Muscular tissue oxygen saturation during robotic hysterectomy and postoperative nausea and vomiting: exploring the potential therapeutic thresholds

Association between muscular tissue desaturation and acute kidney injury in older patients undergoing major abdominal surgery: a prospective cohort study

PURPOSE

Present study was designed to investigate the association between muscular tissue desaturation and acute kidney injury (AKI) in older patients undergoing major abdominal surgery.

METHOD

A total of 253 patients (≥ 65 years old) who underwent abdominal surgery with expected duration ≥ 2 h were enrolled. Muscular tissue oxygen saturation (SmtO2) was monitored at quadriceps and bilateral flanks during surgery. Muscular desaturation was defined as SmtO2 < 90% baseline lasting for > 60 s. The primary outcome was the incidence of AKI within postoperative 7 days. The association between muscular desaturation and AKI was analyzed by multivariable logistic regression model. The secondary outcomes indicated the other complications within postoperative 30 days.

RESULTS

Among 236 patients, 44 (18.6%) of them developed AKI. The incidence of muscular desaturation at quadriceps was 28.8% (68/236). Patients with muscular desaturation had higher incidence of AKI than those without desaturation (27.9% [19/68], vs. 14.9% [25/168], P = 0.020). After adjustment of confounders, multivariable analysis showed that muscular desaturation at quadriceps was significantly associated with an increased risk of AKI (OR = 2.84, 95% CI 1.21-6.67, P = 0.016). Muscular desaturations at left and right flank were also associated with an increased risk of AKI (OR = 6.38, 95% CI 1.78-22.89, P = 0.004; OR = 8.90, 95% CI 1.42-45.63; P = 0.019, respectively). Furthermore, patients with muscular desaturation may have a higher risk of pulmonary complications, sepsis and stroke at 30-day follow-up.

CONCLUSION

Muscular desaturation was associated with postoperative AKI in older patients undergoing major abdominal surgery which may serve as a predictor of AKI.

Impact of Preoperative Gum Chewing on Postoperative Anti-Emetic Use in Robot-Assisted Laparoscopic Surgery for Benign Ovarian Masses: A Prospective, Single-Blinded Randomized Controlled Trial

Background and Objectives: Postoperative nausea and vomiting (PONV) is a common issue for females undergoing gynecological surgeries, including those assisted by robotic systems. Despite available prophylactic measures, the incidence of PONV remains high, negatively impacting recovery and increasing healthcare costs. This study evaluates whether preoperative gum chewing reduces the need for anti-emetic drugs in females undergoing robot-assisted laparoscopic surgery for benign ovarian mass. Materials and Methods: This prospective, single-blinded, randomized controlled trial enrolled 92 adult females scheduled for robot-assisted laparoscopic surgery to treat benign ovarian mass. Following exclusions, the remaining participants were randomly assigned to either a gum-chewing group or a no-gum-chewing group. The gum-chewing group chewed sugar-free gum for 15 min in the holding area before surgery. The primary outcome measured was the need for anti-emetics to control PONV during the first hour in the post-anesthesia care unit (PACU). Secondary outcomes included the number of anti-emetic requests. No preemptive anti-emetics were administered during surgery. Results: Out of the initial 92 patients, 88 were included in the final analysis, with 44 in each group. The incidence of PONV requiring anti-emetics in the PACU was significantly lower in the gum-chewing group (79.5%) compared to the no-gum-chewing group (95.5%). Additionally, the number of anti-emetic requests was higher in the no-gum-chewing group. No postoperative complications such as tooth or jaw pain/injury or gastric content regurgitation were reported. Conclusions: Preoperative gum chewing for 15 min immediately before surgery significantly reduced the incidence of PONV in females undergoing robot-assisted laparoscopic surgery for benign ovarian mass. This simple, non-pharmacological intervention improved patient comfort and reduced the need for anti-emetic medications without any adverse effects. Further studies are needed to confirm these findings and to develop guidelines for incorporating preoperative gum chewing into clinical practice.

Association of intraoperative cerebral and somatic tissue oxygen saturation with postoperative acute kidney injury in adult patients undergoing multiple valve surgery

BACKGROUND

The association between tissue oxygenation with postoperative acute kidney injury (AKI) in adult patients undergoing multiple valve surgery has not been specifically studied.

METHODS

In this prospective exploratory cohort study, 99 patients were enrolled. The left forehead, the left forearm, the left upper thigh, and the left renal region tissue oxygen saturation using near-infrared spectroscopy were monitored. The association between each threshold and AKI was assessed. The relative and absolute thresholds were < 70%, < 75%, < 80%, < 85%, < 90%, < 95%, and < 100% baseline, and baseline-standard deviation (SD), -1.5 SD, -2 SD, -2.5 SD, and -3 SD. Multivariate logistic regression analysis was adopted to explore the association.

RESULTS

AKI occurred in 53 (54%) patients. The absolute value-based SrrO2 thresholds associated with AKI were baseline-3 SD (odds ratio [OR], 4.629; 95% confidence interval [CI], 1.238-17.314; P = 0.023) and baseline-2.5 SD (OR, 2.842; 95% CI, 1.025-7.881; P = 0.045) after adjusting for the potential confounders, those are renal region tissue oxygen saturation of 55% and 60%, but not statistically significant after correcting for multiple testing (corrected P = 0.114 and 0.179, respectively).

CONCLUSION

The SrrO2 desaturation, defined as < baseline - 2.5 SD or < baseline - 3 SD, may be associated with AKI. The thresholds need to be verified in future large-scale studies.

TRIAL REGISTRATIONS

The study was registered at ClinicalTrials.gov, first trial registration: 26/10/2017, identifier: NCT03323203.

Muscular tissue desaturation and pneumonia in patients receiving lung cancer surgery: a cohort study

BACKGROUND

Post-operative pneumonia (POP) is a common complication of lung cancer surgery, and muscular tissue oxygenation is a root cause of post-operative complications. However, the association between muscular tissue desaturation and POP in patients receiving lung cancer surgery has not been specifically studied. This study aimed to investigate the potential use of intra-operative muscular tissue desaturation as a predictor of POP in patients undergoing lung cancer surgery.

METHODS

This cohort study enrolled patients (≥55 years) who had undergone lobectomy with one-lung ventilation. Muscular tissue oxygen saturation (SmtO 2 ) was monitored in the forearm (over the brachioradialis muscle) and upper thigh (over the quadriceps) using a tissue oximeter. The minimum SmtO 2 was the lowest intra-operative measurement at any time point. Muscular tissue desaturation was defined as a minimum baseline SmtO 2 of <80% for >15 s. The area under or above the threshold was the product of the magnitude and time of desaturation. The primary outcome was the association between intra-operative muscular tissue desaturation and POP within seven post-operative days using multivariable logistic regression. The secondary outcome was the correlation between SmtO 2 in the forearm and that in the thigh.

RESULTS

We enrolled 174 patients. The overall incidence of muscular desaturation (defined as SmtO 2 < 80% in the forearm at baseline) was approximately 47.1% (82/174). The patients with muscular desaturation had a higher incidence of pneumonia than those without desaturation (28.0% [23/82] vs. 12.0% [11/92]; P  = 0.008). The multivariable analysis revealed that muscular desaturation was associated with an increased risk of pneumonia (odds ratio: 2.995, 95% confidence interval: 1.080-8.310, P  = 0.035) after adjusting for age, American Society of Anesthesiologists status, Assess Respiratory Risk in Surgical Patients in Catalonia score, smoking, use of peripheral nerve block, propofol, and study center.

CONCLUSION

Muscular tissue desaturation, defined as a baseline SmtO 2 < 80% in the forearm, may be associated with an increased risk of POP.

TRIAL REGISTRATION

No. ChiCTR-ROC-17012627.

Association Between Cerebral Desaturation and Postoperative Delirium in Thoracotomy With One-Lung Ventilation: A Prospective Cohort Study

BACKGROUND

The association between cerebral desaturation and postoperative delirium in thoracotomy with one-lung ventilation (OLV) has not been specifically studied.

METHODS

A prospective observational study performed in thoracic surgical patients. Cerebral tissue oxygen saturation (Scto2) was monitored on the left and right foreheads using a near-infrared spectroscopy oximeter. Baseline Scto2 was measured with patients awake and breathing room air. The minimum Scto2 was the lowest measurement at any time during surgery. Cerebral desaturation and hypersaturation were an episode of Scto2 below and above a given threshold for ≥15 seconds during surgery, respectively. The thresholds based on relative changes by referring to the baseline measurement were <80%, <85%, <90%, <95%, and <100% baseline for desaturation and >105%, >110%, >115%, and >120% baseline for hypersaturation. The thresholds based on absolute values were <50%, <55%, <60%, <65%, and <70% for desaturation and >75%, >80%, >85%, and >90% for hypersaturation. The given area under the threshold (AUT)/area above the threshold (AAT) was analyzed. Delirium was assessed until postoperative day 5. The primary analysis was the association between the minimum Scto2 and delirium using multivariable logistic regression controlled for confounders (age, OLV time, use of midazolam, occurrence of hypotension, and severity of pain). The secondary analysis was the association between cerebral desaturation/hypersaturation and delirium, and between the AUT/AAT and delirium using multivariable logistic regression controlled for the same confounders. Multiple testing was corrected using the Holm-Bonferroni method. We additionally monitored somatic tissue oxygen saturation on the forearm and upper thigh.

RESULTS

Delirium occurred in 35 (20%) of 175 patients (65 ± 6 years old). The minimum left or right Scto2 was not associated with delirium. Cerebral desaturation defined by <90% baseline for left Scto2 (odds ratio [OR], 5.82; 95% confidence interval [CI], 2.12-19.2; corrected P =.008) and <85% baseline for right Scto2 (OR, 4.27; 95% CI, 1.77-11.0; corrected P =.01) was associated with an increased risk of delirium. Cerebral desaturation defined by other thresholds, cerebral hypersaturation, the AUT/AAT, and somatic desaturation and hypersaturation were all not associated with delirium.

CONCLUSIONS

Cerebral desaturation defined by <90% baseline for left Scto2 and <85% baseline for right Scto2, but not the minimum Scto2, may be associated with an increased risk of postthoracotomy delirium. The validity of these thresholds needs to be tested by randomized controlled trials.

Intraoperative systemic vascular resistance is associated with postoperative nausea and vomiting after laparoscopic hysterectomy

BACKGROUND

The incidence of postoperative nausea and vomiting (PONV) in patients undergoing laparoscopic hysterectomy is very high compared with other surgeries, even when many prophylactic measures have been taken. However, the pathogenesis of PONV is multifactorial. Female sex, a history of motion sickness or PONV, nonsmokers, and perioperative opioid use are the most closely related factors. Among the multiple risk factors, suboptimal gastrointestinal (GI) perfusion may be attributed to some cases of PONV, and increased systemic vascular resistance (SVR) may lead to GI ischemia. The hypothesis of this research was that SVR is related to PONV.

AIM

To investigate the relationship between SVR and PONV in patients undergoing laparoscopic hysterectomy.

METHODS

A total of 228 patients who underwent elective laparoscopic hysterectomy were included in this prospective observational study. SVR was monitored using a noninvasive hemodynamic monitoring system. Four indices of SVR, the baseline, mean, area under the curve (AUC), and weighted AUC, were used for analysis. The incidence and severity of nausea and vomiting were evaluated while patients were awake and throughout the intervals from 0 to 2 h, 2 to 6 h, and 6 to 24 h starting upon arrival at the post-anesthesia care unit. The associations between various SVR indices and PONV were investigated by logistic regression. P < 0.05 was considered statistically significant.

RESULTS

The incidence of PONV in the study was 56.14% (128/228), and PONV tended to appear within 6 h after surgery. Five variables were significant in univariate analyses, however, only SVR mean [odds ratio (OR) = 1.015, 95%CI: 1.005-1.109, P = 0.047] and duration of surgery (OR = 1.316, 95%CI: 1.003-2.030, P = 0.012) were associated with PONV after logistic regression analysis. Furthermore, patients with high SVR mean were more likely to suffer from PONV after laparoscopic hysterectomy. On average, patients who developed PONV needed more time to tolerate diet and demonstrated poorer sleep quality on the first night after surgery.

CONCLUSION

In this study, PONV was a common complication after laparoscopic hysterectomy. SVR was associated with PONV, and high SVR mean was associated with a significantly increased risk of PONV.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Journal of Clinical Monitoring and Computing 2019 end of year summary: monitoring tissue oxygenation and perfusion and its autoregulation

Tissue perfusion monitoring is increasingly being employed clinically in a non-invasive fashion. In this end-of-year summary of the Journal of Clinical Monitoring and Computing, we take a closer look at the papers published recently on this subject in the journal. Most of these papers focus on monitoring cerebral perfusion (and associated hemodynamics), using either transcranial doppler measurements or near-infrared spectroscopy. Given the importance of cerebral autoregulation in the analyses performed in most of the studies discussed here, this end-of-year summary also includes a short description of cerebral hemodynamic physiology and its autoregulation. Finally, we review articles on somatic tissue oxygenation and its possible association with outcome.

Muscular Tissue Oxygen Saturation and Posthysterectomy Nausea and Vomiting

Background

Suboptimal tissue perfusion and oxygenation during surgery may be responsible for postoperative nausea and vomiting in some patients. This trial tested the hypothesis that muscular tissue oxygen saturation–guided intraoperative care reduces postoperative nausea and vomiting.

Methods

This multicenter, pragmatic, patient- and assessor-blinded randomized controlled (1:1 ratio) trial was conducted from September 2018 to June 2019 at six teaching hospitals in four different cities in China. Nonsmoking women, 18 to 65 yr old, and having elective laparoscopic surgery involving hysterectomy (n = 800) were randomly assigned to receive either intraoperative muscular tissue oxygen saturation–guided care or usual care. The goal was to maintain muscular tissue oxygen saturation, measured at flank and on forearm, greater than baseline or 70%, whichever was higher. The primary outcome was 24-h postoperative nausea and vomiting. Secondary outcomes included nausea severity, quality of recovery, and 30-day morbidity and mortality.

Results

Of the 800 randomized patients (median age, 50 yr [range, 27 to 65]), 799 were assessed for the primary outcome. The below-goal muscular tissue oxygen saturation area under the curve was significantly smaller in patients receiving muscular tissue oxygen saturation–guided care (n = 400) than in those receiving usual care (n = 399; flank, 50 vs. 140% · min, P &lt; 0.001; forearm, 53 vs. 245% · min, P &lt; 0.001). The incidences of 24-h postoperative nausea and vomiting were 32% (127 of 400) in the muscular tissue oxygen saturation–guided care group and 36% (142 of 399) in the usual care group, which were not significantly different (risk ratio, 0.89; 95% CI, 0.73 to 1.08; P = 0.251). There were no significant between-group differences for secondary outcomes. No harm was observed throughout the study.

Conclusions

In a relatively young and healthy female patient population, personalized, goal-directed, muscular tissue oxygen saturation–guided intraoperative care is effective in treating decreased muscular tissue oxygen saturation but does not reduce the incidence of 24-h posthysterectomy nausea and vomiting.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

Intraoperative physiological ranges associated with improved outcomes after major spine surgery: an observational study

OBJECTIVE

There is inadequate information about the values of many intraoperative physiological measurements that are associated with improved outcomes after surgery. The purpose of this observational study is to investigate the optimal physiological ranges during major spine surgery.

SETTING

A teaching hospital in the USA.

PARTICIPANTS

A convenience sample of 102 patients receiving major posterior spine surgery with multilevel spinal fusion in a prone position.

METHODS

Physiological variables, including but not limited to mean arterial pressure (MAP) and cerebral and somatic tissue oxygen saturation (SctO₂/SstO₂), were recorded. The results of these measurements were associated with length of hospital stay and composite complication data and were analysed based on thresholds (ie, a cut-off value for optimal and suboptimal physiology) and the area under the curve (AUC) values. The AUC values were measured as the area enclosed by the actual tracing and the threshold. The outcomes were dichotomised into above-average and below-average (ie, improved) categories.

RESULTS

Analyses based on thresholds identified the following variables associated with above-average outcomes: MAP <60 mm Hg, temperature <35°C, heart rate >90 beats per minute (bpm), SctO₂ <60% and SstO₂ >80%. Analyses based on AUC values identified the following as associated with above-average outcomes: MAP <70 and >100 mm Hg, temperature <36°C, heart rate >90 bpm, tidal volume (based on ideal body weight)<6 mL/kg, tidal volume (based on actual body weight) >10 mL/kg and peak airway pressure <15 cmH₂O.

CONCLUSION

The following physiological ranges are associated with improved outcomes (ie, shorter hospitalisation and fewer complications) during major spine surgery: MAP of 70-100 mm Hg, temperature ≥36°C, heart rate <90 bpm, tidal volume based on ideal body weight >6 mL/kg, SctO₂ >60% and SstO₂ <80%.

Tourniquet-induced tissue hypoxia characterized by near-infrared spectroscopy during ankle surgery: an observational study

BACKGROUND

Pneumatic tourniquet inflation during extremity surgery leads to profound and prolonged tissue ischemia. Its effect on tissue oxygenation is inadequately studied.

METHODS

Patients undergoing elective ankle surgery with tourniquet application participated in this observational cohort study. Somatic and cerebral tissue oxygen saturation (SstO₂ and SctO₂) were monitored using tissue near-infrared spectroscopy. Oxygenation was monitored distally (SstO₂-distal) and proximally to the tourniquet, on the contralateral leg, and the forehead (a total of 4 tissue beds). Tissue oxygenation at different time points was compared. The magnitude, duration, and load (product of magnitude and duration) of tissue desaturation during tourniquet inflation were correlated with tissue resaturation and hypersaturation after tourniquet deflation.

RESULTS

Data of 26 patients were analyzed. The tourniquet inflation time was 120 ± 31 mins. Following a rapid desaturation from 77 ± 8% pre-inflation to 38 ± 20% 10 mins post-inflation, SstO₂-distal slowly and continuously desaturated and reach the nadir (16 ± 11%) toward the end of inflation. After deflation, SstO₂-distal rapidly resaturated from 16 ± 11% to 91 ± 5% (i.e., hypersaturation); SstO₂ monitored proximally to the tourniquet and on contralateral leg had significant but small desaturation (~ 2-3%, p <  0.001); in contrast, SctO₂ remained stable. The desaturation load had a significant correlation with resaturation magnitude (p <  0.001); while the desaturation duration had a significant correlation with hypersaturation magnitude (p = 0.04).

CONCLUSIONS

Tissue dys-oxygenation following tourniquet application can be reliably monitored using tissue oximetry. Its outcome significance remains to be determined.