Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2024.111730
Jane Y. Xu MPH , Hannah E. Madden BS , Pablo Martínez-Camblor PhD , Stacie G. Deiner MD
Background
Frailty, a syndrome of decreased resilience to physiologic stress, has been associated with increased postoperative length of stay (LOS) for specific procedures. Yet, the literature lacks large-scale analyses examining the relationship between frailty and LOS across surgical procedure.
Study design
We conducted a retrospective cohort study of patients aged 65+ undergoing inpatient surgery including emergency procedures between 2015 and 2019 using American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data. Frailty, measured by the modified 5-item frailty index (mFI-5), was categorized as non-frail (mFI-5 < 2) or frail (mFI-5 ≥ 2). We modeled LOS, adjusting for demographic variables, comorbidities, and surgical factors, and conducted a subgroup analysis based on emergency surgery status and surgical procedure type.
Main results
Among 1,254,809 patients, 29.0 % were frail. A higher proportion of frail patients were Black (10 % vs. 5.5 %), Hispanic (6.1 % vs. 3.8 %), of ASA class IV/V (23.3 % vs. 9.1 %), malnourished (2.7 % vs. 1.9 %), and underwent vascular surgery (16.5 % vs. 8.3 %). They experienced longer median LOS across all surgical procedures, except bariatric surgery. Unadjusted analysis revealed that mFI-5 scores of 4 and 5 were associated with increased median LOS by 3.5 days (95 % CI 3.36–3.64) and 4.64 days (95 % CI 3.96–5.32), respectively, compared to mFI-5 scores of 0. In adjusted analysis, frailty remained a significant risk factor for increased median LOS, with an mFI-5 score of 5 associated with a 3-day longer increase (95 % CI 2.79–3.22) compared to an mFI-5 score of 0. Subgroup analysis showed that each one-point increase in mFI-5 score had the strongest association with increased median LOS in emergency surgery (0.5 days, 95 % CI 0.48–0.52) and lower extremity bypass surgery (0.53 days, 95 % CI 0.47–0.59).
Conclusions
Frailty is an independent risk factor for prolonged postoperative LOS among older surgical patients, even after adjustment for patient and procedure covariates. Other independent risk factors for increased LOS include emergent surgery, malnutrition, and higher ASA class.
背景:虚弱是一种生理应激恢复能力下降的综合征,与特定手术术后住院时间(LOS)的增加有关。然而,文献缺乏对手术过程中虚弱和LOS之间关系的大规模分析。研究设计:我们使用美国外科医师学会国家手术质量改进计划(ACS NSQIP®)的数据,对2015年至2019年期间接受住院手术(包括急诊手术)的65岁以上患者进行了回顾性队列研究。用改良的5项衰弱指数(mFI-5)来衡量的衰弱被归类为非衰弱(mFI-5)。体弱多病患者比例较高的是黑人(10%比5.5%)、西班牙裔(6.1%比3.8%)、ASA IV/V级(23.3%比9.1%)、营养不良(2.7%比1.9%)和接受血管手术(16.5%比8.3%)。除了减肥手术外,他们在所有手术过程中都经历了更长的中位LOS。未经调整的分析显示,与mFI-5评分为0相比,mFI-5评分为4和5分别与中位LOS增加3.5天(95% CI 3.36-3.64)和4.64天(95% CI 3.96-5.32)相关。在调整分析中,虚弱仍然是中位LOS增加的重要危险因素,与mFI-5评分为0相比,mFI-5评分为5与3天的延长相关(95% CI 2.79-3.22)。亚组分析显示,mFI-5评分每增加1分,与急诊手术(0.5天,95% CI 0.48-0.52)和下肢搭桥手术(0.53天,95% CI 0.47-0.59)中位LOS增加的相关性最强。结论:即使在调整了患者和手术协变量后,虚弱也是老年手术患者术后长期LOS的独立危险因素。其他导致LOS增加的独立危险因素包括紧急手术、营养不良和ASA等级升高。
{"title":"Frailty as an independent risk factor for prolonged postoperative length of stay: A retrospective analysis of 2015–2019 ACS NSQIP data","authors":"Jane Y. Xu MPH , Hannah E. Madden BS , Pablo Martínez-Camblor PhD , Stacie G. Deiner MD","doi":"10.1016/j.jclinane.2024.111730","DOIUrl":"10.1016/j.jclinane.2024.111730","url":null,"abstract":"<div><h3>Background</h3><div>Frailty, a syndrome of decreased resilience to physiologic stress, has been associated with increased postoperative length of stay (LOS) for specific procedures. Yet, the literature lacks large-scale analyses examining the relationship between frailty and LOS across surgical procedure.</div></div><div><h3>Study design</h3><div>We conducted a retrospective cohort study of patients aged 65+ undergoing inpatient surgery including emergency procedures between 2015 and 2019 using American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) data. Frailty, measured by the modified 5-item frailty index (mFI-5), was categorized as non-frail (mFI-5 < 2) or frail (mFI-5 ≥ 2). We modeled LOS, adjusting for demographic variables, comorbidities, and surgical factors, and conducted a subgroup analysis based on emergency surgery status and surgical procedure type.</div></div><div><h3>Main results</h3><div>Among 1,254,809 patients, 29.0 % were frail. A higher proportion of frail patients were Black (10 % vs. 5.5 %), Hispanic (6.1 % vs. 3.8 %), of ASA class IV/V (23.3 % vs. 9.1 %), malnourished (2.7 % vs. 1.9 %), and underwent vascular surgery (16.5 % vs. 8.3 %). They experienced longer median LOS across all surgical procedures, except bariatric surgery. Unadjusted analysis revealed that mFI-5 scores of 4 and 5 were associated with increased median LOS by 3.5 days (95 % CI 3.36–3.64) and 4.64 days (95 % CI 3.96–5.32), respectively, compared to mFI-5 scores of 0. In adjusted analysis, frailty remained a significant risk factor for increased median LOS, with an mFI-5 score of 5 associated with a 3-day longer increase (95 % CI 2.79–3.22) compared to an mFI-5 score of 0. Subgroup analysis showed that each one-point increase in mFI-5 score had the strongest association with increased median LOS in emergency surgery (0.5 days, 95 % CI 0.48–0.52) and lower extremity bypass surgery (0.53 days, 95 % CI 0.47–0.59).</div></div><div><h3>Conclusions</h3><div>Frailty is an independent risk factor for prolonged postoperative LOS among older surgical patients, even after adjustment for patient and procedure covariates. Other independent risk factors for increased LOS include emergent surgery, malnutrition, and higher ASA class.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111730"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142872258","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2024.111729
Ho-Jin Lee M.D., Ph.D. , Ji-Yeon Sim M.D., Ph.D. , Inkyung Song Ph.D. , Srdjan S. Nedeljkovic M.D. , Duk Kyung Kim M.D., Ph.D. , Ah-Young Oh M.D., Ph.D. , Seung Zhoo Yoon M.D., Ph.D. , Young-Jin Moon M.D., Ph.D. , Mi-Hye Park M.D., Ph.D. , Insun Park M.D., Ph.D. , Jina Kim M.S. , Sang Rim Lee M.S. , Sunyoung Cho Ph.D. , Jae-Hyon Bahk M.D., Ph.D.
Study objective
VVZ-149 is a small molecule that inhibits the glycine transporter type 2 and the serotonin receptor 5-hydroxytryptamine 2 A. In this Phase 3 study, we investigated the efficacy and safety of VVZ-149 as a single-use injectable analgesic for treating moderate to severe postoperative pain after laparoscopic colectomy.
A continuous 10-h intravenous infusion of VVZ-149 (n = 141) or placebo (n = 143) administered after emergence from anesthesia.
Measurements
Pain intensity was assessed using a numeric rating scale (NRS) from the start of infusion for 48 h. The primary efficacy measure was the Sum of Pain Intensity Difference (SPID) for the first 12 h after the start of drug infusion. Other efficacy measures included SPID at other time points, opioid consumption via on-demand patient-controlled analgesia (PCA) and rescue medication, and proportion of patients who did not require rescue opioids for 48 h post-dose.
Main results
Pain relief as measured by SPID was significantly improved by 35 % in the VVZ-149 group compared to the placebo group at 6 h (p = 0.0193) and 12 h (p = 0.0047) after the start of infusion. Significantly lower pain intensity scores were observed between 4–10 h in the VVZ-149 group compared to the placebo group (p = 0.0007), reaching mild pain (mean NRS <4) at 8 h. VVZ-149 alleviated pain during the first 12 h post-dose with 30.8 % less opioid consumption and 60.2 % fewer PCA requests when compared with placebo. A higher proportion of patients receiving VVZ-149 were rescue opioid-free during 2–6 h (p = 0.0026) and 6–12 h (p = 0.0024) compared with the placebo group. VVZ-149 administration in post-colectomy patients was generally safe and well tolerated.
Conclusions
When compared to placebo, VVZ-149 infusion demonstrated a significant reduction of pain within the first 12 h after surgery with a substantial decrease in opioid use. VVZ-149 rapidly lowers the pain intensity starting at as early as 4 h post-dose, allowing subjects to experience mild pain levels from 8 h through 48 h. Therefore, the analgesic effect of VVZ-149 was shown to effectively relieve pain and reduce opioid use for treating moderate to severe pain in the early postoperative care setting.
{"title":"Reduction of postoperative pain and opioid consumption by VVZ-149, first-in-class analgesic molecule: A confirmatory phase 3 trial of laparoscopic colectomy","authors":"Ho-Jin Lee M.D., Ph.D. , Ji-Yeon Sim M.D., Ph.D. , Inkyung Song Ph.D. , Srdjan S. Nedeljkovic M.D. , Duk Kyung Kim M.D., Ph.D. , Ah-Young Oh M.D., Ph.D. , Seung Zhoo Yoon M.D., Ph.D. , Young-Jin Moon M.D., Ph.D. , Mi-Hye Park M.D., Ph.D. , Insun Park M.D., Ph.D. , Jina Kim M.S. , Sang Rim Lee M.S. , Sunyoung Cho Ph.D. , Jae-Hyon Bahk M.D., Ph.D.","doi":"10.1016/j.jclinane.2024.111729","DOIUrl":"10.1016/j.jclinane.2024.111729","url":null,"abstract":"<div><h3>Study objective</h3><div>VVZ-149 is a small molecule that inhibits the glycine transporter type 2 and the serotonin receptor 5-hydroxytryptamine 2 A. In this Phase 3 study, we investigated the efficacy and safety of VVZ-149 as a single-use injectable analgesic for treating moderate to severe postoperative pain after laparoscopic colectomy.</div></div><div><h3>Design</h3><div>Randomized, parallel group, double-blind, Phase 3 clinical trial (Trial no. <span><span>NCT05764525</span><svg><path></path></svg></span>).</div></div><div><h3>Setting</h3><div>5 tertiary referral centers in South Korea.</div></div><div><h3>Patients</h3><div>284 patients undergoing laparoscopic colectomy.</div></div><div><h3>Interventions</h3><div>A continuous 10-h intravenous infusion of VVZ-149 (<em>n</em> = 141) or placebo (<em>n</em> = 143) administered after emergence from anesthesia.</div></div><div><h3>Measurements</h3><div>Pain intensity was assessed using a numeric rating scale (NRS) from the start of infusion for 48 h. The primary efficacy measure was the Sum of Pain Intensity Difference (SPID) for the first 12 h after the start of drug infusion. Other efficacy measures included SPID at other time points, opioid consumption via on-demand patient-controlled analgesia (PCA) and rescue medication, and proportion of patients who did not require rescue opioids for 48 h post-dose.</div></div><div><h3>Main results</h3><div>Pain relief as measured by SPID was significantly improved by 35 % in the VVZ-149 group compared to the placebo group at 6 h (<em>p</em> = 0.0193) and 12 h (<em>p</em> = 0.0047) after the start of infusion. Significantly lower pain intensity scores were observed between 4–10 h in the VVZ-149 group compared to the placebo group (<em>p</em> = 0.0007), reaching mild pain (mean NRS <4) at 8 h. VVZ-149 alleviated pain during the first 12 h post-dose with 30.8 % less opioid consumption and 60.2 % fewer PCA requests when compared with placebo. A higher proportion of patients receiving VVZ-149 were rescue opioid-free during 2–6 h (<em>p</em> = 0.0026) and 6–12 h (<em>p</em> = 0.0024) compared with the placebo group. VVZ-149 administration in post-colectomy patients was generally safe and well tolerated.</div></div><div><h3>Conclusions</h3><div>When compared to placebo, VVZ-149 infusion demonstrated a significant reduction of pain within the first 12 h after surgery with a substantial decrease in opioid use. VVZ-149 rapidly lowers the pain intensity starting at as early as 4 h post-dose, allowing subjects to experience mild pain levels from 8 h through 48 h. Therefore, the analgesic effect of VVZ-149 was shown to effectively relieve pain and reduce opioid use for treating moderate to severe pain in the early postoperative care setting.</div><div><strong>Registration number</strong>: Trial Number <span><span>NCT05764525</span><svg><path></path></svg></span></div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111729"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142869393","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2024.111733
Muhan Li , Tingting Ma , Xueke Yin , Xin Zhang , Tenghai Long , Min Zeng , Juan Wang , Qianyu Cui , Shu Li , Daniel I. Sessler , Rong Wang , Yuming Peng
Backgrounds
The cerebral oximetry index (COx) uses near-infrared spectroscopy to estimate cerebral autoregulation during cardiac surgery. However, the relationship between intraoperative loss of cerebral autoregulation and postoperative delirium or stroke remains unclear in patients recovering from carotid endarterectomy (CEA).
Methods
Our prospective observational cohort study enrolled patients scheduled for CEA. COx was estimated as the coefficient of a continuous, moving Spearman correlation between mean arterial pressure and cerebral oxygen saturation. A receiver operating characteristics curve with Youden's index identified the optimal COx threshold for predicting a composite of postoperative delirium or new-onset overt stroke.
Results
One hundred and forty patients scheduled for CEA were enrolled. The incidence of delirium was 10.7 % (15/140) and the incidence of stroke was 3.6 % (5/140), including 1 patient who had both. The cumulative anesthesia time when COx exceeded 0.3 was longer in patients with complications than those without. When COx > 0.6, the corresponding predictive ability was AUC = 0.69, Youden index = 0.61, P = 0.0003, with a positive predictive value of 100 %. In the post hoc subgroup analyses, before clamping, the greatest increase in the risk was observed when COx > 0.7 for 20 min (Odds ratio = 3.10, 95 % CI 2.20, 3.78). In contrast, COx was not predictive during clamping. After clamping, the optimal COx threshold was 0.4 (AUC = 0.85, Youden index = 0.82, P < 0.0001), with the positive predictive value being 100 %.
Conclusions
COx is a promising metric for predicting postoperative delirium or new-onset overt stroke in patients having CEA. The optimal COx threshold was 0.7 in the pre-clamping phase and 0.4 in the post-clamping phase.
{"title":"Cerebral oximetry index indicates delirium or stroke after carotid endarterectomy: An observational study","authors":"Muhan Li , Tingting Ma , Xueke Yin , Xin Zhang , Tenghai Long , Min Zeng , Juan Wang , Qianyu Cui , Shu Li , Daniel I. Sessler , Rong Wang , Yuming Peng","doi":"10.1016/j.jclinane.2024.111733","DOIUrl":"10.1016/j.jclinane.2024.111733","url":null,"abstract":"<div><h3>Backgrounds</h3><div>The cerebral oximetry index (CO<sub>x</sub>) uses near-infrared spectroscopy to estimate cerebral autoregulation during cardiac surgery. However, the relationship between intraoperative loss of cerebral autoregulation and postoperative delirium or stroke remains unclear in patients recovering from carotid endarterectomy (CEA).</div></div><div><h3>Methods</h3><div>Our prospective observational cohort study enrolled patients scheduled for CEA. CO<sub>x</sub> was estimated as the coefficient of a continuous, moving Spearman correlation between mean arterial pressure and cerebral oxygen saturation. A receiver operating characteristics curve with Youden's index identified the optimal CO<sub>x</sub> threshold for predicting a composite of postoperative delirium or new-onset overt stroke.</div></div><div><h3>Results</h3><div>One hundred and forty patients scheduled for CEA were enrolled. The incidence of delirium was 10.7 % (15/140) and the incidence of stroke was 3.6 % (5/140), including 1 patient who had both. The cumulative anesthesia time when CO<sub>x</sub> exceeded 0.3 was longer in patients with complications than those without. When CO<sub>x</sub> > 0.6, the corresponding predictive ability was AUC = 0.69, Youden index = 0.61, <em>P</em> = 0.0003, with a positive predictive value of 100 %. In the <em>post hoc</em> subgroup analyses, before clamping, the greatest increase in the risk was observed when CO<sub>x</sub> > 0.7 for 20 min (Odds ratio = 3.10, 95 % CI 2.20, 3.78). In contrast, CO<sub>x</sub> was not predictive during clamping. After clamping, the optimal CO<sub>x</sub> threshold was 0.4 (AUC = 0.85, Youden index = 0.82, <em>P</em> < 0.0001), with the positive predictive value being 100 %.</div></div><div><h3>Conclusions</h3><div>CO<sub>x</sub> is a promising metric for predicting postoperative delirium or new-onset overt stroke in patients having CEA. The optimal CO<sub>x</sub> threshold was 0.7 in the pre-clamping phase and 0.4 in the post-clamping phase.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111733"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142894703","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
To determine whether individualized fraction of inspired oxygen (iFiO2) improves pulmonary atelectasis after elective laparoscopic colorectal surgery relative to 60 % FiO2.
Design
This was a single-center, prospective, randomized study.
Setting
This study was conducted in a single tertiary care hospital in China.
Patients
A total of 84 eligible inpatients who underwent elective laparoscopic colorectal surgery between August 2021 and May 2022 were included in the study.
Interventions
The patients were randomly assigned to receive either a fixed fraction of inspiration oxygen (fFiO2 group) or individualized FiO2 based on physiological SpO2 (iFiO2 group).
Measurements
The primary outcome was the lung ultrasound score (LUS) at 30 min after extubation. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, the length of post-anesthetic care unit stay, the ratio of lung capacity on the third day after surgery compared with before surgery, the incidence of nausea and vomiting, and surgical site infections after surgery. Additionally, the airway plate pressure, airway peak pressure, pulmonary dynamic compliance, PaO2, oxygenation index, alveolar–arterial oxygen tension gradient (A-aDO2), and pulmonary shunt fraction (Qs/Qt) were considered.
Main results
The LUS was significantly lowered in the iFiO2 group (5 [4, 7]) compared with the fFiO2 group (8 [4, 10]) (P = 0.03). Based on the criterion for determining atelectasis, 25 patients (62.5 %) in the fFiO2 group experienced significant atelectasis compared with 15 patients (37.5 %) in the iFiO2 group (P = 0.025). At the end of surgery, PaO2, A-aDO2, and Qs/Qt were significantly reduced in patients in the iFiO2 group compared with those in the fFiO2 group.
Conclusions
The use of iFiO2 during operation significantly reduces the LUS and pulmonary atelectasis in patients undergoing laparoscopic colorectal surgery under general anesthesia.
{"title":"Individual FiO2 guided by SPO2 prevents hyperoxia and reduces postoperative atelectasis in colorectal surgery: A randomized controlled trial","authors":"Xia Wei , Xia Kang , Lijun Zhang , Jinzhu Huang , Weiyu Feng , Pengyu Duan , Bing Zhang","doi":"10.1016/j.jclinane.2024.111732","DOIUrl":"10.1016/j.jclinane.2024.111732","url":null,"abstract":"<div><h3>Study objective</h3><div>To determine whether individualized fraction of inspired oxygen (iFiO<sub>2</sub>) improves pulmonary atelectasis after elective laparoscopic colorectal surgery relative to 60 % FiO<sub>2</sub>.</div></div><div><h3>Design</h3><div>This was a single-center, prospective, randomized study.</div></div><div><h3>Setting</h3><div>This study was conducted in a single tertiary care hospital in China.</div></div><div><h3>Patients</h3><div>A total of 84 eligible inpatients who underwent elective laparoscopic colorectal surgery between August 2021 and May 2022 were included in the study.</div></div><div><h3>Interventions</h3><div>The patients were randomly assigned to receive either a fixed fraction of inspiration oxygen (fFiO<sub>2</sub> group) or individualized FiO<sub>2</sub> based on physiological SpO<sub>2</sub> (iFiO<sub>2</sub> group).</div></div><div><h3>Measurements</h3><div>The primary outcome was the lung ultrasound score (LUS) at 30 min after extubation. Secondary outcomes included the length of hospital stay, admission to the intensive care unit, the length of post-anesthetic care unit stay, the ratio of lung capacity on the third day after surgery compared with before surgery, the incidence of nausea and vomiting, and surgical site infections after surgery. Additionally, the airway plate pressure, airway peak pressure, pulmonary dynamic compliance, PaO<sub>2</sub>, oxygenation index, alveolar–arterial oxygen tension gradient (A-aDO<sub>2</sub>), and pulmonary shunt fraction (Qs/Qt) were considered.</div></div><div><h3>Main results</h3><div>The LUS was significantly lowered in the iFiO<sub>2</sub> group (5 [4, 7]) compared with the fFiO<sub>2</sub> group (8 [4, 10]) (<em>P</em> = 0.03). Based on the criterion for determining atelectasis, 25 patients (62.5 %) in the fFiO<sub>2</sub> group experienced significant atelectasis compared with 15 patients (37.5 %) in the iFiO<sub>2</sub> group (<em>P</em> = 0.025). At the end of surgery, PaO<sub>2</sub>, A-aDO<sub>2</sub>, and Qs/Qt were significantly reduced in patients in the iFiO<sub>2</sub> group compared with those in the fFiO<sub>2</sub> group.</div></div><div><h3>Conclusions</h3><div>The use of iFiO<sub>2</sub> during operation significantly reduces the LUS and pulmonary atelectasis in patients undergoing laparoscopic colorectal surgery under general anesthesia.</div><div>Clinical trial registration: ChiCTRT2100049615.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111732"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142894790","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2025.111744
Leonardo Marquez M.D. , Sara Medellin M.D. , Lu Wang M.S. , Kamal Maheshwari M.D. , Andrew Shaw M.B., F.R.C.A., F.R.C.P.C., M.M.H.C. , Daniel I. Sessler M.D.
Postoperative acute kidney injury (AKI) is common after non-cardiac surgery. Normal saline and lactated Ringer's solution are both used for volume replacement during surgery. Normal saline decreases renal blood flow and causes hyperchloremic acidosis whereas lactated Ringer's does not. The incidence of AKI is similar with modest volumes of each fluid. But it remains unclear whether larger volumes of normal saline provoke AKI.
Objective
Evaluate whether intraoperative crystalloid volume modifies the relationship between the AKI risk and treatment group.
Design
Secondary analysis of a single-center multiple cross-over cluster trial.
Setting
Intraoperative care.
Patients
We enrolled 8616 adults who had colorectal or orthopedic surgery at a large academic institution.
Interventions
Clusters of patients were alternately assigned to intraoperative normal saline or lactated Ringer's solution.
Measurements
The primary outcome was the incidence of acute kidney injury (AKI) as a function of intraoperative crystalloid volume (0–1, 1–2, 3–4, or 4+ liters) and the type of crystalloid. Our secondary outcome was the change in postoperative serum chloride concentration during the first 24 h.
Main results
The risk of AKI did not differ significantly in patients given 0–1, 1–2, or 3–4 L saline or lactated Ringers solutions. In contrast, patients given 2–3 or > 4 L of lactated Ringer's solution had a higher risk of AKI than those given saline. Patients assigned to normal saline had progressively greater plasma chloride concentrations than those given lactated Ringer's across all volume categories.
Conclusions
While saline administration clearly causes volume-dependent hyperchloremia, we found no evidence to support the theory that large volumes of saline provoke AKI. Therefore, either fluid seems reasonable for intraoperative use.
{"title":"Volume of intraoperative normal saline versus lactated Ringer's solution on acute kidney injury: A secondary analysis of the SOLAR trial","authors":"Leonardo Marquez M.D. , Sara Medellin M.D. , Lu Wang M.S. , Kamal Maheshwari M.D. , Andrew Shaw M.B., F.R.C.A., F.R.C.P.C., M.M.H.C. , Daniel I. Sessler M.D.","doi":"10.1016/j.jclinane.2025.111744","DOIUrl":"10.1016/j.jclinane.2025.111744","url":null,"abstract":"<div><div>Postoperative acute kidney injury (AKI) is common after non-cardiac surgery. Normal saline and lactated Ringer's solution are both used for volume replacement during surgery. Normal saline decreases renal blood flow and causes hyperchloremic acidosis whereas lactated Ringer's does not. The incidence of AKI is similar with modest volumes of each fluid. But it remains unclear whether larger volumes of normal saline provoke AKI.</div></div><div><h3>Objective</h3><div>Evaluate whether intraoperative crystalloid volume modifies the relationship between the AKI risk and treatment group.</div></div><div><h3>Design</h3><div>Secondary analysis of a single-center multiple cross-over cluster trial.</div></div><div><h3>Setting</h3><div>Intraoperative care.</div></div><div><h3>Patients</h3><div>We enrolled 8616 adults who had colorectal or orthopedic surgery at a large academic institution.</div></div><div><h3>Interventions</h3><div>Clusters of patients were alternately assigned to intraoperative normal saline or lactated Ringer's solution.</div></div><div><h3>Measurements</h3><div>The primary outcome was the incidence of acute kidney injury (AKI) as a function of intraoperative crystalloid volume (0–1, 1–2, 3–4, or 4+ liters) and the type of crystalloid. Our secondary outcome was the change in postoperative serum chloride concentration during the first 24 h.</div></div><div><h3>Main results</h3><div>The risk of AKI did not differ significantly in patients given 0–1, 1–2, or 3–4 L saline or lactated Ringers solutions. In contrast, patients given 2–3 or > 4 L of <em>lactated Ringer's</em> solution had a higher risk of AKI than those given saline. Patients assigned to normal saline had progressively greater plasma chloride concentrations than those given lactated Ringer's across all volume categories.</div></div><div><h3>Conclusions</h3><div>While saline administration clearly causes volume-dependent hyperchloremia, we found no evidence to support the theory that large volumes of saline provoke AKI. Therefore, either fluid seems reasonable for intraoperative use.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111744"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142965160","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2024.111711
Betul Kozanhan, Munise Yildiz, Mahmut Sami Tutar
{"title":"Assessing the safety of tramadol use in breastfeeding women undergoing perioperative care","authors":"Betul Kozanhan, Munise Yildiz, Mahmut Sami Tutar","doi":"10.1016/j.jclinane.2024.111711","DOIUrl":"10.1016/j.jclinane.2024.111711","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111711"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142824271","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-02-01DOI: 10.1016/j.jclinane.2024.111737
Yahui Xu , Nie Zhang
{"title":"Artificial neural networks and machine learning in anesthesia and perioperative medicine: Reflections on the 2024 Nobel prize in physics","authors":"Yahui Xu , Nie Zhang","doi":"10.1016/j.jclinane.2024.111737","DOIUrl":"10.1016/j.jclinane.2024.111737","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111737"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142894686","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
This study evaluated the spread of a local anesthetic, using MRI and sensory blockade, after an intertransverse process block (ITPB) at the medial aspect of the retro-superior costotransverse ligament (retro-SCTL) space – the medial retro-SCTL space block.
Methods
Ten healthy volunteers received a single-injection ultrasound-guided medial retro-SCTL space block at the T4-T5 level using a mixture of 10 ml 0.5 % bupivacaine with 0.5 ml gadolinium. At 15 min, they underwent a high resolution, fat suppressed, T1 weighted MRI scan of the cervicothoracic spine. Loss of sensation to cold was assessed at 15 and 60 min, and then hourly for 5-h, after the block.
Results
MRI showed consistent (100 %) spread of local anesthetic to the intercostal and paravertebral spaces, anterolateral aspect of the vertebral body (sympathetic chain), costotransverse space, neural foramina, and epidural space in all participants. However, sensory blockade was variable across the ipsilateral hemithorax. Hypoesthesia was more common than anesthesia in both the anterior (median [IQR], 3.5 [2–5] vs 0 [0–1.25], p < 0.001) and posterior (median [IQR], 6[3–7] vs 2[1–3], p < 0.001) hemithorax. Additionally, more dermatomes exhibited anesthesia in the posterior compared to the anterior hemithorax (median [IQR], 2[1–3] vs 0[0–1.25], p = 0.01). A variable number of contralateral dermatomes were also affected in 3 (30 %) volunteers. There was no statistically significant correlation between the local anesthetic spread and the number of hypoesthetic (r = 0.53, p = 0.11) or anesthetic (r = 0.09, p = 0.78) dermatomes on the ipsilateral hemithorax.
Conclusions
A single-injection medial retro-SCTL space block, at the T4-T5 level with 10.5 ml of local anesthetic, consistently spreads to the ipsilateral intercostal and paravertebral spaces, sympathetic chain, costotransverse space, neural foramina and epidural space, but produces ipsilateral sensory blockade that is variable and wider over the posterior than anterior hemithorax.
{"title":"Intertransverse process block (ITPB) at the retro-superior costotransverse ligament (retro-SCTL) space: Evaluation of local anesthetic spread using MRI and sensory blockade in healthy volunteers","authors":"Pawinee Pangthipampai MD , Palanan Siriwanarangsun MD , Jatuporn Pakpirom MD , Ranjith Kumar Sivakumar MD , Manoj Kumar Karmakar MD","doi":"10.1016/j.jclinane.2024.111718","DOIUrl":"10.1016/j.jclinane.2024.111718","url":null,"abstract":"<div><h3>Background</h3><div>This study evaluated the spread of a local anesthetic, using MRI and sensory blockade, after an intertransverse process block (ITPB) at the medial aspect of the retro-superior costotransverse ligament (retro-SCTL) space – the medial retro-SCTL space block.</div></div><div><h3>Methods</h3><div>Ten healthy volunteers received a single-injection ultrasound-guided medial retro-SCTL space block at the T4-T5 level using a mixture of 10 ml 0.5 % bupivacaine with 0.5 ml gadolinium. At 15 min, they underwent a high resolution, fat suppressed, T1 weighted MRI scan of the cervicothoracic spine. Loss of sensation to cold was assessed at 15 and 60 min, and then hourly for 5-h, after the block.</div></div><div><h3>Results</h3><div>MRI showed consistent (100 %) spread of local anesthetic to the intercostal and paravertebral spaces, anterolateral aspect of the vertebral body (sympathetic chain), costotransverse space, neural foramina, and epidural space in all participants. However, sensory blockade was variable across the ipsilateral hemithorax. Hypoesthesia was more common than anesthesia in both the anterior (median [IQR], 3.5 [2–5] vs 0 [0–1.25], <em>p</em> < 0.001) and posterior (median [IQR], 6[3–7] vs 2[1–3], p < 0.001) hemithorax. Additionally, more dermatomes exhibited anesthesia in the posterior compared to the anterior hemithorax (median [IQR], 2[1–3] vs 0[0–1.25], <em>p</em> = 0.01). A variable number of contralateral dermatomes were also affected in 3 (30 %) volunteers. There was no statistically significant correlation between the local anesthetic spread and the number of hypoesthetic (<em>r</em> = 0.53, <em>p</em> = 0.11) or anesthetic (<em>r</em> = 0.09, <em>p</em> = 0.78) dermatomes on the ipsilateral hemithorax.</div></div><div><h3>Conclusions</h3><div>A single-injection medial retro-SCTL space block, at the T4-T5 level with 10.5 ml of local anesthetic, consistently spreads to the ipsilateral intercostal and paravertebral spaces, sympathetic chain, costotransverse space, neural foramina and epidural space, but produces ipsilateral sensory blockade that is variable and wider over the posterior than anterior hemithorax.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"101 ","pages":"Article 111718"},"PeriodicalIF":5.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142864433","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-29DOI: 10.1016/j.jclinane.2025.111766
Zhi-hang Tang MD , Qi Chen MD , Wei Huang MD , Jia-nan Wang MD , Xiao-hua Zou PhD , Yang Xiao PhD , Xiao-tong Shi PhD , Hai-hong Deng PhD , Jing-jing Li PhD , Lun Wu PhD , Wen-zhi Liu PhD , Si-guang Hu PhD , Zheng-yang Zhou PhD , Heng-ning Qi PhD , Guo-hui Luan Phd , Wei Luo PhD , Yong Wang PhD , Wu-hua Ma Phd
Study objective
Difficult airway management is a significant challenge in clinical anesthesia, critical care, and emergency medicine. Inadequate management can lead to severe complications including organ damage and death. This study assessed the variability in difficult airway management across China and focused on how patient and operator factors influenced outcomes in operating rooms.
Design
A multicenter observational cross-sectional study.
Setting
This study was conducted from November 2022 to November 2023 and included 25 secondary and tertiary hospitals across various regions in China.
Patients
In the total of 181,399 general anesthesia patients, 384 (0.21 %) were identified as having difficult airways.
Interventions
Data were gathered from a specialized questionnaire comprising four sections with 27 questions and analyzed using logistic regression in SPSS to identify key factors that influenced effective management of difficult airways.
Measurements
This study focused on preoperative assessment, anesthesia selection, intubation attempts, and contingency planning for difficult airway management practices among anesthesiologists.
Main results
In anticipated difficult airways, rapid sequence induction was used in 51.7 % of the cases, maintaining spontaneous breathing under general anesthesia in 11.1 %, and awake intubation in 36 %. For unanticipated difficult airways, 95.9 % of the anesthesiologists opted for rapid sequence induction. Limited mouth opening was the most common cause of difficult airways and obesity and ankylosing spondylitis were identified as significant factors. The logistic regression analysis identified the type of difficult airway, anesthesiologist experience, and assessment methods as key factors influencing the first attempt intubation success.
Conclusions
The accuracy of difficult airway assessment and first attempt intubation success is influenced by both patient-related factors and the anesthesiologist's expertise. Regional and institutional variability in decision-making and tool selection underscores the critical need for standardized guidelines and comprehensive training to enhance airway management outcomes across diverse clinical settings in China.
{"title":"Difficult airway management in 25 hospitals across China: A multicenter cross-sectional study","authors":"Zhi-hang Tang MD , Qi Chen MD , Wei Huang MD , Jia-nan Wang MD , Xiao-hua Zou PhD , Yang Xiao PhD , Xiao-tong Shi PhD , Hai-hong Deng PhD , Jing-jing Li PhD , Lun Wu PhD , Wen-zhi Liu PhD , Si-guang Hu PhD , Zheng-yang Zhou PhD , Heng-ning Qi PhD , Guo-hui Luan Phd , Wei Luo PhD , Yong Wang PhD , Wu-hua Ma Phd","doi":"10.1016/j.jclinane.2025.111766","DOIUrl":"10.1016/j.jclinane.2025.111766","url":null,"abstract":"<div><h3>Study objective</h3><div>Difficult airway management is a significant challenge in clinical anesthesia, critical care, and emergency medicine. Inadequate management can lead to severe complications including organ damage and death. This study assessed the variability in difficult airway management across China and focused on how patient and operator factors influenced outcomes in operating rooms.</div></div><div><h3>Design</h3><div>A multicenter observational cross-sectional study.</div></div><div><h3>Setting</h3><div>This study was conducted from November 2022 to November 2023 and included 25 secondary and tertiary hospitals across various regions in China.</div></div><div><h3>Patients</h3><div>In the total of 181,399 general anesthesia patients, 384 (0.21 %) were identified as having difficult airways.</div></div><div><h3>Interventions</h3><div>Data were gathered from a specialized questionnaire comprising four sections with 27 questions and analyzed using logistic regression in SPSS to identify key factors that influenced effective management of difficult airways.</div></div><div><h3>Measurements</h3><div>This study focused on preoperative assessment, anesthesia selection, intubation attempts, and contingency planning for difficult airway management practices among anesthesiologists.</div></div><div><h3>Main results</h3><div>In anticipated difficult airways, rapid sequence induction was used in 51.7 % of the cases, maintaining spontaneous breathing under general anesthesia in 11.1 %, and awake intubation in 36 %. For unanticipated difficult airways, 95.9 % of the anesthesiologists opted for rapid sequence induction. Limited mouth opening was the most common cause of difficult airways and obesity and ankylosing spondylitis were identified as significant factors. The logistic regression analysis identified the type of difficult airway, anesthesiologist experience, and assessment methods as key factors influencing the first attempt intubation success.</div></div><div><h3>Conclusions</h3><div>The accuracy of difficult airway assessment and first attempt intubation success is influenced by both patient-related factors and the anesthesiologist's expertise. Regional and institutional variability in decision-making and tool selection underscores the critical need for standardized guidelines and comprehensive training to enhance airway management outcomes across diverse clinical settings in China.</div></div>","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"102 ","pages":"Article 111766"},"PeriodicalIF":5.0,"publicationDate":"2025-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143065869","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-01-24DOI: 10.1016/j.jclinane.2025.111767
Yael Frank , Franklin Dexter , Carlos E. Guerra-Londono
{"title":"Percentage contribution of anesthetic induction on total case fresh gas flow under inhalational anesthesia: A retrospective cohort study","authors":"Yael Frank , Franklin Dexter , Carlos E. Guerra-Londono","doi":"10.1016/j.jclinane.2025.111767","DOIUrl":"10.1016/j.jclinane.2025.111767","url":null,"abstract":"","PeriodicalId":15506,"journal":{"name":"Journal of Clinical Anesthesia","volume":"102 ","pages":"Article 111767"},"PeriodicalIF":5.0,"publicationDate":"2025-01-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143038962","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}