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Devlin JW. Pharmacologic Treatment Strategies for Delirium in Hospitalized Adults: Past, Present, and Future. Semin Neurol 2024. [PMID: 39313210 DOI: 10.1055/s-0044-1791246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/25/2024]
Abstract
Despite the use of multidomain prevention strategies, delirium still frequently occurs in hospitalized adults. With delirium often associated with undesirable symptoms and deleterious outcomes, including cognitive decline, treatment is important. Risk-factor reduction and the protocolized use of multidomain, nonpharmacologic bundles remain the mainstay of delirium treatment. There is a current lack of strong evidence to suggest any pharmacologic intervention to treat delirium will help resolve it faster, reduce its symptoms (other than agitation), facilitate hospital throughput, or improve post-hospital outcomes including long-term cognitive function. With the exception of dexmedetomidine as a treatment of severe delirium-associated agitation in the ICU, current practice guidelines do not recommend the routine use of any pharmacologic intervention to treat delirium in any hospital population. Future research should focus on identifying and evaluating new pharmacologic delirium treatment interventions and addressing key challenges and gaps surrounding delirium treatment research.
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Affiliation(s)
- John W Devlin
- Department of Pharmacy and Health Systems Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Bonnet MP, Guckert P, Boccara C, Daoui C, Beloeil H. New set of indicators with consensus definition for anaesthesia-related severe morbidity: A scoping review followed by a Delphi study. J Clin Anesth 2024; 99:111626. [PMID: 39293147 DOI: 10.1016/j.jclinane.2024.111626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 07/11/2024] [Accepted: 09/10/2024] [Indexed: 09/20/2024]
Abstract
STUDY OBJECTIVE Monitoring anaesthesia-related severe morbidity constitutes a good opportunity for assessing quality and safety of care in anaesthesia. Several recent studies attempted to describe and define indicators for anaesthesia-related severe morbidity with limitations: no formal experts' consensus process, overlap with surgical complications, no consensual definitions, inapplicability in clinical practice. The aim of this study was to provide a set of indicators for anaesthesia-related severe morbidity based on outcomes and using clinically useful consensual definitions. DESIGN 1/ scoping review of studies published in 2010-2021 on outcomes of anaesthesia-related severe morbidity with different definitions; 2/ International experts' consensus on indicators for anaesthesia-related severe morbidity with specific definitions using a Delphi process. MAIN RESULTS After including 142 studies, 68 outcomes for anaesthesia-related severe morbidity were identified and organized in 34 indicators divided into 8 categories (cardiovascular, respiratory, sepsis, renal, neurological, medication error, digestive and others). The indicators were then submitted to the experts. After 2 Delphi rounds, the 26 indicators retained by the experts with their corresponding consensual definition were: acute heart failure, cardiogenic shock, acute respiratory distress syndrome, pulmonary embolism and thrombosis, bronchospasm or laryngospasm, pneumonia, inhalation pneumonitis, pneumothorax, difficult or impossible intubation, atelectasis, self-extubation or accidental extubation, sepsis or septic shock, transient ischemic attack, postoperative confusion or delirium, post-puncture headache, medication error, liver failure, unplanned intensive care unit admission, multiple-organ failure. CONCLUSIONS This study provides a new consensual set of indicators for anaesthesia-related severe morbidity with specific definitions, that could be easily applied in clinical practice as in research.
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Affiliation(s)
- Marie-Pierre Bonnet
- Sorbonne University, Department of Anaesthesia and Critical Care Medicine, Armand Trousseau Hospital, DMU DREAM, GRC 29, AP-HP, 75012 Paris, France;; Université Paris Cité, Centre for Epidemiology and Statistics (CRESS), Obstetrical Perinatal and Paediatric Epidemiology Research Team, EPOPé, INSERM, INRA, 75014 Paris, France.
| | - Perrine Guckert
- Department of Anaesthesia and Intensive Care, Rennes University Hospital, University Rennes 1, 35000 Rennes, France
| | - Cécile Boccara
- Department of Anaesthesia and Critical Care Medicine, Armand Trousseau Hospital, DMU DREAM, AP-HP, 75012 Paris, France
| | - Chafia Daoui
- Chef de projets - Réseau Recherche SFAR, Société Française d'Anesthésie et de Réanimation, 75016 Paris, France
| | - Hélène Beloeil
- Univ Rennes, CHU Rennes, Inserm, COSS 12142, CIC 1414, Anaesthesia and Intensive Care Department, F-35000 Rennes, France
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Wacker J, Haller G, Hendrickx JFA, Ponschab M. A survey and analysis of peri-operative quality indicators promoted by National Societies of Anaesthesiologists in Europe: The EQUIP project. Eur J Anaesthesiol 2024; 41:00003643-990000000-00219. [PMID: 39262333 PMCID: PMC11451932 DOI: 10.1097/eja.0000000000002054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024]
Abstract
BACKGROUND To capture preventable peri-operative patient harm and guide improvement initiatives, many quality indicators (QIs) have been developed. Several National Anaesthesiologist Societies (NAS) in Europe have implemented quality indicators. To date, the definitions, validity and dissemination of such quality indicators, and their comparability with validated published indicators are unknown. OBJECTIVES The aim of this study was to identify all quality indicators promoted by NAS in Europe, to assess their characteristics and to compare them with published validated quality indicators. DESIGN A cross-sectional study with mixed methods analysis. Using a survey questionnaire, representatives of 37 NAS were asked if their society provided quality indicators to their members and, if so, to provide the list, definitions and details of quality indicators. Characteristics of reported quality indicators were analysed. SETTING The 37 NAS affiliated with the European Society of Anaesthesiology and Intensive Care (ESAIC) at the time. Data collection, translations: March 2018 to February 2020. PARTICIPANTS Representatives of all 37 NAS completed the survey. MAIN OUTCOME MEASURES QIs reported by NAS. RESULTS Only 12 (32%) of the 37 NAS had made a set of quality indicators available to their members. Data collection was mandatory in six (16.2%) of the 37 countries. We identified 163 individual quality indicators, which were most commonly descriptive (60.1%), anaesthesia-specific (50.3%) and related to intra-operative care (21.5%). They often measured structures (41.7%) and aspects of safety (35.6%), appropriateness (20.9%) and prevention (16.6%). Patient-centred care (3.7%) was not well covered. Only 11.7% of QIs corresponded to published validated or well established quality indicator sets. CONCLUSIONS Few NAS in Europe promoted peri-operative quality indicators. Most of them differed from published sets of validated indicators and were often related to the structural dimension of quality. There is a need to establish a European-wide comprehensive core set of usable and validated quality indicators to monitor the quality of peri-operative care. TRIAL REGISTRATION No registration.
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Affiliation(s)
- Johannes Wacker
- From the University of Zurich, Faculty of Medicine, Zurich, Switzerland (JW), Institute of Anesthesia and Intensive Care, Hirslanden Clinic, Zurich (JW), Department of Acute Care Medicine, Division of Anesthesiology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland (GH), Department of Epidemiology and Preventive Medicine, Health Services Management and Research Unit, Monash University, Melbourne, Victoria, Australia (GH), Department of Anesthesiology, Intensive Care and Pain Therapy, OLV Hospital, Aalst (JFAH), Department of Basic and Applied Medical Sciences, Ghent University, Ghent (JFAH), Department of Anesthesiology, UZLeuven, Leuven, Belgium & Department of Cardiovascular Sciences, KULeuven, Leuven, Belgium (JFAH), Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna (MP), Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital Linz, Academic Teaching Hospital of the Paracelsus Medical University, Salzburg, Austria (MP)
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Verret M, Le JBP, Lalu MM, Jeffers MS, McIsaac DI, Nicholls SG, Turgeon AF, Ramchandani R, Li H, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, O'Hearn K, Gilron I, Poulin P, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis. Br J Anaesth 2024; 133:615-627. [PMID: 39019769 PMCID: PMC11347795 DOI: 10.1016/j.bja.2024.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia. METHODS We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points). RESULTS We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes. CONCLUSIONS Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023439896).
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada.
| | - John B P Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Matthew S Jeffers
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
| | - Rashi Ramchandani
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Hongda Li
- MDCM, Faculty of Medicine and Health Science, McGill University, Montreal, QC, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Fiona Zivkovic
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Megan Graham
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Maxime Lê
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Allison Geist
- Patient Partner, The Ottawa Hospital, Ottawa, ONT, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, ONT, Canada
| | - Patricia Poulin
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, University of Ottawa and The Ottawa Hospital Pain Clinic, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Royal Inland Hospital, Kamloops, BC, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, The Ottawa Hospital, Ottawa, ON, Canada; Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
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Bendel D, Wong T, Bedford J, Odor PM. Data Infrastructure for Improvement in Perioperative Medicine: Experience at a London Tertiary Hospital. Br J Hosp Med (Lond) 2024; 85:1-12. [PMID: 39212573 DOI: 10.12968/hmed.2024.0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Adoption of electronic health record systems offers an opportunity to collate massive volumes of complex information about patient care. Healthcare data can inform performance management, enable predictive analytics and enhance strategic decision making. A data-driven approach to improving patient care is vital to address the growing burden of morbidity and mortality associated with major surgery. We describe our methodology for transforming and utilising process of care data in an electronic health record system to develop a registry for quality improvement purposes in patients undergoing major surgery at a single UK hospital. We highlight development of our data-driven vision, technical aspects of processing raw data into metrics relevant to clinical decision making, alongside challenges encountered. Finally, we outline how our data infrastructure supports clinical governance, quality improvement and research. In sharing our experiences, we hope to enable others to embed and access the transformative clinical insights that healthcare data can yield.
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Affiliation(s)
- Daniel Bendel
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Trust, London, UK
| | - Teresa Wong
- Department of Anaesthesia, Woodlands Health, Singapore, Singapore
| | - James Bedford
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Trust, London, UK
| | - Peter M Odor
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Trust, London, UK
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Tran L, Stern C, Harford P, Ludbrook G, Whitehorn A. Effectiveness and safety of enhanced postoperative care units for non-cardiac, non-neurological surgery: a systematic review protocol. JBI Evid Synth 2024; 22:1626-1635. [PMID: 38482608 DOI: 10.11124/jbies-23-00439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
OBJECTIVE The proposed systematic review will evaluate the evidence on the effectiveness and safety of enhanced post-operative care (EPC) units on patient and health service outcomes in adult patients following non-cardiac, non-neurological surgery. INTRODUCTION The increase in surgical procedures globally has placed a significant economic and societal burden on health care systems. Recognizing this challenge, EPC units have emerged as a model of care, bridging the gap between traditional, ward-level care and intensive care. EPC offers benefits such as higher staff-to-patient ratios, close patient monitoring (eg, invasive monitoring), and access to critical interventions (eg, vasopressor support). However, there is a lack of well-established guidelines and empirical evidence regarding the safety and effectiveness of EPC units for adult patients following surgery. INCLUSION CRITERIA This review will include studies involving adult patients (≥18 years) undergoing any elective or emergency non-cardiac, non-neurological surgery, who have been admitted to an EPC unit. Experimental, quasi-experimental, and observational study designs will be eligible. METHODS This review will follow the JBI methodology for systematic reviews of effectiveness. The search strategy will identify published and unpublished studies from the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), and Scopus, as well as gray literature sources, from 2010 to the present. Two independent reviewers will screen studies, extract data, and critically appraise selected studies using standardized JBI assessment tools. Where feasible, a statistical meta-analysis will be performed to combine study findings. The certainty of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. REVIEW REGISTRATION PROSPERO CRD42023455269.
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Affiliation(s)
- Liem Tran
- JBI, Faculty of Health and Medical Sciences, School of Public Health, The University of Adelaide, SA, Australia
- Department of Anaesthesia, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Cindy Stern
- JBI, Faculty of Health and Medical Sciences, School of Public Health, The University of Adelaide, SA, Australia
| | - Philip Harford
- JBI, Faculty of Health and Medical Sciences, School of Public Health, The University of Adelaide, SA, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Guy Ludbrook
- Department of Anaesthesia, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
- Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA, Australia
| | - Ashley Whitehorn
- JBI, Faculty of Health and Medical Sciences, School of Public Health, The University of Adelaide, SA, Australia
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Meco BC, Guclu CY, Berger-Estilita J, Radtke FM. The way towards ethical anesthesia care: no aim - no game - no fame or blame? Curr Opin Anaesthesiol 2024; 37:432-438. [PMID: 38841922 DOI: 10.1097/aco.0000000000001391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
PURPOSE OF REVIEW This review explores the intricacies of ethical anesthesia, exploring the necessity for precision anesthesia and its impact on patient-reported outcomes. The primary objective is to advocate for a defined aim, promoting the implementation of rules and feedback systems. The ultimate goal is to enhance precision anesthesia care, ensuring patient safety through the implementation of a teamwork and the integration of feedback mechanisms. RECENT FINDINGS Recent strategies in the field of anesthesia have evolved from intraoperative monitorization to a wider perioperative patient-centered precision care. Nonetheless, implementing this approach encounters significant obstacles. The article explores the evidence supporting the need for a defined aim and applicable rules for precision anesthesia's effectiveness. The implementation of the safety culture is underlined. The review delves into the teamwork description with structured feedback systems. SUMMARY Anesthesia is a multifaceted discipline that involves various stakeholders. The primary focus is delivering personalized precision care. This review underscores the importance of establishing clear aims, defined rules, and fostering effective and well tolerated teamwork with accurate feedback for improving patient-reported outcomes. The Safe Brain Initiative approach, emphasizing algorithmic monitoring and systematic follow-up, is crucial in implementing a fundamental and standardized reporting approach within patient-centered anesthesia care practice.
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Affiliation(s)
- Basak Ceyda Meco
- Departement of Anaesthesia and Intensive Care, Ankara University Faculty of Medicine
- Ankara University Brain Research Center (BAUM), Ankara, Turkey
| | - Cigdem Yildirim Guclu
- Departement of Anaesthesia and Intensive Care, Ankara University Faculty of Medicine
| | - Joana Berger-Estilita
- Institute of Anaesthesiology and Intensive Care, Salemspital, Hirslanden Medical Group
- Institute for Medical Education, University of Bern, Bern, Switzerland
- CINTESIS@RISE-Center for Health Technology and Services Research, Faculty of Medicine, Porto, Portugal
| | - Finn M Radtke
- Department of Anaesthesia and Intensive Care, Sjaellands University Hospital Nykøbing Falster, & University of Southern Denmark, Odense, Denmark
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Hewson DW, Tedore TR, Hardman JG. Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence. Br J Anaesth 2024; 133:380-399. [PMID: 38811298 PMCID: PMC11282476 DOI: 10.1016/j.bja.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Tiffany R Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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Osorio D, Maldonado D, Rijs K, van der Marel C, Klimek M, Calvache JA. Efficacy of different routes of acetaminophen administration for postoperative pain in children: a systematic review and network meta-analysis. Can J Anaesth 2024; 71:1103-1116. [PMID: 38622469 PMCID: PMC11269386 DOI: 10.1007/s12630-024-02760-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 04/17/2024] Open
Abstract
PURPOSE Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population. METHODS We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales. RESULTS We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78). CONCLUSION The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question. STUDY REGISTRATION PROSPERO (CRD42021286495); first submitted 19 November 2021.
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Affiliation(s)
- Danilo Osorio
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia
| | - Diana Maldonado
- Department of Anesthesiology, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Koen Rijs
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | | | - Markus Klimek
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands
| | - Jose A Calvache
- Department of Anesthesiology, Universidad del Cauca, Popayán, Colombia.
- Department of Anesthesiology, Erasmus University MC, Rotterdam, The Netherlands.
- Department of Anesthesiology, Erasmus University MC, Dr. Molewaterplein 40, 3015 GD, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
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Macrosson D, Beebeejaun A, Odor PM. A systematic review and meta-analysis of thoracic epidural analgesia versus other analgesic techniques in patients post-oesophagectomy. Perioper Med (Lond) 2024; 13:80. [PMID: 39044196 PMCID: PMC11267804 DOI: 10.1186/s13741-024-00437-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 07/14/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Oesophageal cancer surgery represents a high perioperative risk of complications to patients, such as postoperative pulmonary complications (PPCs). Postoperative analgesia may influence these risks, but the most favourable analgesic technique is debated. This review aims to provide an updated evaluation of whether thoracic epidural analgesia (TEA) has benefits compared to other analgesic techniques in patients undergoing oesophagectomy surgery. Our hypothesis is that TEA reduces pain scores and PPCs compared to intravenous opioid analgesia in patients post-oesophagectomy. METHODS Electronic databases PubMed, Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomised trials of analgesic interventions in patients undergoing oesophagectomy surgery. Only trials including thoracic epidural analgesia compared with other analgesic techniques were included. The primary outcome was a composite of respiratory infection, atelectasis and respiratory failure (PPCs), with pain scores at rest and on movement as secondary outcomes. Data was pooled using random effect models and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs). RESULTS Data from a total of 741 patients in 10 randomised controlled trials (RCTs) from 1993 to 2023 were included. Nine trials were open surgery, and one trial was laparoscopic. Relative to intravenous opioids, TEA significantly reduced a composite of PPCs (risk ratio (RR) 3.88; 95% confidence interval (CI) 1.98-7.61; n = 222; 3 RCTs) and pain scores (0-100-mm visual analogue scale or VAS) at rest at 24 h (MD 9.02; 95% CI 5.88-12.17; n = 685; 10 RCTs) and 48 h (MD 8.64; 95% CI 5.91-11.37; n = 685; 10 RCTs) and pain scores on movement at 24 h (MD 14.96; 95% CI 5.46-24.46; n = 275; 4 RCTs) and 48 h (MD 16.60; 95% CI 8.72-24.47; n = 275; 4 RCTs). CONCLUSIONS Recent trials of analgesic technique in oesophagectomy surgery are restricted by small sample size and variation of outcome measurement. Despite these limitations, current evidence indicates that thoracic epidural analgesia reduces the risk of PPCs and severe pain, compared to intravenous opioids in patients following oesophageal cancer surgery. Future research should include minimally invasive surgery, non-epidural regional techniques and record morbidity, using core outcome measures with standardised endpoints. TRIAL REGISTRATION Prospectively registered on PROSPERO (CRD42023484720).
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Affiliation(s)
- Duncan Macrosson
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, England.
- University College London, London, England.
| | - Adam Beebeejaun
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, England
- University College London, London, England
| | - Peter M Odor
- Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, England
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11
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Gasteiger L, Fiala A, Naegele F, Gasteiger E, Seisl A, Bonaros N, Mair P, Velik-Salchner C, Holfeld J, Höfer D, Stundner O. The Impact of Preoperative Combined Pectoserratus and/or Interpectoral Plane (Pectoralis Type II) Blocks on Opioid Consumption, Pain, and Overall Benefit of Analgesia in Patients Undergoing Minimally Invasive Cardiac Surgery: A Prospective, Randomized, Controlled, and Triple-blinded Trial. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00428-2. [PMID: 39304477 DOI: 10.1053/j.jvca.2024.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 05/26/2024] [Accepted: 06/25/2024] [Indexed: 09/22/2024]
Abstract
OBJECTIVE Acute postoperative pain remains a major obstacle in minimally invasive cardiac surgery (MICS). Evidence of the analgesic benefit of chest wall blocks is limited. This study was designed to assess the influence of combined pectoserratus plane block plus interpectoral plane block (PSPB + IPPB) on postoperative pain and the overall benefit of analgesia compared with placebo. DESIGN A prospective, randomized, triple-blinded study was conducted. SETTING The setting was the operating room and intensive care unit of a university hospital. PARTICIPANTS A total of 60 patients undergoing elective right-lateral MICS were enrolled. INTERVENTIONS Patients were randomly assigned to preoperative PSPB + IPPB with 30 mL of ropivacaine 0.5% or saline. MEASUREMENTS AND MAIN RESULTS The primary endpoint was total intravenous morphine milligram equivalents administered in the first 24 hours after extubation. Secondary endpoints included the Overall Benefit of Analgesia Score (OBAS) at 24 hours after extubation and repeated Visual Analogue Scale (VAS). Values for intravenous morphine milligram equivalents administered in the first 24 hours after extubation were significantly lower (median [interquartile range]: 4.2 mg [2.1 - 7.9] v 8.3 mg [4.2 - 15.7], p = 0.025; mean difference: 6.7 mg [0.94 - 12 mg], p = 0.024, Cohen's d: 0.64 [0.09 - 1.2]). Moreover, OBAS at 24 hours and VAS after extubation were significantly lower (4.0 [3.0 - 6.0] v 7.0 [3.0 - 9.0], p = 0.043; 0.0 cm [0.0 - 2.0] v 1.5 cm [0.3 - 3.0], p = 0.030). VAS did not differ between groups at later points. CONCLUSIONS Preoperative PSPB + IPPB reduced 24-hour postextubation opioid consumption, pain at extubation, and OBAS. Given its low risk and expedient placement, it could be a helpful addition to MICS protocols. Future studies should evaluate these findings in multicenter settings and further elucidate the optimal timing of block placement.
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Affiliation(s)
- Lukas Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Anna Fiala
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Felix Naegele
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Elisabeth Gasteiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria.
| | - Anna Seisl
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Corinna Velik-Salchner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Holfeld
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Höfer
- Department of Cardiac Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ottokar Stundner
- Department of Anaesthesiology and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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12
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Hayashi M, Yamamoto N, Kuroda N, Kano K, Miura T, Kamimura Y, Shiroshita A. Peripheral Nerve Blocks in the Preoperative Management of Hip Fractures: A Systematic Review and Network Meta-Analysis. Ann Emerg Med 2024; 83:522-538. [PMID: 38385910 DOI: 10.1016/j.annemergmed.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/23/2024]
Abstract
STUDY OBJECTIVE We conducted a systematic review and network meta-analysis to evaluate the comparative efficacy of peripheral nerve block types for preoperative pain management of hip fractures. METHODS We searched Cochrane, Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar for randomized clinical trials. We included participants aged more than 16 years with hip fractures who received peripheral nerve blocks or analgesics for preoperative pain management. The primary outcomes were defined as absolute pain score 2 hours after block placement, preoperative consumption of morphine equivalents, and length of hospital stay. We used a random-effects network meta-analysis conceptualized in the Bayesian framework. Confidence of evidence was assessed using Confidence in Network Meta-Analysis (CINeMA). RESULTS We included 63 randomized controlled studies (4,778 participants), of which only a few had a low risk of bias. The femoral nerve block, 3-in-1 block, fascia iliaca compartment block, and pericapsular nerve group block yielded significantly lowered pain scores at 2 hours after block placement compared with those with no block (standardized mean differences [SMD]: -1.1; 95% credible interval [CrI]: -1.7 to -0.48, [confidence of evidence: low]; SMD: -1.8; 95% CrI: -3.0 to -0.55, [low]; SMD: -1.4; 95% CrI: -2.0 to -0.72, [low]; SMD: -2.3; 95% CrI: -3.2 to -1.4, [moderate], respectively). The pericapsular nerve group block, 3-in-1 block, fascia iliaca compartment block, and femoral nerve block resulted in lower pain scores than the no-block group. Additionally, the pericapsular nerve group block yielded a lower pain score than femoral nerve block or fascia iliaca compartment block (SMD: -1.21; 95% CrI: -2.18 to -0.23, [very low]: SMD: -0.92; 95% CrI: -1.70 to -0.16, [low]). However, both the fascia iliaca compartment block and femoral nerve block did not show a reduction in morphine consumption compared with no block. To our knowledge, no studies have compared the pericapsular nerve group block with other methods regarding morphine consumption. Furthermore, no significant difference was observed between peripheral nerve blocks and no block in terms of the length of hospital stay. CONCLUSIONS Compared with no block, preoperative peripheral nerve blocks for hip fractures appear to reduce pain 2 hours after block placement. Comparing different blocks, pericapsular nerve group block might be superior to fascia iliaca compartment block and femoral nerve block for pain relief, though the confidence evidence was low in most comparisons because of the moderate to high risk of bias in many of the included studies and the high heterogeneity of treatment strategies across studies. Therefore, further high-quality research is needed.
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Affiliation(s)
- Minoru Hayashi
- Department of Emergency Medicine Fukui Prefectural Hospital, Yotsui, Fukui, Japan
| | - Norio Yamamoto
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan; Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan.
| | - Naoto Kuroda
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Pediatrics, Wayne State University, Detroit, MI; Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Kenichi Kano
- Department of Emergency Medicine Fukui Prefectural Hospital, Yotsui, Fukui, Japan
| | - Takanori Miura
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Orthopedic Surgery, Akita Rosai Hospital, Odate, Japan
| | - Yuji Kamimura
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Department of Anesthesiology and Intensive Care Medicin, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Akihiro Shiroshita
- Scientific Research WorkS Peer Support Group (SRWS-PSG), Osaka, Japan; Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
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13
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Gutierrez Del Arroyo A, Patel A, Abbott TEF, Begum S, Dias P, Somanath S, Middleditch A, Cleland S, Brealey D, Pearse RM, Ackland GL. Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial. Br J Anaesth 2024; 132:857-866. [PMID: 38341283 PMCID: PMC11103084 DOI: 10.1016/j.bja.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 12/27/2023] [Accepted: 01/04/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations. METHODS In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors. RESULTS Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]). CONCLUSIONS Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.
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Affiliation(s)
- Ana Gutierrez Del Arroyo
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Akshaykumar Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Salma Begum
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Priyanthi Dias
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sameer Somanath
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | | | - David Brealey
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK; UCL Hospitals NHS Foundation Trust, London, UK
| | - Rupert M Pearse
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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14
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Hewson DW, Ferry J, Macfarlane AJR. Celebrating the state of the art and innovations in regional anaesthesia in the British Journal of Anaesthesia. Br J Anaesth 2024; 132:1012-1015. [PMID: 38448273 DOI: 10.1016/j.bja.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 02/15/2024] [Accepted: 02/18/2024] [Indexed: 03/08/2024] Open
Abstract
To coincide with the annual scientific meeting of Regional Anaesthesia UK in London 2024, where there is a joint scientific session with the British Journal of Anaesthesia, a special regional anaesthesia edition of the journal has been produced. This editorial offers some highlights from the manuscripts contained within the special edition.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care Medicine, Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK; Department of Anaesthesia, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jenny Ferry
- Department of Anaesthesia, Aneurin Bevan University Health Board, Newport, UK
| | - Alan J R Macfarlane
- Department of Anaesthesia, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK; School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, UK.
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15
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Admiraal M, Marhofer P, Hopkins PM, Hollmann MW. Peripheral regional anaesthesia and outcomes: a narrative review of the literature from 2013 to 2023. Br J Anaesth 2024; 132:1082-1096. [PMID: 37957079 PMCID: PMC11103102 DOI: 10.1016/j.bja.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/02/2023] [Accepted: 10/06/2023] [Indexed: 11/15/2023] Open
Abstract
The use of peripheral regional anaesthesia continues to increase, yet the evidence supporting its use and impact on relevant outcomes often lacks scientific rigour, especially when considering the use of specific blocks for a particular surgical indication. In this narrative review, we consider the relevant literature in a 10-yr period from 2013. We performed a literature search (MEDLINE and EMBASE) for articles reporting randomised controlled trials and other comparative trials of peripheral regional anaesthetic blocks vs systemic analgesia in adult patients undergoing surgery. We evaluated measures of effective treatment and complications. A total of 128 studies met our inclusion criteria. There remains variability in the technical conduct of blocks and the outcomes used to evaluate them. There is a considerable body of evidence to support the use of interscalene blocks for shoulder surgery. Saphenous nerve (motor-sparing) blocks provide satisfactory analgesia after knee surgery and are preferred to femoral nerve blocks which are associated with falls when patients are mobilised early as part of enhanced recovery programmes. There are additional surgical indications where the efficacy of cervical plexus, intercostal nerve, and ilioinguinal/iliohypogastric nerve blocks have been demonstrated. In the past 10 yr, there has been a consolidation of the evidence indicating benefit of peripheral nerve blocks for specific indications. There remains great scope for rigorous, multicentre, randomised controlled trials of many peripheral nerve blocks. These would benefit from an agreed set of patient-centred outcomes.
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Affiliation(s)
- Manouk Admiraal
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Peter Marhofer
- Department of Anaesthesia, General Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.
| | - Philip M Hopkins
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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16
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Berger-Estilita J, Marcolino I, Radtke FM. Patient-centered precision care in anaesthesia - the PC-square (PC) 2 approach. Curr Opin Anaesthesiol 2024; 37:163-170. [PMID: 38284262 PMCID: PMC10911256 DOI: 10.1097/aco.0000000000001343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
PURPOSE OF REVIEW This review navigates the landscape of precision anaesthesia, emphasising tailored and individualized approaches to anaesthetic administration. The aim is to elucidate precision medicine principles, applications, and potential advancements in anaesthesia. The review focuses on the current state, challenges, and transformative opportunities in precision anaesthesia. RECENT FINDINGS The review explores evidence supporting precision anaesthesia, drawing insights from neuroscientific fields. It probes the correlation between high-dose intraoperative opioids and increased postoperative consumption, highlighting how precision anaesthesia, especially through initiatives like Safe Brain Initiative (SBI), could address these issues. The SBI represents multidisciplinary collaboration in perioperative care. SBI fosters effective communication among surgical teams, anaesthesiologists, and other medical professionals. SUMMARY Precision anaesthesia tailors care to individual patients, incorporating genomic insights, personalised drug regimens, and advanced monitoring techniques. From EEG to cerebral/somatic oximetry, these methods enhance precision. Standardised reporting, patient-reported outcomes, and continuous quality improvement, alongside initiatives like SBI, contribute to improved patient outcomes. Precision anaesthesia, underpinned by collaborative programs, emerges as a promising avenue for enhancing perioperative care.
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Affiliation(s)
- Joana Berger-Estilita
- Institute of Anaesthesiology and Intensive Care, Salemspital, Hirslanden Medical Group
- Institute for Medical Education, University of Bern, Bern, Switzerland
- CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, Porto, Portugal
| | - Isabel Marcolino
- Institute of Anaesthesiology and Intensive Care, Spital Limmattal, Schlieren, Switzerland
| | - Finn M. Radtke
- Department of Anaesthesia and Intensive Care, Hospital of Nykøbing Falster, University of Southern Denmark, Odense, Denmark
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Verret M, Lam NH, Lalu M, Nicholls SG, Turgeon AF, McIsaac DI, Hamtiaux M, Bao Phuc Le J, Gilron I, Yang L, Kaimkhani M, Assi A, El-Adem D, Timm M, Tai P, Amir J, Srichandramohan S, Al-Mazidi A, Fergusson NA, Hutton B, Zivkovic F, Graham M, Lê M, Geist A, Bérubé M, Poulin P, Shorr R, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Intraoperative pharmacologic opioid minimisation strategies and patient-centred outcomes after surgery: a scoping review. Br J Anaesth 2024; 132:758-770. [PMID: 38331658 PMCID: PMC10925893 DOI: 10.1016/j.bja.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/08/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Postoperative patient-centred outcome measures are essential to capture the patient's experience after surgery. Although a large number of pharmacologic opioid minimisation strategies (i.e. opioid alternatives) are used for patients undergoing surgery, it remains unclear which strategies are most promising in terms of patient-centred outcome improvements. This scoping review had two main objectives: (1) to map and describe evidence from clinical trials assessing the patient-centred effectiveness of pharmacologic intraoperative opioid minimisation strategies in adult surgical patients, and (2) to identify promising pharmacologic opioid minimisation strategies. METHODS We searched MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases from inception to February 2023. We included trials investigating the use of opioid minimisation strategies in adult surgical patients and reporting at least one patient-centred outcome. Study screening and data extraction were conducted independently by at least two reviewers. RESULTS Of 24,842 citations screened for eligibility, 2803 trials assessed the effectiveness of intraoperative opioid minimisation strategies. Of these, 457 trials (67,060 participants) met eligibility criteria, reporting at least one patient-centred outcome. In the 107 trials that included a patient-centred primary outcome, patient wellbeing was the most frequently used domain (55 trials). Based on aggregate findings, dexmedetomidine, systemic lidocaine, and COX-2 inhibitors were promising strategies, while paracetamol, ketamine, and gabapentinoids were less promising. Almost half of the trials (253 trials) did not report a protocol or registration number. CONCLUSIONS Researchers should prioritise and include patient-centred outcomes in the assessment of opioid minimisation strategy effectiveness. We identified three potentially promising pharmacologic intraoperative opioid minimisation strategies that should be further assessed through systematic reviews and multicentre trials. Findings from our scoping review may be influenced by selective outcome reporting bias. STUDY REGISTRATION OSF - https://osf.io/7kea3.
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Affiliation(s)
- Michael Verret
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada.
| | - Nhat H Lam
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Ottawa Methods Centre, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada; Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Myriam Hamtiaux
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - John Bao Phuc Le
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology & Perioperative Medicine, Biomedical & Molecular Sciences, Centre for Neuroscience Studies and School of Policy Studies, Queen's University, Kingston, ON, Canada
| | - Lucy Yang
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Alexandre Assi
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - David El-Adem
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Makenna Timm
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tai
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Joelle Amir
- Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Sriyathavan Srichandramohan
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Abdulaziz Al-Mazidi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Nicholas A Fergusson
- Department of Anesthesiology, Perioperative & Pain Medicine, University of Calgary, Calgary, AB, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Fiona Zivkovic
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Megan Graham
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Maxime Lê
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Allison Geist
- Patient partner, The Ottawa Hospital, Ottawa, ON, Canada
| | - Mélanie Bérubé
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Centre de Recherche du CHU de Québec-Université Laval, Université Laval, Québec City, QC, Canada; Faculty of Nursing, Université Laval, Québec City, QC, Canada; Quebec Pain Research Network, Sherbrooke, QC, Canada
| | - Patricia Poulin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Department of Anesthesiology and Pain Medicine, University of Ottawa, Civic Campus, The Ottawa Hospital, Ottawa, ON, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Verret M, Le JBP, Lalu MM, McIsaac DI, Nicholls S, Turgeon AF, Hutton B, Zivkovic F, Graham M, Le M, Geist A, Berube M, Gilron I, Poulin P, Daudt H, Martel G, McVicar J, Moloo H, Fergusson DA. Effectiveness of dexmedetomidine during surgery under general anaesthesia on patient-centred outcomes: a systematic review and Bayesian meta-analysis protocol. BMJ Open 2024; 14:e080012. [PMID: 38307526 PMCID: PMC10836371 DOI: 10.1136/bmjopen-2023-080012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 01/09/2024] [Indexed: 02/04/2024] Open
Abstract
INTRODUCTION Dexmedetomidine is a promising pharmaceutical strategy to minimise opioid use during surgery. Despite its growing use, it is uncertain whether dexmedetomidine can improve patient-centred outcomes such as quality of recovery and pain. METHODS AND ANALYSIS We will conduct a systematic review and meta-analysis following the recommendations of the Cochrane Handbook for Systematic Reviews. We will search MEDLINE, Embase, CENTRAL, Web of Science and CINAHL approximately in October 2023. We will include randomised controlled trials evaluating the impact of systemic intraoperative dexmedetomidine on patient-centred outcomes. Patient-centred outcome definition will be based on the consensus definition established by the Standardised Endpoints in Perioperative Medicine initiative (StEP-COMPAC). Our primary outcome will be the quality of recovery after surgery. Our secondary outcomes will be patient well-being, function, health-related quality of life, life impact, multidimensional assessment of postoperative acute pain, chronic pain, persistent postoperative opioid use, opioid-related adverse events, hospital length of stay and adverse events. Two reviewers will independently screen and identify trials and extract data. We will evaluate the risk of bias of trials using the Cochrane Risk of Bias Tool (RoB 2.0). We will synthesise data using a random effects Bayesian model framework, estimating the probability of achieving a benefit and its clinical significance. We will assess statistical heterogeneity with the tau-squared and explore sources of heterogeneity with meta-regression. We have involved patient partners, clinicians, methodologists, and key partner organisations in the development of this protocol, and we plan to continue this collaboration throughout all phases of this systematic review. ETHICS AND DISSEMINATION Our systematic review does not require research ethics approval. It will help inform current clinical practice guidelines and guide development of future randomised controlled trials. The results will be disseminated in open-access peer-reviewed journals, presented at conferences and shared among collaborators and networks. PROSPERO REGISTRATION NUMBER CRD42023439896.
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Affiliation(s)
- Michael Verret
- Departments of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec, Quebec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - John Bao Phuc Le
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Stuart Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alexis F Turgeon
- Departments of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, Quebec, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec, Quebec, Canada
| | - Brian Hutton
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Fiona Zivkovic
- Patient Partner, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Megan Graham
- Patient Partner, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Maxime Le
- Patient Partner, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Allison Geist
- Patient Partner, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Melanie Berube
- Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec - Université Laval Research Center, Québec, Quebec, Canada
- Faculty of Nursing, Université Laval, Québec, Quebec, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, Kingston, Ontario, Canada
| | - Patricia Poulin
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Helena Daudt
- Pain Canada, Pain BC, Vancouver, Alberta, Canada
| | - Guillaume Martel
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jason McVicar
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Husein Moloo
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Surgery, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Yang L, Chen W, Chen D, He J, Wang J, Qu Y, Yang Y, Tang Y, Zeng H, Deng W, Liu H, Huang L, Li X, Du L, Liu J, Li Q, Song H. Cohort profile: the China surgery and anesthesia cohort (CSAC). Eur J Epidemiol 2024; 39:207-218. [PMID: 38198037 PMCID: PMC10904502 DOI: 10.1007/s10654-023-01083-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 11/12/2023] [Indexed: 01/11/2024]
Abstract
The China Surgery and Anaesthesia Cohort (CSAC) study was launched in July 2020 and is an ongoing prospective cohort study recruiting patients aged 40-65 years who underwent elective surgeries with general anaesthesia across four medical centres in China. The general objective of the CSAC study is to improve our understanding of the complex interaction between environmental and genetic components as well as to determine their effects on a wide range of interested surgery/anaesthesia-related outcomes. To achieve this goal, we collected enriched phenotypic data, e.g., sociodemographic characteristics, lifestyle factors, perioperative neuropsychological changes, anaesthesia- and surgery-related complications, and medical conditions, at recruitment, as well as through both active (at 1, 3, 7 days and 1, 3, 6, 12 months after surgery) and passive (for more than 1 year after surgery) follow-up assessments. We also obtained omics data from blood samples. In addition, COVID-19-related information was collected from all participants since January 2023, immediately after COVID-19 restrictions were eased in China. As of July 18, 2023, 12,766 participants (mean age = 52.40 years, 57.93% were female) completed baseline data collection (response rate = 94.68%), among which approximately 70% donated blood and hair samples. The follow-up rates within 12 months after surgery were > 92%. Our initial analyses have demonstrated the incidence of and risk factors for chronic postsurgical pain (CPSP) and postoperative cognitive dysfunction (POCD) among middle-aged Chinese individuals, which may prompt further mechanistic exploration and facilitate the development of effective interventions for preventing those conditions. Additional studies, such as genome-wide association analyses for identifying the genetic determinants of CPSP and POCD, are ongoing, and their findings will be released in the future.
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Affiliation(s)
- Lei Yang
- Department of Anesthesiology and West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China
| | - Wenwen Chen
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Junhui He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Junren Wang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yuanyuan Qu
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yao Yang
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China
- Med-X Center for Informatics, Sichuan University, Chengdu, China
| | - Yuling Tang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Huolin Zeng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Wanxin Deng
- Surgical Anesthesia Center, The First People's Hospital of Longquanyi District, Chengdu, China
| | - Hongxin Liu
- Surgical Anesthesia Center, The First People's Hospital of Longquanyi District, Chengdu, China
| | - Lining Huang
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xuze Li
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lei Du
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.
| | - Huan Song
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Guo Xue Lane 37, Chengdu, China.
- Med-X Center for Informatics, Sichuan University, Chengdu, China.
- Center of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavík, Iceland.
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden.
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20
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Bijkerk V, Jacobs LM, Albers KI, Gurusamy KS, van Laarhoven CJ, Keijzer C, Warlé MC. Deep neuromuscular blockade in adults undergoing an abdominal laparoscopic procedure. Cochrane Database Syst Rev 2024; 1:CD013197. [PMID: 38288876 PMCID: PMC10825891 DOI: 10.1002/14651858.cd013197.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Laparoscopic surgery is the preferred option for many procedures. To properly perform laparoscopic surgery, it is essential that sudden movements and abdominal contractions in patients are prevented, as it limits the surgeon's view. There has been a growing interest in the potential beneficial effect of deep neuromuscular blockade (NMB) in laparoscopic surgery. Deep NMB improves the surgical field by preventing abdominal contractions, and it is thought to decrease postoperative pain. However, it is uncertain if deep NMB improves intraoperative safety and thereby improves clinical outcomes. OBJECTIVES To evaluate the benefits and harms of deep neuromuscular blockade versus no, shallow, or moderate neuromuscular blockade during laparoscopic intra- or transperitoneal procedures in adults. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 31 July 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or publication status) in adults undergoing laparoscopic intra- or transperitoneal procedures comparing deep NMB to moderate, shallow, or no NMB. We excluded trials that did not report any of the primary or secondary outcomes of our review. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. all-cause mortality, 2. health-related quality of life, and 3. proportion of participants with serious adverse events. Our secondary outcomes were 4. proportion of participants with non-serious adverse events, 5. readmissions within three months, 6. short-term pain scores, 7. measurements of postoperative recovery, and 8. operating time. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We included 42 randomised clinical trials with 3898 participants. Most trials included participants undergoing intraperitoneal oncological resection surgery. We present the Peto fixed-effect model for most dichotomous outcomes as only sparse events were reported. Comparison 1: deep versus moderate NMB Thirty-eight trials compared deep versus moderate NMB. Deep NMB may have no effect on mortality, but the evidence is very uncertain (Peto odds ratio (OR) 7.22, 95% confidence interval (CI) 0.45 to 115.43; 12 trials, 1390 participants; very low-certainty evidence). Deep NMB likely results in little to no difference in health-related quality of life up to four days postoperative (mean difference (MD) 4.53 favouring deep NMB on the Quality of Recovery-40 score, 95% CI 0.96 to 8.09; 5 trials, 440 participants; moderate-certainty evidence; mean difference lower than the mean clinically important difference of 10 points). The evidence is very uncertain about the effect of deep NMB on intraoperatively serious adverse events (deep NMB 38/1150 versus moderate NMB 38/1076; Peto OR 0.95, 95% CI 0.59 to 1.52; 21 trials, 2231 participants; very low-certainty evidence), short-term serious adverse events (up to 60 days) (deep NMB 37/912 versus moderate NMB 42/852; Peto OR 0.90, 95% CI 0.56 to 1.42; 16 trials, 1764 participants; very low-certainty evidence), and short-term non-serious adverse events (Peto OR 0.94, 95% CI 0.65 to 1.35; 11 trials, 1232 participants; very low-certainty evidence). Deep NMB likely does not alter the duration of surgery (MD -0.51 minutes, 95% CI -3.35 to 2.32; 34 trials, 3143 participants; moderate-certainty evidence). The evidence is uncertain if deep NMB alters the length of hospital stay (MD -0.22 days, 95% CI -0.49 to 0.06; 19 trials, 2084 participants; low-certainty evidence) or pain scores one hour after surgery (MD -0.31 points on the numeric rating scale, 95% CI -0.59 to -0.03; 22 trials, 1823 participants; very low-certainty evidence; mean clinically important difference 1 point) and 24 hours after surgery (MD -0.60 points on the numeric rating scale, 95% CI -1.05 to -0.15; 16 trials, 1404 participants; very low-certainty evidence; mean clinically important difference 1 point). Comparison 2: deep versus shallow NMB Three trials compared deep versus shallow NMB. The trials did not report on mortality and health-related quality of life. The evidence is very uncertain about the effect of deep NMB compared to shallow NMB on the proportion of serious adverse events (RR 1.66, 95% CI 0.50 to 5.57; 2 trials, 158 participants; very low-certainty evidence). Comparison 3: deep versus no NMB One trial compared deep versus no NMB. There was no mortality in this trial, and health-related quality of life was not reported. The proportion of serious adverse events was 0/25 in the deep NMB group and 1/25 in the no NMB group. AUTHORS' CONCLUSIONS There was insufficient evidence to draw conclusions about the effects of deep NMB compared to moderate NMB on all-cause mortality and serious adverse events. Deep NMB likely results in little to no difference in health-related quality of life and duration of surgery compared to moderate NMB, and it may have no effect on the length of hospital stay. Due to the very low-certainty evidence, we do not know what the effect is of deep NMB on non-serious adverse events, pain scores, or readmission rates. Randomised clinical trials with adequate reporting of all adverse events would reduce the current uncertainties. Due to the low number of identified trials and the very low certainty of evidence, we do not know what the effect of deep NMB on serious adverse events is compared to shallow NMB and no NMB. We found no trials evaluating mortality and health-related quality of life.
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lotte Mc Jacobs
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Kim I Albers
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | | | - Christiaan Keijzer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Michiel C Warlé
- Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
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21
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Holder-Murray J, Esper SA, Althans AR, Knight J, Subramaniam K, Derenzo J, Ball R, Beaman S, Luke C, La Colla L, Schott N, Williams B, Lorenzi E, Berry LR, Viele K, Berry S, Masters M, Meister KA, Wilkinson T, Garrard W, Marroquin OC, Mahajan A. REMAP Periop: a randomised, embedded, multifactorial adaptive platform trial protocol for perioperative medicine to determine the optimal enhanced recovery pathway components in complex abdominal surgery patients within a US healthcare system. BMJ Open 2023; 13:e078711. [PMID: 38154902 PMCID: PMC10759097 DOI: 10.1136/bmjopen-2023-078711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023] Open
Abstract
INTRODUCTION Implementation of enhanced recovery pathways (ERPs) has resulted in improved patient-centred outcomes and decreased costs. However, there is a lack of high-level evidence for many ERP elements. We have designed a randomised, embedded, multifactorial, adaptive platform perioperative medicine (REMAP Periop) trial to evaluate the effectiveness of several perioperative therapies for patients undergoing complex abdominal surgery as part of an ERP. This trial will begin with two domains: postoperative nausea/vomiting (PONV) prophylaxis and regional/neuraxial analgesia. Patients enrolled in the trial will be randomised to arms within both domains, with the possibility of adding additional domains in the future. METHODS AND ANALYSIS In the PONV domain, patients are randomised to optimal versus supraoptimal prophylactic regimens. In the regional/neuraxial domain, patients are randomised to one of five different single-injection techniques/combination of techniques. The primary study endpoint is hospital-free days at 30 days, with additional domain-specific secondary endpoints of PONV incidence and postoperative opioid consumption. The efficacy of an intervention arm within a given domain will be evaluated at regular interim analyses using Bayesian statistical analysis. At the beginning of the trial, participants will have an equal probability of being allocated to any given intervention within a domain (ie, simple 1:1 randomisation), with response adaptive randomisation guiding changes to allocation ratios after interim analyses when applicable based on prespecified statistical triggers. Triggers met at interim analysis may also result in intervention dropping. ETHICS AND DISSEMINATION The core protocol and domain-specific appendices were approved by the University of Pittsburgh Institutional Review Board. A waiver of informed consent was obtained for this trial. Trial results will be announced to the public and healthcare providers once prespecified statistical triggers of interest are reached as described in the core protocol, and the most favourable interventions will then be implemented as a standardised institutional protocol. TRIAL REGISTRATION NUMBER NCT04606264.
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Affiliation(s)
| | - Stephen A Esper
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alison R Althans
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joshua Knight
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Kathirvel Subramaniam
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Derenzo
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ryan Ball
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shawn Beaman
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charles Luke
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Luca La Colla
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nicholas Schott
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brian Williams
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | - Kert Viele
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Scott Berry
- Berry Consultants Statistical Innovation, Austin, Texas, USA
| | - Miranda Masters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Katie A Meister
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Todd Wilkinson
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Oscar C Marroquin
- Clinical Analytics, UPMC, Pittsburgh, Pennsylvania, USA
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Aman Mahajan
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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22
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Holder AL, Khanna AK, Scott MJ, Rossetti SC, Rinehart JB, Linn DD, Weichert J, Dellinger RP. A Delphi Process to Identify Relevant Outcomes That May Be Associated With a Predictive Analytic Tool to Detect Hemodynamic Deterioration in the Intensive Care Unit. Cureus 2023; 15:e50169. [PMID: 38186415 PMCID: PMC10771798 DOI: 10.7759/cureus.50169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Background The critical care literature has seen an increase in the development and validation of tools using artificial intelligence for early detection of patient events or disease onset in the intensive care unit (ICU). The hemodynamic stability index (HSI) was found to have an AUC of 0.82 in predicting the need for hemodynamic intervention in the ICU. Future studies using this tool may benefit from targeting those outcomes that are more relevant to clinicians and most achievable. Methods A three-round Delphi study was conducted with a panel of 10 critical care physicians and three nurses in the United States to identify outcomes that may be most relevant and achievable with the HSI when evaluated for use in the ICU. To achieve criteria for relevance, at least 65% of panelists had to rate an outcome as a 4 or 5 on a 5-point scale. Results Nineteen of 24 outcomes that may be associated with the HSI achieved consensus for relevance. The Kemeny-Young approach was used to develop a matrix depicting the distribution of outcomes considering both relevance and achievability. "Reduces time spent in hemodynamic instability" and "reduces times to recognition of hemodynamic instability" were the highest-ranking outcomes considering both relevance and achievability. Conclusion This Delphi study was a feasible method to identify relevant outcomes that may be associated with an appropriate predictive analytic tool in the ICU. These findings can provide insight to researchers looking to study such tools to impact outcomes relevant to critical care practitioners. Future studies should test these tools in the ICU that target the most clinically relevant and achievable outcomes, such as time spent hemodynamically unstable or time until actionable nursing assessment or treatment.
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Affiliation(s)
- Andre L Holder
- Critical Care Medicine, Emory University School of Medicine, Atlanta, USA
| | - Ashish K Khanna
- Anesthesiology, Wake Forest School of Medicine, Winston-Salem, USA
| | - Michael J Scott
- Anesthesiology, University of Pennsylvania, Philadelphia, USA
| | - Sarah C Rossetti
- Biomedical Informatics and Nursing, Columbia University Medical Center, New York, USA
| | | | - Dustin D Linn
- Hospital Patient Monitoring, Philips Research North America, Cambridge, USA
| | - Jochen Weichert
- Clinical Development, Philips Research Netherlands BV, Eindhoven, NLD
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23
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van Hoorn BT, Tromp DJ, van Rees RCM, van Rossenberg LX, Cazemier HK, van Heijl M, Tromp Meesters RC. Effectiveness of a digital vs face-to-face preoperative assessment: A randomized, noninferiority clinical trial. J Clin Anesth 2023; 90:111192. [PMID: 37467628 DOI: 10.1016/j.jclinane.2023.111192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/21/2023]
Abstract
STUDY OBJECTIVE Digitalizing the preoperative assessment clinic can be a solution to keep up with the growing demand for surgery. It remains unclear if a digital preoperative assessment clinic is as safe, and effective in terms of patient health outcomes and experience compared to face-to-face consultations. This study aimed to compare quality of recovery and mental state in patients undergoing a digital preoperative assessment versus regular face-to-face consultations. DESIGN This was a single centre, randomized (1:1), parallel, open-label, noninferiority trial. SETTING The preoperative clinic and preoperative unit of an urban secondary care hospital. PATIENTS All adult, Dutch speaking, ASA I-IV patients with access to an online computer who required surgery. INTERVENTIONS Digital preoperative screening, consisting of an electronic screening questionnaire and web-based platform with personalized information and recommendations related to the procedure, or face-to-face screening, consisting of two 20-min in-hospital consultations. MEASUREMENTS The primary endpoint was quality of recovery, measured 48 h after surgery. The analysis followed a per-protocol principle, and only patients who underwent the intended screening were included in the analysis. The noninferiority margin was set at -6. The trial was registered at ClinicalTrials.gov, NCT05535205, during the study on 09/08/2022, before analysing results. MAIN RESULTS Between March 1, 2021 and 30 august 2021, 480 patients were assessed for eligibility. 400 patients were randomly assigned to the digital group (n = 200) or face-to-face group (n = 201), of which respectively 117 and 124 patients were eventually included in the primary analysis. The mean quality of recovery score of patients undergoing digital screening (158) was non-inferior to that of patients undergoing face-to-face screening (155), with a mean difference of 3·2 points and a 97.5% lower confidence limit of -2.1 points. There were no adverse events. CONCLUSIONS A digital preoperative screening is not inferior to face-to-face consultations in patients undergoing predominantly low to moderate risk surgery. Given its potential to reduce physician workload, reallocate healthcare resources, and lower healthcare costs, a digital preoperative screening may be a better choice for preoperative assessments.
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Affiliation(s)
| | - Daniel J Tromp
- Department of General Surgery, University of Utrecht, Utrecht, the Netherlands
| | | | | | - Hanna K Cazemier
- Department of Anaesthesia, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Mark van Heijl
- Department of General Surgery, University of Utrecht, Utrecht, the Netherlands
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24
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Wallis CJD, Jerath A, Aminoltejari K, Kaneshwaran K, Salles A, Coburn N, Wright FC, Gotlib Conn L, Klaassen Z, Luckenbaugh AN, Ranganathan S, Riveros C, McCartney C, Armstrong K, Bass B, Detsky AS, Satkunasivam R. Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries. JAMA Surg 2023; 158:1185-1194. [PMID: 37647075 PMCID: PMC10469289 DOI: 10.1001/jamasurg.2023.3744] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/07/2023] [Indexed: 09/01/2023]
Abstract
Importance Sex- and gender-based differences in a surgeon's medical practice and communication may be factors in patients' perioperative outcomes. Patients treated by female surgeons have improved 30-day outcomes. However, whether these outcomes persist over longer follow-up has not been assessed. Objective To examine whether surgeon sex is associated with 90-day and 1-year outcomes among patients undergoing common surgeries. Design, Setting, and Participants A population-based retrospective cohort study was conducted in adults in Ontario, Canada, undergoing 1 of 25 common elective or emergent surgeries between January 1, 2007, and December 31, 2019. Analysis was performed between July 15 and October 20, 2022. Exposure Surgeon sex. Main Outcomes and Measures An adverse postoperative event, defined as the composite of death, readmission, or complication, was assessed at 90 days and 1 year following surgery. Secondarily, each of these outcomes was assessed individually. Outcomes were compared between patients treated by female and male surgeons using generalized estimating equations with clustering at the level of the surgical procedure, accounting for patient-, procedure-, surgeon-, anesthesiologist-, and facility-level covariates. Results Among 1 165 711 included patients, 151 054 were treated by a female and 1 014 657 by a male surgeon. Overall, 14.3% of the patients had 1 or more adverse postoperative outcomes at 90 days and 25.0% had 1 or more adverse postoperative outcomes 1 year following surgery. Among these, 2.0% of patients died within 90 days and 4.3% died within 1 year. Multivariable-adjusted rates of the composite end point were higher among patients treated by male than female surgeons at both 90 days (13.9% vs 12.5%; adjusted odds ratio [AOR], 1.08; 95% CI, 1.03-1.13) and 1 year (25.0% vs 20.7%; AOR, 1.06; 95% CI, 1.01-1.12). Similar patterns were observed for mortality at 90 days (0.8% vs 0.5%; AOR 1.25; 95% CI, 1.12-1.39) and 1 year (2.4% vs 1.6%; AOR, 1.24; 95% CI, 1.13-1.36). Conclusions and Relevance After accounting for patient, procedure, surgeon, anesthesiologist, and hospital characteristics, the findings of this cohort study suggest that patients treated by female surgeons have lower rates of adverse postoperative outcomes including death at 90 days and 1 year after surgery compared with those treated by male surgeons. These findings further support differences in patient outcomes based on physician sex that warrant deeper study regarding underlying causes and potential solutions.
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Affiliation(s)
- Christopher J. D. Wallis
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, Mount Sinai Hospital, Toronto, Ontario, Canada
- Department of Surgical Oncology, University Health Network, Toronto, Ontario, Canada
| | - Angela Jerath
- Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Khatereh Aminoltejari
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Arghavan Salles
- Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Natalie Coburn
- Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Frances C. Wright
- Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Lesley Gotlib Conn
- Department of Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Zachary Klaassen
- Division of Urology, Medical College of Georgia–Augusta University, Augusta
| | - Amy N. Luckenbaugh
- Department of Urology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sanjana Ranganathan
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Carlos Riveros
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Colin McCartney
- Department of Anesthesia, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Kathleen Armstrong
- Division of Plastic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Barbara Bass
- George Washington University, School of Medicine and Health Sciences, Washington, DC
| | - Allan S. Detsky
- Department of Medicine, Mount Sinai Hospital and University Health Network, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Raj Satkunasivam
- Department of Urology, Houston Methodist Hospital, Houston, Texas
- Center for Outcomes Research, Houston Methodist Hospital, Houston, Texas
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
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25
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Howell SJ, Absalom AR. Consensus guidelines, Delphi methods, and evidence around anaesthetic technique for endoscopic retrograde cholangiopancreatography. Br J Anaesth 2023; 131:634-636. [PMID: 37718092 DOI: 10.1016/j.bja.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 09/19/2023] Open
Abstract
Consensus guidelines on the anaesthetic management of endoscopic retrograde cholangiopancreatography (ERCP) have recently been published. The rigorous synthesis of expert opinion is invaluable when there are limited data, and these guidelines are a significant step forward. This review both guides practice and identifies important research questions. We challenge those working in this field to collaborate and produce the evidence for whether monitored anaesthesia care (MAC) is associated with a lower incidence of adverse events and better outcomes than general anaesthesia for ERCP.
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Affiliation(s)
- Simon J Howell
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK.
| | - Anthony R Absalom
- Department of Anesthesiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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26
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Bailey CR. Patients have great expectations, but there is more to do. Anaesthesia 2023; 78:1199-1202. [PMID: 37499115 DOI: 10.1111/anae.16105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 07/29/2023]
Affiliation(s)
- C R Bailey
- Department of Anaesthesia and Peri-operative Medicine, Guy's and St. Thomas' NHS Foundation Trust, London, UK
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Cuninghame S, Jerath A, Gorsky K, Sivajohan A, Francoeur C, Withington D, Burry L, Cuthbertson BH, Orser BA, Martin C, Owen AM, Slessarev M. Effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review and meta-analysis. Br J Anaesth 2023; 131:314-327. [PMID: 37344338 DOI: 10.1016/j.bja.2023.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Sedation of critically ill patients with inhaled anaesthetics may reduce lung inflammation, time to extubation, and ICU length of stay compared with intravenous (i.v.) sedatives. However, the impact of inhaled anaesthetics on cognitive and psychiatric outcomes in this population is unclear. In this systematic review, we aimed to summarise the effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults. METHODS We searched MEDLINE, EMBASE, and PsycINFO for case series, retrospective, and prospective studies in critically ill adults sedated with inhaled anaesthetics. Outcomes included delirium, psychomotor and neurological recovery, long-term cognitive dysfunction, ICU memories, anxiety, depression, post-traumatic stress disorder (PTSD), and instruments used for assessment. RESULTS Thirteen studies were included in distinct populations of post-cardiac arrest survivors (n=4), postoperative noncardiac patients (n=3), postoperative cardiac patients (n=2), and mixed medical-surgical patients (n=4). Eight studies reported delirium incidence, two neurological recovery, and two ICU memories. One study reported on psychomotor recovery, long-term cognitive dysfunction, anxiety, depression, and PTSD. A meta-analysis of five trials found no difference in delirium incidence between inhaled and i.v. sedatives (relative risk 0.95 [95% confidence interval: 0.59-1.54]). Compared with i.v. sedatives, inhaled anaesthetics were associated with fewer hallucinations and faster psychomotor recovery but no differences in other outcomes. There was heterogeneity in the instruments used and timing of these assessments. CONCLUSIONS Based on the limited evidence available, there is no difference in cognitive and psychiatric outcomes between adults exposed to volatile sedation or intravenous sedation in the ICU. Future studies should incorporate outcome assessment with validated tools during and after hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021236455.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Asaanth Sivajohan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Conall Francoeur
- Centre de Recherche CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Davinia Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Beverley A Orser
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Adrian M Owen
- Western Institute for Neuroscience, Western University, London, ON, Canada; Department of Psychology and Department of Physiology and Pharmacology, Western University, London, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada; Western Institute for Neuroscience, Western University, London, ON, Canada.
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28
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Bello C, Nübling M, Luedi MM, Heidegger T. Patient satisfaction in anesthesiology: a narrative review. Curr Opin Anaesthesiol 2023; 36:452-459. [PMID: 37222215 DOI: 10.1097/aco.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE OF REVIEW Healthcare is increasingly expanding its view in outcome discussions to integrate patient-reported outcomes such as patient satisfaction. Involving patients in the evaluation of services and the development of quality improvement strategies is paramount, especially in the service-oriented discipline of anaesthesiology. RECENT FINDINGS Currently, while the development of validated patient satisfaction questionnaires is well established, the use of rigorously tested scores in research and clinical practice is not standardized. Furthermore, most questionnaires are validated for specific settings, which limits our ability to draw relevant conclusions from them, especially considering the rapidly expanding scope of anaesthesia as a discipline and the addition of same-day surgery. SUMMARY For this manuscript, we review recent literature regarding patient satisfaction in the inpatient and ambulatory anaesthesia setting. We discuss ongoing controversies and briefly digress to consider management and leadership science regarding 'customer satisfaction'.
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Affiliation(s)
- Corina Bello
- Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Spitalstrasse, Grabs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Markus M Luedi
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas Heidegger
- Department of Anesthesiology, Spitalregion Rheintal, Werdenberg, Sarganserland, Spitalstrasse, Grabs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
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Liu Y, Qiu Y, Fu Y, Liu J. Evaluation of postoperative recovery: past, present and future. Postgrad Med J 2023; 99:808-814. [PMID: 37490361 DOI: 10.1136/postgradmedj-2022-141652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/02/2022] [Indexed: 02/05/2023]
Abstract
Postoperative recovery, as a window to observe perioperative treatment effect and patient prognosis, is a common outcome indicator in clinical research and has attracted more and more attention of surgeons and anaesthesiologists. Postoperative recovery is a subjective, multidimensional, long-term, complex process, so it is unreasonable to only use objective indicators to explain it. Currently, with the widespread use of patient-reported outcomes, various scales become the primary tools for assessing postoperative recovery. Through systematic search, we found 14 universal recovery scales, which have different structures, contents and measurement properties, as well as their own strengths and weaknesses. We also found that it is urgently necessary to perform further researches and develop a scale that can serve as the gold universal standard to evaluate postoperative recovery. In addition, with the rapid development of intelligent equipment, the establishment and validation of electronic scales is also an interesting direction.
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Affiliation(s)
- Yijun Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, China
| | - Yanhua Qiu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, China
| | - Yifan Fu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, China
| | - Jin Liu
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
- The Research Units of West China(2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, Chengdu, China
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30
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Zorrilla-Vaca A, Grant MC, Rehman M, Sarin P, Mendez-Pino L, Urman RD, Varelmann D. Performance Comparison of Pulmonary Risk Scoring Systems in Lung Resection. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00343-9. [PMID: 37330329 DOI: 10.1053/j.jvca.2023.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/03/2023] [Accepted: 05/19/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To validate and compare the performance of different pulmonary risk scoring systems to predict postoperative pulmonary complications (PPCs) in lung resection surgery. DESIGN Retrospective cohort study SETTING: A historic single-center cohort of lung resection surgeries PARTICIPANTS: Adult patients undergoing lung resection surgery under 1-lung ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The accuracy of the following pulmonary risk scoring systems were used to predict pulmonary complications: the ARISCAT (Assess respiratory RIsk in Surgical patients in CATalonia), the LAS VEGAS (Local Assessment of VEntilatory management during General Anesthesia for Surgery), the SPORC (Score for Prediction of Postoperative Respiratory Complications), and a recent thoracic-specific risk score, named CARDOT. Discrimination and calibration were assessed using the concordance (c) index and the intercept of LOESS (locally estimated scatterplot)-smoothed curves, respectively. Additional models were constructed that incorporated predicted postoperative forced expiratory volume (ppoFEV1) into each scoring system. Of the 2,104 patients undergoing lung surgery, 123 developed postoperative pulmonary complications (PPCs; 5.9%). All scoring systems had poor discriminatory power to predict PPCs (ARISCAT c-index 0.60, 95% confidence interval [CI] 0.55-0.65; LAS VEGAS c-index 0.68, 95% CI 0.63-0.73; SPORC c-index 0.63, 95% CI 0.59-0.68; CARDOT c-index 0.64, 95% CI 0.58-0.70), but the inclusion of ppoFEV1 slightly improved the performance of LAS VEGAS (c-index 0.70, 95% CI 0.66-0.75) and CARDOT (c-index 0.68, 95% CI 0.62-0.73). Analysis of calibration showed a slight overestimation when using ARISCAT (intercept -0.28) and LAS VEGAS (intercept -0.27). CONCLUSIONS None of the scoring systems appeared to have adequate discriminatory power to predict PPCs among patients undergoing lung resection. An alternative risk score is necessary to better predict patients at risk of PPCs after thoracic surgery.
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Affiliation(s)
- Andres Zorrilla-Vaca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Universidad del Valle, Hospital Universidad del Valle, Cali, Colombia.
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD
| | - Muhammad Rehman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Pankaj Sarin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Laura Mendez-Pino
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, Columbus, OH
| | - Dirk Varelmann
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Reijnders-Boerboom GT, Albers KI, Jacobs LM, van Helden E, Rosman C, Díaz-Cambronero O, Mazzinari G, Scheffer GJ, Keijzer C, Warlé MC. Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis. Int J Surg 2023; 109:1400-1411. [PMID: 37026807 PMCID: PMC10389627 DOI: 10.1097/js9.0000000000000289] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 02/03/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group. MATERIALS AND METHODS We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay. RESULTS Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73). CONCLUSIONS Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.
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Affiliation(s)
| | - Kim I. Albers
- Departments of Anesthesiology
- Surgery, Radboudumc, Nijmegen, The Netherlands
| | | | | | | | - Oscar Díaz-Cambronero
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
| | - Guido Mazzinari
- Department of Anesthesiology, La Fé University and Polytechnic Hospital, Valencia, Spain
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32
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Calamai I, Greco M, Savi M, Vitiello G, Garbero E, Spina R, Pisani L, Mongodi S, Finazzi S. Thoracic UltrasONOgraphy Reporting: The TUONO Consensus. Diagnostics (Basel) 2023; 13:diagnostics13091535. [PMID: 37174927 PMCID: PMC10177560 DOI: 10.3390/diagnostics13091535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/08/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
The widespread use of the lung ultrasound (LUS) has not been followed by the development of a comprehensive standardized tool for its reporting in the intensive care unit (ICU) which could be useful to promote consistency and reproducibility during clinical examination. This work aims to define the essential features to be included in a standardized reporting tool and provides a structured model form to fully express the diagnostic potential of LUS and facilitate intensivists in the use of a LUS in everyday clinical ICU examination. We conducted a modified Delphi process to build consensus on the items to be integrated in a standardized report form and on its structure. A committee of 19 critical care physicians from 19 participating ICUs in Italy was formed, including intensivists experienced in ultrasound from both teaching hospitals and referral hospitals, and internationally renowned experts on the LUS. The consensus for 31 statements out of 33 was reached at the third Delphi round. A structured model form was developed based on the approved statements. The development of a standardized model as a backbone to report a LUS may facilitate the guidelines' application in clinical practice and increase inter-operator agreement. Further studies are needed to evaluate the effects of standardized reports in critically ill patients.
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Affiliation(s)
- Italo Calamai
- Anesthesia and Intensive Care Unit AUsl Toscana Centro, Ospedale San Giuseppe, Viale Boccaccio 16/20, 50053 Empoli, Italy
| | - Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Marzia Savi
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Gaia Vitiello
- Laboratory of Clinical Data Science, Mario Negri Institute of Pharmacological Research IRCCS, 20156 Ranica, Italy
| | - Elena Garbero
- Laboratory of Clinical Data Science, Mario Negri Institute of Pharmacological Research IRCCS, 20156 Ranica, Italy
| | - Rosario Spina
- Anesthesia and Intensive Care Unit AUsl Toscana Centro, Ospedale San Giuseppe, Viale Boccaccio 16/20, 50053 Empoli, Italy
| | - Luigi Pisani
- Intensive Care Unit, Ospedale Generale Regionale Miulli, 70021 Acquaviva delle Fonti, Italy
- Mahidol Oxford Tropical Research Unit, Bangkok 10400, Thailand
| | - Silvia Mongodi
- Anaesthesia and Intensive Care, San Matteo Hospital, 94403 Pavia, Italy
| | - Stefano Finazzi
- Laboratory of Clinical Epidemiology, Mario Negri Institute of Pharmacological Research IRCCS, 20156 Ranica, Italy
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Mahajan A, Mythen MM. Innovations in Practices and Technologies That Will Shape Perioperative Medicine. Anesth Analg 2023; 136:623-626. [PMID: 36928145 DOI: 10.1213/ane.0000000000006439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Affiliation(s)
- Aman Mahajan
- From the Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Health System, Pittsburgh, Pennsylvania
| | - Monty Michael Mythen
- Department of Anaesthesia and Critical Care, University College London, London, United Kingdom
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34
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Wacker J. Quality indicators for anesthesia and perioperative medicine. Curr Opin Anaesthesiol 2023; 36:208-215. [PMID: 36689392 PMCID: PMC9973445 DOI: 10.1097/aco.0000000000001227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Routine monitoring of care quality is fundamental considering the high reported rates of preventable perioperative morbidity and mortality. However, no set of valid and feasible quality indicators is available as the gold standard for comprehensive routine monitoring of the overall quality of perioperative care. The purpose of this review is to describe underlying difficulties, to summarize current trends and initiatives and to outline the perspectives in support of suitable perioperative quality indicators. RECENT FINDINGS Most perioperative quality indicators used in the clinical setting are based on low or no evidence. Evidence-based perioperative quality indicators validated for research purposes are not always applicable in routine care. Developing a core set of perioperative quality indicators for clinical practice may benefit from matching feasible routine indicators with evidence-based indicators validated for research, from evaluating additional new indicators, and from including patients' views. SUMMARY A core set of valid and feasible quality indicators is essential for monitoring perioperative care quality. The development of such a set may benefit from matching evidence-based indicators with feasible standard indicators and from including patients' views.
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Affiliation(s)
- Johannes Wacker
- Institute of Anaesthesia and Intensive Care, Hirslanden Clinic
- University of Zurich, Faculty of Medicine, Zurich, Switzerland
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35
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Abstract
The global volume of surgery is increasing. Adverse outcomes after surgery have resource implications and long-term impact on quality of life and consequently represent a significant and underappreciated public health issue. Standardization of outcome reporting is essential for evidence synthesis, risk stratification, perioperative care planning, and to inform shared decision-making. The association between short- and long-term outcomes, which persists when corrected for base-line risk, has significant implications for patients and providers and warrants further investigation. Candidate mechanisms include sustained inflammation and reduced physician activity, which may, in the future, be mitigated by targeted interventions.
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Affiliation(s)
- David Alexander Harvie
- From the Department of Anaesthesia & Perioperative Care and General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Denny Zelda Hope Levett
- From the Department of Anaesthesia & Perioperative Care and General Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Michael Patrick William Grocott
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton, United Kingdom
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36
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Marchesini V, Disma N. Outcomes in pediatric anesthesia: towards a universal language. Curr Opin Anaesthesiol 2023; 36:216-221. [PMID: 36728715 DOI: 10.1097/aco.0000000000001232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW The identification of valid, well defined and relevant outcomes is fundamental to provide a reliable and replicable measure that can be used to improve quality of clinical care and research output. The purpose of this review is to provide an update on what the pediatric anesthesia research community is pursuing on standardized and validated outcomes. RECENT FINDINGS Several initiatives by different research groups have been established during the last years. They all aim to find validated outcomes using the standardized methodology of COMET ( https://www.comet-initiative.org/ ). These initiatives focus on clinical and research outcomes on the field of anesthesia, perioperative medicine, pain and sedation in pediatric age. SUMMARY Clinical outcomes are measurements of changes in health, function or quality of life and they help evaluating quality of care. In order for them to be relevant in quantifying quality improvement, they need to be well defined, standardized and consistent across trials. A great effort from researchers has been made towards the identification of set of outcomes with these features.
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Affiliation(s)
- Vanessa Marchesini
- Pediatric Intensive Care Unit, Royal Melbourne Children's Hospital, Parkville
- Anesthesia and Pain Management Research Group, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Nicola Disma
- Unit for Research in Anesthesia, Department of Pediatric Anesthesia, IRCCS Istituto Giannina Gaslini, Genova, Italy
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Rajendran L, Lenet T, Shorr R, Abou Khalil J, Bertens KA, Balaa FK, Martel G. Should Cell Salvage Be Used in Liver Resection and Transplantation? A Systematic Review and Meta-analysis. Ann Surg 2023; 277:456-468. [PMID: 35861339 PMCID: PMC9891298 DOI: 10.1097/sla.0000000000005612] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the effect of intraoperative blood cell salvage and autotransfusion (IBSA) use on red blood cell (RBC) transfusion and postoperative outcomes in liver surgery. BACKGROUND Intraoperative RBC transfusions are common in liver surgery and associated with increased morbidity. IBSA can be utilized to minimize allogeneic transfusion. A theoretical risk of cancer dissemination has limited IBSA adoption in oncologic surgery. METHODS Electronic databases were searched from inception until May 2021. All studies comparing IBSA use with control in liver surgery were included. Screening, data extraction, and risk of bias assessment were conducted independently, in duplicate. The primary outcome was intraoperative allogeneic RBC transfusion (proportion of patients and volume of blood transfused). Core secondary outcomes included: overall survival and disease-free survival, transfusion-related complications, length of hospital stay, and hospitalization costs. Data from transplant and resection studies were analyzed separately. Random effects models were used for meta-analysis. RESULTS Twenty-one observational studies were included (16 transplant, 5 resection, n=3433 patients). Seventeen studies incorporated oncologic indications. In transplant, IBSA was associated with decreased allogeneic RBC transfusion [mean difference -1.81, 95% confidence interval (-3.22, -0.40), P =0.01, I 2 =86%, very-low certainty]. Few resection studies reported on transfusion for meta-analysis. No significant difference existed in overall survival or disease-free survival in liver transplant [hazard ratio (HR)=1.12 (0.75, 1.68), P =0.59, I 2 =0%; HR=0.93 (0.57, 1.48), P =0.75, I 2 =0%] and liver resection [HR=0.69 (0.45, 1.05), P =0.08, I 2 =0%; HR=0.93 (0.59, 1.45), P =0.74, I 2 =0%]. CONCLUSION IBSA may reduce intraoperative allogeneic RBC transfusion without compromising oncologic outcomes. The current evidence base is limited in size and quality, and high-quality randomized controlled trials are needed.
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Affiliation(s)
- Luckshi Rajendran
- Division of General Surgery, University of Toronto, Toronto, ON, Canada
| | - Tori Lenet
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Risa Shorr
- Library Services, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jad Abou Khalil
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Kimberly A. Bertens
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Fady K. Balaa
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Guillaume Martel
- Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Bedford J, Martin P, Crowe S, Wagstaff D, Santos C, Singleton G, Baumber R, Vindrola‐Padros C, Vohra R, Swart M, Oliver CM, Dorey J, Leeman I, Moonesinghe SR. Development and internal validation of a model for postoperative morbidity in adults undergoing major elective colorectal surgery: the peri-operative quality improvement programme (PQIP) colorectal risk model. Anaesthesia 2022; 77:1356-1367. [PMID: 36130834 PMCID: PMC9826419 DOI: 10.1111/anae.15858] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2022] [Indexed: 01/11/2023]
Abstract
Over 1.5 million major surgical procedures take place in the UK NHS each year and approximately 25% of patients develop at least one complication. The most widely used risk-adjustment model for postoperative morbidity in the UK is the physiological and operative severity score for the enumeration of mortality and morbidity. However, this model was derived more than 30 years ago and now overestimates the risk of morbidity. In addition, contemporary definitions of some model predictors are markedly different compared with when the tool was developed. A second model used in clinical practice is the American College of Surgeons National Surgical Quality Improvement Programme risk model; this provides a risk estimate for a range of postoperative complications. This model, widely used in North America, is not open source and therefore cannot be applied to patient populations in other settings. Data from a prospective multicentre clinical dataset of 118 NHS hospitals (the peri-operative quality improvement programme) were used to develop a bespoke risk-adjustment model for postoperative morbidity. Patients aged ≥ 18 years who underwent colorectal surgery were eligible for inclusion. Postoperative morbidity was defined using the postoperative morbidity survey at postoperative day 7. Thirty-one candidate variables were considered for inclusion in the model. Death or morbidity occurred by postoperative day 7 in 3098 out of 11,646 patients (26.6%). Twelve variables were incorporated into the final model, including (among others): Rockwood clinical frailty scale; body mass index; and index of multiple deprivation quintile. The C-statistic was 0.672 (95%CI 0.660-0.684), with a bootstrap optimism corrected C-statistic of 0.666 at internal validation. The model demonstrated good calibration across the range of morbidity estimates with a mean slope gradient of predicted risk of 0.959 (95%CI 0.894-1.024) with an index-corrected intercept of -0.038 (95%CI -0.112-0.036) at internal validation. Our model provides parsimonious case-mix adjustment to quantify risk of morbidity on postoperative day 7 for a UK population of patients undergoing major colorectal surgery. Despite the C-statistic of < 0.7, our model outperformed existing risk-models in widespread use. We therefore recommend application in case-mix adjustment, where incorporation into a continuous monitoring tool such as the variable life adjusted display or exponentially-weighted moving average-chart could support high-level monitoring and quality improvement of risk-adjusted outcome at the population level.
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Affiliation(s)
- J. Bedford
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - P. Martin
- Department of Applied Health ResearchUniversity College LondonUK
| | - S. Crowe
- Clinical Operational Research UnitUniversity College LondonUK
| | - D. Wagstaff
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - C. Santos
- Health Services Research Centre, National Institute for Academic AnaesthesiaRoyal College of AnaesthetistsLondonUK
| | - G. Singleton
- Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Baumber
- Department of AnaesthesiaRoyal National Orthopaedic Hospital NHS TrustLondonUK
| | - C. Vindrola‐Padros
- Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - R. Vohra
- Department of SurgeryNottingham University Hospitals NHS TrustNottinghamUK
| | - M. Swart
- Department of AnaesthesiaTorbay and South Devon NHS TrustDevonUK
| | - C. M. Oliver
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative MedicineResearch Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
| | - J. Dorey
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - I. Leeman
- Lay CommitteeRoyal College of Anaesthetists and Lay representatives PQIP Project teamLondonUK
| | - S. R. Moonesinghe
- UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Peri‐operative MedicineUniversity College London Hospitals NHS Foundation TrustLondonUK,Centre for Peri‐operative Medicine, Research Department for Targeted InterventionUCL Division of Surgery and Interventional ScienceLondonUK
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Fielding-Singh V, Vanneman MW, Grogan T, Neelankavil JP, Winkelmayer WC, Chang TI, Liu VX, Lin E. Association Between Preoperative Hemodialysis Timing and Postoperative Mortality in Patients With End-stage Kidney Disease. JAMA 2022; 328:1837-1848. [PMID: 36326747 PMCID: PMC9634601 DOI: 10.1001/jama.2022.19626] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 10/04/2022] [Indexed: 11/06/2022]
Abstract
Importance For patients with end-stage kidney disease treated with hemodialysis, the optimal timing of hemodialysis prior to elective surgical procedures is unknown. Objective To assess whether a longer interval between hemodialysis and subsequent surgery is associated with higher postoperative mortality in patients with end-stage kidney disease treated with hemodialysis. Design, Setting, and Participants Retrospective cohort study of 1 147 846 procedures among 346 828 Medicare beneficiaries with end-stage kidney disease treated with hemodialysis who underwent surgical procedures between January 1, 2011, and September 30, 2018. Follow-up ended on December 31, 2018. Exposures One-, two-, or three-day intervals between the most recent hemodialysis treatment and the surgical procedure. Hemodialysis on the day of the surgical procedure vs no hemodialysis on the day of the surgical procedure. Main Outcomes and Measures The primary outcome was 90-day postoperative mortality. The relationship between the dialysis-to-procedure interval and the primary outcome was modeled using a Cox proportional hazards model. Results Of the 1 147 846 surgical procedures among 346 828 patients (median age, 65 years [IQR, 56-73 years]; 495 126 procedures [43.1%] in female patients), 750 163 (65.4%) were performed when the last hemodialysis session occurred 1 day prior to surgery, 285 939 (24.9%) when the last hemodialysis session occurred 2 days prior to surgery, and 111 744 (9.7%) when the last hemodialysis session occurred 3 days prior to surgery. Hemodialysis was also performed on the day of surgery for 193 277 procedures (16.8%). Ninety-day postoperative mortality occurred after 34 944 procedures (3.0%). Longer intervals between the last hemodialysis session and surgery were significantly associated with higher risk of 90-day mortality in a dose-dependent manner (2 days vs 1 day: absolute risk, 4.7% vs 4.2%, absolute risk difference, 0.6% [95% CI, 0.4% to 0.8%], adjusted hazard ratio [HR], 1.14 [95% CI, 1.10 to 1.18]; 3 days vs 1 day: absolute risk, 5.2% vs 4.2%, absolute risk difference, 1.0% [95% CI, 0.8% to 1.2%], adjusted HR, 1.25 [95% CI, 1.19 to 1.31]; and 3 days vs 2 days: absolute risk, 5.2% vs 4.7%, absolute risk difference, 0.4% [95% CI, 0.2% to 0.6%], adjusted HR, 1.09 [95% CI, 1.04 to 1.13]). Undergoing hemodialysis on the same day as surgery was associated with a significantly lower hazard of mortality vs no same-day hemodialysis (absolute risk, 4.0% for same-day hemodialysis vs 4.5% for no same-day hemodialysis; absolute risk difference, -0.5% [95% CI, -0.7% to -0.3%]; adjusted HR, 0.88 [95% CI, 0.84-0.91]). In the analyses that evaluated the interaction between the hemodialysis-to-procedure interval and same-day hemodialysis, undergoing hemodialysis on the day of the procedure significantly attenuated the risk associated with a longer hemodialysis-to-procedure interval (P<.001 for interaction). Conclusions and Relevance Among Medicare beneficiaries with end-stage kidney disease, longer intervals between hemodialysis and surgery were significantly associated with higher risk of postoperative mortality, mainly among those who did not receive hemodialysis on the day of surgery. However, the magnitude of the absolute risk differences was small, and the findings are susceptible to residual confounding.
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Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Stanford, California
| | - Matthew W. Vanneman
- Department of Anesthesiology, Perioperative, and Pain Medicine, School of Medicine, Stanford University, Stanford, California
| | - Tristan Grogan
- Department of Medicine, Statistics Core, David Geffen School of Medicine, University of California, Los Angeles
| | - Jacques P. Neelankavil
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles
| | - Wolfgang C. Winkelmayer
- Selzman Institute for Kidney Health and Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Tara I. Chang
- Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Vincent X. Liu
- Division of Research, Kaiser Permanente, Oakland, California
| | - Eugene Lin
- Division of Nephrology, Department of Medicine, University of Southern California, Los Angeles
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles
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Gencer B, Gale CP, Aktaa S, Halvorsen S, Beska B, Abdelhamid M, Mueller C, Tutarel O, McGreavy P, Schirmer H, Geissler T, Sillesen H, Niessner A, Zacharowski K, Mehilli J, Potpara T. European Society of Cardiology Quality Indicators for the Cardiovascular Preoperative Assessment and Management of patients considered for non-cardiac surgery. Developed in collaboration with the European Society of Anaesthesiology & Intensive Care. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022:qcac057. [PMID: 36069905 DOI: 10.1093/ehjqcco/qcac057] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
AIMS To establish a set of quality indicators (QIs) for the cardiovascular (CV) assessment and management of patients undergoing non-cardiac surgery. METHODS AND RESULTS The Quality Indicator Committee of the European Society of Cardiology (ESC) and European Society of Anaesthesiology & Intensive Care (ESAIC) in collaboration with Task Force members of the 2022 ESC Guidelines on CV assessment and management of patients undergoing non-cardiac surgery followed the ESC methodology for QI development. This included 1) identification, by constructing a conceptual framework of care, of domains of the CV assessment and management of patients with risk factors or established cardiovascular disease (CVD) who are considered for or undergoing non-cardiac surgery, 2) development of candidate QIs following a systematic literature review, 3) selection of the final set of QIs using a modified Delphi method, 4) evaluation of the feasibility of the developed QIs. In total, eight main and nine secondary QIs were selected across six domains: 1) Structural framework (written policy), 2) Patient education and quality of life (CV risk discussion), 3) Peri-operative risk assessment (indication for diagnostic tests), 4) Peri-operative risk mitigation (use of hospital therapies), 5) Follow-up (post-discharge assessment) and 6) Outcomes (major CV events). CONCLUSION We present the 2022 ESC/ESAIC QIs for the CV assessment and management of patients with risk factors or established CVD who are considered for or are undergoing non-cardiac surgery. These indicators are supported by evidence from the literature, underpinned by expert consensus and align with 2022 ESC Guidelines on CV assessment and management of patients undergoing non-cardiac surgery.
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Affiliation(s)
- Baris Gencer
- Cardiology Division, Geneva University Hospitals, Geneva, Switzerland
- Institute of Primary Health Care (BIHAM), Bern University, Bern, Switzerland
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
| | - Ben Beska
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
- Leeds Institute for Data Analytics and Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Magdy Abdelhamid
- Cardiology Department, Faculty of Medicine, Kase Al Ainy, Cairo University, Cairo, Egypt
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Heart Center, University Hospital Basel, Basel, Switzerland, University of Basel, Basel, Switzerland
| | - Oktay Tutarel
- Department of Congenital Heart Disease and Paediatric Cardiology, German Heart Centre Munich, TUM School of Medicine, Technical University of Munich, Munich, Germany
| | - Paul McGreavy
- Patient representatives, European Society of Cardiology (ESC)
| | - Henrik Schirmer
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, Campus Ahus, University of Oslo, Lørenskog, Norway
| | - Tobias Geissler
- Department of Cardiology and Angiology, University Hospital Tübingen, Tübingen, Germany
| | - Henrik Sillesen
- Vascular Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Alexander Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Kai Zacharowski
- Department Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Julinda Mehilli
- Department of Cardiology, LMU University Hospital and German Centre for Cardiovascular Research (DZHK), partner site Munich Heart Alliance, Munich, Germany
- Department of Cardiology, Medizinische Klinik I, Landshut-Achdorf Hospital, Landshut, Germany
| | - Tatjana Potpara
- Cardiology Clinic, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Serbia
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Abstract
OBJECTIVES We aim to describe on the role of exercise in preparation for cancer treatments (prehabilitation) that include surgery and neoadjuvant or nonsurgical approaches. We discuss the evidence for the role of exercise and provide guidelines to exercise prescription and examples of the structure of prehabilitation exercise programs. DATA SOURCE We use peer-reviewed articles obtained through PubMed searches with search terms: exercise, oncology, cancer surgery, exercise physiology, respiratory exercises, prehabilitation, and behavior change. CONCLUSION The emergence of prehabilitation in preparing patients for cancer care has followed a rapidly upward trajectory over the past 20 years. Exercise prehabilitation remains the cornerstone of management, particularly in patients attending for major surgery. Multimodal approaches to supporting patients before cancer treatment are now well accepted and include screening and individualized treatments of functional, nutritional, and psychological impairments. Respiratory training before surgery and the addition of behavior change strategies to improve adherence to interventions and promote improved longer-term outcomes are now included in many prehabilitation programs. For exercise to be an effective treatment in improving fitness and strength, supervised aerobic and resistance exercises at moderate intensity are recommended. There remains debate regarding the use of higher-intensity exercise, the appropriate outcome to measure efficacy, and the mechanisms driving the efficacy of exercise. IMPLICATIONS FOR NURSING PRACTICE We provide background evidence and knowledge pertaining to the role and provision of exercise prehabilitation. Understanding screening, risk factors, and potential efficacy assists in knowing who to refer for prehabilitation and what the programs include. This enables more effective com munication with patients attending for cancer treatments.
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Affiliation(s)
- Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences; Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Australia; Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia.
| | - Lara Edbrooke
- Department of Physiotherapy, Melbourne School of Health Sciences; Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Australia; Department of Health Services Research, Peter MacCallum Cancer Centre, Melbourne, Australia
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Li H, Wang H, Pan Y, Huang Q, Li X, Zeng X, Zhou L. Efficacy of High-Quality Nursing Service for the Patients during the Anesthesia Recovery Period: A Meta-Analysis. Appl Bionics Biomech 2022; 2022:3528915. [PMID: 35979241 PMCID: PMC9377987 DOI: 10.1155/2022/3528915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/17/2022] [Accepted: 07/19/2022] [Indexed: 11/22/2022] Open
Abstract
Background To investigate the efficacy of high-quality nursing service for the patients during the anesthesia recovery period. Methods We used the National Library of Medicine (PubMed), Cochrane Library of Excerpta Medica Database (EMBASE), China National Knowledge Infrastructure (CNKI), Wanfang, and very important person (VIP) databases for conducting a systematic literature study. We employed the fixed-effects model for evaluating the standardized mean differences (SMDs) with 95% confidence intervals (CIs). The sensitivity and publication bias were estimated for determining the efficacy of high-quality nursing services during the recovery period of anesthesia. Results In our study, the result showed that the efficiency of recovery time of spontaneous respiration was significantly improved in the experimental group (SMD = -1.48, 95%CI = [-1.62, -1.34]). In this analysis, the extubation time of the experimental group was lower than that of the control group. In control group [WMD = -15.54, 95% CI (-21.24, -9.83), P < 0.00001], the improvement of extubation time was more obvious on high-quality nursing. Moreover, the incidence of agitation in the experimental group was lower than that of the control group, and the score of nursing satisfaction was higher than that in the control group (P = 0.01). The funnel plots identified no publication bias during the identification of efficacy. Conclusions The high-quality nursing care for patients during the resuscitation period can shorten the recovery time of their self-consciousness and self-breathing, reduce the occurrence rate of restlessness, improve patients' anxiety and depression, reduce complications, and play a certain clinical application effect.
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Affiliation(s)
- Hui Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Heng Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yan Pan
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qian Huang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xueping Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiaoqi Zeng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Li Zhou
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
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Siow WS, Tay L, Mah CL. Quality improvement initiative: how the setting up of an anaesthesia consultant-led perioperative outreach service addressed anaesthesia-specific issues to improve anaesthesia consult and surgery timings for hip fracture patients. BMJ Open Qual 2022; 11:bmjoq-2021-001738. [PMID: 35940697 PMCID: PMC9364401 DOI: 10.1136/bmjoq-2021-001738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 07/24/2022] [Indexed: 11/04/2022] Open
Abstract
BackgroundSurgery is recommended within 48 hours of hip fractures for better perioperative outcomes. Yet, such targets still commonly remain a challenge. Our institution is no exception.As part of a hospital-wide initiative, our anaesthesia department focused on improving perioperative processes with aims to reduce the time to first anaesthesia consult and surgery for hip fracture patients. Acknowledging multiple causes for surgical delay, we decided first to address anaesthesia-specific factors—(a) first anaesthetist contact usually happens after surgery is offered which leaves a short runway for preoptimisation, (b) this is compounded by varying degrees of anaesthetist involvement for follow-up thereafter. (c) There is a need to calibrate our perioperative care standards and (d) enforce more consistent auditing in quality assurance. This project was conducted in a 1000-bed hospital serving eastern Singapore.InterventionWe created an integrated anaesthesia consultant-led outreach service for hip fracture patients, based on a perioperative workflow system to provide proactive anaesthetist consults within 24 hours of admission in advance of surgical decision. This was streamlined with a coordinated follow-up system for preoptimisation until surgery.MethodsOur quality improvement project applied the iterative Plan-Do-Study-Act model from pilot to sustainability stage. We collected data at baseline followed by 6-monthly audits from electronic databases.Primary outcomes measured were time to first anaesthesia consult and surgery. Secondary outcomes included rate of critical care reviews and admission, mortality rate, length of stay and time to nerve blocks.ResultsPost implementation, our service reviewed >600 hip fracture patients. Median time to anaesthesia consult reduced significantly from 35.3 hours (2019) to 21.5 hours (2021) (p=0.029). Median time to surgery was reduced from 61.5 hours (2019) to 50 hours (2021) (p=0.897) with a 13.6% increase in patients operated <48 hours. Critical care admissions, 6-monthly and 12-monthly mortality rates and time to nerve block were reduced with a greater percentage of patients discharged within 10 days.ConclusionOur project focused on improving anaesthesia perioperative processes to address surgical delays in hip fracture patients. Our consultant-led anaesthesia service ensured that proactive anaesthesia care was delivered to provide sufficient time for preoptimisation with greater standardisation to follow-up, better communication and quality assurance.
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Affiliation(s)
- Wei Shyan Siow
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
| | - Leeanna Tay
- ValueCare Programme Office, Centre of Performance Excellence, Changi General Hospital, Singapore
| | - Chou Liang Mah
- Department of Anaesthesia and Surgical Intensive Care, Changi General Hospital, Singapore
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Hutchings A, O'Neill S, Lugo-Palacios D, Moler Zapata S, Silverwood R, Cromwell D, Keele L, Bellingan G, Moonesinghe SR, Smart N, Hinchliffe R, Grieve R. Effectiveness of emergency surgery for five common acute conditions: an instrumental variable analysis of a national routine database. Anaesthesia 2022; 77:865-881. [PMID: 35588540 PMCID: PMC9540551 DOI: 10.1111/anae.15730] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/14/2022] [Accepted: 03/20/2022] [Indexed: 12/29/2022]
Abstract
The effectiveness of emergency surgery vs. non-emergency surgery strategies for emergency admissions with acute appendicitis, gallstone disease, diverticular disease, abdominal wall hernia or intestinal obstruction is unknown. Data on emergency admissions for adult patients from 2010 to 2019 at 175 acute National Health Service hospitals in England were extracted from the Hospital Episode Statistics database. Cohort sizes were: 268,144 (appendicitis); 240,977 (gallstone disease); 138,869 (diverticular disease); 106,432 (hernia); and 133,073 (intestinal obstruction). The primary outcome was number of days alive and out of hospital at 90 days. The effectiveness of emergency surgery vs. non-emergency surgery strategies was estimated using an instrumental variable design and is reported for the cohort and pre-specified sub-groups (age, sex, number of comorbidities and frailty level). Average days alive and out of hospital at 90 days for all five cohorts were similar, with the following mean differences (95%CI) for emergency surgery minus non-emergency surgery after adjusting for confounding: -0.73 days (-2.10-0.64) for appendicitis; 0.60 (-0.10-1.30) for gallstone disease; -2.66 (-15.7-10.4) for diverticular disease; -0.07 (-2.40-2.25) for hernia; and 3.32 (-3.13-9.76) for intestinal obstruction. For patients with 'severe frailty', mean differences (95%CI) in days alive and out of hospital for emergency surgery were lower than for non-emergency surgery strategies: -21.0 (-27.4 to -14.6) for appendicitis; -5.72 (-11.3 to -0.2) for gallstone disease, -38.9 (-63.3 to -14.6) for diverticular disease; -19.5 (-26.6 to -12.3) for hernia; and - 34.5 (-46.7 to -22.4) for intestinal obstruction. For patients without frailty, the mean differences (95%CI) in days alive and out of hospital were: -0.18 (-1.56-1.20) for appendicitis; 0.93 (0.48-1.39) for gallstone disease; 5.35 (-2.56-13.28) for diverticular disease; 2.26 (0.37-4.15) for hernia; and 18.2 (14.8-22.47) for intestinal obstruction. Emergency surgery and non-emergency surgery strategies led to similar average days alive and out of hospital at 90 days for five acute conditions. The comparative effectiveness of emergency surgery and non-emergency surgery strategies for these conditions may be modified by patient factors.
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Affiliation(s)
- A Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S O'Neill
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - D Lugo-Palacios
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - S Moler Zapata
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - R Silverwood
- Centre for Longitudinal Studies, University College London, London, UK
| | - D Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - L Keele
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - G Bellingan
- Department of Critical Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - S R Moonesinghe
- Department for Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, UK
| | - N Smart
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - R Hinchliffe
- Bristol Surgical Trials Centre, University of Bristol, Bristol, UK
| | - R Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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