Journal of perioperative practice最新文献

Background: Preoperative cognitive impairment is a strong risk factor for the development of postoperative delirium in older patients. The cognitive screening of patients in low- and middle-income countries remains a challenge due to socio-economic and cultural differences.

Method: This study was performed in 153 older patients undergoing lower limb orthopaedic surgery. Patients who were unable to speak and understand the Hindi language, patients with hearing (unaided) or speaking impairment, and patients with altered mental status were excluded. One day prior to the scheduled surgery, cognitive screening of patients using the animal fluency test and six-item screener was performed. Patients were screened daily for postoperative delirium using the confusion assessment method until 3 days after the surgery.

Results: The incidence of postoperative delirium was 6% in our study population. We found that statistically significant difference between the patients who developed postoperative delirium and those who remained unaffected, in terms of frailty, animal fluency test score, and duration of surgery. Frailty and the duration of surgery independently affected postoperative delirium. The receiver operating characteristic curve of animal fluency test and six-item screener showed areas under the curve of 0.796 and 0.656, respectively. The best cut-off point of animal fluency test for prediction of postoperative delirium was less than 8.50 with a sensitivity of 77.8% and a specificity of 66%.

Conclusion: The preoperative cognitive screening using animal fluency test can predict the occurrence of postoperative delirium with fair accuracy in older patients undergoing orthopaedic surgery. In contrast, the six-item screener demonstrated a weak association with postoperative delirium within our study population.

Purpose: Early recognition of paediatric emergence delirium (ED) by post-anaesthesia care unit (PACU) nurses is critical for the effective management and prevention of complications. This project aimed to enhance nursing education and standardise the use of the Paediatric Anaesthesia Emergence Delirium (PAED) scale as a reliable tool for assessing ED.

Design: This project involved an educational intervention for PACU nurses to train them in using the PAED scale for ED evaluation. The effectiveness of the PAED scale was compared with the more commonly used Face, Legs, Activity, Cry, Consolability (FLACC) scale in the evaluation of postoperative paediatric patients.

Methods: An educational programme was designed for PACU nurses, with pre-and post-surveys administered to assess the impact of the educational intervention on their knowledge, confidence, and familiarity with ED and the PAED scale. This project included time trials comparing the use of the PAED and FLACC scales during patient simulations after the educational intervention.

Findings: Following the educational programe, nurses demonstrated increased confidence and familiarity with ED and the PAED scale. Furthermore, the use of the PAED scale following the educational intervention significantly reduced the time required to evaluate patients and initiate treatment for ED compared with the FLACC scale.

Conclusion: Equipping nurses with the knowledge and skills to effectively implement the PAED scale improves ED's timely recognition and treatment, leading to safer, more efficient care for postoperative paediatric patients. This project demonstrates the importance of evidence-based tools and targeted nursing education.

Background: The transverse abdominis plane block is increasingly being used as a less-invasive alternative to thoracic epidural analgesia for effective pain management. This study aimed to compare transverse abdominis plane block with opioid-based thoracic epidural analgesia in terms of postoperative opioid consumption.

Methods: Patients in the thoracic epidural analgesia group received a continuous infusion of 0.1% levobupivacaine with 2mcg/ml of fentanyl, while those in the transverse abdominis plane group received 6-hourly boluses of 0.4ml/kg of 0.25% levobupivacaine. The primary objective was to compare the average fentanyl consumption, measured as intravenous fentanyl equivalents, over 72 hours.

Results: Data of 35 patients were analysed. Fentanyl consumption at the end of 72 hours was significantly lower in the transverse abdominis plane group (median [interquartile range] 495 mcg (255, 750), and mean (95% confidence interval) 717.35mcg (403.54-1031.16)) compared to the thoracic epidural analgesia group (median [interquartile range] 760mcg (750, 760), and mean (95% confidence interval) 787mcg (746.81-827.19)) with a p value of 0.010. Pain scores at rest and during movement were comparable between the groups (p > 0.05). However, the median pain scores during movement were significantly lower in the thoracic epidural analgesia group at 60 and 72 hours (p ⩽ 0.05).

Conclusion: Multimodal analgesia with transverse abdominis plane resulted in lower opioid consumption over 72 hours compared to thoracic epidural analgesia.

Studies comparing the intentional increase in oxygen delivery and normal oxygen delivery during general anaesthesia in elderly patients undergoing major abdominal surgery are limited and have reported contradictory findings. Therefore, the study aimed to evaluate the effect of intraoperative increase in systemic oxygen delivery on postoperative outcomes and quality of life in elderly patients undergoing major abdominal surgery. This randomised, blinded, parallel-arm, pragmatic clinical trial included elderly patients of >60 years of age undergoing major abdominal surgery. The patients in the intervention arm received noradrenaline or increased fractional inspiration of oxygen to augment central venous oxygen saturation ⩾75%. The primary outcome measure was composite of in-hospital mortality and major organ complications. The secondary outcome measure included comparison of quality of life. A total of 160 patients were assessed for eligibility, and 146 were randomised in the study groups. The mean arterial and central venous oxygen saturation increased and were significantly higher in the intervention arm. The composite primary outcome occurred in 49.31% in the intervention arm and 57.53% in the usual care arm (relative risk; 95% confidence interval: 0.85; 0.63-1.16; absolute risk reduction; 8.22%; p = 0.32). Furthermore, quality of life at the end of three months was similar (0.658 ± 0.19 versus 0.647 ± 0.19; p = 0.771). In conclusion, central venous oxygen saturation-guided increase in systemic oxygen delivery during the intraoperative period of major abdominal surgery in elderly patients did not reduce predefined composite outcome of in-hospital mortality or organ-specific complications.

Acute kidney injury (AKI) remains a common yet under-recognised perioperative complication associated with significant morbidity and mortality. Despite technological advances in monitoring and interventions, preoperative identification of at-risk patients remains suboptimal. This project aimed to assess the need and efficacy of a renal risk-stratification tool at a large Level 1 trauma centre in Eastern Georgia, combining qualitative findings and retrospective chart review analysis to guide perioperative AKI prevention. The project involved a two-phase approach: assess the need for a risk tool by surveying stakeholders, followed by piloting the Bell et al model retrospectively on 125 randomly selected patients at the facility. Findings revealed 42% of patients were at moderate to high risk for AKI, emphasising the utility of structured renal assessments to inform clinical decisions and improve outcomes.

Introduction: Identifying risk factors for acute kidney injury (AKI) following major non-cardiac surgery is challenging due to heterogeneous findings and variable relevance across published studies. This complexity hinders the development of a standardised prognostic model.

Methods: A systematic review and meta-analysis were conducted based on an extensive literature search (2002-2022) in PubMed, Scopus, Web of Science, Cochrane Central, LILACS, and Dart Europe. Studies were independently screened and selected, with extraction of relevant preoperative and intraoperative variables. Meta-analysis was performed using RevMan 5.4.

Results: Out of 533 studies, ten met inclusion criteria. Significant risk factors for postoperative AKI included diabetes mellitus (OR: 1.65, CI: 1.20-2.27), hypertension (OR: 1.86, CI: 1.36-2.54), ACE inhibitors or ARBs use (OR: 1.76, CI: 1.48-2.09), ischaemic heart disease (OR: 1.93, CI: 1.55-2.41), and male sex (OR: 1.28, CI: 1.07-1.53). Protective factors were female sex (OR: 0.72, CI: 0.54-0.96) and higher preoperative haemoglobin (MD: -0.41, CI: -0.52 to -0.30). Trends without statistical significance were noted for older age, low glomerular filtration rate, prolonged operative time, and higher serum creatinine.

Conclusions: Comorbidities and certain pharmacological treatments significantly elevate postoperative AKI risk. These findings underscore the need for vigilant preoperative risk stratification.PROSPERO registration:CRD420251111455.

Background: Acute kidney injury (AKI) is a serious complication in older patients with hip fractures. However, the prevalence and risk factors for both pre- and postoperative AKI remain poorly characterised. This study aimed to assess AKI prevalence before and after surgery in hip fracture patients and to identify associated clinical and surgical risk factors.

Methods: This retrospective observational study was conducted on patients admitted with hip fractures throughout 2020. AKI was defined using KDIGO criteria. Data collected included patient demographics, biochemical markers, perioperative details, and mortality outcomes. Statistical analysis compared AKI and non-AKI groups and examined surgical associations.

Results: A total of 190 patients were included. Preoperative AKI occurred in 2.1%, and postoperative AKI in 19.8%, with an overall AKI prevalence of 21.6%. Patients who developed AKI had significantly higher weight (p = 0.046) and longer hospital stays (p < 0.001). Postoperative AKI was significantly associated with being an inpatient at the time of fracture (p = 0.046). AKI development was also significantly associated with increased mortality (p = 0.001).

Conclusion: One in five hip fracture patients developed AKI, which was linked to higher mortality. Key risk factors included higher body weight, inpatient fractures, and prolonged admission. Early identification and tailored perioperative care are vital for improving outcomes.

Background: Video laryngoscopy improves glottic visualisation without requiring alignment of oral, pharyngeal and laryngeal axes. This study compared the intubation characteristics with the McGrath video laryngoscope in adults using a stylet, bougie or no intubating aid.

Methods: Seventy-two adult patients were randomised into three groups of 24 (group P, S and B). Using the McGrath video laryngoscope, group P was intubated with an unaided endotracheal tube, group S was intubated with a stylet and group B was intubated with a bougie. The intubation time was assessed as the primary outcome. Secondary outcome included the first-attempt success rate, overall success rate, ease of insertion, number of attempts and hemodynamic response to insertion.

Results: The mean intubation time was significantly less in group S (21.38[2.58] sec) compared to group P (24.38 [2.43] sec) and group B (27.25[2.82] sec) (p-value < 0.001). First-attempt success rate, overall success rate, ease of insertion, number of attempts and hemodynamic response to insertion were comparable in the three groups.

Conclusion: Intubation with McGrath video laryngoscope using a stylet required less intubation time in comparison to the use of a bougie or without any intubating aids, while the first-attempt success rate and overall success rate were comparable.

Traumatic brain injury in morbidly obese patients (body mass index ⩾ 35 kg/m²) presents complex perioperative challenges due to compounded respiratory, cardiovascular, and metabolic dysfunctions. Reduced functional residual capacity, obstructive sleep apnoea, and increased thoracoabdominal pressures impair oxygenation and elevate intracranial pressure. Cardiovascular comorbidities such as hypertension and arrhythmias further compromise cerebral perfusion. Altered pharmacokinetics in obesity demand weight-adjusted anaesthetic dosing to avoid over- or under-sedation. This narrative review highlights the need for a structured, evidence-based approach involving preoperative optimisation, advanced airway planning, lung-protective ventilation, and invasive haemodynamic monitoring to maintain cerebral perfusion pressure. Postoperative strategies should include cautious extubation, continuous positive airway pressure or high-flow nasal oxygen, multimodal analgesia, and close neurological monitoring. Dexmedetomidine offers neuroprotective advantages with minimal respiratory depression. Multidisciplinary collaboration among anaesthesia, neurosurgery, and intensive care teams is critical to minimising perioperative risks and improving outcomes in this high-risk population.