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Background

The efficacy and safety of opioid-free anaesthesia during bariatric surgery remain debated, particularly when administering multimodal analgesia. As multimodal analgesia has become the standard of care in many centres, we aimed to determine if such a strategy coupled with either dexmedetomidine (opioid-free anaesthesia) or remifentanil with a morphine transition (opioid-based anaesthesia), would reduce postoperative morphine requirements and opioid-related adverse events.

Methods

In this prospective double-blind study, 172 class III obese patients having laparoscopic gastric bypass surgery were randomly allocated to receive either sevoflurane–dexmedetomidine anaesthesia with a continuous infusion of lidocaine and ketamine (opioid-free group) or sevoflurane–remifentanil anaesthesia with a morphine transition (opioid-based group). Both groups received at anaesthesia induction a bolus of magnesium, lidocaine, ketamine, paracetamol, diclofenac, and dexamethasone. The primary outcome was 24-h postoperative morphine consumption. Secondary outcomes included postoperative quality of recovery (QoR40), incidence of hypoxaemia, bradycardia, and postoperative nausea and vomiting (PONV).

Results

Eighty-six patients were recruited in each group (predominantly women, 70% had obstructive sleep apnoea). There was no significant difference in postoperative morphine consumption (median [inter-quartile range]: 16 [13–26] vs 15 [10–24] mg, P=0.183). The QoR40 up to postoperative day 30 did not differ between groups, but PONV was less frequent in the opioid-free group (37% vs 59%, P=0.005). Hypoxaemia and bradycardia were not different between groups.

Conclusions

During bariatric surgery, a multimodal opioid-free anaesthesia technique did not decrease postoperative morphine consumption when compared with a multimodal opioid-based strategy. Quality of recovery did not differ between groups although the incidence of PONV was less in the opioid-free group.

Clinical trial registration

NCT05004519.

Background

Careful administration of either spinal (intrathecal) or general anaesthesia probably has a greater impact on outcomes after hip fracture surgery than which method is used per se. Intraoperative hypotension is associated with poorer outcomes, but appears less prevalent using lower doses of spinal anaesthesia.

Methods

In this observational single-centre study, intraoperative noninvasive blood pressure data were analysed from 280 patients undergoing unilateral hip fracture surgery after the administration of hyperbaric spinal bupivacaine 0.5%, 1.3 ml (0.65 mg).

Results

Mean cohort mean arterial pressure (MAP) remained within 10% of baseline (spinal injection) MAP for 97/98 (99.0%) subsequent aggregated 1-min recording intervals. The prevalences of lowest MAP <70 mm Hg and <55 mm Hg were significantly lower than historical equivalents (Anaesthesia Sprint Audit of Practice 1 and 2) (52.9% and 10.4% vs 71.9% and 23.8%, respectively, both <0.0001). The proportions of 10 551 MAP readings <70 mm Hg and <55 mm Hg were 6.7% and 0.4%, respectively. Forty-five (16.1%) patients had relatively persistent hypotension (MAP ≤70 mm Hg for five or more intraoperative readings), and were statistically more likely to be frail (Nottingham Hip Fracture Score ≥7/10, 37.8% vs 19.6%, P=0.0109) and be taking alpha-/beta-blockers (44.4% vs 24.3%, P=0.0099) than the remaining ‘normotensive’ cohort. Surgical anaesthesia remained effective for up to 190 min, with only one patient requiring supplemental local anaesthesia during skin closure.

Conclusions

Low doses of hyperbaric spinal 0.5% bupivacaine (1.3 ml, 6.5 mg) are associated with minimal reductions in blood pressure during surgery and provide adequate duration of surgical anaesthesia. Randomised comparisons of lower vs higher/standard doses of spinal anaesthesia are now required to confirm outcome benefits in this vulnerable patient group.

Clinical trial registration

NCT05799300.

Background

Enhanced Recovery After Surgery (ERAS) protocols for bariatric surgery improve clinical outcomes. However, the impact of ERAS protocols on patient satisfaction is unknown. Virtual reality has been implemented as an effective adjunct to standard analgesic regimens. This study seeks to find out if immersive virtual reality in the immediate postoperative period could improve the subjective quality of recovery and further reduce opioid requirements for bariatric surgery patients compared with ERAS care alone.

Methods

This is a single-centre, randomised clinical trial of patients recovering from laparoscopic bariatric surgery. Once in the post-anaesthesia care unit (PACU), participants will receive either an immersive virtual reality plus ERAS protocol or ERAS protocol alone. The primary outcome will be the Quality of Recovery-15 (QoR-15) score at PACU discharge. Secondary outcomes include PACU opioid requirements, length of PACU stay, PACU pain scores, QoR-15 score on postoperative day 1, hospital length of stay, opioid requirements, and opioid-related adverse effects until hospital discharge.

Conclusions

Positive findings from this study could introduce virtual reality as a non-pharmacological adjunct during PACU care that improves subjective recovery for patients undergoing bariatric surgery.

Clinical trial registration

NCT04754165.

Background

There is limited evidence to understand what impact, if any, recovery services might have for patients across the socioeconomic spectrum after critical illness. We analysed data from a multicentre critical care recovery programme to understand the impact of this programme across the socioeconomic spectrum.

Methods

The setting for this pre-planned secondary analysis was a critical care rehabilitation programme—Intensive Care Syndrome: Promoting Independence and Return to Employment. Data were collected from five hospital sites running this programme. We utilised a Bayesian approach to analysis and explore any possible effect of the InS:PIRE intervention on Health-Related Quality of Life (HRQoL) across the socioeconomic gradient. A Bayesian quantile, non-linear mixed effects regression model, using a compound symmetry covariance structure, accounting for multiple timepoints was utilised. The Scottish Index of Multiple Deprivation (SIMD) was used to measure socioeconomic status and HRQoL was measured using the EQ-5D-5L.

Results

In the initial baseline cohort of 182 patients, 55% of patients were male, the median age was 58 yr (inter-quartile range: 50–66 yr) and 129 (79%) patients had two or more comorbidities at ICU admission. Using the neutral prior, there was an overall probability of intervention benefit of 100% (β=0.71, 95% credible interval: 0.34–1.09) over 12 months to those in the SIMD≤3 cohort, and an 98.6% (β=−1.38, 95% credible interval: −2.62 to −0.16) probability of greater benefit (i.e. a steeper increase in improvement) at 12 months in the SIMD≤3 vs SIMD≥4 cohort in the EQ-visual analogue scale.

Conclusions

Using multicentre data, this re-analysis suggests, but does not prove, that an integrated health and social care intervention is likely to improve outcomes across the socioeconomic gradient after critical illness, with a potentially greater benefit for those from deprived communities. Future research designed to prospectively analyse how critical care recovery programmes could potentially improve outcomes across the socioeconomic gradient is warranted.

This editorial discusses a survey of anaesthesia trainees and trainers from the UK concerning training in regional anaesthesia. The study found a large disparity in the number and diversity of regional anaesthesia procedures carried out by trainees during their initial training and that the presence of a departmental regional anaesthesia training lead improves the quality of teaching of these techniques. This study emphasises the fact that there is still a huge effort required to provide adequate training in regional anaesthetic techniques in the UK if patients are to benefit from the optimal postoperative analgesia they provide: the same probably applies also in many other European countries.

Background

Neutrophil-derived heparin-binding protein (HBP) plays a role in the pathophysiology of impaired endothelial dysfunction during inflammation. HBP has been suggested as a predictor of organ dysfunction and disease progression in sepsis. We investigated the effects of heparins on plasma concentrations of HBP in patients undergoing surgery.

Methods

We studied three groups of patients receiving heparins during or after surgery. The vascular surgery group received 3000–7500 U, whereas the cardiac surgery group received 27 500–40 000 U. After major general surgery, the third group received 5000 U of low-molecular-weight heparin (LMWH) subcutaneously. Serial plasma HBP concentrations were measured after these treatments with two different methods: Axis-Shield ELISA and Joinstar FIC-Q100. In addition, plasma myeloperoxidase and syndecan-1 were measured in the cardiac surgery group.

Results

During vascular surgery, heparin induced a six-fold increase in HBP within 2 min, from 3.6 (2.4–5.4) to 21.4 (9.0–35.4) ng ml⁻¹ (P<0.001). During cardiac surgery, the higher dose of heparin elevated HBP concentrations from 5.3 (2.7–6.1) to 48.7 (38.4–70.1) ng ml⁻¹ (P<0.0001) within 3 min. Patients receiving LMWH showed an increase from a baseline of 5.7 (3.7–12.1) ng ml⁻¹ to a peak HBP concentration of 14.8 (9.5–18.1) ng ml⁻¹ (P<0.0001) after 3 h. Plasma concentrations of myeloperoxidase, but not syndecan-1, also responded with a rapid increase after heparin. There was a strong correlation between the two methods for HBP analysis (r=0.94).

Conclusions

Plasma concentrations of HBP increased rapidly and dose-dependently after heparin administration. Subcutaneous administration of LMWH increases plasma HBP, but to a lesser degree.

Clinical trial registration

ClinicalTrials.gov identifier: NCT04146493.

Background

There is limited knowledge about the effect of liberal intraoperative oxygen on non-infectious complications and overall recovery from surgery.

Methods

In this retrospective cohort study, we investigated associations between mean intraoperative fraction of inspired oxygen (FiO₂), and outcome in adults undergoing elective surgery lasting more than 2 h at a large metropolitan New Zealand hospital from 2012 to 2020. Patients were divided into low, medium, and high oxygen groups (FiO₂ ≤ 0.4, 0.41–0.59, ≥0.6). The primary outcome was days alive and out of hospital at 90 days (DAOH₉₀). The secondary outcomes were post-operative complications and admission to the ICU.

Results

We identified 15,449 patients who met the inclusion criteria. There was no association between FiO₂ and DAOH₉₀ when high FiO₂ was analysed according to three groups. Using high FiO₂ as the reference group there was an adjusted mean (95% confidence interval [CI]) difference of 0.09 (−0.06 to 0.25) days (P = 0.25) and 0.28 (−0.05 to 0.62) days (P = 0.2) in the intermediate and low oxygen groups, respectively. Low FiO₂ was associated with increased surgical site infection: the adjusted odds ratio (OR) for low compared with high FiO₂ was 1.53 (95% CI 1.12–2.10). Increasing FiO₂ was associated with respiratory complications: the adjusted OR associated with each 10% point increase in FiO₂ was 1.17 (95% CI 1.08–1.26) and the incidence of being admitted to an ICU had an adjusted OR of 1.1 (95% CI 1.03–1.18).

Conclusions

We found potential benefits, and risks, associated with liberal intraoperative oxygen administration indicating that randomised controlled trials are warranted.