Perioperative Medicine最新文献

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.

Objective: This study aimed to investigate the efficacy of endovascular embolization in treating ruptured intracranial aneurysms (RIAs).

Methods: RIA patients (n = 89) were grouped according to different surgical methods. The control group (n = 42) received aneurysm clipping surgery, whereas the observation group (n = 47) received endovascular embolization. The National Institutes of Health Stroke Scale (NIHSS) was used to assess neurological function pre-treatment and at 7 days post-treatment. Oxidative stress status, including superoxide dismutase (SOD) levels and serum malondialdehyde (MDA) levels, was compared between the two groups pre-treatment and at 7 days post-treatment. Intraoperative bleeding, operative time, and hospitalization time were compared between the two groups. Vascular endothelial function, including von Willebrand factor (vWF), endothelin-1 (ET-1), and nitric oxide (NO), was evaluated pre-treatment and 3 months post-treatment. Postoperative complications and surgical outcomes were observed.

Results: After treatment, compared to the control group, the observation group had lower NIHSS scores, higher SOD levels, and lower MDA levels, with statistically significant differences (all P < 0.001); the observation group also had less intraoperative bleeding, shorter operation times, and shorter hospital stays, along with lower vWF and ET-1 levels, higher NO levels, and statistically significant differences (all P < 0.001). The incidence of postoperative complications was lower in the observation group, with a statistically significant difference (P = 0.048). The therapeutic effect was better in the observation group, with a statistically significant difference (P = 0.041).

Conclusion: Compared with microscopic aneurysm clipping, endovascular embolization offers better efficacy for patients with RIA and causes less vascular endothelial damage.

Background: Painless gastroscopy is preferred by both patients and physicians, as it minimizes discomfort during the procedure. Alfentanil, a short-acting opioid analgesic, possesses pharmacological properties that make it suitable for inducing analgesia during gastroscopy. However, research on the optimal dosage of alfentanil when used in combination with propofol for gastroscopy is limited. Therefore, this study aimed to investigate the 50% and 95% effective doses (ED50 and ED95, respectively) of alfentanil in combination with propofol for gastroscopy, using Narcotrend monitoring.

Methods: Elective gastroscopy was performed in 51 patients aged 18-80 years, with a body mass index of 18-28 kg/m², and American Society of Anesthesiologists Class I or II. Based on their age, they were categorized into the youth group (18-60 years) and the elderly group (61-80 years). The patients were connected to the vital signs monitor and Narcotrend, and propofol was administered intravenously until the Narcotrend index was at Stage C1-C2 (65-74) and had stabilized for 1 min. Following this, alfentanil was administrated (initial dose, 5 µg/kg); if a positive reaction to the gastroscope placement was elicited, the dose was increased to a higher level in the next patient; otherwise, the dose was decreased to a lower level, with a dose gradient of 0.5 µg/kg. Gastroscope insertion was started 90 s later, and the criteria for a positive reaction to gastroscope insertion included coughing, nausea, and/or motor reaction during or within 1 min of gastroscope insertion. The test was stopped if seven folds occurred during the study. The ED50 values with their 95% confidence intervals (CIs) of alfentanil in combination with propofol for the inhibition of gastroscopic placement were calculated.

Results: Under the sedation conditions induced using alfentanil and propofol and detected using Narcotrend, the ED50 (95% CI) were 5.39 µg/kg (4.76-6.47) in the youth group and 5.69 µg/kg (4.67-6.31) in the elderly group, respectively.

Conclusions: The ED50 of alfentanil combined with propofol for gastroscopy under Narcotrend monitoring were 5.39 µg/kg in the youth group and 5.69 µg/kg in the elderly group, respectively.

Purpose: This study aimed to examine the feasibility and effects of preoperative 5 mg of melatonin and intraoperative 50 mg of ketamine on postoperative delirium (POD) prevention in candidates for colorectal cancer surgery.

Methods: In this randomized controlled trial, adults (> 18 years) who were candidates for elective colorectal cancer surgery were included in the study. Patients were randomized into four groups: placebo/saline (PS), melatonin/saline (MS), placebo/ketamine (PK), and melatonin/ketamine (MK). The groups received either 5 mg of oral melatonin or a placebo the night before surgery and 50 mg of ketamine or normal saline after anesthesia induction. The occurrence and severity of POD and pain severity were assessed via the confusion assessment method for the intensive care unit (CAM-ICU) and visual analogue scale (VAS), respectively (twice daily), until postoperative day 4.

Results: One-hundred and four patients (51% male, mean age: 56.29 ± 12.65) with a rate of 4.7 patients per week were recruited, with an attrition rate of 13.3%. The prevalence of POD was 17.3%, 22.23%, 16.67%, and 16.67% in the PS group, the MS group, the MK group, and the PK group, respectively. Compared with the control, none of the interventions significantly reduced the likelihood of POD occurrence.

Conclusion: This randomized controlled trial demonstrated the feasibility of recruiting and retaining surgical patients for a multi-arm perioperative intervention study. Although the interventions did not significantly reduce the incidence of POD, the study design and procedures were feasible, with acceptable recruitment and attrition rates. Compared to placebo, none of the interventions significantly reduced the incidence of POD; however, time was a significant factor, with POD incidence, severity, and pain decreasing longitudinally.

Trial regsitration: IR.TUMS.IKHC.REC.1401.374, registration date: 14 February 2023 and IRCT code: IRCT20120527009886N2, registration date: 07/03/2023.

Severe burn injuries complicated by acute respiratory failure present unique challenges in critical care medicine. Although the use of veno-venous extracorporeal membrane oxygenation (V-V ECMO) can offer life-saving support for this patient cohort, the perioperative management of burn patients on ECMO remains poorly standardized, and evidence-based guidelines are lacking. This perspective outlines the experiences gained from managing burn patients undergoing surgery while on V-V ECMO at a major burn center. Over a 3-year period, 14 patients with an average burned total body surface area (TBSA) involvement of 41% were treated with ECMO support. Several key strategies contributed to the safe surgical management of these patients. Looking ahead, there is a clear need for multicenter registry data and collaborative efforts to establish standardized perioperative protocols for burn patients receiving ECMO. Individualized anticoagulation management using point-of-care techniques such as thromboelastography, and the evaluation of optimal surgical timing strategies, will be essential areas for future research. In conclusion, interdisciplinary teamwork and structured perioperative management protocols can enable safe surgical treatment of burn patients on ECMO. Broader collaboration and standardized data collection are crucial steps to improving outcomes and establishing best practices for this complex patient population.

Background: The occurrence of pulmonary complications is common following major surgery, resulting in a diversity of detrimental outcomes. Nevertheless, there is a dearth of documentation examining the occurrence rate of pulmonary complications and related hazard factors following lumbar spine surgery by using a large-scale national database.

Methods: We conducted a retrospective database analysis from 2010 to 2019 by using the Nationwide Inpatient Sample (NIS). Patients undergoing lumbar spine surgery were included in the study. Patient demographics, in-hospital mortality, insurance type, total charges, hospital type, length of stay in hospital (LOS), preoperative comorbidities, as well as medical and surgical complications were appraised.

Results: In total, 932,563 lumbar spine operations were recorded in the NIS database from 2010 to 2019. The overall incidence of pulmonary complications following lumbar spine surgery was 3.54%. Patients with pulmonary complications after lumbar spine surgery presented prolonged LOS, higher in-hospital charges, and more preoperative complications (p < 0.001). Many preoperative comorbidities and postoperative complications were associated with pulmonary complications, which involved alcohol abuse, deficiency anemia, coagulopathy, diabetes (uncomplicated), drug abuse, metastatic cancer, psychoses, renal failure, weight loss, blood transfusion, cardiac arrest, postoperative delirium, septicemia, thrombocytopenia, hemorrhage/seroma/hematoma, nerve injuries and wound infection. Additionally, advanced age (≥ 75 years), number of comorbidity, type of insurance (Medicaid and Private insurance), teaching hospital, urban hospital were also associated with pulmonary complications.

Conclusions: The results of our study revealed a relatively low incidence of pulmonary complications subsequent to lumbar spine surgery. Investigating risk factors associated with postoperative pulmonary complications can be beneficial in ensuring proper management and mitigating the adverse effects.

Background: Morbidity and mortality following aortic valve surgery is high. Low antibody levels to endotoxin core and to staphylococcus is associated with poor outcome following cardiac surgery. Transcatheter aortic valve implantation (TAVI) is an alternative treatment to surgery. This study examines the relationship between antibody levels and outcome following TAVI.

Methods: Using enzyme-linked immunosorbent assays (ELISA), we measured pre-procedure levels of antibodies to endotoxin core (EndoCAb) and 2 common staphylococcal epitopes on saved serum of 112 adult patients scheduled to undergo elective TAVI. Primary outcome measure was post-procedure length of stay (LOS) in hospital with secondary outcome being development of infective complications. Correlations were examined using Spearman rank order or Kendall Tau-b methods. Patients were quartiled according to antibody levels and outcomes compared between quartile groups. Differences between groups were examined using Student t-test, one-way ANOVA, and Kruskal-Wallis tests.

Results: One hundred twenty-two patients (64 M, 58 F) were recruited with mean age of 86 years. Little correlation was seen between any of the individual antibody levels or combined ranked antibody level with length of stay following TAVI (correlation coefficients-teichoic acid r² = 0.02, alpha-toxin r² = 0.02, EndoCAb r² < 0.02, combined rank r² = 0.03). When groups were quartiled, there was little difference between median length of stay across all quartiles for each antibody (ANOVA-teichoic acid p = 0.153, alpha-toxin p = 0.332, EndoCAb p = 0.848, combined rank p = 0.374). There were no differences in the number developing post-operative infections between the quartiles for each antibody type (ANOVA-teichoic acid p = 0.994, alpha-toxin p = 0.962, EndoCAb p = 0.918, combined rank p = 0.855).

Conclusions: This study indicates that there is little association between post-procedural length of stay in hospital following TAVI and pre-procedural antibody levels to endotoxin or staphylococcus, unlike that seen with surgical patients. Understanding this relationship may enable improved selection of therapeutic options for patients with impaired immunity needing aortic valve interventions.

Trial registration: The patients in this study are a sub-group of a larger observational cohort study looking at the prevalence of cardiac amyloid in the elderly with aortic stenosis in those patients undergoing transcatheter aortic valve replacement.

Clinicaltrials: gov Identifier: NCT03029026.

Background: Recent trials demonstrated renoprotective effects of amino acid infusion in cardiac surgery patients, but real-world utilization patterns and outcomes across surgical specialties remain unknown. We investigated perioperative amino acid administration patterns and associated acute kidney injury (AKI) risk across different surgical populations.

Methods: Retrospective cohort study using the INSPIRE database (2011-2020) from Seoul National University Hospital. Adult patients undergoing surgery with ≥ 24-h stays were included. Amino acid preparations were identified by ATC codes, and AKI was defined by KDIGO criteria. Primary outcomes were AKI incidence and utilization patterns across surgical departments.

Results: Among 22,972 patients, 899 (3.9%) received peri-operative amino acid preparations with an overall AKI incidence of 3.7%. Utilization varied 60-fold across departments (0.2-11.5%). Surgery-specific patterns emerged: cardiac surgery showed no AKI events in amino acid users (0/50) versus 4.2% in non-users (p = 0.267), while non-cardiac surgery demonstrated increased AKI risk with amino acid use (7.4% vs 3.4%; RR = 2.16, 95% CI 1.65-2.85, p < 0.001). Multivariable analysis confirmed amino acid use as an independent AKI predictor (OR = 2.01, 95% CI 1.52-2.60). Machine learning analysis confirmed amino acids as the strongest AKI predictor, with Random Forest achieving superior performance (AUC-ROC 0.782) and revealing significant non-linear interactions. Propensity score matching (799 pairs) confirmed the association (OR = 1.63, 95% CI 1.05-2.52, p = 0.029).

Conclusions: Perioperative amino acid administration demonstrates surgery-specific patterns with differential AKI associations. These findings suggest that surgery-specific factors should be considered when developing amino-acid protocols, although causality cannot be established from this observational study.