Perioperative Medicine最新文献

Background: The airway should be thoroughly and accurately evaluated before anesthesia induction and endotracheal intubation. Awake direct laryngoscopy (ADL) can provide rapid, accurate, and intuitive airway assessment, especially for suspected difficult airways, and sometimes eliminates the need for fiberoptic intubation in some suspicious difficult airway cases. However, an optimal regimen has not been determined.

Methods: In this double-blind, controlled study, prior to ADL, 60 patients scheduled for general anesthesia were randomly allocated to receive 0.75 μg/kg of dexmedetomidine (Dex group, n = 20), 0.15 mg/kg of nalbuphine (Nal group, n = 20), or a placebo (control group, n = 20) intravenously over 10 min. At the same time, all study subjects received nebulized lidocaine for 15 min. The primary outcome was patient tolerance as assessed by a 5-point ADL comfort score, while secondary outcomes included satisfaction, coughing, pain, nausea and vital signs.

Results: Patients undergoing ADL in the Nal group had higher tolerance scores than those in the control and Dex groups [4 (3,4) vs. 3 (2,2.75), P < 0.017, and 4 (3,4) vs. 2 (2,2,75), P < 0.001, respectively] and higher satisfaction [7 (6,8) vs. 4 (3,5.75), P < 0.017, and 7 (6,8) vs. 5.5 (5,6), P < 0.001, respectively]. Additionally, the Nal group had significantly fewer adverse events, such as pain and nausea than the control and Dex groups. The sedation score and peripheral oxygen and saturation were significantly higher in the Nal group than in the Dex group, with no difference between the Nal and control groups (P < 0.001, P = 0.159, respectively).

Conclusions: Intravenous nalbuphine in combination with lidocaine aerosol inhalation significantly improved patient tolerance and satisfaction while reducing nausea, coughing, pain, sedation, and SpO₂ levels during ADL.

Background: Preoperative health optimisation for elective surgery entails supporting patients to improve their health in preparation for their treatment and recovery. While there is consensus that this process should address obesity, approaches vary across England. Despite guidance from the National Institute for Health and Care Excellence to the contrary, restrictive approaches with body mass index thresholds for referral to arthroplasty are in use. This qualitative study aimed to investigate the views of professionals on the current use and future implications of these policies.

Methods: Semi-structured interviews were conducted with 20 professionals including clinicians, commissioners, policymakers, and health service managers, with experience of developing and/or implementing health optimisation policies for elective arthroplasty. Participants were sampled from areas in England with and without restrictive policies. We undertook thematic analysis of the interview data.

Results: Participants described pre-surgical health optimisation as an important trigger for health improvement but identified current resourcing and inadequacies in provision of weight management support as significant barriers to success. Participants expressed concerns about the appropriateness and fairness of including obesity as a determinant to restrict access to surgery. They described short-term financial pressures underlying the use of restrictive body mass index thresholds and a lack of an evidence base, such that policies amounted to rationing and risked exacerbations of health inequalities. The study identified four priorities for improvements to future health optimisation practices: developing and implementing national guidance with flexibility for local variation, initiating patient engagement in primary care with onward integration across all services, improving resourcing to support effective equitable impact, and addressing wider determinants of obesity through societal change.

Conclusions: Overall, participants had limited expectations of the impact of health optimisation policies on obesity without additional support, investment, and national guideline implementation. They raised strong concerns over current restrictive approaches. We conclude that addressing concerns around weight management support service availability and impacts on health inequalities is essential for shaping effective health optimisation policies. Future policy direction should support health optimisation to be offered early (ideally in primary care). Health optimisation interventions should be non-restrictive, inclusive, and well-monitored, particularly around equality impact.

Simplified rapid hydration has been proven to be non-inferior to standard hydration in preventing contrast-associated acute kidney injury among chronic kidney disease patients undergoing coronary angiography. The current investigation aimed to further confirm the feasibility and safety of the newly proposed hydration method-simplified rapid hydration (SH) in each risk stratification by Mehran risk score (MRS). Eligible patients (n = 954) randomized to the SH group and standard hydration group were allocated into 2 groups based on MRS: low to moderate-risk and high to very high-risk groups. Primary endpoints were the incidence of contrast-associated acute kidney injury (CA-AKI) and acute heart failure (AHF) (SH vs standard hydration). Secondary endpoints included serum creatinine (Scr), blood urea nitrogen (BUN), cystatin-C (Cys-C), and C-reactive protein (CRP) at 24 h, 48 h, and 72 h after PCI procedure, and the incidence of major adverse cardiac events (MACE). MRS was associated with a higher incidence of CA-AKI (OR = 1.101, 95%CI 1.049-1.156, P < 0.001). In the low to moderate-risk and high to very-high-risk groups, the incidence of CA-AKI in the SH and standard hydration group was 3.3% versus 4.9% (P = 0.5342), 10% versus 12% (P = 0.6392), respectively. Meanwhile, there might be subtle differences in renal function indexes and inflammatory indicators between SH and the control group at different time points. The preventive effect of SH in CA-AKI was similar to standard hydration regardless of MRS-guided risk stratification.

Background: Preoperative oral carbohydrate intake can improve the postoperative recovery of fasting patients in many kinds of surgeries; however, the effect of carbohydrates on patients undergoing daytime oral surgery is still unclear. This study was designed to evaluate the effect of preoperative oral carbohydrate intake on the quality of recovery of patients undergoing daytime oral surgery using the quality of recovery-15 (QoR-15) questionnaire.

Methods: Ninety-two patients scheduled for daytime oral surgery were randomly allocated to the midnight fasting group (F group, n = 45) or the carbohydrate-Outfast loading group (O group, n = 47). Participants in the F group fasted from midnight the day before surgery. Patients in the O group also fasted but received the Outfast drink (4 ml/kg) 2-3 h before the induction of anesthesia. QoR-15 questionnaire, patient well-being, and satisfaction were assessed before anesthesia induction and 24 h after surgery. Perioperative blood glucose, postoperative exhaust time, and adverse events were also recorded.

Results: The QoR-15 scores were significantly higher in the O group than in the F group preoperatively and postoperatively. Seven parameters representing patient well-being evaluated on a numeric rating scale (NRS, 0-10) were lower in the O group than in the F group postoperatively, except for the hunger and sleep quality scores. Patient satisfaction scores on a 5-point scale were higher in the O group than in the F group preoperatively and postoperatively. Meanwhile, the postoperative exhaust time was significantly shorter in the O group compared to the F group, while there were no significant differences in blood glucose concentrations between two groups.

Conclusions: Preoperative oral carbohydrate intake could improve postoperative recovery quality, well-being, and satisfaction of patients undergoing daytime oral surgery 24 h after surgery, and may serve as a treatment option for patients undergoing daytime oral surgery.

Trial registration: This trial was registered in the Chinese Clinical Trial Registry (ChiCTR2100053753) on 28/11/2021.

Background: This monocentric randomized controlled pilot trial investigates the impact of virtual reality (VR) hypnosedation on perioperative anxiety, pain, patient satisfaction, and medication usage during port implantation under local anesthesia.

Methods: A total of 120 patients undergoing elective port implantation between January 2022 and August 2023 were enrolled and randomized in a 1:1 ratio to either a VR hypnosedation group or a control group. The VR group used a commercially available VR headset with the HypnoVR application, providing various environments, musical backgrounds, and a guiding voice, while the control group underwent the procedure without VR. Patients with ASA > 3, chronic pain, cognitive issues, and contraindications against VR use were excluded. The main outcomes measured were perioperative pain and anxiety scores, with secondary outcomes including perioperative medication usage. Due to the nature of the interventions, blinding of patients and physicians was not feasible. Statistical analysis was primarily descriptive and exploratory, focusing on estimating effect sizes for future trials.

Results: The study found no significant differences in immediate postoperative pain with 1.43 ± 1.63 vs. 1.6 ± 2.05 (p = 0.62) or anxiety scores 30.65 ± 9.13 vs. 31.78 ± 13.34 (p = 0.60) between the no VR and VR group, respectively. Additionally, there was a trend to less usage of certain medications, particularly remifentanil (mean dose of 200 mg vs. 100 mg (p = 0.12)) and novaminsulfon (mean dose of 1250 mg vs. 900 mg (p = 0.26)) in the VR group vs. no VR group, respectively. However, these differences were not statistically significant and therefore no definitive conclusions can be drawn regarding medication usage based on this data.

Conclusion: While VR hypnosedation did not significantly reduce perioperative pain or anxiety in this pilot trial, the observed trends in reduced medication usage suggest potential benefits. These findings warrant further investigation in larger, confirmatory trials to better understand the role of VR in enhancing patient comfort and potentially reducing reliance on pharmacological interventions during surgical procedures.

Trial registration: German Clinical Trials Register: DRKS00028508; registration date 15 March 2022; Universal Trial Number: U1111-1275-4995.

Background: Post-partum hemorrhage (PPH) is a leading cause of maternal death worldwide. However, the effect of blood transfusion in patients undergoing cesarean section remains unclear.

Materials and methods: The analysis was based on the retrospective evaluation of the pre- and post-operative data for 1231 patients who underwent a cesarean section at our hospital between January 2016 and June 2020. Patients were classified into the blood transfusion group (BT) and the no blood transfusion group (NBT) based on their intra-operative blood transfusion status.

Results: After propensity score matching, 322 patients were included in both groups and between-group differences in length of hospital stay (LOS), perioperative systemic inflammation indicators, and post-operative complications were evaluated. The LOS was longer in the BT (median, 6.6 days) than the NBT (median, 4.2 days) group (P = 0.026). The post-operative complication rate was higher for the BT than NBT group, as follows: vomiting, 3.2% vs. 4.9%, P = 0.032; fever, 5.41% vs. 2.24%, P = 0.032; wound complications, 15.44% vs. 10.45%, P = 0.028; and intestinal obstructions, 5.88% vs. 2.75%, P = 0.034. Systemic inflammation indicators increased significantly, from the pre-operative baseline, for both groups at post-operative day (POD) 1 and POD3. On multivariate analysis, intra-operative blood transfusion was associated with a longer LOS (hazard ratio, 1.52; 95% confidence interval, 1.07-2.25).

Conclusion: Intraoperative blood transfusion for cesarean section was associated with increased levels of systemic inflammation indicators, higher post-operative complication rates, and prolonged hospital stay.

Background: Although pulse oximetry technology, which is considered the standard of care to ensure optimum oxygenation, is indispensable in clinical practice, especially in the detection of hypoxemia, it has some limitations in the detection of hyperoxemia. Oxygen Reserve Index can provide clinicians with a crucial pathway in detecting and preventing hyperoxia, noninvasively. Our aim in this study is to determine the hyperoxia detection ability of ORi and to investigate the effectiveness of ORi and SpO₂-guided FiO₂ titration in preventing hyperoxia.

Methods: This prospective randomized study was conducted in the operating theater of Health Sciences University İzmir Tepecik Training and Research Hospital from September 1, 2020, to December 1, 2022. Patients undergoing major abdominal surgery were divided into two groups: the control group and the SpO2 + ORi group. FiO2 titration was performed in the SpO2 + ORi group to maintain the ORi between 0.00 and 95% < SpO2 ≤ 98%. Parameters were recorded before induction, 10 min after intubation, and every hour during the operation.

Results: A positive linear relationship of 75.8% (r = 0.758) was found between PaO2 and ORi in the ORi + SpO2 group (p < 0.001). Moderate hyperoxemia was observed in 31.6% of patients in the control group, while it was not observed in the ORi + SpO2 group at the 3rd hour. PaO2 values decreased significantly over time in the ORi + SpO2 group with FiO2 titration (p < 0.001).

Conclusion: The combined use of SpO2 and ORi has been demonstrated to successfully guide FiO2 titration for optimal oxygenation and reduce hyperoxemia.

Objective: The lifetime risk of stroke is one in four people. As the population aged over 60 constantly expands, the impact of stroke on perioperative care is of increasing concern. This study investigates the effect of preoperative stroke on short- and long-term outcomes, hypothesizing that it decreases both 1-year mortality and days alive and at home up to 30 days after surgery (DAH30).

Methods: This cohort study investigated 290,306 adult patients with (7214) and without (283,092) preoperative stroke undergoing major non-cardiovascular, non-ambulatory surgery at 23 hospitals in Sweden between 2007 and 2014. Data were pre- and postoperatively matched with quality registers. Using logistic regression, significant independent risk factors influencing the risk of 1-year mortality and impeded DAH30 were identified with adjusted odds ratios calculated.

Results: Preoperative stroke was associated with higher 1-year mortality and lower DAH30, even after full adjustment for other co-morbid and surgical factors.

Conclusions: This large cohort showed preoperative stroke to impact both the patient-centered short-term outcome DAH30 and 1-year mortality. These findings should be considered in perioperative planning.

Background: A systematic review and network meta-analysis (NMA) to compare the safety and efficacy of pericapsular nerve group block (PENGB) with other regional analgesia techniques in patients undergoing total hip arthroplasty (THA).

Methods: We searched PubMed, Embase, Web of Science, and the Cochrane Library for relevant research from inception to May, 2024. Randomized controlled trials (RCTs) comparing PENGB with other regional analgesia techniques in patients undergoing THA were included. The primary outcome was resting pain scores at 6 h after surgery. The NMA was made by using Stata 15.1 software. Potential risk of bias was assessed by using CINeMA. Sensitivity and subgroup analyses were performed on the primary outcome.

Results: A total of 11 RCTs including 766 patients were eligible for inclusion. For postoperative resting and movement pain scores within 24 h analysis, PENGB + periarticular local anesthetic infiltration (PLAI) was found to be significantly more effective than other treatments and its Surface under the cumulative ranking curve (SUCRA) was the lowest. Moreover, PENGB + PLAI was ranked the best in reducing opioid consumption within 24 h and the length of hospital stay. PENGB was found to have significantly lower incidence of quadriceps motor block and postoperative nausea and vomiting (PONV).

Conclusions: PENGB is more likely to reduce the incidence of quadriceps motor block and PONV in patients undergoing THA, but PENGB + PLAI is superior to other regional analgesia techniques (PLAI, PENGB, fascia iliaca compartment block, and quadratus lumborum block) in improving postoperative pain and shortening the length of hospital stay.

Trial registration number: CRD42024538421.