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Cost burden following esophagectomy:A single centre observational study

World Journal of Gastrointestinal Surgery 2024年第7期16卷 2255-2269页

作者： Vered Buchholz Dong Kyu Lee David S Liu Ahmad Aly Stephen A Barnett Riley Hazard Peter Le Benjamin Kioussis Vijayaragavan Muralidharan laurence weinberg Department of Surgery Austin HealthMelbourne 3084VictoriaAustralia Department of Anesthesiology and Pain Medicine Dongguk University Ilsan HospitalSeoul 14566GoyangSouth Korea Department of Surgery Austin HealthThe University of MelbourneMelbourne 3084VictoriaAustralia Department of Anesthesia Austin HealthMelbourne 3084VictoriaAustralia Department of Anesthesia Austin HospitalHeidelberg 3084VictoriaAustralia Department of Critical Care The University of MelbourneMelbourne 3084VictoriaAustralia

BACKGROUND Cost analyses of patients undergoing esophagectomy is valuable for identifying modifiable expenditure drivers to target and curtail costs while improving the quality of *** aimed to define the cost-complication relationship after esophagectomy and delineate the incremental contributions to *** To assess the relationship between the hospital costs and potential cost drivers post esophagectomy and investigate the relationship between the cost-driving variables(predicting variables)and hospital costs(dependent variable).METHODS In this retrospective single center study,the severity of complications was graded using the Clavien-Dindo(CD)classification *** esophagectomy complications were categorized and defined according to consensus *** costing data included the in-hospital costs of the index admission and any unplanned admission within 30 postoperative *** used correlation analysis to assess the relationship between key clinical variables and hospital costs(in United States dollars)to identify cost drivers.A mediation model was used to investigate the relationship between these variables and hospital *** A total of 110 patients underwent primary esophageal *** median admission cost was $47822.7(interquartile range:35670.2-68214.0).The total effects on costs were $13593.9(95%CI:10187.1-17000.8,P<0.001)for each increase in CD severity grade,$4781(95%CI:3772.7-5789.3,P<0.001)for each increase in the number of complications,and $42552.2(95%CI:8309-76795.4,P=0.015)if a key esophagectomy complication *** esophagectomy complications drove the costs directly by $11415.7(95%CI:992.5-21838.9,P=0.032).CONCLUSION The severity and number of complications,and the development of key esophagectomy complications significantly contributed to total hospital *** institutional initiatives and strategies are needed to enhance patient outcomes and minimize costs.

关键词： Anesthesia Esophagectomy Complications Cancer Surgery

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Perioperative fluid management in major hepatic resection: an integrative review

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Hepatobiliary & Pancreatic Diseases International 2017年第5期16卷 458-469页

作者： Osamu Yoshino Marcos Vinicius Perini Christopher Christophi laurence weinberg Department of Surgery Austin Hospital and University of Melbourne Melbourne Victoria Australia Anaesthesia Perioperative Pain Medicine Unit University of Melbourne Melbourne Victoria Australia

BACKGROUND: Fluid intervention and vasoactive pharmacological support during hepatic resection depend on the preference of the attending clinician, institutional resources, and practice culture. Evidence-based recommendations to guide perioperative fluid management are currently limited. Therefore, we provide a contemporary clinical integrative overview of the fundamental principles underpinning fluid intervention and hemodynamic optimization for adult patients undergoing major hepatic resection. DATA SOURCES: A literature review was performed of MEDLINE, EMBASE and the Cochrane Central Registry of Controlled Trials using the terms 'surgery', 'anesthesia', 'starch', 'hydroxyethyl starch derivatives', 'albumin', 'gelatin', 'liver resection', 'hepatic resection', 'fluids', 'fluid therapy', 'crystalloid', 'colloid', 'saline', 'plasma-Lyte', 'plasmalyte', 'hartmann's', 'acetate', and 'lactate'. Search results for MEDLINE and EMBASE were additionally limited to studies on human populations that included adult age groups and publications in English. RESULTS: A total of 113 articles were included after appropriate inclusion criteria screening. Perioperative fluid management as it relates to various anesthetic and surgical techniques is ***: Clinicians should have a fundamental understanding of the surgical phases of the resection, hemodynamic goals, and anesthesia challenges in attempts to individualize therapy to the patient's underlying pathophysiological condition. Therefore, an ideal approach for perioperative fluid therapy is always individualized. Planning and designing large-scale clinical trials are imperative to define the optimal type and amount of fluid for patients undergoing major hepatic resection. Further clinical trials evaluating different intraoperative goal-directed strategies are also eagerly awaited.

关键词： hepatic resection liver resection fluid therapy anesthesia crystalloid colloid goal-directed therapy

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Relationship between acute hypercarbia and hyperkalaemia during surgery

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World Journal of Clinical Cases 2019年第22期7卷 3711-3717页

作者： laurence weinberg Amelia Russell Lois Mackley Charles Dunnachie Joshua Meyerov Chong Tan Michael Li Raymond Hu Dharshi Karalapillai Department of Anaesthesia Austin HealthMelbourneVictoria 3084Australia Department of Intensive Care Austin HealthMelbourneVictoria 3084Australia Melbourne Medical School University of MelbourneVictoria 3010Australia

BACKGROUND The relationship between hyperkalaemia and metabolic acidosis is well described in the critical care setting;however,the relationship between acute respiratory acidosis and plasma potassium concentration is less well *** a controlled model of increasing levels of hypercarbia,we tested the hypothesis of whether increasing levels of hypercarbia are associated with changes in plasma potassium *** To determine whether increasing levels of hypercarbia are associated with changes in plasma potassium *** We performed a post-hoc study examining changes in serum potassium in 24 patients who received increased levels of hypercarbia during cardiac *** blood gases and plasma concentrations of potassium were measured at baseline,3 min prior to,and then every 3 min for 15 min during the intervention of *** primary endpoint was the absolute change in serum K+at 15 min compared to the baseline K+*** following secondary endpoints were evaluated:(1)The association between CO2 and serum K+concentration;and(2)The correlation between plasma pH and serum K+*** During the intervention,PaCO2 increased from 43.6 mmHg(95%CI:40.1 to 47.1)at pre-intervention to 83.9 mmHg(95%CI:78.0 to 89.8)at 15 min after intervention;P<*** mean(SD)serum potassium increased from 4.16(0.35)mmol/L at baseline to 4.28(0.33)mmol/L at 15 min(effect size 0.09 mol/L;P=0.22).There was no significant correlation between PaCO2 and potassium(Pearson’s coefficient 0.06;95%CI:-0.09 to 0.21)or between pH and potassium(Pearson’s coefficient-0.07;95%CI:-0.22 to 0.09).CONCLUSION Acute hypercarbia and subsequent respiratory acidaemia were not associated with hyperkalaemia in patients undergoing major surgery.

关键词： Anaesthesia Intensive care Biochemistry Surgery

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Thromboelastography in elective total hip arthroplasty

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World Journal of Orthopedics 2021年第8期12卷 555-564页

作者： Patryck Lloyd-Donald Wen-Shen Lee Guo-Ming Liu Rinaldo Bellomo Larry McNicol laurence weinberg Department of Anesthesia Austin HealthHeidelberg 3084VictoriaAustralia Department of Intensive Care Austin HospitalMelbourne 3084VictoriaAustralia Department of Surgery The University of MelbourneAustin HealthMelbourne 3084VictoriaAustralia

BACKGROUND Hypercoagulability plays an important role in predisposing patients to venous thromboembolism(VTE)after total hip arthroplasty(THA).We used thromboelastography(TEG)to examine the coagulation status of patients undergoing *** To examine coagulation as measured by TEG in patients undergoing THA who received standard VTE chemoprophylaxis with *** After ethical approval,we performed a retrospective analysis of data collected in patients undergoing primary elective *** analyzed TEG data on samples performed before skin incision,intraoperatively and for 5 d *** coagulation tests were performed preoperatively and on postoperative day *** Twenty patients undergoing general anesthesia and 32 patients undergoing spinal anesthesia(SA)were *** demonstrated a progressively hypercoagulable state postoperatively,characterized by elevated maximum *** also demonstrated transient intraoperative hypercoagulability in patients receiving *** contrast,conventional coagulation tests were normal in all patients,pre-and postoperatively,except for an increase in plasma fibrinogen day 5 *** Despite VTE prophylaxis,patients following total hip replacement remain in a hypercoagulable state as measured by both TEG and conventional *** group may benefit from more optimal anticoagulation and/or additional perioperative hemostatic monitoring,via TEG or otherwise.

关键词： Surgery Orthopedic Anesthesia Hip arthroplasty Hypercoagulability Thrombelastography

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Haemostatic management for aortic valve replacement in a patient with advanced liver disease

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世界临床病例杂志 2014年第10期2卷 596-603页

作者： laurence weinberg Irene Kearsey Clarissa Tjoakarfa George Matalanis Sean Galvin Scott Carson Rinaldo Bellomo Larry McNicol Peter McCall Department of Anaesthesia Austin HospitalMelbourne Victoria 3084 Australia Department of Cardiac Surgery Austin HospitalMelbourne Victoria 3084 Australia Department of Intensive Care Austin HospitalMelbourne Victoria 3084 Australia

Redo-sternotomy and aortic valve replacement in patients with advanced liver disease is rare and associated with a prohibitive morbidity and mortality. Refractory coagulopathy is common and a consequence of intense activation of the coagulation system that can be triggered by contact of blood with the cardiopulmonary bypass circuitry, bypass-induced fibrinolysis, plate-let activation and dysfunction, haemodilution, surgical trauma, hepatic decompensation and hypothermia. Management can be further complicated by right heart dysfunction, porto-pulmonary hypertension, poor myocardial protection, and hepato-renal syndrome. Complex interactions between coagulation/fibrinolysis and systemic inflammatory response syndrome reactions like "post-perfusion-syndrome" also compound haemostatic failure. Given the limited information available for the specific management and prevention of cardiopulmonary bypass-induced haemostatic failure, this report serves to guide the anaesthesia and medical management of future cases of a similar kind. We discuss our multimodal management of haemostatic failure using pharmacological strategies, thromboelastography, continuous cerebral and liver oximetry, and continuous cardiac output monitoring.

关键词： Cardiac surgery Liver failure Coagulopathy Cardiopulmonary bypass

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Outcomes of central hepatectomy versus extended hepatectomy

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Hepatobiliary & Pancreatic Diseases International 2019年第3期18卷 249-254页

作者： Jenny Chan Luke Bradshaw Nezor Houli laurence weinberg Marcos V Perini Michael Fink Vijayaragavan Muralidharan Graham Starkey Robert Jones Bao Zhong Wang Christopher Christophi Mehrdad Nikfarjam Department of Surgery University of Melbourne Austin Health Heidelberg Melbourne Victoria Australia Department of Surgery University of Melbourne Northern Health Epping Victoria Australia Department of Anaesthesia University of Melbourne Austin Health Heidelberg Melbourne Victoria Australia

Background: Central hepatectomy(CH) is more difficult than extended hepatectomy(EH) and is associated with greater morbidity. In this modern era of liver management with aims to prevent posthepatectomy liver failure(PHLF), there is a need to assess outcomes of CH as a parenchyma-sparing procedure for centrally located liver tumors. Methods: A total of 178 major liver resections performed by specialist surgeons from two Australian tertiary institutions between June 2009 and March 2017 were reviewed. Eleven patients had CH and 24 had EH over this study period. Indications and perioperative outcomes were compared between the groups. Results: The main indication for performing CH was colorectal liver metastases. There was no perioperative mortality in the CH group and four(16.7%) in the EH group( P = 0.285). No group differences were found in median operative time [CH vs. EH: 450 min(290–840) vs. 523 min(310–860), P = 0.328], intraoperative blood loss [850 mL(40 0–150 0) vs. 650 mL(10 0–20 0 0), P = 0.746] or patients requiring intraoperative blood transfusion [1(9.1%) vs. 7(30.4%), P = 0.227]. There was a trend towards fewer hepatectomyspecific complications in the CH group [3(27.3%) vs. 13(54.2%), P = 0.167], including PHLF(CH vs. EH: 0 vs. 29.2%, P = 0.072). Median length of stay was similar between groups [CH vs. EH: 9 days(5–23) vs. 12 days(4–85), P = 0.244]. Conclusions: CH has equivalent postoperative outcomes to EH. There is a trend towards fewer hepatectomy-specific complications, including PHLF. In appropriate patients, CH may be considered as a safe parenchyma-sparing alternative to EH.

关键词： Central hepatectomy Mesohepatectomy Central bisectionectomy Central bisegmentectomy Extended hepatectomy

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Plasma-Lyte 148: A clinical review

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World Journal of Critical Care Medicine 2016年第4期5卷 235-250页

作者： laurence weinberg Neil Collins Kiara Van Mourik Chong Tan Rinaldo Bellomo Department of Surgery Perioperative Pain Medicine Unit University of Melbourne Depart-ment of Anesthesia Austin Hospital Department of Anesthesia Joondalup Health Campus Department of Intensive Care Austin Hospital

AIM To outline the physiochemical properties and specific clinical uses of Plasma-Lyte 148 as choice of solution for fluid intervention in critical illness, surgery and perioperative *** We performed an electronic literature search from Medline and Pub Med(via Ovid), anesthesia and pharmacology textbooks, and online sources including studies that compared Plasma-Lyte 148 to other crystalloid solutions. The following keywords were used: "surgery", "anaesthesia", "anesthesia", "anesthesiology", "anaesthesiology", "fluids", "fluid therapy", "crystalloid", "saline", "plasma-Lyte", "plasmalyte", "hartmann's", "ringers" "acetate", "gluconate", "malate", "lactate". All relevant articles were accessed in full. We summarized the data and reported the data in tables and text. RESULTS We retrieved 104 articles relevant to the choice of Plasma-Lyte 148 for fluid intervention in critical illness, surgery and perioperative medicine. We analyzed the data and reported the results in tables and *** Plasma-Lyte 148 is an isotonic, buffered intravenous crystalloid solution with a physiochemical composition that closely reflects human plasma. Emerging data supports the use of buffered crystalloid solutions in preference to saline in improving physicochemical outcomes. Further large randomized controlled trials assessing the comparative effectiveness of PlasmaLyte 148 and other crystalloid solutions in measuring clinically important outcomes such as morbidity and mortality are needed.

关键词： Surgery Anesthesia Fluid therapy Crystalloids Saline Plasma-Lyte Hartmann’s Ringers Acetate Gluconate Lactate

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Pharmacokinetics and pharmacodynamics of lignocaine: A review

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World Journal of Anesthesiology 2015年第2期4卷 17-29页

作者： laurence weinberg Benjamin Peake Chong Tan Mehrdad Nikfarjam Anesthesia Perioperative Pain Unit University of Melbourne Department of Anesthesia Austin Hospital Department of Surgery University of Melbourne Department of Hepatobiliary Surgery Austin Hospital

Lignocaine is an essential drug on World Health Organisation essential drug list, considered efficacious, safe and cost-effective for any health-care system. Despite its ubiquitous use in medicine and surgery, there are few detailed reviews of its pharmacokinetics and pharmacodynamics. Being an amide-type local anesthetic and Class 1b antiarrhythmic, lignocaine is most frequently used clinically for its anesthetic and antiarrhythmic benefits. However, lignocaine has important antinociceptive, immuno-modulating, and antiinflammatory properties. Information pertaining to the pharmacokinetics and pharmacodynamics of lignocaine was examined by performing a literature search of Pub Med, Embase and MEDLINE(via Ovid), pharmacology textbooks and online sources. We present a focused synopsis of lignocaine's pharmacological composition, indications for use and mechanisms of action, focusing on its anti-inflammatory, immuno-modulating and analgesia effects. In addition we review the dosing regimes and infusion kinetics of lignocaine in the clinical setting. Finally, we review the evidence for ligocaine's modulation of the inflammatory response during major surgery and its specific effects on cancer recurrence. These indirect effects of local anesthetics in tumor development may stem from the reduction of neuroendocrine responses to the stress response elicited by major surgery and tissue damage, enhanced preservation of immune-competence, in addition to opioid-sparing effects of modulating tumor growth.

关键词： Lignocaine Humans Pharmacokinetics Pharmacodynamics Adult

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Transthoracic echocardiography assists appropriate pulmonary artery catheter placement: An observational study

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World Journal of Anesthesiology 2015年第2期4卷 30-38页

作者： Chong Oon Tan laurence weinberg David Andrew Story Larry Mc Nicol Department of Anaesthesia the Austin Hospital Department of Surgery Melbourne Medical School the University of Melbourne

AIM: To investigate the utility of transthoracic echocardiography in confirming appropriate pulmonary artery catheter(PAC) placement. METHODS: Three commonly used transthoracic echocardiography(TTE) views were used to confirm PAC position in 103 patients undergoing elective cardiac surgery- the parasternal short axis right ventricular inflow-outflow view; the subcostal short axis right ventricular inflow-outflow view; and the parasternal short axis ascending aortic view. All PACs were inserted by the managing anesthesiologist under pressure waveform guidance alone, who was blinded to all sonographic information. A sonographer blinded to all pressure waveform information confirmed visualisation of an "empty" PA before PAC insertion, and visualisation of the PAC balloon in the main PA(MPA) or right PA(RPA) after attempts at placement were complete. Agreement, sensitivity and specificity of TTE in confirming appropriate PAC placement was compared against pressure waveformguidance as the "gold standard". The successful view used was compared against patients' anthropomorphic indices, presence of lung hyperinflation, and insertion of PAC during positive pressure ventilation. Agreement between TTE and pressure waveform guidance was analysed using Cohen's Kappa statistic. The relative proportion of total RPA seen by subcostal vs parasternal TTE views was also compared with a further 20 patients' computed tomography(CT) pulmonary angiograms(CTPA), to determine efficacy in detection of distal RPA PAC placement. RESULTS: Appropriate positioning of the PAC balloon, and its to-and-fro movement consistent with a nonwedged state, within the MPA or RPA was confirmed by TTE in 98 of the 103 patients [sensitivity 95%(95%CI: 89%-98%)], and absence of the PAC balloon before insertion correctly established in 100 patients [specificity 97%(92%-99%)]. This was in very good agreement with pressure waveform guidance [Cohen's Kappa 0.92,(0.87-0.98)]. The subcostal view was the best view to

关键词： Transthoracic echocardiography Pulmonary artery catheter Main pulmonary artery Right pulmonary artery Pulmonary artery rupture Intensive care unit

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Burden of chronic diseases among sarcoma survivors treated with anthracycline chemotherapy:results from an observational study

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Journal of Cancer Metastasis and Treatment 2020年第1期6卷 246-257页

作者： laurence H.Baker Philip S.Boonstra Denise K.Reinke Erin J.Peregrine Antalis Bradley J.Zebrack Richard L.weinberg Department Internal Medicine University of Michigan Medical SchoolAnn ArborMI 48109USA Department of Biostatistics University of MichiganAnn ArborMI 48109USA School of Social Work University of MichiganAnn ArborMI 48109USA Division of Cardiovascular Medicine Department of Internal MedicineUniversity of MichiganAnn ArborMI 48109USA

Aim:Cardiovascular disease is a leading cause of mortality among long-term cancer survivors treated with large total doses of *** increase in coronary artery disease(CAD)among childhood cancer survivors by age 45 has been observed and is driven by primarily anthracycline chemotherapy and to a lesser extent chest radiation that includes the heart in the radiation *** risk factors and associated chronic diseases(hypertension,etc.)are well known for CAD and can be often prevented or treated,thus reducing the risk of CAD in these *** piloted a risk-based survivorship clinic in an academic medical center to characterize the distribution of risk factors for CAD and improve the quality of life in a population of sarcoma survivors treated with ***:We followed a prospective cohort of sixty-one survivors of bone and soft tissue sarcoma treated with doxorubicin chemotherapy(>400 mg/m2)and at least 2 years post-therapy attending the sarcoma survivorship *** collected clinical,demographic data,and patient reported outcomes via PROMIS questionnaires ***:We demonstrated a high burden of chronic diseases in this *** six chronic conditions that are known risk factors for CAD(hypertension,diabetes,obesity,chronic inflammation,kidney disease and dyslipidemia),more than one-fourth(26%,16/61)of patients had three or more of these risk factors at baseline visit,and 49%(30/61)had two or ***:The results of this pilot study support the presence of modifiable CAD risk factors in this population of sarcoma ***-based guidelines for high-risk survivors of rare cancers are needed.

关键词： Coronary artery disease cardiovascular disease sarcoma anthracycline cancer survivor

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