Perioperative Medicine最新文献

Background: Perioperative hyperglycemia is associated with worse patient outcomes. Characterizing quality gaps in day-of-surgery glucose management can guide quality improvement teams to address this risk factor for infection, readmission, and death.

Methods: This retrospective cohort study used administrative and electronic health record data to describe process, outcome, and balancing measures of day-of-surgery glycemic management for adult patients with and without diabetes undergoing surgery at 6 hospitals in Alberta, Canada between 2019 and 2024. Participants were stratified by diabetes, prediabetes, no diabetes and unknown diabetes status. We report the association between hyperglycemia (blood glucose ≥ 10.0 mmol.L^-1) and length of stay, admission to ICU, and 30-day readmissions as an exploratory analysis.

Results: There were 12,275 eligible procedures including 3,164 procedures performed on patients with diabetes (25.8%). Of patients with diabetes, 85.4% (n = 2,703) had at least one glucose measurement on the day of surgery and 37.1% (n = 1,004) had hyperglycemia. About half of patients with diabetes and hyperglycemia received insulin (51.4%, n = 516). More than 10% of patients with prediabetes, no diabetes, and unknown diabetes status had hyperglycemia and less than 20% received insulin. Patients with hyperglycemia on the day of surgery had longer length of stay (4.49 days; 95% CI 4.70 to 5.18 days; p < 0.0001), postoperative ICU admission (aOR 5.37; 95% CI 4.45-6.49; p < 0.001) and odds of 30-day readmission (aOR 2.19; 95% CI 1.89-2.54; p < 0.0001).

Conclusions: There were important quality gaps in glucose measurement and hyperglycemia treatment for patients with diabetes. Hyperglycemia was common and clinically significant among patients without diabetes. Future work to understand the prevalence of hyperglycemia in patients without diabetes and to address quality gaps in day-of-surgery glucose measurement are needed.

Objectives: There is increasing evidence that prehabilitation before surgery may improve patient outcomes and should be established in perioperative care pathways. We aimed to explore the logistics of running a randomised controlled study delivering multimodal prehabilitation (exercise and lifestyle modification) of patients having aortic aneurysm repair. Our primary objective was to assess the feasibility of recruitment, retention, and adherence to study interventions. Secondary objectives were patient outcomes such as function, quality of life and postoperative complications.

Design: A feasibility, assessor-blinded, parallel-group, randomised controlled trial. Following ethical approval, adults scheduled for elective open or endovascular abdominal aortic aneurysm repair were randomised to one of three groups: (1) control, current standard practice with no prehabilitation workshop; (2) non-mentored prehabilitation, a prehabilitation workshop with no further patient contact; and (3) mentored prehabilitation, a prehabilitation workshop with addition of regular mentoring for up to eight weeks after the workshop. Primary feasibility outcomes included: adherence to study interventions (wearing trackers for >80% of the time, attendance to workshop if allocated) and 30% more activity in intervention groups than in control group); screening and recruitment; retention to eight-week follow-up; and maintenance of blinding to the outcome assessor. Secondary exploratory patient outcomes included complications; mortality; length of stay; quality of life; and functional outcomes.

Results: In total, 60 patients were screened, 45 were enrolled and randomised, and 43 were included in the intention-to-treat analyses. Feasibility of screening and recruitment was achieved, with 45/60 (75%) patients screened being recruited. Participant retention was achieved, with 40/43 (93.0%) of participants attending their eight-week follow-up and 23/43 (53.5%) wearing trackers for >80% of the time, usually due to device failure. Maintenance of blinding was achieved. Participants did not demonstrate a 30% increase in activity levels across the 3 groups. There were no significant differences in secondary patient outcomes.

Conclusions: The primary feasibility targets were partially met in terms of recruitment, retention, wearing of trackers, workshop attendance and completion of follow up procedures. However, the participants did not achieve 30% more activity in the workshop groups compared to the control group. A full randomised controlled trial is feasible with modifications to study design and prehabilitation interventions.

Trial registration: Clinicaltrials.gov ID NCT04169217).

Background: Geriatric patients commonly pose a significant challenge, mainly in emergency settings where the time to optimize the high-risk patient with other associated co-morbidities is inadequate, which predisposes these patients to a number of adverse outcomes postoperatively. There is paucity of data on intraoperative findings and predictors for length of hospital stay among elderly surgical patients in Uganda. This study assessed the intraoperative findings and predictors for length of hospital stay among elderly patients undergoing emergency exploratory laparotomy at Jinja, Lira, Hoima, and Fort Portal Regional Referral Hospitals in eastern, northern and western Uganda, respectively.

Methods: This was a prospective observational cohort in which elderly patients (≥ 65 years) that underwent emergency exploratory laparotomy were enrolled and followed up until time of discharge to assess for the number of days spent in hospital. The intraoperative findings were documented during surgery per study participant. SPSS version 26 was used for analysis, with modified Poisson regression done to determine the significant predictors. P < 0.05 was considered significant.

Results: Of the 86 participants, 29.1% were above 80 years of age. Majority were male (74.4%). The most common diagnosis was intestinal obstruction (55.8%) followed by gut perforation (30.2%). Of the 77 that survived, prolonged hospital stay was seen in 35.1%. The median length of hospital stay was 7 days, while the mean was 8.57 days. In the multivariable analysis, American association of anesthesiology class III and having a perforation were associated with prolonged hospital stay (P < 0.05 for all).

Conclusion: Over one third of the study participants had a prolonged hospital stay. Optimization of patients should focus on improving the American association of anesthesiology score, in order to create chances of early discharge and reduce cases of prolonged hospital stays.

Background: Intraoperative hypotension (IOH) is associated with adverse outcomes in high-risk surgical patients. Preoperative malnutrition may increase susceptibility to IOH, but evidence regarding its association with IOH assessed through multiple dimensions remains limited. This study aimed to evaluate the association between malnutrition and IOH.

Methods: This retrospective cohort study included 1504 adult patients who underwent elective high-risk non-cardiac surgery under general anesthesia. Nutritional status was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. IOH was evaluated across four dimensions: incidence, cumulative duration, proportion of anesthesia time in IOH, and lowest mean arterial pressure (MAP), based on both absolute (MAP < 65 mmHg) and relative (≥ 20% reduction from baseline) thresholds. The proportion of time in relative IOH, which demonstrated the most clinically meaningful difference, was pre-specified as the primary outcome for multivariable analysis. Associations were examined using propensity score matching and multivariable beta regression analysis.

Results: Compared to non-malnourished patients, malnourished individuals had a significantly greater proportion of time in relative IOH (0.48 ± 0.16 vs. 0.39 ± 0.17, Cohen's d = 0.54, P < 0.001), along with longer IOH duration and lower nadir MAP. Absolute IOH metrics showed no significant group differences. Malnutrition remained independently associated with increased relative IOH after adjustment for relevant covariates (P < 0.001). Subgroup and sensitivity analyses confirmed the robustness of these findings.

Conclusions: Preoperative malnutrition is independently associated with increased intraoperative hemodynamic instability when assessed by relative blood pressure thresholds. These findings underscore the importance of incorporating nutritional risk into perioperative risk stratification and highlight the need for prospective studies to validate these associations.

Purpose: Although both perineural and intravenous dexamethasone have been shown to extend the analgesic duration of single-shot interscalene brachial plexus blocks (ISB), the optimal route of administration remains uncertain. This meta-analysis systematically compares the efficacy and safety of perineural versus intravenous dexamethasone as adjuvants to ISB in patients undergoing arthroscopic shoulder surgery.

Methods: Primary outcomes assessed were analgesia duration, sensory block duration, and motor block duration. Secondary outcomes included postoperative pain scores, opioid consumption, and the incidence of adverse events, such as local anesthetic systemic toxicity (LAST). We systematically searched PubMed, Embase, and Web of Science from inception to May 31, 2021 under a prespecified protocol; studies published thereafter were beyond the scope of this review.

Results: A total of seven studies involving 846 patients were included in this analysis. Compared with intravenous administration, perineural injection of dexamethasone significantly prolonged analgesia duration (weighted mean difference WMD: 1.699 h; 95% confidence interval CI: 0.014-3.384; p = 0.048) and reduced postoperative pain scores at 12 h (WMD: -0.652; 95% CI: -1.129 to -0.176; p = 0.007). No significant differences were observed in sensory or motor block durations, postoperative pain scores, and opioid consumption at 24 h, or the incidence of adverse events, including dyspnea, sleep disturbances, and postoperative glucose level fluctuations.

Conclusions: Compared with the intravenous route, perineural dexamethasone modestly prolongs the duration of analgesia after single-shot interscalene block (approximately 2 h). However, the associated reductions in postoperative pain scores are small and unlikely to reach commonly cited MCID thresholds, rendering the overall clinical importance uncertain. These findings support cautious interpretation and individualized route selection rather than generalized claims of superiority.

Background: Scoliosis correction surgery involves surgical wounds, intense intraoperative stimulation, and severe postoperative pain, often necessitating the use of potent-opioids-based patient-controlled intravenous analgesia (PCIA), which have obvious side effects. An effective pain management strategy with both ensuring sufficient analgesia and minimizing opioid-related adverse effects is an urgent need in clinical practice. The ultrasound-guided erector spinae plane block (ESPB) has been reported to provide effective and safe analgesia in many surgical types. Building on this evidence, we hypothesize that ESPB can significantly reduce postoperative pain scores, decrease perioperative opioid consumption, and mitigate opioid-related side effects when compared to PCIA.

Methods: This study is a randomized controlled trial designed to test the superiority of ESPB in providing postoperative analgesia compared with PCIA. Forty participants undergoing idiopathic scoliosis surgery will be enrolled and randomly allocated in a 1:1 ratio into either the ESPB group or the PCIA group. The primary outcome is the resting numerical rating scale (NRS) pain score within 2 h postoperatively. The secondary outcomes include perioperative opioid consumption, the incidence of opioid-related adverse effects, and postoperative NRS pain scores on movement.

Discussion: The study will provide evidence for ESPB as an innovative and effective method for postoperative analgesia in scoliosis correction surgery. The results of this trial will contribute to the development of multimodal analgesia regime for managing spinal surgery.

Trial registration: The National Institutes of Health Clinical Trials Registry, NCT06728046. Registered on December 6, 2024.

Objectives: Perioperative blood transfusion in elderly patients is associated with various complications. This study aimed to develop a clinical prediction model for intraoperative blood transfusion in elderly patients undergoing hip fracture surgery to minimize transfusion requirements and related risks.

Method: Patients who underwent hip surgery between January 2021 and December 2023 at Xiangyang Central Hospital (Hubei, China) were retrospectively included in this study. Relevant factors for postoperative blood transfusion were analyzed using univariate and multivariate logistic regression analysis. A nomogram was established with the identified relevant factors, and its performance was evaluated using the area under the subject operating characteristic curve, calibration curve, and decision curve analysis.

Result: A total of 1092 patients were included in this study for evaluation. Through logistic regression analysis, we identified surgery type, preoperative hemoglobin level, platelet count, osteoporosis, and cerebrovascular disease as relevant factors for postoperative blood transfusion. The nomogram was established, and the areas under the curve of the subjects' work characteristics were found to be 0.730 (95% confidence interval [CI]: 0.686-0.773) and 0.726 (95% CI: 0.671-0.781) for the training and test sets, respectively.

Conclusion: In this study, we identified surgery type, preoperative hemoglobin level, platelet count, osteoporosis, and cerebrovascular disease as the risk factors for postoperative blood transfusion in elderly hip fracture patients. The nomogram, established based on these risk factors, showed an acceptable discriminative ability to predict intraoperative blood transfusion in elderly patients during hip fracture surgery.

Trial registration: This clinical trial was registered at http://www.chictr.org.cn/ (ChiCTR2400085204, June 03, 2024).

Background: Peritoneal symptoms, including visceral pain, abdominal discomfort, and vagal responses (e.g., nausea, bradycardia), are common during abdominal surgeries under spinal anesthesia. This study compared intrathecal dexmedetomidine and fentanyl for their effectiveness in controlling these symptoms during appendectomy.

Methods: This randomized, double-blinded clinical trial included 150 patients of the American Society of Anesthesiologists I, II physical status scheduled for emergency open appendectomy. Participants were randomly assigned to receive either intrathecal dexmedetomidine (5 μg, Group D) or fentanyl (25 μg, Group F), both combined with 0.5% hyperbaric bupivacaine.

Results: Dexmedetomidine significantly reduced the incidence of peritoneal symptoms compared to fentanyl: abdominal discomfort (9.5% vs. 33.3%), visceral pain (10.8% vs. 53.3%), nausea (9.5% vs. 34.7%), and vomiting (6.8% vs.34.7%) (P < 0.001). The time to first rescue analgesia was significantly longer in the dexmedetomidine group (396 vs. 243 min; P < 0.001). Bradycardia was more frequent in group D (25.7% vs. 1.3%, P < .001); no cases of respiratory depression were observed. Hypotension occurred slightly more frequently in group D, whereas shivering was more prevalent in group F; however, neither difference reached statistical significance. The VAS was significantly higher in group F than in group D at four and six hours postoperatively (P < 0.001).

Conclusions: Dexmedetomidine provides superior peritoneal symptom control and prolonged analgesia compared to fentanyl as an intrathecal adjuvant in spinal anesthesia for appendectomy. Despite a higher incidence of bradycardia, its opioid-sparing benefits and overall safety make it a valuable alternative, particularly for procedures involving significant visceral manipulation.

Background: Preoperative anemia is a major clinical problem that increases perioperative patient morbidity and mortality. Additionally, preoperative anemia causes hemodynamic instability, delayed recovery after anaesthesia and surgery, prolong length of hospital stay and increases risk of postoperative infection. However, the prevalence of preoperative anemia remains unexplored in conflict affected areas.

Objective: To assess prevalence and severity of preoperative anemia and associated factors among orthopedic patients in Bahir Dar city Comprehensive Referral Hospitals, Northwest Ethiopia, 2024.

Methods: Multi-center cross-sectional study was conducted. Data was collected using questionnaire and checklist. All consecutive scheduled emergency and elective patients were included in the study. Data was transformed from Epi data to SPSS and logistic regression analysis was done. Both crude and adjusted odds ratio were used to assess the strength of association. Hosmer -Lemeshow test and multi collinearity were checked. Variables with a p-value of less than 0.05 were considered as statistically significant.

Results: A total of 820 patients were included in this study with a response rate of 99.9%. Prevalence of preoperative anemia was 46.7% (n = 383/820) with (95%, CI = 0.33353- 0.5987) in this study. Emergency orthopedic cases (AOR = 3.014, CI = 2.480-5.717), traumatic related orthopedic cases (AOR = 2.01, CI = 1.480- 3.21), repeated history of anesthesia and orthopedic surgery (AOR = 3.11, CI = 1.480- 3.54), presence of coexisting diseases (AOR = 1.501, CI = 1.002- 3.74) and preoperative blood loss greater than 500 ml (AOR = 3.001, CI = 2.012- 5.104) were associated with preoperative anemia. CONCLUSION AND RECOMMENDATION: The prevalence of preoperative anemia among orthopedic patients was high in the study area. Orthopedic patients should be screened for preoperative anemia routinely. Additionally, nutritional and iron therapy should be given for mild to moderate anemia. Moreover, blood transfusion should be considered for patients with severe anemia.

Background: Enhanced Recovery After Surgery (ERAS) in cardiac surgery was designed to improve outcomes, reduce complications, and optimize recovery. Despite these efforts, perioperative anemia, a key modifiable risk factor that affects 20 to 41% of patients, remains under-addressed and is strongly associated with increased transfusion rates, morbidity, and mortality. Patient Blood Management (PBM) has demonstrated efficacy in improving outcomes by optimizing hemoglobin levels, reducing blood loss, and minimizing transfusions, although it is not yet fully integrated into cardiac ERAS pathways.

Main text: ERAS pathways are patient-centered, multidisciplinary, preventive and evidence-based. Although the principles of PBM align with ERAS, detailed PBM targets are often neglected in ERAS-based line of care. In cardiac surgery, the risks associated with anemia and transfusion are substantially higher than in other surgical specialties. However, perioperative interventions might manage anemia, mitigate bleeding risks, and improve tolerance to anemia in this particularly sensitive population. Implementation challenges include the need for institutional culture shifts and multidisciplinary education maintaining clinical awareness to support individualized recovery trajectories.

Conclusion: Integrating PBM into cardiac ERAS-based pathways addresses a critical gap that could lead to improved patient outcomes, reduced complications, lower transfusion rates, and optimized resource utilization. While healthcare progressively focuses on safety, quality, and value-based care, the convergence of ERAS and PBM offers a comprehensive approach to advancing perioperative medicine in cardiac surgery.