Anaesthesia, analgesia, and the surgical stress response

Preoperative Exposure to Fine Particulate Matter and Risk of Postoperative Complications: A Single Center Observational Cohort Bayesian Analysis

Background & Objectives

While exposure to fine particulate matter air pollution (PM 2.5 ) is known to cause adverse health effects, its impact on postoperative outcomes in US adults remains understudied. Perioperative exposure to PM 2.5 may induce inflammation that insidiously interacts with the systemic inflammatory response after surgery, leading to higher postoperative complications.

Methods

We conducted a single center, retrospective cohort study using data from 64,313 surgical patients living along Utah's Wasatch Front and undergoing elective surgical procedures at a single academic medical center from 2016-2018. Patients' addresses were geocoded and linked to daily Census-tract level PM 2.5 estimates preoperatively. We hypothesized that elevated PM 2.5 concentrations in the seven days prior to surgery would be associated with an increase in a bundle of major postoperative complications. A hierarchical Bayesians regression model was fit adjusting for age, sex, season, neighborhood disadvantage, and the Elixhauser index of comorbidities.

Results

Postoperative complications increased in a dose-dependent manner with higher concentrations of PM 2.5 exposure, with a relative increase of 7% in the odds of complications for every 10ug/m3 increase in the highest single-day 24-hr PM 2.5 exposure during the 7 days prior to surgery. The association persisted after controlling for comorbidities and potential confounders; our inferences were robust to modeling choices and sensitivity analysis.

Discussion & Conclusion

In this large Utah cohort, exposure to elevated PM 2.5 concentrations in the week before surgery was associated with increased postoperative complications in a dose-dependent manner, suggesting a potential impact of air pollution on surgical outcomes. These findings merit replication in larger datasets to identify populations at risk and to define the interaction and impact of different pollutants. PM 2.5 exposure is a potential perioperative risk factor and, given the unmitigated air pollution in urban areas, a global health concern.

Refining pain management in mice by comparing multimodal analgesia and NSAID monotherapy for neurosurgical procedures

While neurosurgical interventions are frequently used in laboratory mice, refinement efforts to optimize analgesic management based on multimodal approaches appear to be rather limited. Therefore, we compared the efficacy and tolerability of combinations of the non-steroidal anti-inflammatory drug carprofen, a sustained-release formulation of the opioid buprenorphine, and the local anesthetic bupivacaine with carprofen monotherapy. Female and male C57BL/6J mice were subjected to isoflurane anesthesia and an intracranial electrode implant procedure. Given the multidimensional nature of postsurgical pain and distress, various physiological, behavioral, and biochemical parameters were applied for their assessment. The analysis revealed alterations in Neuro scores, home cage locomotion, body weight, nest building, mouse grimace scales, and fecal corticosterone metabolites. A composite measure scheme allowed the allocation of individual mice to severity classes. The comparison between groups failed to indicate the superiority of multimodal regimens over high-dose NSAID monotherapy. In conclusion, our findings confirmed the informative value of various parameters for assessment of pain and distress following neurosurgical procedures in mice. While all drug regimens were well tolerated in control mice, our data suggest that the total drug load should be carefully considered for perioperative management. Future studies would be of interest to assess potential synergies of drug combinations with lower doses of carprofen.

Neuroinflammatory Approach to Surgical Trauma: Biomarkers and Mechanisms of Immune and Neuroendocrine Responses

The severity and invasiveness of clinical outcomes from organic responses to trauma are influenced by individual, surgical, and anesthetic factors. A stress response elicits neuroendocrine and immune reactions that may lead to multi-organ dysfunction. The degree of neuroinflammatory reflex activation from trauma can increase pro-inflammatory cytokine production, leading to endothelial dysfunction, glycocalyx damage, neutrophil activation, and multisystem tissue destruction. A shift in patient treatment towards a neuroinflammatory perspective has prompted a new evaluation protocol for surgical patients, required to understand surgical pathogenesis and its link to chosen anesthetic-surgical methods. The goal of this study is to summarize and disseminate the present knowledge about the mechanisms involved in immune and neuroendocrine responses, focusing on video laparoscopic surgeries. This article outlines various measures cited in the literature aimed at reducing the burden of surgical trauma. It reviews anesthetic drugs, anesthetic techniques, and intensive care procedures that are known to have immunomodulatory effects. The results show a preference for more sensitive inflammatory mediators to tissue trauma serving as care tools, indicators for prognosis, and therapeutic outcomes.

Opioid-free general anesthesia: considerations, techniques, and limitations

PURPOSE OF REVIEW

To discuss the role of opioids during general anesthesia and examine their advantages and risks in the context of clinical practice. We define opioid-free anesthesia (OFA) as the absolute avoidance of intraoperative opioids.

RECENT FINDINGS

In most minimally invasive and short-duration procedures, nonopioid analgesics, analgesic adjuvants, and local/regional analgesia can significantly spare the amount of intraoperative opioid needed. OFA should be considered in the context of tailoring to a specific patient and procedure, not as a universal approach. Strategies considered for OFA involve several adjuncts with low therapeutic range, requiring continuous infusions and resources, with potential for delayed recovery or other side effects, including increased short-term and long-term pain. No evidence indicates that OFA leads to decreased long-term opioid-related harms.

SUMMARY

Complete avoidance of intraoperative opioids remains questionable, as it does not necessarily ensure avoidance of postoperative opioids. Multimodal analgesia including local/regional anesthesia may allow OFA for selected, minimally invasive surgeries, but further research is necessary in surgeries with high postoperative opioid requirements. Until there is definitive evidence regarding procedure and patient-specific combinations as well as the dose and duration of administration of adjunct agents, it is imperative to practice opioid-sparing approach in the intraoperative period.

Enhanced Recovery After Surgery Pathways in Pediatric Spinal Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Pediatric spinal fusion surgery is a complex procedure that poses challenges in perioperative management. The enhanced recovery after surgery (ERAS) approach is an evidence-based, multidisciplinary strategy to optimize patient care in an individualized, multidisciplinary way. Despite the benefits of ERAS protocol implementation, the role of ERAS in pediatric spine surgery remains understudied. This systematic review and meta-analysis aims to evaluate the current literature regarding pediatric spinal surgery ERAS protocols and their ability to decrease the length of stay, pain, time-to-stand, and complications.

METHODS

A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Statistical analyses were performed using Cochrane's RevMan (version 5.4).

RESULTS

Seventeen studies totaling 2733 patients were included in this analysis. Patients treated in an ERAS protocol had significant reductions in length of stay (P < 0.001), time-to-stand (P < 0.001), total complications (P = 0.02), and estimated blood loss (P = 0.001).

CONCLUSIONS

ERAS protocol implementation can significantly enhance outcomes for pediatric patients receiving spinal surgery. Consequently, ERAS protocols have the potential to lower healthcare expenses, increase access, and set a new standard of care. Future research should be conducted to expand pediatric ERAS protocols to a diverse range of spinal pathologies and assess the long-term advantages of this practice.

The impact of physical activity on patient-reported outcomes following deep inferior epigastric perforator flap breast reconstruction

INTRODUCTION

Although higher preoperative physical activity levels have been shown to be beneficial to postoperative recovery at large, their effect on patient-reported outcomes after deep inferior epigastric perforator (DIEP) flap breast reconstruction has yet to be investigated. This study aimed to correlate patient physical activity levels with patient-reported outcome measures.

METHODS

A prospectively maintained database of patients who underwent DIEP flap breast reconstruction between July 2021 and June 2022 was analysed. Physical activity levels were assessed using the Global Physical Activity Questionnaire (GPAQ) and patient-reported outcomes were measured using the BREAST-Q questionnaire, both preoperatively and 1 year postoperatively. Patients were stratified into low (<1000 METs) and high (>1000 METs) physical activity groups.

RESULTS

Of the 136 patients who underwent surgery, 51 completed both questionnaires, with 34 responses meeting completeness criteria for statistical analysis. The low-MET group (n = 19) and high-MET group (n = 15) were comparable in age and comorbidities. Postoperatively, the low-MET group exhibited a 54% increase in physical activity levels, whereas the high-MET group showed a 17% decrease (p < 0.01). The low-MET group experienced significant declines in psychosocial well-being (9.3%, p = 0.04) and sexual well-being (14%, p = 0.02), whereas the high-MET group did not show significant changes in these domains. Satisfaction with the unclothed abdomen increased significantly in the low-MET group (2.9 from 2, p = 0.001), while the high-MET group showed a nonsignificant decrease (3.2 from 2.9, p = 0.43). However, abdominal well-being significantly decreased in both groups, with a 56% decline in the high-MET group (p = 0.006) and a 51% decline in the low-MET group (p = 0.0002). The latter reflects the perceived difference between aesthetic appearance and well-being.

CONCLUSIONS

Patients with lower preoperative physical activity levels showed improved activity postsurgery, potentially due to motivational factors from the reconstructive process. Conversely, those with higher preoperative activity levels faced greater challenges in maintaining their activity levels postsurgery, potentially arising from disruptions in daily routines and donor site symptoms, indicating a need for targeted interventions to support this group. Concurrently, patients with higher baseline exercise levels did not show a decrease in psychosocial and sexual well-being, possibly reflecting a higher resilience to the operative process. These findings underscore the importance of integrating physical activity assessments into preoperative evaluations to inform patient-centred care and optimise recovery outcomes.

Biomarkers in the Immuno-oncology Interface of Triple Negative Breast Cancer: A Scoping Review with Perioperative Considerations

PURPOSE OF REVIEW

Identification of biomarkers for immunotherapy treatment in triple negative breast cancer remains crucial for improving outcomes and optimising regimes, particularly in the perioperative setting. There is a need to conduct a scoping review to provide an overview of current research, explore the wider context, and highlight future research considerations in this field.

RECENT FINDINGS

The most commonly assessed biomarkers are PD-L1, TILs and CD8 + cells with correlation to outcomes mainly focused on survival. There is a growing interest in evaluating genetic markers. Conclusions are currently limited by knowledge gaps around contextual factors. Important areas of focus for future research include a greater understanding of complex cellular, genetic and metabolic interactions in the perioperative tumour microenvironment, including patient-specific immune profiles. An important challenge remains elucidating the clinical significance of the immunological effects of interventions at each stage of the perioperative period, including the use of anaesthetic agents.

Cancer treatments as paradoxical catalysts of tumor awakening in the lung

Much of the fatality of tumors is linked to the growth of metastases, which can emerge months to years after apparently successful treatment of primary tumors. Metastases arise from disseminated tumor cells (DTCs), which disperse through the body in a dormant state to seed distant sites. While some DTCs lodge in pre-metastatic niches (PMNs) and rapidly develop into metastases, other DTCs settle in distinct microenvironments that maintain them in a dormant state. Subsequent awakening, induced by changes in the microenvironment of the DTC, causes outgrowth of metastases. Hence, there has been extensive investigation of the factors causing survival and subsequent awakening of DTCs, with the goal of disrupting these processes to decrease cancer lethality. We here provide a detailed overview of recent developments in understanding of the factors controlling dormancy and awakening in the lung, a common site of metastasis for many solid tumors. These factors include dynamic interactions between DTCs and diverse epithelial, mesenchymal, and immune cell populations resident in the lung. Paradoxically, among key triggers for metastatic outgrowth, lung tissue remodeling arising from damage induced by the treatment of primary tumors play a significant role. In addition, growing evidence emphasizes roles for inflammation and aging in opposing the factors that maintain dormancy. Finally, we discuss strategies being developed or employed to reduce the risk of metastatic recurrence.

Effects of Dexmedetomidine on Perioperative Glycemic Control in Adult Diabetic Patients Undergoing Cardiac Surgery

BACKGROUND AND OBJECTIVE

To study the effects of dexmedetomidine (DEX) on perioperative blood glucose levels in adult diabetes mellitus (DM) patients undergoing cardiac surgery.

METHODS AND MATERIAL

A prospective, observational study was conducted on 100 adult diabetic patients aged between 18 and 75 years undergoing cardiac surgery with cardiopulmonary bypass (CPB). The patients were divided into two groups (group D and group C) of 50 each. Group D patients received DEX infusion, whereas the group C patients received 0.9% normal saline infusion.

RESULTS

The blood glucose levels, heart rate, mean arterial pressure, and serum potassium levels at different time points were comparable between the two groups (P > 0.05). The mean dose of insulin required in the combined population as well as in both controlled and uncontrolled DM patients was significantly less in group D than in group C (combined population - 36.03 ± 22.71 vs 47.82 ± 30.19 IU, P = 0.0297; uncontrolled DM - 37.36 ± 23.9 IU vs 48.16 ± 25.15 IU, P = 0.0301; controlled DM - 34.7 ± 21.5 IU vs 47.63 ± 35.25 IU, P = 0.0291). Duration of mechanical ventilation and VIS were comparable between the two groups. The incidence of arrhythmias (20% vs 46%, P = 0.0059) and delirium (6% vs 20%, P = 0.0384) was significantly less in group D than in group C. None of the patients in either group had stroke, myocardial ischemia, and mortality.

CONCLUSION

The results suggested that DEX infusion during the intraoperative period was very effective for perioperative glycemic control and reduction of insulin requirement in DM patients undergoing cardiac surgery.

Perioperative Immunosuppressive Factors during Cancer Surgery: An Updated Review

Surgical excision of the primary tumor represents the most frequent and curative procedure for solid malignancies. Compelling evidence suggests that, despite its beneficial effects, surgery may impair immunosurveillance by triggering an immunosuppressive inflammatory stress response and favor recurrence by stimulating minimal residual disease. In addition, many factors interfere with the immune effectors before and after cancer procedures, such as malnutrition, anemia, or subsequent transfusion. Thus, the perioperative period plays a key role in determining oncological outcomes and represents a short phase to circumvent anesthetic and surgical deleterious factors by supporting the immune system through the use of synergistic pharmacological and non-pharmacological approaches. In line with this, accumulating studies indicate that anesthetic agents could drive both protumor or antitumor signaling pathways during or after cancer surgery. While preclinical investigations focusing on anesthetics' impact on the behavior of cancer cells are quite convincing, limited clinical trials studying the consequences on survival and recurrences remain inconclusive. Herein, we highlight the main factors occurring during the perioperative period of cancer surgery and their potential impact on immunomodulation and cancer progression. We also discuss patient management prior to and during surgery, taking into consideration the latest advances in the literature.

Anesthesia Medication's Impacts on Inflammatory and Neuroendocrine Immune Response in Patients Undergoing Digestive Endoscopy

The aim of this study was to explore the impact of anesthetic drugs currently used to perform lower digestive endoscopy on serum concentrations of inflammation markers and catecholamines. We selected 120 patients and divided them into three lots of 40 patients each: L1, in which no anesthetics were used; L2, in which propofol was used; and L3, in which propofol combined with fentanyl was used. All patients had serum concentrations of adrenaline/epinephrine (EPI), noradrenaline/norepinephrine (NE), tumor necrosis factor alpha (TNF-α), interleukin-4 (IL-4), IL-6, IL-8, and IL-10, taken at three time points: at the beginning of the endoscopic procedure (T0), 15 min after (T1), and 2 h after the end of the endoscopic procedure (T2). The results of the research showed changes in the levels of catecholamines and interleukins (ILs) at T0, with an increased response in L1 above the mean recorded in L2 and L3 (p < 0.001). At T1, increased values were recorded in all lots; values were significantly higher in L1. At T2, the values recorded in L3 were significantly lower than the values in L2 (student T, p < 0.001) and L1, in which the level of these markers continued to increase, reaching double values compared to T0 (student T, p < 0.001). In L2 at T1, the dose of propofol correlated much better with NE, EPI, and well-known cytokines. Our results show that propofol combined with fentanyl can significantly inhibit the activation of systemic immune and neuroendocrine response during painless lower digestive endoscopy.

Cohort profile of BIGPROMISE: a perioperative biobank of a high-risk surgical population

PURPOSE

Postoperative complications increase mortality, disability and costs. Advanced understanding of the risk factors for postoperative complications is needed to improve surgical outcomes. This paper discusses the rationale and profile of the BIGPROMISE (biomarkers to guide perioperative management and improve outcome in high-risk surgery) cohort, that aims to investigate risk factors, pathophysiology and outcomes related to postoperative complications.

PARTICIPANTS

Adult patients undergoing major surgery in two tertiary teaching hospitals. Clinical data and blood samples are collected before surgery, at the end of surgery and on the first, second and third postoperative day. At each time point a panel of cardiovascular, inflammatory, renal, haematological and metabolic biomarkers is assessed. Aliquots of plasma, serum and whole blood of each time point are frozen and stored. Data on severe complications are prospectively collected during 30 days after surgery. Functional status is assessed before surgery and after 120 days using the WHO Disability Assessment Schedule (WHODAS) 2.0. Mortality is followed up until 2 years after surgery.

FINDINGS TO DATE

The first patient was enrolled on 8 October 2021. Currently (1 January 2024) 3086 patients were screened for eligibility, of whom 1750 (57%) provided informed consent for study participation. Median age was 66 years (60; 73), 28% were female, and 68% of all patients were American Society of Anaesthesiologists (ASA) physical status class 3. Most common types of major surgery were cardiac (49%) and gastro-intestinal procedures (26%). The overall incidence of 30-day severe postoperative complications was 16%.

FUTURE PLANS

By the end of the recruitment phase, expected in 2026, approximately 3000 patients with major surgery will have been enrolled. This cohort allows us to investigate the role of pathophysiological perioperative processes in the cause of postoperative complications, and to discover and develop new biomarkers to improve risk stratification for adverse postoperative outcomes.

TRIAL REGISTRATION NUMBER

NCT05199025.

Intraoperative Oxygen Consumption and Postoperative Immune Response in Colorectal Oncological Surgery: A Prospective, Monocentric Pilot Study

Surgical resection is the key treatment for colorectal cancer, but the extent of surgical trauma has been implied as a key factor for the oncologic outcome. The immune stress response to surgical trauma generates a cascade of immunological events implying neutrophils' perioperative change generating NETosis, N killer decrease, and platelets' activation that may influence postoperative surgical outcome, tumor cell growth, and future oncogenesis. The present study aimed to investigate the correlation between intraoperative oxygen consumption (VO2) and the dynamic variation of neutrophils, lymphocytes, and platelets in the perioperative period to identify an intraoperative tool that could predict the postoperative immune response. Twenty-six colorectal oncological surgical patients were enrolled in an observational, prospective, monocentric study, over 18 months. Serum neutrophils, lymphocytes, and thrombocytes values were collected in the preoperative period and on the third postoperative day, oxygen consumption was measured and recorded every 15 min during surgery using indirect calorimetry. We compared oxygen consumption measurements registered 30 min after induction of anesthesia (VO2a) and the first value registered after abdominal wall closure (VO2b) to perioperative variation of absolute neutrophils (VNC), lymphocytes (VLC), and platelets (VPC) count. Our results proved a significant correlation between VO2 variation and neutrophils' perioperative dynamic assessed by VNC (correlation coefficient = 0.547, p < 0.01, 95% confidence interval (CI) =0.175, 0.783). We also noticed a correlation between VPC and VO2 (correlation coefficient = -0.603, p < 0.01, 95% CI = -0.815, -0.248). No correlation could be shown between VO2 and VLC variation (p = 0.39). In conclusion, intraoperative VO2 variation measured by indirect calorimetry correlates well with perioperative neutrophils and platelets count dynamic variations and can be used as an early prognosis marker of postoperative immune response and surgical outcome in colorectal oncological surgery.

Prehabilitation of surgical patients: a bibliometric analysis from 2005 to 2023

BACKGROUND

Good preoperative conditions help patients to counteract surgical injury. Prehabilitation is a multimodal preoperative management strategy, including physical, nutritional, psychological, and other interventions, which can improve the functional reserve of patients and enhance postoperative recovery. The purpose of this study is to show the evolution trend and future directions of research related to the prehabilitation of surgical patients.

METHODS

The global literature regarding prehabilitation was identified from The Web of Science Core Collection database. Bibliometric methods of the Bibliometrix package of R (version 4.2.1) and VOSviewer were used to analyze publication trends, cooperative networks, study themes, and co-citation relationships in the field.

RESULTS

A total of 638 publications were included and the number of publications increased rapidly since 2016, with an average annual growth rate of 41.0%. "Annals of Surgery", "British Journal of Surgery" and "British Journal of Anesthesia" were the most cited journals. Experts from the USA, Canada, the UK, and the Netherlands contributed the most in this field, and an initial cooperative network among different countries and clinical teams was formed. Malnutrition, older patients, frailty, and high-risk patients were the hotspots of recent studies. However, among the top 10 cited articles, the clinical effects of prehabilitation were conflicting.

CONCLUSION

This bibliometric review summarized the most influential publications as well as the publication trends and clarified the progress and future directions of prehabilitation, which could serve as a guide for developing evidence-based practices.

The Surgical Stress Response and Anesthesia: A Narrative Review

The human physiological response "to stress" includes all metabolic and hormonal changes produced by a traumatic event at the micro or macro cellular levels. The main goal of the body's first response to trauma is to keep physiological homeostasis. The perioperative non-specific adaptation response can sometimes be detrimental and can produce systemic inflammatory response syndrome (SIRS), characterized by hypermetabolism and hyper catabolism. We performed a narrative review consisting of a description of the surgical stress response's categories of changes (neurohormonal and immunological response) followed by reviewing methods found in published studies to modulate the surgical stress response perioperatively. We described various preoperative measures cited in the literature as lowering the burden of surgical trauma. This article revises the anesthetic drugs and techniques that have an impact on the surgical stress response and proven immune-modulatory effects. We also tried to name present knowledge gaps requiring future research. Our review concludes that proper preoperative measures, adequate general anesthetics, multimodal analgesia, early postoperative mobilization, and early enteral nutrition can decrease the stress response to surgery and ease patient recovery. Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system and inflammatory system, with a consecutive impact on cancer recurrence and long-term outcomes.

Multi-Modal Prehabilitation in Thoracic Surgery: From Basic Concepts to Practical Modalities

Over the last two decades, the invasiveness of thoracic surgery has decreased along with technological advances and better diagnostic tools, whereas the patient's comorbidities and frailty patterns have increased, as well as the number of early cancer stages that could benefit from curative resection. Poor aerobic fitness, nutritional defects, sarcopenia and "toxic" behaviors such as sedentary behavior, smoking and alcohol consumption are modifiable risk factors for major postoperative complications. The process of enhancing patients' physiological reserve in anticipation for surgery is referred to as prehabilitation. Components of prehabilitation programs include optimization of medical treatment, prescription of structured exercise program, correction of nutritional deficits and patient's education to adopt healthier behaviors. All patients may benefit from prehabilitation, which is part of the enhanced recovery after surgery (ERAS) programs. Faster functional recovery is expected in low-risk patients, whereas better clinical outcome and shorter hospital stay have been demonstrated in higher risk and physically unfit patients.

Effect of ultrasound-guided quadratus lumborum block on neuroendocrine stress response and postoperative analgesia in paediatric patients undergoing elective open pyeloplasty - A randomised clinical trial

Background and Aims

Quadratus lumborum block (QLB) is a compartmental block of the anterior abdominal wall. Surgical trauma produces neuroendocrine surgical stress responses, which are modified by anaesthetic blocks. The aim of this study was to evaluate the effect of ultrasound (US)-guided QLB on analgesia and surgical neuroendocrine stress response in paediatric patients undergoing pyeloplasty.

Methods

A randomised trial was conducted in 60 children aged 1-7 years undergoing elective open pyeloplasty. Patients were randomised into Group QLB [US-guided QLB with 0.5 ml/kg of 0.25% ropivacaine after induction of general anaesthesia (GA)], and Group GA, which received only GA. Perioperative haemodynamic parameters, serum cortisol, blood glucose, analgesic consumption and postoperative FLACC scores were recorded. Unpaired t-test, Wilcoxon rank-sum test or Mann-Whitney U test was used to compare variables between the two groups. Two-way analysis of variance or the Friedmann test was used to compare quantitative variables at various points within a group.

Results

A decrease in serum cortisol and blood glucose values was observed in Group QLB at 30 min after surgical incision and 24 h after surgery compared to the preoperative value and compared to Group GA (P < 0.05). The quality of analgesia assessed by the FLACC scale was significantly better in group QLB. Dose of fentanyl consumption (µg/kg) was higher in Group GA compared to Group QLB in the intraoperative and postoperative period (P < 0.05).

Conclusion

QLB is effective as part of multimodal analgesia and attenuates the neuroendocrine stress in paediatric patients undergoing open pyeloplasty.

Fluids and body composition during anesthesia in children and adolescents: A pilot study

The purpose of this study is to evaluate the intracellular and extracellular volume before and after anesthesia in order to ascertain their variations and determine the potential utility of this information in optimizing intraoperative fluid administration practices. A bioimpedance spectroscopy device (body composition monitor, BCM) was used to measure total body fluid volume, extracellular volume, and intracellular volume. BCM measurements were performed before and after general anesthesia in unselected healthy children and adolescents visiting the Pediatric Institute of Southern Switzerland for low-risk surgical procedures hydrated with an isotonic solution. In 100 children and adolescents aged 7.0 (4.8-11) years (median and interquartile range), the average total body water increased perioperatively with a delta value of 182 (0-383) mL/m2 from pre- to postoperatively, as well as the extracellular water content, which had a similar increase with a delta value of 169 (19-307) mL/m2. The changes in total body water and extracellular water content significantly correlated with the amount of fluids administered. The intracellular water content did not significantly change.   Conclusion: Intraoperative administration of isotonic solutions results in a significant fluid accumulation in low-risk schoolchildren during general anesthesia. The results suggest that children without major health problems undergoing short procedures do not need any perioperative intravenous fluid therapy, because they are allowed to take clear fluids up to 1 h prior anesthesia. In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy. What is Known: • Most children who undergo common surgical interventions or investigations requiring anesthesia are nowadays hydrated at a rate of 1700 mL/m2/day with an isotonic solution. • The use bioimpedance spectroscopy for the assessment of fluid status in healthy children has already been successfully validated. • The bioimpedance spectroscopy is already currently widely used in various nephrological settings to calculate fluid overload and determine patient's optimal fluid status. What is New: • Routine intraoperative fluid administration results in a significant fluid accumulation during general anesthesia in low-risk surgical procedures. • This observation might be relevant for children and adolescents with conditions predisposing to fluid retention. • In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.

Comparative Study of Levobupivacaine Versus Levobupivacaine With Dexmedetomidine as an Adjuvant in Transversus Abdominis Block for Postoperative Pain Relief in Abdominal Hysterectomy Patients: A Randomized, Double-Blind Study

Background Adjuvants have been discovered to prolong the analgesic impact of local anesthetics (LA), while the transversus abdominis plane (TAP) block offers sufficient postoperative pain relief after various abdominal procedures. Nevertheless, the impact of the given LA will determine the duration of the TAP block. Thus, in this investigation, we aimed to estimate the analgesic impact of combining dexmedetomidine (DEX) with levobupivacaine in the TAP block for patients having an infraumbilical incision for an abdominal hysterectomy while under spinal anesthetic. Aim This study aimed to determine the analgesic effect of DEX (0.5 mcg/kg) to 20 ml of 0.25% levobupivacaine on each side in the TAP block in patients undergoing total abdominal hysterectomy (TAH). Materials and methods Two groups of 30 patients each, with ASA grades 1 and 2, were randomly selected from patients. Group N, comprising 30 patients, had a bilateral TAP block using 2 mL of normal saline and 20 mL of 0.25% levobupivacaine. Group D (n = 30 patients) was given DEX at a dose of 0.5 mcg/kg (2 mL) in addition to 20 mL of 0.25% levobupivacaine given bilaterally. The TAP block was administered just after skin closure. Time of the initial analgesic dose administration; total fentanyl doses utilized as rescue analgesia; pain scores (numerical rating scale (NRS)) at 2, 4, 6, 8, 12, and 24 hours; and pre- and postoperative cortisol levels were also noted. For each group, 1 gram IV paracetamol was administered every eight hours. Drugs used for rescue analgesia (RA) were diclofenac 75 mg IV stat and fentanyl 1 mcg/kg. Results and discussion In addition to Group N having lower NRS scores at rest, Group D had a considerably longer time for initial rescue analgesia than Group N. There was also a significant decrease in the total fentanyl consumption and postoperative serum cortisol levels in Group D in contrast to Group N. Conclusion Potential adjuvant DEX prolongs postoperative analgesia in patients experiencing abdominal hysterectomy when used alongside LA in TAP.

Senescence: A new kid in the block of the metabolic response to surgical trauma

Tumor growth is associated to chronic metabolic changes which inform the clinical phenotype and the outcome of patients with cancer. Surgery further triggers a cascade of acute neuro-immune responses leading to hypermetabolic and catabolic state. The metabolic mechanisms associated to surgical stress are well described. Preventive and therapeutic strategies have been developed, yet they appear not to benefit all surgical patients with cancer, even in the presence of a similar tumor type as well surgical procedures. Recent studies show that aging is associated with enrichment of senescent cells in different organs and tissues. Senescent cells are characterized by a specific senescence-associated secretory phenotype (SASP), which limits the potential for resilience of tissues and organs. Enhancement of the metabolic and functional recovery of patients with cancer undergoing surgery may therefore require additional therapies addressing SASP and senescent cells. Preliminary results obtained in experimental models recommend to further explore the role of senescence in mediating the metabolic changes and tissue resistance to efficient recovery.

Immune Responses of Healthy Pregnant Women following an Elective Cesarean Section: Effects of Anesthetic Procedures

A weakened immune system and more inflammatory cytokines being released are possible effects of the surgical stress that a cesarean section induces. This kind of reaction, in addition to the altered reaction to catecholamines, has the potential to significantly affect the immune system of the mother and the patients' general postoperative course. This prospective study compared the plasma levels of catecholamines and cytokines in healthy pregnant patients having cesarean sections under spinal anesthesia versus general anesthesia. A total of 30 pregnant women undergoing elective cesarean sections were divided into two groups: 15 who received general anesthesia (GA) and 15 who received spinal anesthesia (SA). Blood samples were collected from all subjects before anesthesia induction (pre-OP), 6 h postoperatively (6 h post-OP), and 12 h (12 h post-OP), to measure levels of tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), IL-8, IL-4, IL-10, norepinephrine (NE), and epinephrine (EPI). When we compared the two groups, we discovered that only IL-6 and IL-4 had significantly higher levels pre-OP, whereas all studied cytokines exhibited an increase in the GA versus SA group at 6 and 12 h post-OP. In the case of catecholamines, we discovered that serum levels are positively related with pro-inflammatory or anti-inflammatory cytokines, depending on the time of day and type of anesthetic drugs. Compared to SA, GA has a more consistent effect on the inflammatory response and catecholamine levels. The findings of this study confirm that the type of anesthesia can alter postoperative immunomodulation to various degrees via changes in cytokine and catecholamine production. SA could be a preferable choice for cesarean section because it is an anesthetic method that reduces perioperative stress and allows for less opioid administration, impacting cytokine production with proper immunomodulation.

Postoperative leukocyte counts as a surrogate for surgical stress response in matched robot- and video-assisted thoracoscopic surgery cohorts of patients: A preliminary report

The objective is to preliminary evaluated postoperative leukocyte counts as a surrogate for the surgical stress response in NSCLC patients who underwent RATS or VATS for further prospective analyses with proper assessment of surgical stress response and tissue trauma. We retrospectively analyzed patients with stageI-IIIA NSCLC who underwent RATS or VATS at a hospital between 8 May 2020 and 31 December 2021. Analysis of leukocytes (including neutrophils and lymphocytes) and albumin on postoperative days (PODs) 1 and 3 in patients with NSCLC treated with RATS or VATS after propensity score matching (PSM). In total, 1824 patients (565 RATS and 1259 VATS) were investigated. The two MIS groups differed significantly with regard to operative time (p < 0.001), chronic lung disease (p < 0.001), the type of pulmonary resection (p < 0.001), the excision site of lobectomy (p = 0.004), and histology of the tumor (p = 0.028). After PSM, leukocyte and neutrophil levels in the RATS group were lower than those in the VATS group on PODs 1 and 3, with those on POD 3 (p < 0.001) being particularly notable. While lymphocyte levels in the RATS group were significantly lower than those in the VATS group only at POD 1 (p = 0.016). There was no difference in albumin levels between the RATS and VATS groups on PODs 1 and 3. The surgical stress response and tissue trauma was less severe in NSCLC patients who underwent RATS than in those who underwent VATS, especially reflected in the neutrophils of leukocytes.

P. Comparison between perfusion index, pleth variability index, and pulse pressure variability for prediction of hypotension during major abdominal surgery under general anaesthesia: A prospective observational study

Background and Aims

Short-term hypotension after general anaesthesia can negatively impact surgical outcomes. This study compared the predictive potential of the pleth variability index (PVI), pulse pressure variability (PPV), and perfusion index (PI) for anaesthesia-induced hypotension. This study's primary objective was to evaluate the predictive potential of PI, PVI, and PPV for hypotension.

Methods

This observational study included 140 adult patients undergoing major abdominal surgery under general anaesthesia. Mean arterial pressure, heart rate, PVI, PPV, and PI were collected at 1-min intervals up to 20 min post anaesthesia induction. Hypotension was assessed at 5-min and 15-min intervals. Receiver operating characteristic (ROC) curves were plotted to determine the diagnostic performance and best cut-off for continuous variables in predicting a dichotomous outcome. Statistical significance was kept at P < 0.05.

Results

Hypotension prevalence within 5 and 15 min of anaesthesia induction was 36.4% and 45%, respectively. A PI cut-off of <3.5 had an area under the ROC curve (AUROC) of 0.647 (P = 0.004) for a 5-min hypotension prediction. The PVI's AUROC was 0.717 (P = 0.001) at cut-off >11.5, while PPV's AUROC was 0.742 (P = 0.001) at cut-off >12.5. At 15 min, PVI's AUROC was 0.615 (95% confidence interval 0.521-0.708, P = 0.020), with 54.9% positive predictive value and 65.2% negative predictive value.

Conclusion

PVI, PPV, and PI predicted hypotension within 5 min after general anaesthesia induction. PVI had comparatively higher accuracy, sensitivity, specificity, and positive predictive value than PI and PPV when predicting hypotension at 15 min.

Postoperative orthostatic intolerance following fast-track unicompartmental knee arthroplasty: incidence and hemodynamics-a prospective observational cohort study

BACKGROUND

Early postoperative mobilization is essential for early functional recovery but can be inhibited by postoperative orthostatic intolerance (OI). Postoperative OI is common after major surgery, such as total knee arthroplasty (TKA). However, limited data are available after less extensive surgery, such as unicompartmental knee arthroplasty (UKA). We, therefore, investigated the incidence of OI as well as cardiovascular and tissue oxygenation responses during early mobilization after UKA.

METHODS

This prospective single-centre observational study included 32 patients undergoing primary UKA. Incidence of OI and cardiovascular and tissue oxygenation responses during mobilization were evaluated preoperatively, at 6 and 24 h after surgery. Perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain during mobilization and opioid usage were recorded.

RESULTS

During mobilization at 6 h after surgery, 4 (14%, 95%CI 4-33%) patients experienced OI; however, no patients terminated the mobilization procedure prematurely. Dizziness and feeling of heat were the most common symptoms. OI was associated with attenuated systolic and mean arterial blood pressure responses in the sitting position (all p < 0.05). At 24 h after surgery, 24 (75%) patients had already been discharged, including three of the four patients with early OI. Only five patients were available for measurements, two of whom experienced OI; one terminated the mobilization procedure due to intolerable symptoms. We observed no statistically significant differences in perioperative fluid balance, bleeding, surgery duration, postoperative hemoglobin, pain, or opioid usage between orthostatic intolerant and tolerant patients.

CONCLUSIONS

The incidence of orthostatic intolerance after fast-track unicompartmental knee arthroplasty is low (~ 15%) and is associated with decreased orthostatic pressure responses. Compared to the previously described orthostatic intolerance incidence of ~ 40% following total knee arthroplasty, early orthostatic intolerance is uncommon after unicompartmental knee arthroplasty, suggesting a procedure-specific component.

TRIAL REGISTRATION

Prospectively registered at ClinicalTrials.gov; registration number: NCT04195360, registration date: 13.12.2019.

Non-opioid analgesic combinations following total hip arthroplasty (RECIPE): a randomised, placebo-controlled, blinded, multicentre trial

BACKGROUND

Multimodal postoperative analgesia following total hip arthroplasty is recommended, but the optimal combination of drugs remains uncertain. The aim of the RECIPE trial was to investigate the relative benefit and harm of the different combinations of paracetamol, ibuprofen, and the analgesic adjuvant dexamethasone for treatment of postoperative pain following total hip arthroplasty.

METHODS

The RECIPE trial was a randomised, blinded, placebo-controlled trial conducted at nine Danish hospitals. Adults scheduled for total hip arthroplasty were randomly assigned (1:1:1:1) using a computer-generated list with stratification by site to receive combinations of oral paracetamol 1000 mg every 6 h, oral ibuprofen 400 mg every 6 h, or a single-dose of intravenous dexamethasone 24 mg in the following groups: paracetamol plus ibuprofen, ibuprofen plus dexamethasone, paracetamol plus dexamethasone, and paracetamol plus ibuprofen plus dexamethasone. The primary outcome was 24 h intravenous morphine consumption, analysed in a modified intention-to-treat population, defined as all randomly assigned participants who underwent total hip arthroplasty. The predefined minimal important difference was 8 mg. Safety outcomes included serious and non-serious adverse events within 90 days and 24 h. The trial was registered with ClinicalTrials.gov, NCT04123873.

FINDINGS

Between March 5, 2020, and Nov 15, 2022, we randomly assigned 1060 participants, of whom 1043 (589 [56%] women and 454 [44%] men) were included in the modified intention-to-treat population. 261 were assigned to paracetamol plus ibuprofen, 262 to ibuprofen plus dexamethasone, 262 to paracetamol plus dexamethasone, and 258 to paracetamol plus ibuprofen plus dexamethasone. Median 24 h morphine consumption was 24 mg (IQR 12-38) in the paracetamol plus ibuprofen group, 20 mg (12-32) in the paracetamol plus dexamethasone group, 16 mg (10-30) in the ibuprofen plus dexamethasone group, and 15 mg (8-26) in the paracetamol plus ibuprofen plus dexamethasone group. The paracetamol plus ibuprofen plus dexamethasone group had a significantly reduced 24 h morphine consumption compared with paracetamol plus ibuprofen (Hodges-Lehmann median difference -6 mg [99% CI -10 to -3]; p<0·0001) and paracetamol plus dexamethasone (-4 mg [-8 to -1]; p=0·0013), however, none of the comparisons showed differences reaching the minimal important threshold of 8 mg. 91 (35%) of 258 participants in the paracetamol plus ibuprofen plus dexamethasone group had one or more adverse events, compared with 99 (38%) of 262 in the ibuprofen plus dexamethasone group, 103 (39%) of 262 in the paracetamol plus dexamethasone group, and 165 (63%) of 261 in the paracetamol plus ibuprofen group.

INTERPRETATION

In adults undergoing total hip arthroplasty, a combination of paracetamol, ibuprofen, and dexamethasone had the lowest morphine consumption within 24 h following surgery and the most favourable adverse event profile, with a lower incidence of serious and non-serious adverse events (primarily driven by differences in nausea, vomiting, and dizziness) compared with paracetamol plus ibuprofen.

FUNDING

The Novo Nordisk Foundation and Næstved-Slagelse-Ringsted Hospitals' Research Fund.

A Randomized Controlled Trial of Intrathecal versus Caudal Morphine-Bupivacaine on Postoperative Analgesia and Cortisol Levels in Pediatric Patients

BACKGROUND

Morphine is commonly used in pediatric caudal blocks. We compared the analgesic efficacy and effect on cortisol levels of intrathecal morphine and bupivacaine with caudal morphine and bupivacaine in children undergoing lower abdominal surgeries.

METHODS

Forty children undergoing lower abdominal surgeries were randomized to receive 4 μg/kg of intrathecal morphine and 0.5% hyperbaric bupivacaine (n = 20), or caudal morphine 40 μg/kg and 0.25% bupivacaine (n = 20). Postoperative analgesia was provided with intravenous (IV) paracetamol (PCM). The primary outcome was time to reach Face, Legs, Activity, Cry, and Consolability (FLACC) score ≥4 postoperatively. Secondary outcomes were perioperative serum cortisol levels, analgesic requirement, and parent satisfaction.

RESULTS

Since seventy 5% of patients receiving intrathecal morphine and bupivacaine did not reach a FLACC score ≥4 within 24 hours, the primary outcome was presented as the Kaplan-Meier curve. The probability of FLACC score <4 was significantly higher with intrathecal morphine and bupivacaine than with caudal morphine and bupivacaine (P < .001). The unadjusted and adjusted (for gender) hazard ratio (95% confidence interval [CI]) of occurrence of pain (FLACC score ≥4) was 0.07 (0.03-0.15, P < .001) and 0.06 (0.03-0.14, P < .001), respectively. The difference in means (95% CI) of cortisol levels between caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) groups were after intubation -0.667 (-4.99 to 3.65, P = .76), at 2 hours intraoperatively 7.88 (3.55-12.2, P < .001), 6 hours postoperatively 16.8 (12.5-21.1, P < .001), and 24 hours postoperatively 15.4 (11.1-19.7, P < .001) μg/dL. Intraoperatively, rescue fentanyl was required by 60% of patients on caudal morphine and bupivacaine against 20% of patients receiving intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 40% [12%-68%]; P = .010). Postoperative rescue fentanyl was required in 45% of patients on caudal morphine and bupivacaine and 5% of patients on intrathecal morphine and bupivacaine. All (100%) patients on caudal morphine and bupivacaine required postoperative PCM against 6 (30%) patients on intrathecal morphine and bupivacaine (absolute risk-reduction [95% CI] of 70% [50%-90%]; P < .001).The median (interquartile range [IQR]) parent satisfaction score for patients on caudal morphine (with bupivacaine) and intrathecal morphine (with bupivacaine) was 0(0-0) and 2(2-2) at 12 hours postoperatively (P < .001) and 0(0-1) and 2(1.5-2) at 24 hours postoperatively (P < .001). One patient in each group developed nausea and vomiting, and 1 patient in the intrathecal group developed pruritus. There was no incidence of respiratory depression.

CONCLUSIONS

Intrathecal morphine and bupivacaine results in longer duration of analgesia, lower analgesic consumption, prevents surgical-stress-related elevation of serum cortisol, and improves parent satisfaction compared to caudal morphine with bupivacaine in children undergoing lower abdominal surgeries.

Energy Expenditure, a New Tool for Monitoring Surgical Stress in Colorectal Oncological Patients: A Prospective, Monocentric Study

BACKGROUND

Surgical stress response in colorectal surgery consists of a neurohormonal and an immunological response and influences oncological outcomes. The intensity of surgical trauma influences mortality, morbidity, and metastasis' occurrence in colorectal neoplasia. Energy expenditure (EE) stands for the body's energy consumed to keep its homeostasis and can be either calculated or measured by direct or indirect calorimetry.

AIM

The present study attempted to evaluate surgical stress response using EE measurement and compare it to the postoperative cortisol dynamic.

METHODS

A prospective, monocentric study was conducted over a period of one year in the Anesthesiology Department including 21 patients from whom serum cortisol values were collected in the preoperative period and on the first postoperative day, and EE was measured and recorded every 15 minutes throughout surgery using the indirect calorimetry method. The study compared EE values' dynamic registered 30 minutes after intubation and 30 minutes before extubating (after abdominal closure) to cortisol perioperative dynamic.

RESULTS

We enrolled 21 patients and 84 measurements were recorded, 42 probes of serum cortisol and 42 measurements of EE. The mean value of the first measurement of serum cortisol was 13.60±3.6 µg and the second was 16.21±6.52 µg. The average value of the first EE recording was 1273.9±278 kcal and 1463.4±398.2 kcal of the second recording. The bivariate analysis performed showed a good correlation between cortisol variation and EE's variation (Spearman coefficient=0.666, p<0.001, CI=0.285, 0.865). In nine cases (42.85%), cortisol value at 24 hours reached the baseline or below the baselines preoperative value. In eight cases (38.09%), patients' EE at the end of the surgery was lower than that recorded at the beginning of the surgery.

CONCLUSIONS

Intraoperative EE variation correlated well with cortisol perioperative dynamic and stood out in this study as a valuable and accessible predictor of surgical stress in colorectal surgery.

Comparison of analgesic efficacy of tramadol, morphine and methadone in cats undergoing ovariohysterectomy

OBJECTIVES

The aim of this study was to compare the analgesic efficacy and the effect on physiological variables and behavior of the use of tramadol, methadone and morphine as preoperative analgesia in healthy cats undergoing elective ovariohysterectomy.

METHODS

Cats undergoing ovariohysterectomy were randomly assigned to receive one of the following premedication treatments intramuscularly: methadone (0.2 mg/kg; n = 10); morphine (0.2 mg/kg; n = 10); or tramadol (3 mg/kg; n = 10). Induction of anesthesia was done with propofol, and maintenance of anesthesia was done with isoflurane. Intraoperative heart rate, arterial blood pressure, respiratory rate, end-tidal isoflurane concentration and frequency of rescue analgesia (fentanyl 2.5 µg/kg) were compared between groups. Postoperative analgesia was assessed using the UNESP-Botucatu Multidimensional Composite Pain Scale, and perioperative serum glucose, cortisol concentrations and postoperative rescue analgesia were evaluated.

RESULTS

Intraoperative rescue analgesia was required in 76.5% of cats at some time during surgery, and 27% of cats required postoperative rescue analgesia up to 6 h after extubation. There were no significant differences between groups with respect to intraoperative and postoperative rescue analgesia, pain scale scores and end-tidal isoflurane concentrations. In the immediate postoperative period, after extubation, most of the patients presented with hypothermia; however, 1-6 h postoperatively, hyperthermia was observed in most of the patients, and was most common in the tramadol group.

CONCLUSIONS AND CLINICAL RELEVANCE

Under the conditions of this study, methadone, morphine and tramadol produced satisfactory postoperative analgesia in most of the cats undergoing ovariohysterectomy, and the effects lasted up to 6 h postoperatively. Intraoperative analgesia was not sufficient in most cases. Significant cardiovascular or respiratory effects contraindicating the use of these drugs were not found. Postanesthetic hyperthermia occurred with all opioids studied and was more frequent in the tramadol group.

Association of clonal haematopoiesis with severe postoperative complications in patients undergoing radical oesophagectomy

BACKGROUND

Clonal haematopoiesis (CH) is an age-associated clonal expansion of blood cells driven by leukaemia-associated somatic mutations. Although CH has been reported to be a risk factor for leukaemia and a number of non-haematopoietic diseases, its role in perioperative medicine remains unexplored.

METHODS

This was a single-centre, prospective, observational study. Patients undergoing radical oesophagectomy were enrolled, and peripheral blood samples were collected for DNA sequencing. Patients with haematopoietic somatic mutations (variant allele frequencies ≥1%) in the DNMT3A gene, TET2 gene, or both were defined as CH carriers. The primary outcome was the incidence of severe postoperative complications (Clavien-Dindo classification ≥3). The secondary outcomes included the major types of postoperative complications, mortality, and other common perioperative variables.

RESULTS

Clonal haematopoiesis was found in 21.2% (33/156) of the patients (mean age: 66 yr [range: 26-79 yr]; 83% males). Some 14/33 (42.4%) patients with CH had severe postoperative complications, compared with patients without CH carriers (28/123 [22.8%]; P=0.024). Multivariable logistic regression analysis showed that CH was associated with an increased risk of developing severe postoperative complications (odds ratio, 3.63; 95% confidence interval, 1.37-9.66; P=0.010). Among the major postoperative complications, the incidence of pulmonary complications was significantly higher in the patients with CH than in those without CH (15 in 33 [45.5%] vs 30 in 123 [24.4%], P=0.018).

CONCLUSIONS

Clonal haematopoiesis was associated with a higher incidence of severe postoperative complications in patients undergoing radical oesophagectomy, suggesting that clonal haematopoiesis can play an important role in perioperative medicine.

CLINICAL TRIAL REGISTRATION

ChiCTR2100044175 (Chinese Clinical Trial Registry, http://www.chictr.org.cn/showproj.aspx?proj=123193).

Effect of Sevoflurane, Isoflurane, and Desflurane on the Random Blood Glucose Levels in Non-diabetic Patients Undergoing General Anesthesia: A Randomized, Single-Blind Study

BACKGROUND

Volatile anesthetic agents like sevoflurane, isoflurane, and desflurane are widely used for maintaining general anesthesia (GA). Their effect on the autonomic system is different and can impact the blood sugar homeostasis. This study compares the intraoperative blood glucose levels in non-diabetic patients undergoing non-cardiac surgery under GA with the three volatile agents.

METHODS

A randomized, single-blind, parallel-arm study recruited 105 non-diabetic patients into three groups. GA induction and maintenance were standardized except for the volatile agent. Capillary blood sugar levels were measured at different time points and compared between and within the groups. A p-value of <0.05 was considered significant.

RESULTS

Entire participants completed the study, and their baseline characteristics were statistically indifferent. Intraoperative blood glucose rise and variation were the highest in the desflurane group and the lowest in the isoflurane group; the differences were statistically significant at 15, 30, and 45 minutes. The highest blood sugar level was noted at 60 minutes in all groups; after that, the level started falling. However, none of the raises were beyond 140 mg% to categorize them as hyperglycemia.

CONCLUSION

Intraoperative glycemic variation was evident with isoflurane, sevoflurane, and desflurane. The maximum increase from the pre-induction level was noted at 60 minutes. However, none of the readings reached the hyperglycemia level. The rise was significantly higher in desflurane-based anesthesia than in isoflurane. This study was, however, conducted in non-diabetic patients; hence, results might not be extrapolated to diabetic patients.

The Impact of Nociception Monitor-Guided Multimodal General Anesthesia on Postoperative Outcomes in Patients Undergoing Laparoscopic Bowel Surgery: A Randomized Controlled Trial

BACKGROUND

Excess surgical stress responses, caused by heightened nociception, can lead to elevated levels of postoperative inflammation, resulting in an increased incidence of complications after surgery. We hypothesized that utilizing nociception monitor-guided multimodal general anesthesia would exert effects on postoperative outcomes (e.g., serum concentrations of C-reactive protein (CRP) after surgery, postoperative complications).

METHODS

This single-center, double-blinded, randomized trial enrolled ASA class I/II adult patients with normal preoperative CRP levels, scheduled for laparoscopic bowel surgery. Patients were randomized to receive either standard care (control group) or nociception monitor-guided multimodal general anesthesia using the nociceptive response (NR) index (NR group), where NR index was kept below 0.85 as possible. The co-primary endpoint was serum concentrations of CRP after surgery or rates of 30-day postoperative complications (defined as Clavien-Dindo grades ≥ II).

MAIN RESULTS

One hundred and four patients (control group, n = 52; NR group, n = 52) were enrolled for analysis. The serum CRP level on postoperative day (POD) 1 was significantly lower in the NR group (2.70 mg·dL-1 [95% confidence interval (CI), 2.19-3.20]) than in the control group (3.66 mg·dL-1 [95% CI, 2.98-4.34], p = 0.024). The postoperative complication rate was also significantly lower in the NR group (11.5% [95% CI, 5.4-23.0]) than in the control group (38.5% [95% CI, 26.5-52.0], p = 0.002).

CONCLUSIONS

Nociception monitor-guided multimodal general anesthesia, which suppressed intraoperative nociception, mitigated serum concentrations of CRP level, and decreased postoperative complications after laparoscopic bowel surgery.

The effect of pectointercostal fascial block on stress response in open heart surgery

Background

Activation of the hypothalamus-pituitary-adrenal (HPA) axis and inflammatory processes are common forms of stress response. The increased stress response is associated with a higher chance of complications. Open hearth surgery is one of the procedures with a high-stress response. Pectointercostal fascial block (PIFB), as a new pain management option in sternotomy, has the potential to modulate the stress response.

Objective

To determine the effect of PIFB on stress response in open heart surgery.

Methods

This study was a Randomized Controlled Trial on 40 open heart surgery. Patients were divided into two groups, control (20 patients) and PIFB (20 patients). Primary parameters included basal and postoperative TNF-α, basal and post sternotomy ACTH, and basal, 0, and 24 hours postoperative NLR. Secondary parameters include the amount of opioid use, length of the post-operative ventilator, length of ICU stay, and Numeric Rating Scale (NRS) 6, 12, 24, and 48 hours postoperative.

Results

The PIFB group had a decrease in ACTH levels with an average change that was not significantly different from the control group (-57.71 ± 68.03 vs. -129.78 ± 140.98). The PIFB group had an average change in TNFα levels and an average increase in NLR 0 hours postoperative that was not significantly lower than the control group (TNFα: -0.52 ± 1.31 vs. 0.54 ± 1.76; NLR: 12.80 ± 3.51 vs. 14.82 ± 4.23). PIFB significantly reduced the amount of opioid use during surgery, NRS at 6, 12, and 24 hours, and the length of post-operative ventilator use (P < 0.05, CI: 95%).

Conclusion

PIFB has a good role in reducing the stress response of open heart surgery and producing good clinical outcomes.

Tumour excisional surgery, anaesthetic-analgesic techniques, and oncologic outcomes: a narrative review

Cancer is a growing global burden; there were an estimated 18 million new cancer diagnoses worldwide in 2020. Excisional surgery remains one of the main treatments for solid organ tumours in cancer patients and is potentially curative. Cancer- and surgery-induced inflammatory processes can facilitate residual tumour cell survival, growth, and subsequent recurrence. However, it has been hypothesised that anaesthetic and analgesic techniques during surgery might influence the risk of cancer recurrence. This narrative review aims to provide an updated summary of recent observational studies and new randomised controlled clinical trials on whether certain specific anaesthetic and analgesic techniques or perioperative interventions during tumour resection surgery of curative intent materially affect long-term oncologic outcomes.

Impact of Propofol-based Total Intravenous Anesthesia Versus Inhalation Anesthesia on Long-term Survival After Cancer Surgery in a Nationwide Cohort

OBJECTIVE

To compare the impact of propofol-based total intravenous anesthesia (TIVA) versus inhalational anesthesia (IA) on the overall survival following cancer surgery.

BACKGROUND

The association between intraoperative anesthetics and patients' long-term outcomes following cancer surgery remains controversial.

METHODS

This retrospective cohort study used nationwide data from the Korean National Health Insurance Service. Adult patients who underwent cancer resection surgery (breast, gastric, lung, liver, kidney, colorectal, pancreatic, esophageal, and bladder cancer) under general anesthesia between January 2007 and December 2016 were included. Patients were divided into propofol-based TIVA or IA groups according to the type of anesthesia received. A total of 312,985 patients (37,063 in the propofol-based TIVA group and 275,922 patients in the IA group) were eligible for analysis. The primary outcome was the comparison of overall survival following surgery between the groups in each cancer type. We compared the all-cause mortality between the 2 groups, stratified by cancer type using time-dependent Cox regression after propensity score-based inverse probability of treatment weighting. We further examined the comparison of overall survival in a meta-analysis using data from our study and previously published data comparing propofol-based TIVA with IA after cancer surgery.

RESULTS

The number of deaths in the propofol-based TIVA and IA groups was 5037 (13.6%) and 45,904 (16.6%), respectively; the median (interquartile range) follow-up duration was 1192 (637-2011) days. Multivariable Cox proportional hazards regression analysis revealed no significant association between the type of general anesthesia and overall survival after cancer surgery in the weighted cohort for each cancer type (all P >0.05) and for total population [adjusted hazard ratio (HR): 0.98, 95% confidence interval (CI): 0.93-1.04]. In a meta-analysis, single-center studies showed higher overall survival in the TIVA group than in the IA group (pooled adjusted HR: 0.65, 95% CI: 0.47-0.91, P =0.01), while multicenter studies showed insignificant pooled adjusted HRs (pooled adjusted HR: 1.05, 95% CI: 0.82-1.33, P =0.71).

CONCLUSIONS

There is no association between the type of general anesthesia used during cancer surgery and postoperative overall, 1-, and 5-year survival.

Cardiac and intramuscular adaptations following short-term exercise prehabilitation in unfit patients scheduled to undergo hepatic or pancreatic surgery: study protocol of a multinuclear MRI study

INTRODUCTION

Short-term exercise prehabilitation programmes have demonstrated promising results in improving aerobic capacity of unfit patients prior to major abdominal surgery. However, little is known about the cardiac and skeletal muscle adaptations explaining the improvement in aerobic capacity following short-term exercise prehabilitation.

METHODS AND ANALYSIS

In this single-centre study with a pretest-post-test design, 12 unfit patients with a preoperative oxygen uptake (VO2) at the ventilatory anaerobic threshold ≤13 mL/kg/min and/or VO2 at peak exercise ≤18 mL/kg/min, who are scheduled to undergo hepatopancreatobiliary surgery at the University Medical Center Groningen (UMCG), the Netherlands, will be recruited. As part of standard care, unfit patients are advised to participate in a home-based exercise prehabilitation programme, comprising high-intensity interval training and functional exercises three times per week, combined with nutritional support, during a 4-week period. Pre-intervention and post-intervention, patients will complete a cardiopulmonary exercise test. Next to this, study participants will perform additional in-vivo exercise cardiac magnetic resonance (MR) imaging and phosphorus 31-MR spectroscopy of the quadriceps femoris muscle before and after the intervention to assess the effect on respectively cardiac and skeletal muscle function.

ETHICS AND DISSEMINATION

This study was approved in May 2023 by the Medical Research Ethics Committee of the UMCG (registration number NL83611.042.23, March 2023) and is registered in the ClinicalTrials.gov register. Results of this study will be submitted for presentation at (inter)national congresses and publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05772819.

Perioperative Complications in Patients with Preeclampsia Undergoing Caesarean Section Surgery

Caesarean section has risks of bleeding, infection and thromboembolism, and neuroendocrine-metabolic, and inflammatory-immune responses that may worsen outcomes in patients with preeclampsia. There is little research examining perioperative, as opposed to peripartum, outcomes in patients with preeclampsia. We conducted a single-centrecentre retrospective cohort study of perioperative patients with preeclampsia over an eight-month period to determine the rate of perioperative complication. Seventy-two patients were included. The maternal complication rate was 59.7 per 100 operations (95% CI 48.2 to 70.3%). Severe complications included pulmonary oedema 2 (2.8%), haemorrhage > 1000 mL 5 (6.9%), and blood transfusion 2 (2.8%). Twenty (27.8%) patients had a hospital length of stay ≥7 days. The rate of anaemia (haemoglobin < 110 g/L) on hospital discharge was 42 per 100 operations (95% CI 31.0 to 53.2%). Patient representation rate to hospital after discharge was 23.6% per 100 operations (95% CI 15.3 to 34.6%). There were no maternal deaths. The neonatal complication rate was 38.9 per 100 operations (95% CI 28.9 to 51.1%) with one foetal death. Patients with preeclampsia undergoing caesarean section are a very high-risk surgical group who experience significant perioperative complications. Urgent action is needed to confirm these findings and improve outcomes in these patients.

Effect of anterior quadratus lumborum block with ropivacaine on the immune response after laparoscopic surgery in colon cancer: a substudy of a randomized clinical trial

BACKGROUND

Surgery induces a temporal change in the immune system, which might be modified by regional anesthesia. Applying a bilateral preoperative anterior quadratus lumborum block has proven to be a safe and effective technique in pain management after abdominal and retroperitoneal surgery, but the effect on the immune response is not thoroughly investigated.

METHODS

This study is a substudy of a randomized, controlled, double-blinded trial of patients undergoing laparoscopic hemicolectomy due to colon cancer. Twenty-two patients were randomized to undergo either a bilateral anterior quadratus lumborum nerve block with a total of 60 mL ropivacaine 0.375% or placebo with corresponding isotonic saline injections. The main objective of this exploratory substudy was to investigate the systemic immune response in the first postoperative day by examining changes in blood transcript levels (n=750) and stimulated secretion of cytokines (n=17) on ex vivo activation with microbial ligands and anti-CD3/CD28.

RESULTS

Using unsupervised data analysis tools, we observed no effect of the bilateral anterior quadratus lumborum nerve block on gene expression in immune cells (permutational multivariate analysis of variance using distance matrices: F=0.52, p=0.96), abundances of major immune cell populations (Wilcoxon rank-sum test: p>0.05), and stimulated cytokine secretion (Wilcoxon rank-sum test: p>0.05).

CONCLUSIONS

Our study provides evidence that administration of bilateral anterior quadratus lumborum nerve block as a part of a multimodal analgesic regimen in an enhanced recovery after surgery for laparoscopic hemicolectomy in this cohort does not alter the systemic immune response.Trial registration number NCT03570541.

The safety and effectiveness of enhanced recovery after surgery (ERAS) in older patients undergoing orthopedic surgery: a systematic review and meta-analysis

INTRODUCTION

To systematically review and analyze the safety and effectiveness of ERAS in older patients undergoing orthopedic surgeries.

MATERIALS AND METHODS

We searched PubMed, EMBASE, CINAHL, MEDLINE (Ovid), Web of Science, the Cochrane Library, and other databases to identify all randomized controlled studies and cohorts. We used the Cochrane Risk of Bias Assessment Tool and the Newcastle‒Ottawa Scale to assess the study quality. A meta-analysis was performed using the inverse variance weighting method.

RESULTS

This study included 15 studies involving a total of 2591 older patients undergoing orthopedic surgeries with 1480 in the ERAS group. The ERAS group had a lower incidence of postoperative complications than the control group (RR 0.52; 95% CI 0.42-0.65). Length of stay was 3.37 days lower in the ERAS group than in the control group (P < 0.01). And the ERAS protocol reduced the patient's postoperative VAS score (P < 0.01). Meanwhile, there was a lack of evidence of significant differences between the ERAS group and the control group in total bleeding and 30-day readmission rate.

CONCLUSIONS

The implementation of the ERAS program in older patients undergoing orthopedic surgeries is safe and effective. However, there is still a lack of standardization of protocols across institutions and centers for orthopedic surgery for older patients. Identifying ERAS components that are beneficial to older patients and developing ERAS protocols that are appropriate for older adults may further improve outcomes.

The effect of spinal versus general anaesthesia on perioperative muscle weakness in patients having bilateral total hip arthroplasty: a single center randomized clinical trial

BACKGROUND

Perioperative neuro-endocrine stress response may contribute to acquired muscle weakness. Regional anaesthesia has been reported to improve the outcome of patients having total hip arthroplasty. In this study, it was hypothesized that spinal anaesthesia (SA) decreases the perioperative neuro-endocrine stress response and perioperatively acquired muscle weakness (PAMW), as compared to general anaesthesia (GA).

METHODS

Fifty subjects undergoing bilateral total hip arthroplasty (THA) were randomly allocated to receive a standardized SA (n = 25) or GA (n = 25). Handgrip strength was assessed preoperatively, on the first postoperative day (primary endpoint) and on day 7 and 28. Respiratory muscle strength was measured by maximal inspiratory pressure (MIP). Stress response was assessed by measuring levels of Adrenocorticotropic hormone (ACTH), cortisol and interleukin-6 (IL-6).

RESULTS

Handgrip strength postoperatively (day 1) decreased by 5.4 ± 15.9% in the SA group, versus 15.2 ± 11.7% in the GA group (p = 0.02). The handgrip strength returned to baseline at day 7 and did not differ between groups at day 28. MIP increased postoperatively in patients randomized to SA by 11.7 ± 48.3%, whereas it decreased in GA by 12.2 ± 19.9% (p = 0.04). On day 7, MIP increased in both groups, but more in the SA (49.0 ± 47.8%) than in the GA group (14.2 ± 32.1%) (p = 0.006). Postoperatively, the levels of ACTH, cortisol and IL-6 increased in the GA, but not in the SA group (p < 0.004).

CONCLUSION

In patients having bilateral THA, SA preserved the postoperative respiratory and peripheral muscle strength and attenuated the neuro-endocrine and inflammatory responses.

TRIAL REGISTRATION

clinicaltrials.gov NCT03600454.

Instrument shank-assisted ovariohysterectomy: a randomized clinical trial of surgical and pain alleviation efficiency of a single-person modified technique

Objectives

To evaluate a modified ovariohysterectomy (OHE) technique performed by a single person and compare it with the conventional method based on time efficiency, trauma, and postoperative pain.

Methods

In a prospective, randomized, experimental study, 18 healthy, large, deep-chested, mixed-breed intact female dogs were randomly allocated to conventional (n = 9) and instrument shank-assisted (n = 9) groups. On the basis of video recordings, the various surgical step durations were analyzed: total surgery time (TST), pedicle intervention time (PIT), suspensory release time (SRT), shanking time (ShT), clamping time (ClpT), ligating time (LigT), and closure time (CT). The Glasgow composite pain scale short-form (GCMPS-SF), university of Melbourne pain scale (UMPS), and Visual Analogue Scales (VAS) were used to measure pain. C-reactive protein (CRP) fluctuation was also investigated. These evaluations were completed before and 6, 24, 48, and 72 h postoperatively.

Results

Instrument shank-assisted OHE was less time-consuming than conventional OHE (p = 0.005), improved PIT by 30.7% (6.44 min for both pedicles, p = 0.014), and correlated strongly with TST (ρ = 0.862, p = 0.003 and ρ = 0.955, p = 0.000, respectively). The two method's surgical step durations were also TST = 47.40 ± 9.9 vs. 34.70 ± 6.7 min, PIT = 20.96 ± 5.78 vs. 14.52 ± 3.73 min, SRT = 78.97 ± 69.10 vs. ShT = 20.39 ± 8.18 s (p = 0.035), ClpT = 50.66 ± 45.04 vs. 63.55 ± 37.15 s (p = 0.662), LigT = 12.82 ± 3.37 vs. 8.02 ± 3.11 min (p = 0.005), and CT = 16.40 ± 4.5 vs. 11.60 ± 2.5 min (p = 0.013), respectively. While both techniques inflicted pain on the animals, the novel approach resulted in a reduction of pain at T6 (GCMPS-SF, p = 0.015 and VAS, p = 0.002), T24 (UMPS, p = 0.003), and T48 (GCMPS-SF, p = 0.015 and UMPS, p = 0.050). Both methods exhibited a peak in CRP level after 24 h, which subsequently returned to baseline after 48 h. However, the shank-assisted method demonstrated a significantly lower reduction in CRP level at the 48-h compared to the other group (p = 0.032).

Conclusion

Instrument shank-assisted technique permitted ovarian removal without an assistant, less damage to animals and reducing its time when compared to a conventional technique, and resulting in an alternative that causes less surgical stress and fatigue. Further research with a larger population size is required to determine the serum CRP levels as an alternative pain biomarker.

Taming Postoperative Delirium with Dexmedetomidine: A Review of the Therapeutic Agent's Neuroprotective Effects following Surgery

Postoperative delirium (POD) represents a perioperative neurocognitive disorder that has dreaded ramifications on a patient's recovery from surgery. Dexmedetomidine displays multiple mechanisms of neuroprotection to assist in preventing POD as a part of a comprehensive anesthetic care plan. This review will cover dexmedetomidine's pharmacological overlap with the current etiological theories behind POD along with pre-clinical and clinical studies on POD prevention with dexmedetomidine. While the body of evidence surrounding the use of dexmedetomidine for POD prevention still requires further development, promising evidence exists for the use of dexmedetomidine in select dosing and circumstances to enhance recovery from surgery.

Effects of multimodal low-opioid anesthesia protocol during on-pump coronary artery bypass grafting: a prospective cohort study

BACKGROUND

The most favorable anesthesia protocol during on-pump coronary artery bypass grafting (CABG) in patients with coronary heart disease remains unclear, despite previous publications regarding the interaction between anesthesia protocol and postoperative complications. The aim of the study was to compare the effect of a multimodal low-opioid anesthesia protocol (MLOP) on early postoperative complications during on-pump CABG.

METHODS

A single-center prospective cohort study including 120 patients undergoing on-pump CABG aged 18 to 65 years, divided into two groups according to undergoing MLOP or routine-opioid anesthesia protocol (ROP). The analyzed parameters were plasma IL-6 levels, complications, duration of mechanical ventilation, length of intensive care unit stay, and hospitalization.

RESULTS

In the MLOP group, the levels of IL-6 at the end of the surgery were 25.6% significantly lower compared to the ROP group (33.4 ± 9.4 vs. 44.9 ± 15.9, p < 0.0001), the duration of mechanical ventilation was significantly shorter (2.0 (2.0; 3.0) h vs. 4.0 (3.0; 5.0) h, p < 0.001), the incidence of low cardiac output syndrome was almost two and half times lower (7 (11.7%) vs. 16 (26.7%), p = 0.037), and also the incidence of postoperative atrial fibrillation was significantly lower (9 (15.0%) vs. 19 (31.7%), p = 0.031).

CONCLUSION

Our study confirms that using MLOP was characterized by significantly lower levels of IL-6 at the end of surgery and a lower incidence of low cardiac output syndrome and postoperative atrial fibrillation than ROP.

TRIAL REGISTRATION

The study is registered in clinicaltrials.gov №NCT05514652.

Comparison of early mobilization protocols on postoperative cognitive dysfunction, pain, and length of hospital stay in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial

Although coronary artery bypass graft (CABG) surgery improves the life expectancy of patients with coronary artery disease, it is associated with various short and long-term complications. Early mobilization has been shown to reduce the risk of these complications. This study aimed to compare the effectiveness of different early mobilization protocols on postoperative cognitive dysfunction (POCD), pain intensity, and length of hospital stay (LOS) in patients undergoing CABG. This three-arm parallel randomized controlled trial included 120 patients undergoing CABG surgery who were randomly assigned to Intervention A, which received a four-phase early mobilization protocol; Intervention B, which received a three-phase early mobilization protocol; and the Control group, which received routine care. Postoperative cognitive dysfunction and pain were assessed using Mini Mental State Examination (MMSE) and visual analog scale (VAS), respectively. Groups were comparable in demographic and clinical characteristics and postoperative cognitive dysfunction at baseline. After the intervention, Group B had statistically significantly (p < 0.001) less cognitive dysfunction (25.8 ± 1.7) compared to Group A (24.1 ± 2.2) and the Control Group (23.4 ± 2.7). Likewise, hospital stay was statistically (p < 0.01) shorter for Group B (7.7 ± 1.5) than the Control group (8.9 ± 1.9). However, the experience of pain was statistically significantly lower over time in Group A than in the other groups (p < 0.001). This study concludes that an early mobilization protocol based on deep breathing exercises and chest physiotherapy may better improve postoperative cognitive dysfunction and length of hospital stay than an early mobilization protocol based on passive and active range of motion activities or routine care.

Delayed Graft Function Among Kidney Transplant Recipients Is Associated With an Increased Risk of Urinary Tract Infection and BK Viremia

Background

Delayed graft function (DGF) among deceased donor kidney transplant recipients (DDKTRs) is a well-known risk factor for allograft rejection, decreased graft survival, and increased cost. Although DGF is associated with an increased risk of rejection, it is unclear whether it also increases the risk of infection.

Methods

We reviewed all adult DDKTRs at our center between 2010 and 2018. The primary outcomes of interest were BK viremia, cytomegalovirus viremia, pneumonia, and urinary tract infection (UTI) within the first year of transplant. Additional analysis was made with censoring follow-up at the time of allograft rejection.

Results

A total of 1512 DDKTRs were included, of whom 468 (31%) had DGF. As expected, several recipient, donor, and baseline immunological characteristics differed by DGF status. After adjustment, DGF was significantly associated with an increased risk of BK viremia (hazard ratio: 1.34; 95% confidence interval, 1.0-1.81; P = 0.049) and UTI (hazard ratio: 1.70; 95% confidence interval, 1.31-2.19; P < 0.001) but not cytomegalovirus viremia or pneumonia. Associations were similar in models censored at the time of rejection.

Conclusions

DGF is associated with an increased risk of early infectious complications, mainly UTI and BK viremia. Close monitoring and appropriate management are warranted for better outcomes in this unique population.

Effect of different analgesic treatments on the pulmonary function in elderly hip fracture patients: A prospective study

BACKGROUND

To investigate the effect of different analgesic methods on lungs in elderly patients with hip fractures.

METHODS

A prospective study was conducted on 78 elderly hip fracture patients undergoing spinal anesthesia for surgery, where 3 analgesic methods were used: postoperative Patient-controlled intravenous analgesia pump (PCIA) (group I), pre and postoperative PCIA (group II), and preoperative fascia iliaca compartment block (FICB) + postoperative PCIA (group III). The following indicators were monitored at admission (T1), on the day of surgery before anesthesia (T2), and 7 days after surgery (T3): heart rate (HR), respiratory rate (RR), forced expiratory volume during the first second, arterial partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2), C-reactive protein (CRP), and interleukin 6 (IL-6). Pulmonary complications such as pulmonary atelectasis and respiratory insufficiency were analyzed.

RESULTS

The HR, RR, forced expiratory volume during the first second, PaO2, PaCO2, IL-6, and CRP levels at T1 after fracture did not significantly differ among the 3 groups (P > .05). After different analgesic treatments post-admission, all indicators at T2 were significantly higher in group I than in groups II and III (P < .05), while there was no significant difference between groups II and III (P > .05). At T3, there were no significant differences in RR, HR, PaO2, PaCO2, and CRP levels among the groups (P > .05), but IL-6 levels at T3 were significantly higher in group I than in groups II and III (P < .05).

CONCLUSION

The use of effective pain relief during surgery can help protect the lung function of elderly patients with hip fractures. When using PCIA with FICB before surgery, respiratory performance may be better protected compared to using unsustained analgesia. This could be due to a decrease in the levels of inflammatory markers such as CRP and interleukin-6.

Enhanced recovery after surgery: comes out to the Sun

ERAS programs aim to reduce the length of hospital stays and lower costs, and minimize the risk of postoperative complications and readmissions while enhancing the overall patient experience. BMC Anesthesiology has initiated a new collection on ERAS, urging investigators to conduct large-scale, high-quality studies that address the existing knowledge gap.

Advances in the Management of Acute Postsurgical Pain: A Review

Despite the millions of surgeries performed every year around the world, postoperative pain remains prevalent and is often addressed with inadequate or suboptimal treatments. Chronic postsurgical pain is surprisingly prevalent, and its rate varies with the type of surgery, as well as with certain patient characteristics. Thus, better clinical training is needed as well as patient education. As pain can be caused by more than one mechanism, multimodal or balanced postsurgical analgesia is appropriate. Pharmacological agents such as opioid and nonopioid pain relievers, as well as adjuvants and nonpharmacologic approaches, can be combined to provide better and opioid-sparing pain relief. Many specialty societies have guidelines for postoperative pain management that emphasize multimodal postoperative analgesia. These guidelines are particularly helpful when dealing with special populations such as pregnant patients or infants and children. Pediatric pain control, in particular, can be challenging as patients may be unable to communicate their pain levels. A variety of validated assessment tools are available for diagnosis. Related to therapy, most guidelines agree on the fact that codeine should be used with extreme caution in pediatric patients as some may be "rapid metabolizers" and its use may be life-threatening. Prehabilitation is a preoperative approach that prepares patients in advance of elective surgery with conditioning exercises and other interventions to optimize their health. Prehabilitation may have aerobic, strength-training, nutritional, and counseling components. Logistical considerations and degree of patient adherence represent barriers to effective prehabilitation programs. Notwithstanding all this, acute postoperative pain represents a clinical challenge that has not yet been well addressed.

Optimizing Nutritional Status of Patients Prior to Major Surgical Intervention

In patients undergoing elective cardiovascular and thoracic surgery, malnutrition and the deterioration of nutritional status are associated with negative outcomes. Recognition of the contributory factors and the complications stemming from surgical stress is important for the prevention and management of these patients. We have reviewed the literature available and focused on the nutritional and metabolic aspects affecting surgical patients, with emphasis on the recommendations of enhanced recovery protocols. The implementation of enhanced recovery protocols and nutritional support guidelines focusing on the surgical patient as part of a multidisciplinary approach would improve the nutritional status of surgical patients at risk for negative outcomes.

Glucocorticoids added to paracetamol and NSAIDs for post-operative pain: A systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as the basic pain treatment regimen for most surgeries. Glucocorticoids have well-known anti-inflammatory and anti-emetic properties and may also demonstrate analgesic effects. We assessed benefit and harm of adding glucocorticoids to a combination of paracetamol and NSAIDs for post-operative pain management.

METHODS

We searched Embase, Medline and CENTRAL for randomised clinical trials investigating the addition of glucocorticoids versus placebo/no intervention to paracetamol and an NSAID in adults undergoing any type of surgery. We assessed three primary outcomes: cumulative opioid consumption at 24 h postoperatively, serious adverse events and pain at rest at 24 h postoperatively. We performed meta-analysis and trial sequential analysis (TSA), assessed risk of bias using the Risk of Bias 2 tool and used the Grading of Recommendations Assessment, Development and Evaluation approach to evaluate the certainty of the evidence.

RESULTS

We identified 12 relevant trials of which nine trials randomising 804 participants were included in quantitative analysis. When added to paracetamol and NSAIDs, we found no evidence of a difference of glucocorticoids versus placebo/no intervention in cumulative opioid consumption at 24 h postoperatively (mean difference [MD] -0.28, TSA-adjusted 95% confidence interval [CI] -1.90 to 1.33, p = .68, moderate certainty of evidence), serious adverse events (risk ratio (RR) 0.99, TSA-adjusted 95% CI 0.27-3.63, p = .93, very low certainty of evidence) or pain on the Numeric Rating Scale at 24 h postoperatively (MD -0.39, TSA-adjusted 95% CI -0.84 to 0.17, p = .10, moderate certainty of evidence). All outcomes were assessed to be at high risk of bias and TSA showed that we had insufficient information for most outcomes.

CONCLUSION

Glucocorticoids added to a baseline therapy of paracetamol and an NSAID likely result in little to no difference in cumulative opioid consumption and pain at rest at 24 h postoperatively. In addition, the evidence is very uncertain about the effect on serious adverse events. For most outcomes we did not have sufficient information to draw firm conclusions and the certainty of the evidence varied from moderate to very low.

EDITORIAL COMMENT

Multimodal approaches for post-operative analgesia are favoured, including paracetamol and nonsteroidal anti-inflammatory drugs. In this meta-analysis, pooled results from clinical trials are assessed to describe possible benefit of addition of glucocorticoid treatment for analgesia. The findings did not identify additional benefit, though the certainty of the evidence was not high.