Chronic postsurgical pain (CPSP) presents a significant impact in the postoperative recovery, affecting patients’ outcomes and quality of life. Numerous prognostic prediction models have been developed to predict the risk of CPSP, however, the clinical utility remains variable. This systematic review and meta-analysis aimed to critically assessed and synthesize the existing CPSP prognostic prediction models in adult patients.
A comprehensive literature search was conducted in PubMed, Embase, and the Cochrane library up to August 2024. A total of 22 models were included in the systematic review, with 19 models subsequently integrated into the meta-analysis.
The overall pooled C-index of the models was 0.79 (95% confidence interval [CI]: 0.75, 0.83; I2 = 88.6%). For studies evaluating CPSP at 3 months postoperatively, the pooled C-index was 0.80 (95% CI: 0.73, 0.87; I2 = 82.1%). At 4 months, the pooled C-index was 0.75 (95% CI: 0.62, 0.87; I2 = 82.8%), while studies considered CPSP at 6 months showed a pooled C-index of 0.81 (95% CI: 0.73, 0.89; I2 = 93.8%). For 12 months post-surgery, the C-index was 0.77 (95% CI: 0.74, 0.79; I2 = 0%). Among models with external validation, the C-index was 0.76 (95% CI: 0.70, 0.82; I2 = 68.2%). For orthopedic surgery, the C-index was 0.82 (95% CI: 0.74, 0.91; I2 = 92.7%). For breast surgery, the C-index was 0.78 (95% CI: 0.75, 0.81; I2 = 0%). For studies reported C-index, the C-index was 0.70 (95% CI: 0.66, 0.73; I2 = 0%) while the C-index was 0.81 (95% CI: 0.77, 0.85; I2 = 88%) for studies reported area under receiver operating characteristic curve.
While prognostic prediction models demonstrated promising discriminative performance, the high overall risk of bias raises concerns about their quality and generalizability. These findings underscore the urgent need for rigorously designed and externally validated models to improve CPSP risk prediction in clinical practice.
Liposomal bupivacaine (LB; Exparel) is a slow-release formulation of bupivacaine used for postoperative pain control that allows for steady and sustained release of bupivacaine over an extended period of time. Although it has been thoroughly investigated in adults since initial approval in 2011, the efficacy and safety of LB use in pediatric patients have still not been fully explored since its more recent approval for pediatrics in March 2021. To assess the current state of the literature regarding the safety and efficacy of LB use in pediatric patients, we queried three online electronic databases. Overall, 26 articles encompassing 1,496 LB patients were selected for review. Outcome data on adverse events, postoperative opioid use, postoperative pain, length of hospital stay, and total hospital costs were extracted. Two published randomized controlled trials were identified, in addition to 15 retrospective cohort studies and 9 case series/case reports. The most commonly reported measures were postoperative opioid use and pain scores, followed by adverse events, length of hospital stay, and lastly, hospital costs. There were no reported instances of local anesthetic systemic toxicity, and no trends were found between surgery type or administration method (nerve block versus intramuscular injection) and surgical outcomes. While the existing literature suggests that LB may reduce pain scores, hospital costs, length of hospital stay, and opioid use, these findings are significantly limited by potential conflicts of interest, gaps in study design, and inconsistent outcome measures. Overall, there is a scarcity of high-quality studies comparing LB to more commonly used local anesthetics, and further investigation through high-quality studies, such as randomized controlled trials, is warranted to determine if LB should be included as part of a multimodal regimen for postoperative pain management in pediatric patients.
This article provides an overview of perioperative strokes—a pressing concern given the rising number of surgical or interventional procedures performed worldwide. Mechanisms underlying perioperative stroke include atherosclerotic plaque instability, induction of a pro-inflammatory state (aggravated by vascular risk factors), hemodynamic dysfunction through hypotension and blood loss, and disruption of the endothelial glycocalyx. The frequency of perioperative stroke varies considerably depending on the type of procedure, being higher with aortic valve and neurovascular procedures. Covert or silent strokes are commonly seen on post-operative magnetic resonance imaging in as many as one in two patients after procedures like brain aneurysm coiling. Risk factors for perioperative stroke include patient factors such as age, sex, race, and comorbidities, as well as operator and procedural factors such as operator experience, institutional procedural volume, use of certain devices, and vascular access site. Overt periprocedural stroke is associated with higher mortality, longer hospital stays, and higher long-term disability. The long-term sequelae of covert strokes are still being characterized, but recent studies have indicated that a higher burden of such infarcts is associated with worse functional and cognitive outcomes. Key considerations to prevent perioperative strokes include screening plus risk factor control, pre-medication, and procedural considerations including anesthetic choice. The management of perioperative ischemic stroke has been aided by advancements in reperfusion therapies and stroke systems of care that allow rapid treatment of major stroke. Ongoing work seeks to address the enduring need for evidence-based therapeutic strategies to prevent these strokes and mitigate their adverse impact.
The mechanisms underlying reversible unconsciousness induced by general anesthetics remain unclear. This study aimed to investigate the effects of four commonly used anesthetics on neuronal spiking patterns in layer 5 of the medial prefrontal cortex (mPFC).
In vivo multi-channel recordings were performed in layer 5 of the mPFC in a mouse model. Neuronal spiking patterns of regular-spiking and fast-spiking neurons were measured and compared across wakefulness loss of the righting reflex (LORR), and recovery of the righting reflex (RORR). Four anesthetic/sedative drugs (sevoflurane, propofol, ketamine, and dexmedetomidine) were tested.
During LORR, most cortical regular-spiking neurons were inhibited, while a small subset was excited. Fast-spiking neurons exhibited significant suppression across all anesthetics. Among these, the firing rate of inhibited regular-spiking neurons was closely associated with the transitions between LORR and RORR. Sevoflurane, propofol, and dexmedetomidine exhibited similar modulatory effects on mPFC neurons, whereas ketamine induced stronger excitatory effects on both regular- and fast-spiking neurons.
Sevoflurane, propofol, and dexmedetomidine exert comparable effects on neuronal spiking in the mPFC, while ketamine induces distinct excitatory effects. Inhibited regular-spiking neurons in layer 5 of the mPFC are closely associated with the reversible transitions between LORR and RORR.
Sarcoidosis is a rare systemic granulomatous disorder characterized by lung involvement but frequently involves the heart, gastrointestinal and lymphatic organs. Few studies have investigated sarcoidosis-related postoperative cardiopulmonary complications, creating a significant knowledge gap. Using a comparative cohort analysis, the authors hypothesized that sarcoidosis would be associated with higher risk for 30-day postoperative pulmonary complications (PPC).
This retrospective study examined hospital system data between January 1, 2013, and January 1, 2022, for patients over 18 years, admitted for procedural intervention. 389 sarcoidosis patients and controls (N = 48,823) were identified. The primary endpoint of PPC, as measured by the Agency for Healthcare Research and Quality PPC composite, and secondary endpoints of major adverse cardiovascular events (MACE), PPC subcomposites, and length of stay (LOS) were analyzed. A Mahalanobis distance matching (MDM) was used to match sarcoidosis and control patients (N = 389) on clinically relevant baseline covariates.
After MDM and adjustment for surgical time and anesthesia type, sarcoidosis diagnosis corresponded to higher composite 30-day PPC (18.5% vs. 9.3%, adjusted odds ratio [ORadj] = 3.32, 95% confidence intervals [CI] 1.8–5.8; p < 0.001), sub-composite respiratory failure/insufficiency (10.5% vs. 5.1%, ORadj = 3.31, 95% CI 1.6–6.7; p < 0.001) but not pneumonia (5.7% vs. 3.9%, ORadj = 2.0, 95% CI 0.8–4.8; p = 0.117). The sarcoidosis cohort had longer LOS (ORadj = 2.33, 95% CI 2.0–2.7; p < 0.001). Sarcoidosis diagnosis was not associated with 30-day MACE (12.3% vs. 12.9%, ORadj = 1.43, 95% CI 0.8–2.4; p = 0.192), atrial fibrillation (6.9% vs. 5.7%; p = 0.931), or congestive heart failure events (5.9% vs. 7.2%; p = 0.526).
Sarcoidosis is associated with a twofold increased risk of 30-day PPC, primarily related to an increased incidence of 30-day respiratory failure/insufficiency. This risk appears to be independent of disease staging, but is associated with the presence of sarcoidosis features on preoperative chest radiography. Postoperatively, sarcoidosis patients experience longer hospital LOS, suggesting that when complications occur, they are more resource-intensive, when compared to controls. These findings highlight opportunities to enhance preoperative multi-disciplinary optimization, and suggest that tailored perioperative care strategies for sarcoidosis patients would be beneficial.
An increased incidence of delirium was reported in patients especially in elderly patient during the acute phase of coronavirus disease 2019 (COVID-19). However, whether COVID-19 history increases the risk of postoperative delirium (POD) in elderly patients remains unclear. This study aims to investigate the association between COVID-19 history and POD in elderly patients undergoing elective surgeries.
In this prospective, two center cohort study, 500 elderly patients undergoing elective surgeries from March to May 2023 were analyzed. The primary exposure was a history of COVID-19. The primary outcome was POD assessed with 3-min diagnostic confusion assessment method or confusion assessment method for the intensive care unit within three days after surgery. We used inverse probability of treatment weighting (IPTW) to balance the differences between patients with or without a history of COVID-19. The association between COVID-19 history and POD was estimated using a logistic regression model with IPTW. Additionally, we next exploringly conducted subgroup analysis and assessed interaction effects to evaluate the impact of COVID-19 history on POD based on frailty/pre-frailty, cancer, surgical type/classification, sex, profession, and residence type.
In this cohort, 412 patients had a history of COVID-19 with an incidence 16% of POD while 88 were uninfected with 15.9% of POD incidence. There was no association between COVID-19 history and POD [adjusted odds ratio (ORadj) 1.20 (0.80–1.79), P = 0.378] in elderly patients undergoing elective surgery. However, POD was significantly increased in patients with COVID-19 history who were pre-frailty/frailty or with cancers [ORadj 2.41 (1.19–5.10) and ORadj 2.29 (1.23–4.39), respectively].
This preliminary exploratory study found no association between a history of COVID-19 and POD in elderly patients undergoing elective surgery.
Registered at the Chinese Clinical Trial Center (https://www.chictr.org.cn/showproj.html?proj=192846) with No. ChiCTR2300069308 on Mar 13, 2023.
京公网安备 11010802042870号
京ICP备2023020795号-1
扫码关注我们
求助内容：
应助结果提醒方式：