Longer Immediate Recovery Time After Anesthesia Increases Risk of Respiratory Complications After Laparotomy for Bariatric Surgery: a Randomized Clinical Trial and a Cohort Study

Incidence and Outcome of Reintubation in the Postanesthesia Care Unit: A Single-Center, Retrospective, Observational Matched Cohort Study in China

PURPOSE

To investigate the incidence and outcome of reintubation after planned extubation (RAP) in the postanesthesia care unit (PACU) in China.

DESIGN

A single-center, retrospective, 1:2 matched cohort study following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement.

METHODS

Among 121,965 patients in the PACU, 14 patients with RAP were included in this study from January 1, 2017 to December 31, 2019. PACU length of stay, postoperative length of stay in hospital, inpatient healthcare costs, and outcomes were compared between the RAP and the matched groups.

FINDINGS

The incidence of RAP was 0.0115%. After propensity score matching, there were no statistically significant differences in age, sex, body mass index (BMI), elective/nonelective procedure, surgical classification, American Society of Anesthesiologists physical status, the duration of anesthesia, or the duration of surgical procedure between the two groups. PACU length of stay, postoperative length of stay in hospital, and inpatient healthcare costs significantly differed between the RAP group and the matched group (P < .01 for all). The percentage of patients with longer PACU length of stay in the RAP group was significantly higher than that in the matched group (92.86% vs 7.14%), with an odds ratio of 29.87 (95% confidence interval = 14.00-2,040.54, P < .001).

CONCLUSIONS

Despite its low incidence, RAP in the PACU may be associated with life-threatening and severe complications with longer PACU length of stay, unexpected intensive care unit admission, longer hospitalization length, longer postoperative length of stay in hospital, and increased inpatient health costs. Appropriate timing of extubation and monitoring in the PACU can effectively prevent the occurrence of RAP and improve patient prognosis.

Enhanced recovery after bariatric surgery: an Italian consensus statement

Background

Enhanced recovery after bariatric surgery (ERABS) is an approach developed to improve outcomes in obese surgical patients. Unfortunately, it is not evenly implemented in Italy. The Italian Society for the Surgery of Obesity and Metabolic Diseases and the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care joined in drafting an official statement on ERABS.

Methods

To assess the effectiveness and safety of ERABS and to develop evidence-based recommendations with regard to pre-, intra-, and post-operative care for obese patients undergoing ERABS, a 13-member expert task force of surgeons and anesthesiologists from Italian certified IFSO center of excellence in bariatric surgery was established and a review of English-language papers conducted. Oxford 2011 Levels of Evidence and U.S. Preventive Services Task Force Grade Definitions were used to grade the level of evidence and the strength of recommendations, respectively. The supporting evidence and recommendations were reviewed and discussed by the entire group at meetings to achieve a final consensus.

Results

Compared to the conventional approach, ERABS reduces the length of hospital stay and does not heighten the risk of major post-operative complications, re-operations, and hospital re-admissions, nor does it increase the overall surgical costs. A total of 25 recommendations were proposed, covering pre-operative evaluation and care (7 items), intra-operative management (1 item, 11 sub-items), and post-operative care and discharge (6 items).

Conclusions

ERABS is an effective and safe approach. The recommendations allow the proper management of obese patients undergoing ERABS for a better outcome.

Efficacy and Safety of Neuromuscular Blockade in Overweight Patients Undergoing Nasopharyngeal Surgery

BACKGROUND Adequate muscle relaxation and rapid recovery of neuromuscular function are essential in the perioperative period. We therefore compared various anesthetic regimens of neuromuscular blockers and antagonists administered to overweight patients undergoing nasopharyngeal surgery. MATERIAL AND METHODS This prospective, randomized, double-blind study was conducted in overweight patients undergoing nasopharyngeal surgery. We randomly assigned 102 patients into 3 groups (each n=34) treated with various muscle relaxant agents and antagonists: rocuronium and sugammadex (Group RS), rocuronium and neostigmine (Group RN), and cisatracurium and neostigmine (Group CN). Then, we compared the efficacy and safety indexes of the 3 groups. RESULTS Onset times of muscular relaxation in Group RS and Group RN (110 s and 120 s) were shorter than in Group CN (183 s). Time from administration of antagonist to recovery of the TOF ratio to 0.9 was shorter in Group RS (3.3 min) than in other groups (20.7 min and 19.1 min, respectively). The incidence of postoperative residual curarization (PORC) was significantly lower in Group RS (5.9%) than in the other 2 groups (both 41.2%). The hemodynamic parameter changes before extubation were significantly higher in Group RN and Group CN than in Group RS. The postoperative pain scores were lowest in Group RS. CONCLUSIONS For overweight patients undergoing nasopharyngeal surgery, the use of rocuronium with sugammadex had the shortest onset time of neuromuscular relaxation, accelerated the reversion of neuromuscular blockade, effectively reduced the occurrence of PORC, relieved postoperative pain, and maintained hemodynamic stability before extubation. The combination of rocuronium and sugammadex may be the best anesthetic regimen for overweight patients undergoing nasopharyngeal surgery.

Propofol Sedation for Intragastric Balloon Removal: Looking for the Optimal Body Weight Descriptor

AIM

Sedation is considered as a prerequisite for the safe and effective conclusion of Bioenterics Intragastric Balloon (BIB) removal (our aim was to ascertain the most appropriate body size scalars for propofol dosing and assess the efficacy and safety of a sedative approach involving the infusion of propofol for BIB removal.

METHOD

Retrospective analysis of prospectively collected data of 414 adults scheduled to undergo BIB removal. Our primary end-point was to delineate the relationship between propofol dosing and body size descriptors namely body mass index, total body weight, ideal body weight, lean body weight (LBW) and normalized LBW. Sedative efficacy of this practice, anesthesia or procedural-related adverse events and patients' satisfaction level served as secondary outcome parameters.

RESULTS

Propofol dose (mg/kg/min) was positively related to all body weight descriptors in an important manner (p < 0.001). Among them, LBW was singled out as the body size descriptor to best capture the appropriate needs of propofol (R² = 0.432; p = 0.000). Hypoxemia, hemodynamic compromise, gastroesophageal reflux or moderate movement occurred rarely; all of them were readily reversed. The majority of participants had no recollection of the noxious phase of the procedure or declared at least adequately satisfied from the experience (84% and 95%, respectively).

CONCLUSION

LBW could serve as relatively more accurate dosing scalar compared to actual or ideal body weight descriptors, in obese individuals undergoing BIB removal under propofol sedation. The conscious/deep sedation based on propofol infusion emerges as a feasible and efficacious sedative approach for this procedure.

Atelectasis in Bariatric Surgery: Review Analysis and Key Practical Recommendations

Obesity is a condition that affects multiple organ systems, particularly the cardiovascular and respiratory system. In recent years, bariatric surgery has been reported to be the gold standard in the treatment of morbid obesity. Body mass index alone is insufficient to predict risks related to anaesthesia and surgery. Obesity contributes to significant postoperative atelectasis and is considered an independent risk factor for postoperative atelectasis owing to decreased functional residual capacity. The treatment and reversibility of atelectasis developed in obese patients undergoing bariatric surgery are challenging. Therefore, an optimisation of pulmonary functions before surgery, lung-sparing ventilation during the perioperative period, awareness of potential postoperative complications and knowledge about preventive measures and therapeutic approaches have become increasingly important in bariatric surgery. The aim of this review was to aid clinicians in the management of atelectasis in patients undergoing bariatric surgery during the perioperative and postoperative period.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Thoracic complications in bariatric surgery patients

Obesity is a health issue that can lead to medical and psychological problems. Recently, bariatric surgery has become the best choice for treatment of selected candidates. As the number of bariatric surgeries increases, various related postoperative complications are being encountered. Most studies have been concerned with abdominal complications and thoracic complications were beyond their scope. The aim of this report was to review thoracic complications following bariatric surgery, in terms of incidence, management, and outcome. A literature search of English language published data concerning thoracic complications related to or following bariatric surgery was performed in November 2018. A total of 10,145 results were found. After screening titles and abstracts, 10,060 noneligible publications were excluded. Eighty-five publications were potentially eligible and their full texts were analyzed. After excluding overlapping series of patients, 44 studies were selected. These included 934 patients. Females accounted for 87.9% of the included patients. Ages ranged between 21 and 64 years (mean 43.86 ± 4.4 years). Most frequently encountered complications were esophageal (80.84%) followed by pulmonary (17.45%). The majority of esophageal complications were functional (82.38%) in contrast to the pulmonary type that were mostly organic (87.73%). There were 5 documented deaths. We concluded that thoracic complications are not infrequent after bariatric surgery. Esophageal and pulmonary are the most common thoracic complications reported. The outcome is usually favorable. Mortality may be avoided when complications are detected early and well-managed.

Postoperative complications with neuromuscular blocking drugs and/or reversal agents in obstructive sleep apnea patients: a systematic review

BACKGROUND

Neuromuscular blocking drugs (NMBD) are administered intra-operatively to facilitate intubation and to achieve muscle relaxation for surgical procedures. Incomplete reversal of NMBD can lead to adverse events in the postoperative period. Patients with obstructive sleep apnea (OSA) may be at higher risk of complications related to the use of NMBD. The objectives of this systematic review were to determine whether: 1) OSA patients are at higher risk of postoperative complications from the use of NMBD than non-OSA patients, and 2) the choice of NMBD reversal agent affects the risk of postoperative complications in OSA patients.

METHODS

A literature search of multiple databases was conducted up to April 2017. The inclusion criteria were: (1) adult surgical patients (≥18 years old) with OSA diagnosed by polysomnography, or history, or suspected by screening questionnaire; (2) patients who were given NMBD and/or NMBD reversal agents intraoperatively; (3) reports on postoperative adverse events, particularly respiratory events were available; (4) published studies were in English; and (5) RCTs or observational cohort studies. The quality of evidence was determined by the Oxford Center for Evidence Based Medicine levels of evidence.

RESULTS

Out of 4123 studies, five studies (2 RCTs and 3 observational studies) including 1126 patients were deemed eligible. These studies were heterogeneous precluding a meta-analysis of the results. Two of three studies (1 RCT, 2 observational studies) reported that OSA patients given NMBD may be at higher risk of developing postoperative pulmonary complications (PPCs) like hypoxemia, residual neuromuscular blockade or respiratory failure compared to non-OSA patients. Two studies (1 RCT, 1 observational study) reported that OSA patients who were reversed with sugammadex vs. neostigmine had less PPCs and chest radiographic changes, but the quality of the included studies was Oxford level of evidence: low to moderate.

CONCLUSIONS

OSA patients who receive intraoperative NMBD may be at higher risk for postoperative hypoxemia, respiratory failure and residual neuromuscular blockade compared to non-OSA patients. There is some, albeit very limited evidence that NMBD reversal with sugammadex may be associated with less PPCs than neostigmine in patients with OSA. More high-quality studies are needed.

Best anaesthetic drug strategy for morbidly obese patients

PURPOSE OF REVIEW

The purpose of this review is to describe an evidence-based drug strategy applicable to any obese patient, rather than to present one standard 'ideal' anaesthetic drug combination. The ultimate choice of specific drugs in any given situation will depend upon clinician experience, patient specifics, and drug availability. The fundamental principle in anaesthesia for the obese patient is to use the shortest acting, least fat soluble agents to ensure rapid recovery to safe levels of alertness and mobility.

RECENT FINDINGS

No new drugs have been introduced over the past few years, but we have seen an introduction of enhanced recovery after surgery-based protocols into bariatric surgery. Our understanding of how obesity affects pharmacokinetics/dynamics of our drugs is improving, with new and better use of established drugs. Allometric scaling is being tested in the different pharmacokinetic/dynamic models used in target controlled infusion devices, with improved performance as a result. Obstructive sleep apnoea has a significant impact upon outcome and utilization of clinical resources, including critical care beds. If an improved drug dosing strategy will reduce this impact, then this would be a step forward.

SUMMARY

This review introduces newer findings to help us use anaesthetic and analgesic drugs more safely in the morbidly obese. However, there remain many areas of uncertainty with a lack of consensus on many issues.