Perioperative Medicine最新文献

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.

Background: The OR generates over 30% of a healthcare facility's total waste, with more than 60% classified as regulated medical waste (RMW). Municipal waste (MW) is commonly incorrectly classified as RMW, resulting in unnecessary costs and environmental burden. As such, this pilot study aimed to determine if interventions that provide visual cues for waste classification and improve ergonomics in the operating room (OR) can improve waste sorting accuracy.

Methods: In groups of two to four, participants were tasked with quickly solving tangram puzzles while periodically given simulated medical waste to dispose of into either a MW container or a RMW container. Groups first engaged in a control simulation, followed by an intervention simulation where educational signage and the novel adapted waste bin was placed in the OR. Sorting accuracy was assessed, and participants completed a post-participation survey.

Results: 23 participants took part of this pilot study. The proportion of correctly classified waste increased between control (53%) and intervention (88%) conditions, p < 0.01. Cost (n = 21) and sustainability (n = 20) were highly cited reasons why it might be important to correctly dispose of waste. Participants cited location of the containers (n = 13), time issues or OR stress (n = 10), and confusion in waste classification (n = 13) as barriers to accurate waste sorting.

Conclusion: Participants had significant improvement in OR waste classification accuracy after the implementation of educational signage and a novel adapted bin system. These strategies can be employed to increase waste sorting accuracy in the OR or be used as an educational tool during trainings to improve staff understanding of proper waste disposal.

Background: Thoracic paravertebral block (TPVB) with liposomal bupivacaine (LB) is increasingly used for postoperative pain control in patients undergoing thoracic surgery, but relevant data are scarce, and there are few data on LB-TPVB combined with drainage tube patient-controlled analgesia (PCA). The aim of this study is to explore the effect of LB-TPVB combined with drainage-tube PCA on postoperative pain after thoracoscopic lobectomy.

Methods: This is a prospective, multicentre, double-blind, randomized controlled study. Participants will be randomly assigned to the standard bupivacaine (SB) group, SB + drainage-tube PCA (DTA) group, LB group, or LB + DTA group. The primary outcome is the 72-h mean Numerical Rating Scale (NRS) pain score at rest. The target sample size is 228 patients, with 57 patients in each group.

Discussion: Our study hypothesizes that preoperative ultrasound-guided thoracic nerve block combined with drainage tube self-controlled analgesia is more effective in reducing postoperative pain following thoracoscopic lobe resection compared to thoracic nerve block alone. Additionally, liposomal bupivacaine was found to be more effective than standard bupivacaine in this context. These results will have implications for improving postoperative analgesia protocols for patients undergoing thoracoscopic lung surgery.

Trial registration: ClinicalTrials.gov, NCT06165991. Registered 29 November 2023, https://clinicaltrials.gov/study/NCT06165991 .

Background: High-flow nasal oxygen (HFNO) is increasingly used for preoxygenation and apneic oxygenation; however, its efficacy during anesthesia induction for frame-based stereoelectroencephalography (SEEG) remains uncertain. This study evaluated whether HFNO is non-inferior to facemask ventilation in maintaining oxygenation during anesthesia induction for frame-based SEEG.

Methods: In this randomized, controlled, non-inferiority trial, adult patients with refractory epilepsy undergoing frame-based SEEG were randomized to either the HFNO or facemask group. The primary endpoint was the lowest peripheral oxygen saturation (SpO₂). Secondary endpoints included arterial blood gas analyses, hemodynamic measures, airway adjuncts use, first-pass intubation success (FPS), time to secure the airway, anesthesiologist satisfaction, patient comfort, and perioperative complications.

Results: Among 46 patients, the median (interquartile range [IQR]) lowest SpO₂ was 98 (97-99) % in the HFNO group vs. 96 (95-98) % in the facemask group, with a median difference of 1% (95 confidence interval [CI], 0-2%), confirming non-inferiority within a 2% margin. Post-intubation partial pressure of oxygen (PaO₂) was significantly higher in the HFNO group than that in the facemask group, with median (IQR) of 437.8 (411.1-474.4) mmHg and 400.6 (365.6-435.2) mmHg, respectively. HFNO reduced the airway adjuncts use (0/23 vs. 6/23 patients; p = 0.022), shortened the time to secure the airway (p = 0.015), and improved anesthesiologist satisfaction and patient comfort (both p < 0.0001). Hemodynamic parameters and FPS were similar between groups.

Conclusion: HFNO is non-inferior to facemask ventilation in maintaining oxygenation during anesthesia induction for frame-based SEEG. Moreover, HFNO reduces the need for airway adjuncts, shortens airway securement time, and enhances both patient and anesthesiologist satisfaction.

Trial registration: This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100044239; first registration date: March 12, 2021; https://www.chictr.org.cn/showproj.html?proj=119780 ).

Background: The Enhanced Recovery After Surgery (ERAS®) Society has overseen the development and publication of more than two dozen specialty-specific guidelines and consensus statements. We conducted an appraisal of existing guidelines to compare and contrast recommendations to identify overarching themes regarding the current role and future direction of those guidelines for clinicians and researchers.

Methods: After deriving a list of potential perioperative interventions associated with an ERAS program, specialty-specific guidelines were evaluated on the basis of their inclusion and the strength of the grade of those elements.

Results: Following appraisal of the existing ERAS guidelines, a list of common interventions emerges, which includes pre-, intra-, and postoperative care elements that are endorsed by the overwhelming majority of surgical specialties. However, this perioperative rubric should be modifiable to include a broader range of potential perioperative elements, where appropriate, based on literature specific to those subspecialty surgeries.

Conclusions: More uniform consensus regarding common care elements is likely to contribute to greater harmony in guidelines development as well as the development of process measures and outcome definitions. Guidelines can thus foster the creation of data repositories, establish program benchmarks, and contribute to future research and knowledge transfer.

Background: Postoperative delirium (POD) is a frequent and serious complication in older patients undergoing orthopedic surgery. This study aimed to compare the effects of midazolam and dexmedetomidine on the incidence of POD in elderly patients undergoing total knee arthroplasty under spinal anesthesia.

Methods: In this prospective, double-blind, randomized, parallel group comparative trial, a total of 175 patients aged 65 years or older were allocated to receive either midazolam or dexmedetomidine for intraoperative sedation. The primary outcome was the incidence of POD, evaluated using the confusion assessment method for five postoperative days. Secondary outcomes included the quality of sedation, incidence of sedation failure, postoperative analgesic profiles, and complication rates.

Results: The incidence of POD was significantly lower in the dexmedetomidine group compared to the midazolam group (13.9% vs. 27.4%, P = 0.045). In addition, dexmedetomidine was associated with superior sedation quality and a significantly lower rate of sedation failure (P = 0.007 and P = 0.018, respectively). Postoperative pain intensity and complication rates were comparable between the two groups.

Conclusion: Dexmedetomidine significantly reduced the incidence of POD and improved sedation quality compared to midazolam. These findings suggest that dexmedetomidine may be a preferable sedative for elderly patients undergoing total knee arthroplasty under spinal anesthesia.

Trial registration: This study was registered with the WHO International Clinical Trials Registry Platform (Trial number: KCT0006587, Registration date: 16th September 2021).

Background: Postoperative ischemic stroke is a severe complication in neurosurgery, while intraoperative hypertension is a frequent event. However, their clinical relationship remains poorly understood.

Methods: This retrospective cohort study analyzed data from patients with brain tumors undergoing craniotomies between January 2017 and December 2023 at Chongqing University Cancer Hospital. Multivariate logistic regression identified risk factors for postoperative stroke. Intraoperative hypertension was defined as a mean arterial pressure (MAP) > 105 mmHg, with indices including peak MAP, duration, and area under the curve (AUC). Restricted cubic spline analysis with three knots (10th, 50th, and 90th percentiles) was performed. The outcome was postoperative in-hospital acute ischemic stroke. The risk of stroke was assessed by quartile categorization of hypertension indices.

Results: A total of 1,786 patients were included in the final analysis. Intraoperative hypertension was identified as a risk factor for postoperative ischemic stroke, alongside age and intraoperative crystalloid infusion rate. Quatile analysis revealed the following risk thresholds of intraoperative hypertension: 1) peak value > 123 mmHg (aOR: 2.118, 95% CI: 1.360-3.297); 2) duration > 5 min (aOR: 1.604, 95% CI: 1.033-2.491); 3) AUC > 530 mmHg*min (aOR: 1.811, 95% CI: 1.165-2.816). Intraoperative hypertension was not significantly associated with postoperative stroke risk.

Conclusion: Intraoperative hypertension is a significant predictor of postoperative ischemic stroke in neurosurgical patients, with peak value, the duration, and AUC all demonstrating independent predictive values. These findings underscore the critical need for vigilant intraoperative blood pressure monitoring and management to mitigate stroke risk in neurosurgical patients.

Background: Postoperative neurocognitive disorders (PNDs) are highly prevalent among the elderly population. Identifying an ideal biomarker for postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) remains a significant challenge. This study aimed to investigate the relationship between these syndromes and various biomarkers, including S-100β, neuron-specific enolase (NSE), interleukin-6 (IL-6), and high-mobility group box-1 (HMGB-1).

Methods: The study included patients aged 60 years and older who underwent surgery for primary urologic malignancies. POD was evaluated in the recovery room using the Confusion Assessment Method (CAM). POCD was assessed preoperatively and at the first week (POCD1) and third month (POCD3) postoperatively using Addenbrooke's Cognitive Examination-III (ACE-III). Biomarker levels of S-100β, neuron-specific enolase (NSE), interleukin-6 (IL-6), and high-mobility group box-1 (HMGB-1) were measured using enzyme-linked immunosorbent assay (ELISA).

Results: A total of 54 patients completed the study. POD was diagnosed in 12 patients (22.2%), while POCD1 and POCD3 were identified in 17 (31.5%) patients and 12 (22.2%) patients respectively. The mean age of the participants was 73.8 ± 7.1 years. Preoperative levels of NSE were significantly higher in patients with POD compared to those without (p = 0.04). Additionally, preoperative and postoperative IL-6 levels, as well as preoperative and postoperative S-100β levels, were significantly elevated in patients with POCD1 compared to those without (p < 0.01, p = 0.01, p < 0.01, and p = 0.03, respectively). Furthermore, preoperative IL-6 and S-100β levels were higher in patients with POCD3 compared to those without (p = 0.01 and p = 0.03, respectively).

Conclusions: In major urologic oncologic surgeries among geriatric patients, IL-6 and S-100β were found to be associated with both POD and POCD, while NSE was specifically associated with POD.

Introduction: Perioperative bronchoaspiration is a serious complication often associated with inadequate fasting or delayed gastric emptying, including that caused by glucagon-like peptide-1 receptor agonists (GLP-1-RAs). Despite growing semaglutide use worldwide, evidence on the effectiveness of current preventive measures-such as residue-free diets-remains limited.

Case presentation: We report a 61-year-old female with obesity and chronic obstructive pulmonary disease who underwent elective coronary angiography. She had been using weekly semaglutide for weight loss, discontinued six days before the procedure, but did not disclose this during preoperative evaluation. Following institutional guidance, she adhered to a 24-h residue-free diet and 12-h fasting. A protocol breach led to omission of preoperative gastric ultrasound. During anesthesia induction, she experienced large-volume regurgitation requiring urgent airway management. Postoperative chest CT revealed aspiration-related inflammatory changes. She recovered uneventfully and later acknowledged omitting semaglutide use from her medical history because she did not consider it a "medication."

Conclusion: This case demonstrates that even stricter dietary measures than those recommended in current guidelines may not eliminate aspiration risk in GLP-1-RA users. Active screening for GLP-1-RA use, consideration of extended discontinuation intervals, and routine bedside gastric ultrasound should be incorporated into perioperative protocols to enhance patient safety.