Perioperative Medicine最新文献

Introduction: Tranexamic acid has been widely used in plastic surgery. However, its efficacy has yet to be fully established. This meta-analysis aimed to determine its effectiveness in aesthetic plastic surgery.

Methods: Following PRISMA guidelines, we conducted a meta-analysis of prospective randomised clinical trials that compared the effects of topical or systematic administration of tranexamic acid versus the control group in aesthetic plastic surgeries. The study was registered on the International Register of Systematic Reviews (PROSPERO) and is available online ( www.crd.york.uk/prospero , CRD42023492585).

Results: Eleven studies encompassing 960 patients were included for the synthesis after critical evaluation. Systematic (MD - 18.05, 95% Cl, - 22.01, - 14.09, p < 0.00001) and topical (MD - 74.93, 95% Cl, - 88.79, - 61.07, p < 0.00001) administration of tranexamic acid reduced total blood loss. Topical tranexamic acid reduced drainage output (p < 0.0006).

Conclusion: Tranexamic acid reduced blood loss in aesthetic plastic surgery. More strictly defined RCTs, using high-quality methodology, are needed to evaluate the advantages and disadvantages of tranexamic acid in aesthetic plastic surgery.

Background: The I-FEED classification, scored 0-8, was reported to accurately describe the clinical manifestations of gastrointestinal impairment after colorectal surgery. Therefore, it is interesting to determine whether the I-FEED scoring system is also applicable to patients undergoing lumbar spine surgery.

Methods: Adult patients undergoing elective lumbar spine surgery were enrolled, and the I-FEED score was measured for 4 days after surgery. The I-FEED scoring system incorporates five elements: intake (score: 0, 1, 3), feeling nauseated (score: 0, 1, 3), emesis (score: 0, 1, 3), results of physical exam (score: 0, 1, 3), and duration of symptoms (score: 0, 1, 2). Daily I-FEED scores were summed, and the highest overall score is used to categorize patients into one of three categories: normal (0-2 points), postoperative gastrointestinal intolerance (POGI; 3-5 points), and postoperative gastrointestinal dysfunction (POGD; 6 + points). The construct validity hypothesis testing determines whether the I-FEED category is consistent with objective clinical findings relevant to gastrointestinal impairment, namely, the longer length of hospital stay (LOS), higher inhospital medical cost, more postoperative gastrointestinal medical treatment, and more postoperative non-gastrointestinal complications.

Results: A total of 156 patients were enrolled, and 25.0% of patients were categorized as normal, 49.4% POGI, and 25.6% POGD. Patients with higher I-FEED scores agreed with the four validity hypotheses. Patients with POGD had a significantly longer length of hospital stay (1 day longer median stay; p = 0.049) and more inhospital medical costs (approximately 500 Taiwanese dollars; p = 0.037), and more patients with POGD required rectal laxatives (10.3% vs. 32.5% vs. 32.5%; p = 0.026). In addition, more patients with POGD had non-gastrointestinal complications (5.1% vs. 11.7% vs. 30.0%; p = 0.034).

Conclusion: This study contributes preliminary validity evidence for the I-FEED score as a measure for postoperative gastrointestinal impairment after elective lumbar spine surgery.

Background: Good preoperative conditions help patients to counteract surgical injury. Prehabilitation is a multimodal preoperative management strategy, including physical, nutritional, psychological, and other interventions, which can improve the functional reserve of patients and enhance postoperative recovery. The purpose of this study is to show the evolution trend and future directions of research related to the prehabilitation of surgical patients.

Methods: The global literature regarding prehabilitation was identified from The Web of Science Core Collection database. Bibliometric methods of the Bibliometrix package of R (version 4.2.1) and VOSviewer were used to analyze publication trends, cooperative networks, study themes, and co-citation relationships in the field.

Results: A total of 638 publications were included and the number of publications increased rapidly since 2016, with an average annual growth rate of 41.0%. "Annals of Surgery", "British Journal of Surgery" and "British Journal of Anesthesia" were the most cited journals. Experts from the USA, Canada, the UK, and the Netherlands contributed the most in this field, and an initial cooperative network among different countries and clinical teams was formed. Malnutrition, older patients, frailty, and high-risk patients were the hotspots of recent studies. However, among the top 10 cited articles, the clinical effects of prehabilitation were conflicting.

Conclusion: This bibliometric review summarized the most influential publications as well as the publication trends and clarified the progress and future directions of prehabilitation, which could serve as a guide for developing evidence-based practices.

Background: Multimodal analgesia regimens are recommended for the postoperative period after hip and knee replacement surgeries. However, there are no data on practice patterns for analgesic use in the immediate postoperative period after hip and knee replacements in Australia.

Objectives: To describe analgesic prescribing patterns in the inpatient postoperative phase for patients undergoing hip and knee replacement.

Methods: Retrospective study of electronic medical record data from two major hospitals in Sydney, Australia. We identified analgesic medication prescriptions for all patients aged 18 years and older who underwent hip or knee replacement surgery in 2019. We extracted data on pain medications prescribed while in the ward up until discharge. These were grouped into distinct categories based on the Anatomical Therapeutic Chemical classification. We described the frequency (%) of pain medications used by category and computed the average oral morphine equivalent daily dose (OMEDD) during hospitalisation.

Results: We identified 1282 surgeries in 1225 patients. Patients had a mean (SD) age of 69 (11.8) years; most (57.1%) were female. Over 99% of patients were prescribed opioid analgesics and paracetamol during their hospital stay. Most patients (61.4%) were managed with paracetamol and opioids only. The most common prescribed opioid was oxycodone (87.3% of patients). Only 19% of patients were prescribed nonsteroidal anti-inflammatories (NSAIDs). The median (IQR) average daily OMEDD was 50.2 mg (30.3-77.9).

Conclusion: We identified high use of opioids analgesics as the main strategies for pain control after hip and knee replacement in hospital. Other analgesics were much less frequently used, such as NSAIDs, and always in combination with opioids and paracetamol.

Background: Postoperative delirium (POD) is a common neurologic disorder among elderly patients after non-cardiac surgery, which leads to various negative outcomes. Sleep disorder is considered an important cause of POD. The objective of this study was to investigate whether the Chinese traditional five-element music intervention could reduce POD by improving sleep quality in elderly patients undergoing non-cardiac surgery.

Methods: A total of 132 patients aged 65 to 90 years who underwent non-cardiac surgery were randomized to two groups: the intervention (n = 60) and the control group (n = 63). Patients in the intervention group were subjected to the Chinese traditional five-element music intervention during the perioperative, while patients in the control group had no music intervention. POD was evaluated using the Confusion Assessment Method (CAM) in the first 5 days after surgery. The Richards‒Campbell Sleep Questionnaire (RCSQ) was used to assess subjective sleep quality. The levels of nocturnal melatonin and cortisol in saliva were measured on the preoperative and the first 2 postoperative days.

Results: The incidence of POD within 5 days was 27.0% in the control group and 11.7% in the intervention group. Preoperative PSQI and MMSE scores were associated with POD. The RCSQ scores on the first postoperative day were significantly decreased in the two groups compared to the preoperative day. Compared to the control group, the RCSQ scores showed a significant improvement in the intervention group on the first postoperative day. Compared to the control group, the level of saliva melatonin in the intervention group showed a significant increase on the first postoperative day. However, there was no statistical difference in cortisol levels between the two groups.

Conclusions: Chinese traditional five-element music intervention decreased the incidence of POD in elderly patients who underwent noncardiac surgery via improving sleep quality, which may be associated with increased levels of melatonin.

Background: The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE).

Methods: Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery.

Results: In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019).

Conclusions: Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased.

Trial registration: Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).

Background: Frailty is common in patients undergoing cardiac surgery and is associated with poorer postoperative outcomes. Ultrasound examination of skeletal muscle morphology may serve as an objective assessment tool as lean muscle mass reduction is a key feature of frailty.

Methods: This study investigated the association of ultrasound-derived muscle thickness, cross-sectional area, and echogenicity of the rectus femoris muscle (RFM) with preoperative frailty and predicted subsequent poor recovery after surgery. Eighty-five patients received preoperative RFM ultrasound examination and frailty-related assessments: Clinical Frailty Scale (CFS) and 5-m gait speed test (GST_5m). Association of each ultrasound measurement with frailty assessments was examined. Area under receiver-operating characteristic curve (AUROC) was used to assess the discriminative ability of each ultrasound measurement to predict days at home within 30 days of surgery (DAH₃₀).

Results: By CFS and GST_5m criteria, 13% and 34% respectively of participants were frail. RFM cross-sectional area alone demonstrated moderate predictive association for frailty by CFS criterion (AUROC: 0.76, 95% CI: 0.66-0.85). Specificity improved to 98.7% (95% CI: 93.6%-100.0%) by utilising RFM cross-sectional area as an 'add-on' test to a positive gait speed test, and thus a combined muscle size and function test demonstrated higher predictive performance (positive likelihood ratio: 40.4, 95% CI: 5.3-304.3) for frailty by CFS criterion than either test alone (p < 0.001). The combined 'add-on' test predictive performance for DAH₃₀ (AUROC: 0.90, 95% CI: 0.81-0.95) may also be superior to either CFS or gait speed test alone.

Conclusions: Preoperative RFM ultrasound examination, especially when integrated with the gait speed test, may be useful to identify patients at high risk of frailty and those with poor outcomes after cardiac surgery.

Trial registration: The study was registered on the Chinese Clinical Trials Registry (ChiCTR2000031098) on 22 March 2020.

Background: Chronic heart failure (HF) is frequent in elderly patients undergoing non-cardiac surgery. Preoperative risk stratification is vital and can be achieved using simple clinical risk scores or preoperative N-terminal prohormone of brain natriuretic peptide (NT-proBNP) measurement. This study aimed to compare the predictivity of the revised cardiac risk index (RCRI), the American University of Beirut cardiovascular risk index (AUB-HAS2), and a score proposed by Andersson et al. for postoperative 30-day morbidity to preoperative NT-proBNP.

Methods: Preoperative NT-proBNP was measured in 199 consecutive patients aged ≥ 65 years undergoing elective non-cardiac surgery with intermediate or high surgical risk. The areas under the receiver operating characteristic curve (AUCROC) for the composite morbidity endpoint (CME) comprising the incidence of any rehospitalisation, acute decompensated HF, acute kidney injury, and any infection at postoperative day 30 were assessed. Multivariable logistic regression analysis derived new scores from the simple risk scores and the NT-proBNP cut-off of 450 pg/mL.

Results: AUB-HAS2, but not RCRI or Andersson score, significantly predicted the CME (AUB-HAS2: AUCROC 0.646, p < 0.001; RCRI: AUCROC 0.560, p = 0.126; Andersson: AUCROC 0.487, p = 0.760). The AUCROC was comparable between preoperative NT-proBNP (0.679, p < 0.001) and AUB-HAS2 (p = 0.334). Multivariable analyses revealed a preoperative NT-proBNP ≥ 450 pg/mL to be the strongest predictor of CME among the individual score components (p < 0.001). Adding preoperative NT-proBNP improved the predictive value of AUB-HAS2 and RCRI (modified AUB-HAS2: AUCROC 0.703, p < 0.001; modified RCRI: AUCROC 0.679, p < 0.001; both p < 0.001 vs original scores). The predictive value of the modified RCRI and AUB-HAS2 was comparable to preoperative NT-proBNP alone (p = 0.988 vs modified RCRI, p = 0.367 vs modified AUB-HAS2).

Conclusions: The predictive value of postoperative morbidity varies significantly between the available simple perioperative risk scores and can be enhanced by preoperative NT-proBNP. New scores, including preoperative NT-proBNP, should be evaluated in large multicentre cohorts.

Trial registration: German Clinical Trials Register: DRKS00027871.

Background: Postoperative delirium is a common complication in older patients, with poor long-term outcomes. This study aimed to investigate risk factors and develop a predictive model for postoperative delirium in older patients after major abdominal surgery.

Methods: This study retrospectively recruited 7577 patients aged ≥ 65 years who underwent major abdominal surgery between January 2014 and December 2018 in a single hospital in Beijing, China. Patients were divided into a training cohort (n = 5303) and a validation cohort (n = 2224) for univariate and multivariate logistic regression analyses and to build a nomogram. Data were collected for 43 perioperative variables, including demographics, medical history, preoperative laboratory results, imaging, and anesthesia information.

Results: Age, chronic obstructive pulmonary disease, white blood cell count, glucose, total protein, creatinine, emergency surgery, and anesthesia time were associated with postoperative delirium in multivariate analysis. We developed a nomogram based on the above 8 variables. The nomogram achieved areas under the curve of 0.731 and 0.735 for the training and validation cohorts, respectively. The discriminatory ability of the nomogram was further assessed by dividing the cases into three risk groups (low-risk, nomogram score < 175; medium-risk, nomogram score 175~199; high-risk, nomogram score > 199; P < 0.001). Decision curve analysis revealed that the nomogram provided a good net clinical benefit.

Conclusions: We developed a nomogram that could predict postoperative delirium with high accuracy and stability in older patients after major abdominal surgery.