Perioperative Medicine最新文献

Background: Cardiovascular complications significantly influence outcomes in kidney transplant recipients, predominantly driven by the multifactorial risks associated with end-stage renal disease (ESRD). This study investigates the utility of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and the revised cardiac risk index (RCRI) in predicting cardiovascular events (CVE) after kidney transplantation (KT), aiming to refine risk assessment and management strategies pre-transplantation.

Methods: From May 2021 to May 2023, 122 ESRD patients scheduled for kidney transplantation were enrolled in a prospective cohort study at a single center. Pre-transplant NT-proBNP levels and RCRI scores were evaluated for their predictive accuracy for in-hospital and 1-month post-transplant CVEs.

Results: The median age of participants was 47.7 years. Pre-existing hypertension was present in 80.3%, diabetes in 26.2%, smoking history in 9.0%, and cardiovascular disease in 23%. A revised cardiac risk index (RCRI) score of 1 was present in 64.8% of cases. Over half of the patients had NT-proBNP levels above 1200 pg/mL. Patients with higher NT-proBNP levels exhibited lower left ventricular ejection fraction (LVEF) and higher systolic pulmonary artery pressure (PAP). Patients who experienced at least one CVE were older, with a trend toward a higher NT-proBNP level in this population. The RCRI showed no significant difference between patients with NT-proBNP levels above or below 1200 pg/mL. Still, it differed among patients with at least one CVE compared to those without. After adjusting the NT-proBNP level, RCRI = 3 had an odds ratio of 9.6 (1.6-57.4) for cardiovascular endpoints compared to those with RCRI 1 and 2.

Conclusion: NT-proBNP alone could not predict 30-day CVE after KT. Regarding the trend toward higher NT-proBNP levels in individuals with at least one CVE, further studies with a larger sample size should be done to assess whether integrating NT-proBNP and RCRI before KT can improve cardiovascular outcomes in this high-risk population.

Objective: This paper aimed to assess the effectiveness of the Roy adaptation model (RAM)-based nursing with continuity of care in improving mental health and quality of life in patients undergoing tumor resection.

Methods: A randomized controlled trial was conducted involving 114 patients diagnosed with malignant tumors, who were randomly assigned to either a control group receiving routine nursing care or an observation group receiving RAM-based nursing integrated with continuity of care. Both groups received sustained interventions over a 3-month period. Psychological resilience was assessed using the Connor-Davidson Resilience Scale (CD-RISC), and quality of life was evaluated with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at baseline and 3 months after the intervention. Following the intervention, satisfaction with nursing care was assessed through a hospital-designed satisfaction survey.

Results: Following the nursing intervention, the CD-RISC score of the observation group was higher than that of the control group (P < 0.05). The observation group showed higher EORTC QLQ-C30 scores in physical functioning, role functioning, emotional functioning, cognitive functioning, social functioning, and global health status compared with the control group, while scores for fatigue, pain, dyspnea, and insomnia were lower in the observation group than in the control group (P < 0.05). Additionally, nursing satisfaction was significantly higher in the observation group compared to the control group (P < 0.05).

Conclusion: The integration of RAM-based nursing with continuity of care significantly enhances postoperative psychological resilience and overall quality of life in patients after tumor surgery. This approach also improves nursing satisfaction, supporting its utility as an effective model for comprehensive postoperative nursing.

Background: Stellate ganglion block (SGB) improves postoperative sleep quality but is associated with a variety of complications. Linearly polarized light irradiation near the stellate ganglion region (LI-SG) is a non-invasive alternative. We investigated the effect of LI-SG on postoperative sleep disorders in patients undergoing modified radical mastectomy of breast cancer.

Methods: This prospective, randomized, controlled trial was conducted between June 2024 to December 2024, enrolling 114 patients undergoing modified radical mastectomy. Participants were randomly assigned to the control or the LI-SG group. The primary outcome was subjective sleep quality assessed using the Pittsburgh Sleep Quality Index (PSQI). Objective sleep measures (sleep efficiency, total sleep time and awaking times), visual analog scale (VAS) score, total number of patient-controlled anesthesia (PCA) compressions, serum indicators, and adverse events were recorded as the secondary outcomes.

Results: Compared to the control group, the PSQI and sleep efficiency, total sleep time and awakening times showed significant improvement at the second (all P < 0.001) and the 5th postoperative day (all P < 0.001) in the LI-SG group. The VAS score (3.51 ± 0.77 vs 2.51 ± 0.47, P < 0.001) and total number of PCA compressions (15.39 ± 2.11 vs 5.62 ± 1.53, P < 0.001) in the LI-SG group were significantly decreased. The serum melatonin was significantly increased, while TNF-α and IL-6 levels were decreased in the LI-SG groups at the second (all P < 0.001) and the 5th postoperative day (all P < 0.001). Furthermore, compared to the control group, the incidence of postoperative nausea and vomiting (16.07% vs 5.17%, P < 0.001) was lower and the patient satisfaction (4 vs 6, P < 0.001) was higher in the LI-SG group.

Conclusion: LI-SG improved the postoperative sleep quality and analgesic effect of patients, while improving patient satisfaction.

Surgical site infections (SSIs) are a major complication in surgical patients, particularly after cardiac surgeries, where the risk of postoperative infection ranges from 3.5% to 26.8%. Mediastinitis, severe concerns associated with open cardiac surgery, is linked to extreme deaths, increased medical expenses during hospitalization. We investigated the incidence and features of mediastinitis over a twenty-nine-year period as patient demographics and surgical indications evolved. Escherichia coli bloodstream infections (BSIs) contribute to significant mortality (5%-30%), with factors contributing to death remaining unclear, particularly with the rise of ESBL-producing organisms. Infective endocarditis (IE) is an infection that affects the cardiac endocardial layer, may cause valve vegetation, abscesses, and myopericarditis. Postoperative management requires a clinician with a deep understanding of cardiopulmonary function to address complications promptly. Infections of cardiac implanted electronic devices (CIEDs) are catastrophic, causing significant morbidity and mortality. Among CIED complications, infections drastically affect survival rates, require re-intervention, and lengthen hospital stays. Research shows a 1% infection rate within 12 months after CIED surgery. Acute Kidney Injury (AKI) is a common complication following major cardiac surgery, particularly in procedures involving cardiopulmonary bypass (on-pump). AKI significantly increases the risk of chronic kidney disease, cardiovascular complications, and mortality. Advanced age and pre-existing chronic kidney disease are recognized as key risk factors. Sepsis-induced cardiomyopathy (SICM), though primarily a general complication of severe sepsis, can also occur in post-cardiac surgery patients who develop sepsis as a secondary complication. The absence of standardized diagnostic criteria highlights an important knowledge gap and underscores the need for further research to improve recognition and management in this high-risk group.

Background: Preoxygenation is crucial for airway management safety. The standard method for preoxygenation is tidal volume breathing (TVB). This study aimed to determine whether an algorithmic approach, which involves stepwise adding pressure support ventilation (PSV) and positive end-expiratory pressure (PEEP) when TVB is inadequate, would improve preoxygenation.

Methods: Two hundred patients planned for general anesthesia and having end-tidal oxygen (ETO₂) < 90% after 3 min TVB were randomly divided into two: TVB was continued or 6 cmH₂O PSV was added. After 1 min PSV (i.e., at minute 4), patients still with ETO₂ < 90% were divided into two again: either PSV was continued or 4 cmH₂O PEEP was also added to PSV. The primary outcome was the time required to achieve ETO₂ ≥ 90%. Adverse effects were noted.

Results: After 4 min, patients with adequate preoxygenation were significantly higher with PSV (76%) compared with TVB (52%, P < 0.001). After 5 min, it was 97% and 100%, respectively. The mean durations of adequate preoxygenation with TVB, PSV, and PSV-PEEP between 4 and 5 min were 274.90 ± 18.55, 268.94 ± 12.24, and 252.38 ± 7.46 s, respectively. The differences between TVB and PSV-PEEP (P < 0.001) and between PSV and PSV-PEEP (P = 0.001) were significant. Total time was significantly longer with TVB (237.17 ± 40.31 s) compared with PSV (222.63 ± 27.24 s; P = 0.003).

Conclusions: An algorithmic approach, stepwise adding PSV and PEEP in patients inadequately preoxygenated with standard TVB, may improve adequate preoxygenation in all patients and reduces the time required. This statistical difference was significant, and although its clinical relevance may differ based on patient condition, it may support safer airway management in critically ill or high-risk patients. No serious adverse effects were observed.

Trial registration: NCT06736197.

Objective: To compare the analgesic and side effect profiles of three intrathecal morphine doses as part of an enhanced recovery protocol in obstetric patients undergoing caesarean section.

Methods: A prospective cohort study including ASA 2 females, over 18 years old having repeat elective caesarean sections. Primary outcomes include total oral morphine equivalents (mg) at 24 and 48 h, proportion of opioid free patients (24 and 48 h), and frequency of ITM-related side-effects. Secondary outcome measures include duration of analgesia, pain scores at 24 h, FAS at 24 h and length of stay.

Results: Five hundred seventy-four patients were divided into 150 mcg (190 patients), 125 mcg (191 patients) and 100 mcg (193 patients) intrathecal morphine groups. Effective analgesia was provided by all doses of ITM with a dose-dependent increase in side-effects. The median opioid consumption at 24 h was 10 mg in the 150 mcg group and 20 mg in the 125 mcg and 100 mcg groups. At 48 h, the median opioid consumption was 30 mg in the 150 mcg group and 45 mg in the 125 mcg and 100 mcg groups. The proportion of opioid-free patients at 24 and 48 h decreased with decreasing dose of ITM; 41% in 150 mcg group, 31% in the 125 mcg group and 28% in the 100 mcg group at 24 h. At 48 h, this reduces to 24% in the 150 mcg group, 15% (37.5% reduction in the 125 mcg group, and 13% (45.8% reduction) in the 100 mcg group. This designates analgesic inferiority of both 125 mcg and 100 mcg ITM doses compared to 150 mcg dosing. There was no significant difference between 125 and 100 mcg dosing. The duration of analgesia was greater in 150 mcg dosing (median duration 21 h) compared to 125 mcg (13 h) and 100 mcg (12 h) groups. No significant difference in pain scores was noted between doses. FAS scores demonstrated a trend towards functional limitation in 125 mcg and 100 mcg dosing compared to 150 mcg. There was no difference between the 125 mcg and 100 mcg groups. Increased pruritus was seen in the 150 mcg and 125 mcg groups (41%) compared to the 100 mcg group (32%). Increased nausea and vomiting was seen in the 150 mcg (49%) and 125 mcg (42%) groups compared to the 100 mcg group (24%). No difference in LOS was noted between doses (median difference 1.1 h).

Conclusion: All doses of ITM provide effective analgesia with 100 mcg dosing providing the best trade-off between analgesic efficacy and side effect profile.

Background: Identifying specific causes of intraoperative hypotension (IOH) is a challenge in clinical practice. Improving the causal treatment of hypotension requires a more detailed understanding of the underlying hemodynamic alterations during hypotension. This study aims to identify distinct hemodynamic endotypes of IOH by applying a deep learning model to high-resolution intraoperative hemodynamic data.

Methods: We conducted a retrospective analysis for surgical patients who had undergone continuous intraoperative monitoring of systemic vascular resistance index (SVRI), stroke volume index (SVI), stroke volume variation (SVV), cardiac index (CI), and heart rate (HR). IOH was defined as a mean arterial pressure (MAP) < 65 mmHg sustained for at least 1 min. A long short-term memory (LSTM)-based autoencoder was developed to compress multivariate time-series data into a two-dimensional latent space. Unsupervised clustering, k-means, was performed on the two-dimensional latent representations, and the optimal number of clusters was determined by Calinski-Harabasz (CH) and Davies-Bouldin (DB) index.

Results: A total of 184 patients experienced at least one episode of IOH, and 1304 hypotensive episodes with 253,380 data points were included for analysis. K-means identified five distinct IOH endotypes. Based on the characteristic hemodynamic profiles of each cluster, we labeled the five endotypes: (1) severe vasodilation with high CI, (2) hypovolemia, (3) myocardial depression, (4) bradycardia, and (5) mild vasodilation with preserved CI. Mild vasodilation with preserved CI occurred mainly in the first and second quartiles of the procedure. Bradycardia occurred throughout the procedure, but more frequently in the fourth quartile. Myocardial depression occurred primarily in the second quartile, and hypovolemia occurred frequently throughout the procedure. It was also observed that intra-event transitions between endotypes within the same hypotensive episode occurred in five events.

Conclusions: Five endotypes of IOH were identified, and this may support the development of causal treatment strategies of intraoperative hypotension, pending future validation.

Background: While intravenous iron improves outcomes in anaemic surgical patients, the impact of iron deficiency (ID) and its treatment in non-anaemic patients remains unclear.

Methods: In this single-centre retrospective analysis, non-anaemic ID patients (age ≥ 18 years) undergoing major cardiac surgery at the University Hospital Frankfurt were included. Primary endpoints were red blood cell (RBC) transfusion rate and use of RBC units. Secondary endpoints were increase in haemoglobin levels and postoperative outcome (mortality, length of stay, mechanical ventilation, laboratory values). Patients were assigned to the following groups: No-Iron (no anaemia, ID, and no iron supplementation) and Iron (anaemia, ID, and iron supplementation).

Results: A total of 3605 patients were screened, of whom 2345 were non-anaemic. Six hundred ninety-eight non-anaemic ID patients were included in the analysis, of whom 90 received intravenous iron supplementation. The overall RBC transfusion rate (43.6% [95% CI: 39.6-47.6] versus 50.0% [95% CI: 39.9-60.1]) and number of transfused blood units (2.0 [IQR: 1.0; 4.0] versus 2.0 [IQR: 1.0; 4.0]) were similar between patients of the No-Iron and Iron groups. Hospital length of stay, mortality, and postoperative complications were similar in both groups. When applying stricter cutoff values to define ID (ferritin < 30 μg/l), a trend toward reduced transfusion rates was observed: total RBC transfusion rate was 50.0% (95% CI: 34.9-65.2) in the No-Iron group and 42.9% (95% CI: 26.8-60.5) in the Iron group. In the case of short-term (1 day prior to surgery) iron supplementation, RBC unit utilisation and postoperative outcomes were comparable between the two groups.

Conclusion: In non-anaemic cardiac surgery patients, (short-term) preoperative intravenous iron supplementation showed no significant impact on RBC transfusion rate, haemoglobin levels, or postoperative outcomes. However, a stricter definition of ID revealed a trend toward reduced transfusion rates.

Background: Enhanced recovery after thyroid surgery remains variably implemented. The optimal approach to endotracheal intubation and timing of postoperative oral intake is still debated.

Objective: To evaluate the safety and feasibility of a modified electromyographic (EMG) endotracheal intubation protocol and early oral intake (EOI) after thyroid surgery, and their impact on recovery, procedural efficiency, and patient comfort.

Design: Single-centre, prospective, 2 × 2 factorial randomised controlled trial.

Setting: Peking Union Medical College Hospital, Beijing, China (April 2023 - February 2024).

Participants: Two hundred adult patients scheduled for elective thyroid surgery with intraoperative neural monitoring.

Interventions: Patients were randomized to receive either modified or conventional EMG intubation protocols, and subsequently to either early oral intake (within 1 h post-extubation) or delayed intake (6 h postoperatively).

Main outcome measures: The primary outcome was the Quality of Recovery-15 (QoR-15) score on postoperative day one. Secondary outcomes included QoR-15 on postoperative day two, intubation time, endotracheal tube readjustment, sore throat, thirst, hunger, nausea, vomiting, incisional pain, patient satisfaction, gastrointestinal recovery time, drainage volume, length of hospital stay, and adverse events.

Results: QoR-15 scores on postoperative day one did not differ significantly between groups. However, the modified intubation protocol reduced intubation time (median difference: - 13.0 s) and sore throat severity. EOI alleviated thirst and hunger without increasing adverse events. No group differences were observed in length of hospital stay or patient satisfaction.

Conclusion: While overall recovery scores remained unchanged, both the modified EMG intubation protocol and early oral intake improved perioperative comfort and procedural efficiency. These strategies are safe, feasible, and may be incorporated into enhanced recovery pathways for thyroid surgery.

Trial registration: ClinicalTrials.gov Identifier: NCT05624463.

Background: Moderate-to-severe pain is a common but often under-recognized complication after open colorectal surgery in older adults, leading to delayed recovery and extended hospitalization. Early identification of high-risk patients is essential for timely pain management. The objective of this study was to develop and internally validate a predictive model, presented as a nomogram, for estimating the risk of moderate-to-severe postoperative pain within 24 h among elderly patients undergoing open colorectal surgery.

Methods: We conducted a retrospective cohort study of 300 patients aged ≥ 60 years who underwent elective open colorectal surgery. Postoperative pain within 24 h was assessed using the Numerical Rating Scale (NRS); NRS ≥ 4 was defined as moderate-to-severe pain. Preoperative psychosocial, cognitive, inflammatory, and perioperative factors were evaluated. Multivariable logistic regression with stepwise AIC selection identified independent predictors. Model performance was assessed using ROC curves, calibration plots, the Hosmer-Lemeshow test, and decision curve analysis (DCA). A nomogram was developed for clinical use.

Results: Of the 300 patients, 120 (40.0%) experienced moderate-to-severe pain. These patients were older and had higher preoperative NRS and CRP levels, along with worse psychosocial and cognitive scores (P < 0.01). Seven variables independently predicted pain severity: GAD-7, PHQ-9, MMSE, MOS-SSS, CRP, operative duration, and undergoing a Miles procedure (P < 0.05). The model showed good discrimination (AUC = 0.79 in training; 0.77 in validation) and calibration. DCA demonstrated net clinical benefit across a range of thresholds.

Conclusion: We developed and validated a nomogram incorporating psychosocial, inflammatory, and procedural factors to predict moderate-to-severe postoperative pain. This tool may enable early risk stratification and guide individualized analgesic strategies in elderly patients.