。 结果: 药代动力学分析包括来自 59 名受试者、 130 份血浆样本和 107 份皮肤样本的数据。2 室模型，中央容积 (Vc) 和外围室容积 (V2)，证明具有最佳拟合。逐步协变量选择产生了消除清除的体表面积和v2 上的体重的显著关系。手术期间皮肤万古霉素浓度持续升高。建模预测皮肤和血浆万古霉素浓度平衡需要 ≥ 5 小时。 结论: 与手术结束时的浓度相比，术前剂量后立即的皮肤万古霉素浓度相对较低。如果在手术开始时需要较高的皮肤浓度，最好延长剂量和切口之间的时间。
METHODS:BACKGROUND:Postoperative cognitive dysfunction (POCD) is a common complication after orthopedic surgery, which is not conducive to the prognosis of the elderly. AIMS:We performed this study to investigate the effects of oxycodone applied for patient-controlled intravenous analgesia (PCIA) on postoperative cognitive function in elderly patients after total hip arthroplasty (THA). METHODS:Ninety-nine participants were enrolled and allocated into two groups: oxycodone group (group O) and sufentanil group (group S). The primary outcome was the incidence of POCD, diagnosed according to the changes in the Mini-mental status examination (MMSE) and Montreal Cognitive Assessment (MoCA) scores. The secondary outcomes included the plasma levels of S-100B protein and neuron-specific enolase (NSE), the amount of postoperative analgesic consumption and the incidence of adverse reactions. RESULTS:The incidence of POCD was significantly lower in patients receiving oxycodone up to the 3rd postoperative day (POD, 1st POD 27.3% vs. 51.1%, P = 0.021; 3rd POD 20.5% vs. 40.0%, P = 0.045), as compared to patients receiving sufentanil. The MMSE and MoCA scores of both groups decreased to varying degrees. However, compared with group S, the MMSE scores at 1st POD, 3rd POD, 5th POD and 7st POD in group O were higher than that in group S, while MoCA scores at 1st POD, 3rd POD and 5th POD in group O were higher. Compared with group S, the plasma levels of S-100B protein in group O at 4 h, 8 h, 12 h post-surgery were lower. While the plasma levels of NSE in group O at 4 h, 8 h, 12 h, 24 h post-surgery were lower. Number of PCIA boluses and consumption of analgesic drug during the first two POD were similar between two groups. However, postoperative incidence of nausea, vomiting and pruritus was significantly lower in patients receiving oxycodone. CONCLUSION:Oxycodone applied for PCIA in elderly patients after THA could reduce the incidence of POCD, improve postoperative cognitive function and decrease the adverse reactions.
METHODS:BACKGROUND:Primary treatment for Blount disease has changed in the last decade from osteotomies or staples to tension band plate (TBP)-guided hemiepiphysiodesis. However, implant-related issues have been frequently reported with Blount cases. The purpose of our study is to evaluate the surgical failure rates of TBP in Blount disease and characterize predictors for failure. METHODS:We performed an Institutional Review Board-approved retrospective chart-review of pediatric patients with Blount disease to evaluate the results of TBP from 2008 to 2017 and a systematic literature review. Blount cases defined as pathologic tibia-vara with HKA (hip-knee-ankle) axis and MDA (metaphyseal-diaphyseal angle) deviations ≥11 degrees were included in the analysis. Surgical failure was categorized as mechanical and functional failure. We studied both patient and implant-related characteristics and compared our results with a systematic review. RESULTS:In 61 limbs of 40 patients with mean follow-up of 38 months, we found 41% (25/61) overall surgical failure rate and 11% (7/61) mechanical failure rate corresponding to 11% to 100% (range) and 0% to 50% (range) in 8 other studies. Statistical comparison between our surgical failure and nonfailure groups showed significant differences in deformity (P=0.001), plate material (P=0.042), and obesity (P=0.044) in univariate analysis. The odds of surgical failure increased by 1.2 times with severe deformity and 5.9 times with titanium TBP in the multivariate analysis after individual risk-factor adjustment. All 7 mechanical failures involved breakage of cannulated screws on the metaphyseal side. CONCLUSIONS:Most of the studies have reported high failure rates of TBP in Blount cases. Besides patient-related risk factors like obesity and deformity, titanium TBP seems to be an independent risk factor for failure. Solid screws were protective for mechanical failure, but not for functional failure. In conclusion, efficacy of TBP still needs to be proven in Blount disease and implant design may warrant reassessment. LEVEL OF EVIDENCE:Level III-retrospective comparative study with a systematic review.
METHODS:INTRODUCTION:As cancer treatments continue to improve the overall survival rates, more patients with a history of cancer will present for anatomic total shoulder arthroplasty (TSA). Therefore, it is essential for orthopaedic surgeons to understand the differences in care required by this growing subpopulation. Although the current research suggests that good outcomes can be predicted when appropriately optimized patients with cancer undergo lower extremity total joint arthroplasty, similar studies for TSA are lacking. The primary study question was to examine whether a history of cancer was associated with an increased rate of venous thromboembolism (VTE) after TSA. Secondarily, we sought to examine any association between a history of prostate and breast cancer and surgical or medical complications after TSA. METHODS:Using a national insurance database, male patients with a history of prostate cancer and female patients with a history of breast cancer undergoing anatomic TSA for primary osteoarthritis were identified and compared with control subjects matched 3:1 based on age, sex, diabetes mellitus, and tobacco use. Patients with a history of VTE and patients who underwent reverse TSA or hemiarthroplasty were excluded. RESULTS:Female patients with a history of breast cancer and male patients with a history of prostate cancer undergoing TSA had significantly higher incidences of acute VTE (including deep venous thrombosis and pulmonary embolism) compared with matched control subjects (female patients: odds ratio, 1.41; 95% confidence interval, 1.10 to 1.81; P = 0.024 and male patients: odds ratio, 1.37; 95% confidence interval, 1.05 to 1.79; P = 0.023). No significant differences were noted in the incidences of any other complications assessed. CONCLUSION:Although a personal history of these malignancies does represent a statistically significant risk factor for acute VTE after anatomic TSA, the overall VTE rate remains modest and acceptable. The rates of other surgical and medical complications are not significantly increased in patients with a history of these cancers after TSA compared with control subjects.