Perioperative Medicine最新文献

Background and objectives: Remimazolam tosylate is a novel anesthetic agent known for its rapid onset, non-irritating and non-polluting properties, effective sedation with minimal respiratory depression, short duration of action, and suitability for continuous infusion. Additionally, it can be efficiently antagonized by flumazenil. This study aims to explore the feasibility and safety of Remimazolam tosylate for anesthesia induction while maintaining spontaneous respiration.

Methods: This prospective, randomized controlled trial involved patients aged 18-65 years with non-difficult airways who were scheduled for endotracheal intubation under general anesthesia. Participants, after receiving the same protocol of dexmedetomidine sedation and Lidocaine surface anesthesia, were randomly assigned to either the sevoflurane induction group or the remimazolam tosylate induction group, with 30 patients in each group. Anesthesia induction was performed while maintaining spontaneous respiration, followed by endotracheal intubation.

Results: All enrolled patients successfully underwent intubation, and no severe respiratory depression or other complications were observed in either group (Successful anesthesia induction intubation is defined as follows: (1) successful anesthesia induction without the need for rescue measures during the induction of anesthesia, (2) no awakening during anesthesia induction, (3) spontaneous breathing is preserved throughout the entire procedure, and (4) successful completion of intubation.). There were no statistically significant differences in heart rate, blood pressure, oxygen saturation, or blood gas results between the groups. Regarding the time required for anesthesia induction, the average time to achieve the condition for topical anesthesia to the throat was 7.3 min in the remimazolam group and 17.7 min in the sevoflurane group, which was statistically significant (P < 0.01). The total time to complete intubation was 11.4 min in the remimazolam group and 21.3 min in the sevoflurane group, which was statistically significant (P < 0.01). During the local anesthetic throat spray procedure, 47% of patients in the sevoflurane group and 80% in the remimazolam group experienced coughing. This difference was statistically significant. During intubation, 20% of patients in the sevoflurane group and 33% in the remimazolam group continued to cough, but this difference was not statistically significant..

Conclusion: Compared with sevoflurane, remimazolam can be safely and effectively used for intubation while preserving spontaneous breathing, with a shorter time to achieve conditions for topical anesthesia and intubation.

Background: Obesity is now recognized as a major global health challenge, associated with various comorbidities. Sleeve gastrectomy, a minimally invasive surgery, is accompanied by short-term complications such as postoperative pain, which undermines the advantages of this technique. Therefore, this study aims to compare the efficacy of intraperitoneal instillation with bupivacaine versus magnesium sulfate on early postoperative outcomes in patients undergoing sleeve gastrectomy.

Materials and methods: This study was conducted in Iran as a randomized controlled trial. A total of 105 patients candidates for laparoscopic sleeve gastrectomy were divided into three groups of 35 patients each: Group A(bupivacaine), Group B (magnesium sulfate), and Group C (normal saline). The VAS was used to assess postoperative pain in the first 24 h after surgery. Data were analyzed using SPSS version 16.

Results: Based on the results of the Kruskal-Wallis test, there was a significant difference in abdominal pain levels among the study groups at 1, 2, 4, and 6 h post-surgery (P-value < 0.05). Abdominal pain levels in both the bupivacaine and magnesium sulfate groups were significantly lower than those in the control group during the initial postoperative hours; however, no significant difference was observed between the bupivacaine and magnesium sulfate groups. Total rescue analgesic requests in the bupivacaine group was significantly lower than that in the control group (P-value = 0.010), with no significant difference observed between the bupivacaine and magnesium sulfate groups. Neither drug caused a significant difference in postoperative shoulder pain levels or the incidence of postoperative nausea and vomiting (P-value = 0.562).

Conclusion: This study revealed that intraperitoneal administration of bupivacaine at 1, 2, and 4 h postoperatively, and magnesium sulfate at 2, 4, and 6 h postoperatively, significantly reduced pain in patients undergoing sleeve gastrectomy compared to those who didn't receive these analgesics. The lack of efficacy of both interventions in alleviating shoulder pain underscores the necessity of investigating alternative approaches to achieve comprehensive pain management in this patient population.

Trial registration: Clinical Trial Registration  https://www.irct.ir/ , identifier (IRCT20230129057271N2).

Background: Very early hospital revisits following hemorrhoidectomy, particularly within 3 days of discharge, may reflect preventable peri-discharge complications more accurately than traditional 30-day readmission rates. However, few studies have systematically examined risk factors associated with this short-term outcome under real-world conditions.

Methods: We conducted a retrospective cohort study of 662 patients who underwent conventional hemorrhoidectomy for grade III or IV hemorrhoids at Lotung Poh-Ai Hospital between 2021 and 2023. The primary outcome was return to the emergency department (ED) within 3 days of discharge. Clinical, operative, and postoperative variables were analyzed using multivariate logistic regression.

Results: Of 662 patients, 46 (6.95%) returned to the ED within 3 days. The most common presenting symptom was severe wound pain (78.3%). Multivariate analysis identified thrombosed hemorrhoids (adjusted odds ratio [aOR], 3.05; 95% CI, 1.56-5.96; p = 0.001) and use of ≥ 2 postoperative analgesics (aOR, 3.96; 95% CI, 1.99-7.84; p < 0.001) as independent predictors of early ED revisit. Other clinical and laboratory variables were not significantly associated.

Conclusions: This study is among the first to identify specific predictors of ED visits within 3 days after hemorrhoidectomy. The presence of thrombosed hemorrhoids and escalated analgesic use may signal patients at risk for very early unplanned revisits. These findings challenge reliance on 30-day readmission metrics and support 72-h revisit rates as a sensitive quality indicator for discharge appropriateness and perioperative care.

Background: Cerebral oxygenation is an important area of concern during shoulder surgery in the beach chair position. Although infrequent, patients may experience serious morbidity or mortality secondary to the cerebral ischaemia which may follow cerebral desaturation. There is no published randomised control trial studying the effect of spontaneous ventilation vs intermittent positive pressure ventilation (IPPV) on cerebral oximetry.

Methods: We randomised 40 patients (20 in each treatment group) undergoing arthroscopic shoulder surgery to either breathe spontaneously or receive IPPV during their surgery. Other elements of anaesthetic care were standardised. We recorded a baseline measure of cerebral oxygen saturation immediately prior to induction of anaesthesia for each cerebral hemisphere. We measured cerebral oxygenation throughout the intraoperative period, but the treating anaesthetist was blinded to this data. The primary outcome was time-averaged change in cerebral oxygenation during the intraoperative period. The secondary outcome was the incidence of cerebral desaturation events, defined as a ≥ 20% fall below baseline, or an absolute value of 55% or less.

Results: We collected and analysed data on all 40 patients. The intraoperative increase in cerebral oximetry (mean, sd) for the left and right cerebral hemispheres was 10.5 (7.62) and 12.6 (6.24) for spontaneously breathing patients and 12.9 (7.65) and 11.0 (6.49) for IPPV patients (p = 0.332 and p = 0.427 respectively). There were three cerebral desaturation events in spontaneously breathing patients and eight in ventilated patients (p = 0.155).

Conclusions: Ventilatory strategy (IPPV vs spontaneous ventilation) did not have a statistically significant impact on cerebral oxygenation in this study.

Trial registration: This trial was retrospectively registered on 10/2/2023 with the ANZCTR. TRN ACTRN12623000143628.

Background: Intraoperative hypothermia, defined as a core temperature < 36.0 °C, is a common complication during gastrointestinal surgery, potentially affecting patient outcomes. This study aimed to develop a predictive model for intraoperative hypothermia based on clinical features.

Methods: In this retrospective, single-center study, we analyzed data from 418 patients who underwent gastrointestinal surgery between January and March 2024 at the First Hospital of Putian City, China. Core temperature was measured intraoperatively using a deep nasal probe every 15 min. Five machine learning models (logistic regression, random forest, support vector machine, XGBoost, and multilayer perceptron) were evaluated to develop a prediction model for hypothermia. Logistic regression (LR) was identified as the optimal model and used to develop a nomogram based on key features.

Results: Among 25 clinical features, 12 showed significant differences between the two groups. The LR model demonstrated the best predictive performance [accuracy = 0.808, area under the curve (AUC) = 0.872] and identified six key predictors: temperature at surgery start, surgery duration, cisatracurium use, preoperative temperature, anesthesia time, and preoperative red blood cell count. A nomogram constructed with these features exhibited excellent predictive ability (AUC = 0.877) and clinical utility, as confirmed by decision curve analysis.

Conclusion: This study highlights key predictors of intraoperative hypothermia and presents a reliable nomogram for risk prediction in patients undergoing gastrointestinal surgery. These findings can inform targeted interventions and improve perioperative care. Further validation with diverse cohorts is warranted to enhance generalizability.

Background: Malnutrition increases the risk of mortality. However, the predictive role of preoperative nutritional status in postoperative mortality remains underexplored. This study investigates the link between preoperative objective nutritional indices and postoperative mortality across all adult surgical patients and evaluates the predictive value of malnutrition for postoperative mortality.

Methods: This retrospective study included patients aged 18 or older who underwent surgery. Nutritional status was assessed using the Geriatric Nutritional Risk Index (GNRI) and the Prognostic Nutritional Index (PNI). Logistic regression analysis was performed to explore the relationship between preoperative nutritional status and postoperative mortality and to evaluate the predictive value of nutrition scores for mortality.

Results: The study included 79,648 patients. Among them, 12,392 (15.6%) were identified with malnutrition by GNRI, 13,773 (17.3%), by PNI, and 8,633 (10.8%) by both indices. A total of 276 patients died within 30 days after surgery. After adjusting for traditional risk factors, poorer nutritional scores were linked to increased mortality risk. GNRI and PNI also enhanced the predictive accuracy of postoperative mortality models, as evidenced by significant improvements in integrated discrimination and net reclassification.

Conclusions: Poor preoperative nutritional status, as indicated by GNRI and PNI scores, is associated with a higher risk of postoperative mortality. Integrating these scores into mortality prediction models significantly enhances their accuracy. These findings highlight the importance of screening surgical patients for malnutrition risk to inform perioperative nutritional management.

Trial registration: The Institutional Review Board (IRB) of Seoul National University Hospital No. H-2210-078-1368).

Aims: Remimazolam is a novel, ultra-short-acting intravenous benzodiazepine. Its efficacy in reducing the occurrence of postoperative delirium (POD) and neurocognitive disorders remains unclear. Therefore, we conducted a meta-analysis to evaluate the long-term effects of remimazolam on POD and neurocognitive disorders.

Methods and results: We searched PubMed, Embase, and Web of Science, covering the period from their inception to September 30, 2024. Randomized controlled trials (RCTs) and cohort studies comparing remimazolam with propofol or other sedative medical therapy were included. The primary outcome was the incidence of POD, while secondary outcomes included hypotension, hypoxia, bradycardia, agitation, and vomiting. A total of 11 studies involving 2188 patients were included (remimazolam group: 981, control group: 1207). Compared to the control group, remimazolam showed no significant improvement in POD (OR = 0.79, 95% confidence interval (CI) 0.53-1.17, p = 0.24, I2 = 50%), vomiting (OR = 1.35, 95% CI 0.85-2.15, p = 0.21, I2 = 0%), hypoxia (OR = 0.59, 95% CI 0.12-3.00, p = 0.53, I2 = 76%), and agitation (OR = 0.48, 95% CI 0.15-1.46, p = 0.19, I2 = 62%). However, remimazolam was associated with a lower incidence of hypotension (OR = 0.29, 95% CI 0.20-0.42, p < 0.001, I2 = 0%) and bradycardia (OR = 0.19, 95% CI 0.05-0.76, p = 0.03, I2 = 67%).

Conclusion: Our research indicates that remimazolam exhibits no superiority in preventing postoperative delirium. Further prospective studies are needed to confirm the effects of remimazolam on postoperative cognitive dysfunction.

Systematic review protocol: International Prospective Register of Systematic Reviews (PROSPERO): CRD42024593338.

Background: Obstructive sleep apnea (OSA) is an independent risk factor for perioperative respiratory complications. The STOP-Bang Questionnaire (SBQ) is a widely used screening tool; however, its utility in predicting respiratory depression during deep sedation for gastrointestinal endoscopy warrants further exploration. This study aimed to evaluate the predictive performance of the SBQ for respiratory depression in this patient population.

Methods: This prospective observational cohort study enrolled patients who underwent esophagogastroduodenoscopy (EGD) and colonoscopy under deep sedation at Dongguan Binhaiwan Central Hospital from November 2024 to February of the following year. The data collected included demographics, medical history, vital signs, and SBQ scores. Standard sedation monitoring was complemented by portable sleep monitoring systems to record the Apnea-Hypopnea Index (AHI). Patients were grouped based on their lowest intraoperative pulse oximetry (SpO₂) level. Spearman correlation, Kappa test, Receiver Operating Characteristic (ROC) curve analysis, and binary logistic regression were used to analyze the relationships between SBQ scores, AHI, and respiratory depression events.

Results: Data of 349 patients were included in the final analysis. Transient hypoxemia (SpO₂ < 90%) occurred in 65 (18.6%) patients, with 12 (3.4%) patients experiencing severe hypoxemia (SpO₂ < 80%). Both SBQ scores and AHI demonstrated significant negative correlations with SpO₂ levels (r = -0.520 and r = -0.737, respectively; both P < 0.001). Using SpO₂ < 85% as the threshold, the Area Under the ROC Curve (AUC) for the SBQ score was 0.942. The optimal SBQ cutoff value was 2.5, yielding a sensitivity of 0.871 and a specificity of 0.912. Logistic regression identified snoring (OR = 14.240), observed apnea (OR = 7.092), and elevated BMI (OR = 10.904) as independent predictors of severe hypoxemia.

Conclusion: Respiratory depression events are relatively common during deeply sedated gastroenteroscopies. The SBQ score effectively predicts this risk, particularly in identifying patients susceptible to severe hypoxemia. An SBQ score ≥ 3 serves as a practical threshold for recognizing high-risk individuals, with snoring, observed apnea, and high BMI as key warning indicators. SBQ is a valid and concise preoperative screening tool for this patient group.

Clinical trial registration: Registry: ClinicalTrials.gov; Name: Preoperative Assessment of Hypoxia Risk in Painless GI Endoscopy; URL: https://www.chictr.org.cn/showproj.html?proj=272808 .

Background: Early return to intended oncological therapy (RIOT) after cancer resection is a determinant for long-term oncological outcomes. Sugammadex is increasingly used to reverse the muscle relaxant effect of rocuronium during general anesthesia. It has been shown to improve early postoperative outcomes, but its impact on RIOT is unknown. This study tested the hypothesis that the administration of sugammadex during mastectomy for nonmetastatic breast cancer resection would be associated with better RIOT-related outcomes compared with neostigmine.

Methods: Women ≥ 18 years who required mastectomy for nonmetastatic breast cancer resection from 2015 to 2022 were included in the retrospective study. They were grouped according to the administration of sugammadex or neostigmine. The study outcomes included time to RIOT, the incidence of RIOT at 90 and 180 days, length of hospital stay, and rate of 30-day hospital readmission. A multivariate analysis was conducted to test the association between sugammadex use and RIOT-related outcomes.

Results: Of 888 patients who met the study criteria, 319 received neostigmine and 569 received sugammadex. Sugammadex patients achieved RIOT at 90 days in 81.9% of the cases, whereas 70.8% of neostigmine patients were able to achieve RIOT (P < 0.001). Similar results were found for RIOT at 180 days (85.8% vs. 76.8%, respectively; P < 0.001). Sugammadex patients achieved RIOT faster than neostigmine patients (37 days, 95% CI: 35-41 days; P < 0.001). However, the multivariate analysis for RIOT initiation and time to RIOT did not show statistically significant differences.

Conclusion: The administration of sugammadex, compared with neostigmine, is not associated with significant improvements in RIOT-related variables after breast cancer surgery.