Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions

Hemodynamic changes in the prone position according to fluid loading after anaesthesia induction in patients undergoing lumbar spine surgery: a randomized, assessor-blind, prospective study

INTRODUCTION

A change from the supine to prone position causes hemodynamic alterations. We aimed to evaluate the effect of fluid preloading in the supine position, the subsequent hemodynamic changes in the prone position and postoperative outcomes.

PATIENTS AND METHODS

This prospective, assessor-blind, randomized controlled trial was conducted between March and June 2023. Adults scheduled for elective orthopaedic lumbar surgery under general anaesthesia were enrolled. In total, 80 participants were randomly assigned to fluid maintenance (M) or loading (L) groups. Both groups were administered intravenous fluid at a rate of 2 ml/kg/h until surgical incision; Group L was loaded with an additional 5 ml/kg intravenous fluid for 10 min after anaesthesia induction. The primary outcome was incidence of hypotension before surgical incision. Secondary outcomes included differences in the mean blood pressure (mBP), heart rate, pleth variability index (PVi), stroke volume variation (SVV), pulse pressure variation (PPV), stroke volume index and cardiac index before surgical incision between the two groups. Additionally, postoperative complications until postoperative day 2 and postoperative hospital length of stay were investigated.

RESULTS

Hypotension was prevalent in Group M before surgical incision and could be predicted by a baseline PVi >16. The mBP was significantly higher in Group L immediately after fluid loading. The PVi, SVV and PPV were lower in Group L after fluid loading, with continued differences at 2-3 time points for SVV and PPV. Other outcomes did not differ between the two groups.

CONCLUSION

Fluid loading after inducing general anaesthesia could reduce the occurrence of hypotension until surgical incision in patients scheduled for surgery in the prone position. Additionally, hypotension could be predicted in patients with a baseline PVi >16. Therefore, intravenous fluid loading is strongly recommended in patients with high baseline PVi to prevent hypotension after anaesthesia induction and in the prone position.

TRIAL NUMBER

KCT0008294 (date of registration: 16 March 2023).

The preventive effect of oral 76% Meglumine Diatrizoate for the postoperative ileus

After emergency surgery for intestinal obstruction caused by colorectal cancer, postoperative ileus (POI) is more likely to occur in the early-stage oral intake. POI incited the occurrence of postoperative complications and prolongs hospital stay. Reducing the occurrence of POI will Enhance Recovery After Surgery (ERAS).

AIM

The aim of this study is to observe and evaluate the preventive effect of postoperative oral administration of 76% Meglumine Diatrizoate in reducing the incidence of POI and promoting intestinal absorption during the recovery of intestinal peristalsis in patients after intestinal obstruction surgery.

METHODS

From October 2018 to December 2021, 94 patients (47 vs 47) with intestinalobstruction were rolled. Patients with an ASA score of 4 or higher and gastrointestinal perforation with peritonitis were excluded. After 24 hours of surgery, the patients were divided into experimental group and control group disposed of with an opaque airtight envelope method, patient-side single blind. After intestinal peristalsis recovery (2.45 ± 0.62 d vs 2.60 ± 0.68 d, P > 0.05), the experimental group was given 76% Meglumine Diatrizoate 20 ml orally 9am and the control group was given 10% glucose 20 ml for three consecutive days. POI cases, the time taken to achieve full daily oral calorie and discharge days were counted.

RESULTS

The time required to achieve full daily oral calorie (11.04 ± 2.70 d vs 14.09 ± 3.74 d, p < 0.05), POI cases (10/47 vs 20/47, p < 0.05) and discharge days (14.00 ± 4.89 d vs 16.77 ± 5.94 d, p < 0.05) are significantly different between the two groups.

CONCLUSIONS

Oral 76% Meglumine Diatrizoate is safe and effective, which can reduce the occurrence of POI, promote the recovery of intestinal absorption and shorten the length of hospital stay effectively.

Intraoperative Ventilation/Perfusion Mismatch and Postoperative Pulmonary Complications after Major Noncardiac Surgery: A Prospective Cohort Study

BACKGROUND

Postoperative pulmonary complications can increase hospital length of stay, postoperative morbidity, and mortality. Although many factors can increase the risk of postoperative pulmonary complications, it is not known whether intraoperative ventilation/perfusion (V/Q) mismatch can be associated with an increased risk of postoperative pulmonary complications after major noncardiac surgery.

METHODS

This study enrolled patients undergoing general anesthesia for noncardiac surgery and evaluated intraoperative V/Q distribution using the automatic lung parameter estimator technique. The assessment was done after anesthesia induction, after 1 h from surgery start, and at the end of surgery. Demographic and procedural information were collected, and intraoperative ventilatory and hemodynamic parameters were measured at each timepoint. Patients were followed up for 7 days after surgery and assessed daily for postoperative pulmonary complication occurrence.

RESULTS

The study enrolled 101 patients with a median age of 71 [62 to 77] years, a body mass index of 25 [22.4 to 27.9] kg/m2, and a preoperative Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score of 41 [34 to 47]. Of these patients, 29 (29%) developed postoperative pulmonary complications, mainly acute respiratory failure (23%) and pleural effusion (11%). Patients with and without postoperative pulmonary complications did not differ in levels of shunt at T1 (postoperative pulmonary complications: 22.4% [10.4 to 35.9%] vs. no postoperative pulmonary complications:19.3% [9.4 to 24.1%]; P = 0.18) or during the protocol, whereas significantly different levels of high V/Q ratio were found during surgery (postoperative pulmonary complications: 13 [11 to 15] mmHg vs. no postoperative pulmonary complications: 10 [8 to 13.5] mmHg; P = 0.007) and before extubation (postoperative pulmonary complications: 13 [11 to 14] mmHg vs. no postoperative pulmonary complications: 10 [8 to 12] mmHg; P = 0.006). After adjusting for age, ARISCAT, body mass index, smoking, fluid balance, anesthesia type, laparoscopic procedure and surgery duration, high V/Q ratio before extubation was independently associated with the development of postoperative pulmonary complications (odds ratio, 1.147; 95% CI, 1.021 to 1.289; P = 0.02). The sensitivity analysis showed an E-value of 1.35 (CI, 1.11).

CONCLUSIONS

In patients with intermediate or high risk of postoperative pulmonary complications undergoing major noncardiac surgery, intraoperative V/Q mismatch is associated with the development of postoperative pulmonary complications. Increased high V/Q ratio before extubation is independently associated with the occurrence of postoperative pulmonary complications in the first 7 days after surgery.

EDITOR’S PERSPECTIVE

New set of indicators with consensus definition for anaesthesia-related severe morbidity: A scoping review followed by a Delphi study

STUDY OBJECTIVE

Monitoring anaesthesia-related severe morbidity constitutes a good opportunity for assessing quality and safety of care in anaesthesia. Several recent studies attempted to describe and define indicators for anaesthesia-related severe morbidity with limitations: no formal experts' consensus process, overlap with surgical complications, no consensual definitions, inapplicability in clinical practice. The aim of this study was to provide a set of indicators for anaesthesia-related severe morbidity based on outcomes and using clinically useful consensual definitions.

DESIGN

1/ scoping review of studies published in 2010-2021 on outcomes of anaesthesia-related severe morbidity with different definitions; 2/ International experts' consensus on indicators for anaesthesia-related severe morbidity with specific definitions using a Delphi process.

MAIN RESULTS

After including 142 studies, 68 outcomes for anaesthesia-related severe morbidity were identified and organized in 34 indicators divided into 8 categories (cardiovascular, respiratory, sepsis, renal, neurological, medication error, digestive and others). The indicators were then submitted to the experts. After 2 Delphi rounds, the 26 indicators retained by the experts with their corresponding consensual definition were: acute heart failure, cardiogenic shock, acute respiratory distress syndrome, pulmonary embolism and thrombosis, bronchospasm or laryngospasm, pneumonia, inhalation pneumonitis, pneumothorax, difficult or impossible intubation, atelectasis, self-extubation or accidental extubation, sepsis or septic shock, transient ischemic attack, postoperative confusion or delirium, post-puncture headache, medication error, liver failure, unplanned intensive care unit admission, multiple-organ failure.

CONCLUSIONS

This study provides a new consensual set of indicators for anaesthesia-related severe morbidity with specific definitions, that could be easily applied in clinical practice as in research.

A Nomogram for Predicting Postoperative Pulmonary Complications in Critical Patients Transferred to ICU After Abdominal Surgery

OBJECTIVE

The purpose of this study was to investigate the risk factors associated with postoperative pulmonary complications(PPCs) in critically ill patients transferred to intensive care unit(ICU) after abdominal surgery and develop a predictive model for this disease.

METHODS

Data for 3716 patients who were admitted to ICU after abdominal surgery in Peking University People's Hospital between January 2015 and December 2020 were retrospectively collected and analyzed to identify the risk factors and develop a nomogram prediction model. Data for patients admitted to ICU following abdominal surgery at Peking University People's Hospital from March 2021 to December 2022 were prospectively collected as a validation set to validate and assess the model.

RESULTS

10 independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model was constructed for PPCs in this group patients, the area under ROC curve was 0.771[95%CI: 0.756,0.786] and 0.759[95%CI: 0.726,0.792] in the training set and validation set, respectively.

CONCLUSIONS

In this study, independent risk factors for PPCs in critically ill patients transferred to ICU after abdominal surgery were identified. A nomogram prediction model for PPCs in critically ill surgical population was constructed using these factors, demonstrating a good predictive value.

Effect of preoperative natural killer cell on postoperative pulmonary complications in patients of lung cancer - A single-center retrospective cohort study

BACKGROUND

The effect of preoperative natural killer (NK) cell abnormalities on postoperative pulmonary complications (PPCs) after thoracoscopic radical resection of lung cancer is still unclear. The main purpose of this study was to investigate the relationship between the preoperative NK cell ratio and PPCs.

METHODS

The patients who underwent thoracoscopic radical resection for lung cancer were divided into a normal group and an abnormal group according to whether the proportion of preoperative NK cells was within the reference range. The main outcome was the incidence of PPCs during postoperative hospitalization. The demographic and perioperative data were collected. Propensity score matching was used to exclude systematic bias. Univariate logistic regression was used to test the relationship between the preoperative NK cell ratio and the incidence of PPCs. The restrictive cubic spline curve was used to analyze the dose-effect relationship between the preoperative NK cell ratio and the incidence of PPCs.

RESULTS

A total of 4161 patients were included. After establishing a matching cohort, 910 patients were included in the statistical analysis. The incidence of PPCs in the abnormal group was greater than that in the normal group (55.2% vs. 31.6%). The incidence of PPCs first decreased and then increased with increasing NK cell ratio. The proportion of patients with Grade 3 or higher PPCs in the normal group was lower than that in the abnormal group [108 (23.7%) vs. 223 (49%)]. The indwelling time of the thoracic drainage tube in the abnormal group was longer than that in the normal group [3 (3, 4) vs. 3 (3, 5)]. A preoperative abnormal NK cell ratio constituted a risk factor for PPCs in each subgroup.

CONCLUSION

Lung cancer patients with an abnormal proportion of peripheral blood NK cells before surgery were more likely to develop PPCs, their disease degree was more severe, and they had a prolonged duration of chest tube indwelling. Compared with those with abnormally high NK cell ratios, those with abnormally low NK cell ratios had more pronounced PPCs.

Practices to prevent non-ventilator hospital-acquired pneumonia: a narrative review

Nosocomial infection has significant consequences in health care, both at the individual level due to increased morbidity and mortality, and at the organizational level due to increased costs. Hospital-acquired pneumonia (HAP) is the most common nosocomial infection, and is associated with high excess mortality, frequent use of broad-spectrum antimicrobials and increased length of stay. This review explores the preventative strategies that have been examined in non-ventilator HAP (NV-HAP). The management of aspiration risk, interventions for oral hygiene, role of mobilization and physiotherapy, modification of environmental factors, and vaccination are discussed. Many of these interventions are low risk, acceptable to patients and have good cost-benefit ratios. However, the evidence base for prevention of NV-HAP is weak. This review identifies the lack of a unified research definition, under-recruitment to studies, and variation in intervention and outcome measures as limitations in the existing literature. Given that the core risk factors for acquisition of NV-HAP are increasing, there is an urgent need for research to address the prevention of NV-HAP. This review calls for a unified definition of NV-HAP, and identification of a core outcome set for studies in NV-HAP, and suggests future directions for research in NV-HAP. Improving care for people with NV-HAP will reduce morbidity, mortality and healthcare costs significantly.

Effect of rigorous fluid management using monitoring of ECW ratio by bioelectrical impedance analysis in critically ill postoperative patients: A prospective, single-blind, randomized controlled study

BACKGROUND & AIMS

Precise assessment of postoperative volume status is important to administrate optimal fluid management. Bioelectrical impedance analysis (BIA) which measures the body composition using electric character. Extracellular water (ECW) ratio by BIA represented as the ratio of ECW to total body water (TBW) and is known to reflect the hydration status. Based on this, we aimed to determine whether aggressive fluid control using ECW ratio could improve clinical outcomes through a single blind, randomized controlled trial.

METHODS

From November 2021 to December 2022, intensive care unit (ICU) patients admitted after surgery were randomly assigned to an intervention group or a control group whether postoperative fluid management was controlled via BIA. Among patients in the intervention group, dehydrated patients received a bolus infusion with crystalloid fluid whereas diuretics were administrated to overhydrated patients until the value of ECW ratio fell within its normal setting range (0.390-0.406). Contrarily, BIA was performed once a day for the control group. Patients in the control group received traditional fluid treatment regardless of BIA results. Primary outcome was in-hospital mortality in two groups. The secondary outcomes were postoperative morbidities, 28-day mortality.

RESULTS

77 patients of the intervention group and 90 patients of the control group were finally analyzed. The in-hospital mortality (0 in intervention, 4.4% in control, p = 0.125) and 28-day mortality (1.3% in intervention, 14.4% in control, p = 0.002) showed lower incidence in the intervention group than in the control group. In multivariate analysis, the overhydrated status whose ECW ratio exceeding 0.406 [odds ratio (OR): 2.731, 95% confidence interval (CI): 1.001-7.663, p = 0.049] and high capillary leak index (CLI) value at ICU admission (OR: 1.024, 95% CI: 1.008-1.039, p = 0.002) were risk factors of postoperative morbidities. Regarding the 28-day mortality, high CLI value (OR: 1.025, 95% CI: 1.002-1.050, p = 0.037) and traditional strategy without BIA monitoring (OR: 9.903, 95% CI: 1.095-89.566, p = 0.041) were the significant predisposing factors.

CONCLUSION

Our results revealed the rigorous fluid treatment with volume control based on ECW ratio by BIA failed to achieve significant improvement in in-hospital mortality, but it could reduce 28-day mortality of ICU patients. Monitoring of ECW ratio may help establish optimal fluid treatment strategies for postoperative ICU patients who are susceptible to fluid imbalances with fluid overload.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT06097923, retrospectively registered on October 16, 2023, https://clinicaltrials.gov/study/NCT06097923?term=NCT06097923&rank=1.

High intraoperative fluid load associated with prolonged length of hospital stay and complications after non-cardiac surgery in neonates

Inappropriate perioperative fluid load can lead to postoperative complications and death. This retrospective study was designed to investigate the association between intraoperative fluid load and outcomes in neonates undergoing non-cardiac surgery. From April 2020 to September 2022, 940 neonates who underwent non-cardiac surgery were retrospectively enrolled and their perioperative data were harvested for further analysis. According to recorded intraoperative fluid volumes defined as ml.kg-1 h-1, patients were mandatorily divided into quintile with fluid load as restrictive (quintile 1, Q1), moderately restrictive (Q2), moderate (Q3), moderately liberal (Q4), and liberal (Q5). The primary outcomes were defined as prolonged length of hospital stay (LOS) (postoperative LOS ≥ 14 days), complications beyond prolonged LOS, and 30-day mortality. Secondary outcomes included postoperative complications within 14 days of hospital stay. The intraoperative fluid load was in Q1 of 6.5 (5.3-7.3) (median and IQR); Q2: 9.2 (8.7-9.9); Q3: 12.2 (11.4-13.2); Q4: 16.5 (15.4-18.0); and Q5: 26.5 (22.3-32.2) ml.kg-1 h-1. The odd of prolonged LOS was positively correlated with an increase fluid volume (Q5 quintile: OR 2.602 [95% CI 1.444-4.690], P = 0.001), as well as complications beyond prolonged LOS (Q5: OR 3.322 [95% CI 1.656-6.275], P = 0.001). The overall 30-day mortality rate was increased with high intraoperative fluid load but did not reach to a statistical significance after adjusted with confounders. Furthermore, the highest quintile of fluid load (26.5 ml.kg-1 h-1, IQR [22.3-32.2]) (Q5 quintile) was significantly associated with longer postoperative mechanical ventilation time compared with Q1 (Q5: OR 2.212 [95% CI 1.101-4.445], P = 0.026).    Conclusion: Restrictive intraoperative fluid load had overall better outcomes, whilst high fluid load was significantly associated with prolonged LOS and complications after non-cardiac surgery in neonates.    Trial registration:  Chictr.org.cn Identifier: ChiCTR2200066823 (December 19, 2022). What is Known: • Inappropriate perioperative fluid load can lead to postoperative complications and even death. What is New: • High perioperative fluid load was significantly associated with an increased length of stay after non-cardiac surgery in neonates, whilst low fluid load was consistently related to better postoperative outcomes.

Effectiveness of dexmedetomidine on patient-centred outcomes in surgical patients: a systematic review and Bayesian meta-analysis

BACKGROUND

Dexmedetomidine is increasingly used for surgical patients requiring general anaesthesia. However, its effectiveness on patient-centred outcomes remains uncertain. Our main objective was to evaluate the patient-centred effectiveness of intraoperative dexmedetomidine for adult patients requiring surgery under general anaesthesia.

METHODS

We conducted a systematic search of MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL from inception to October 2023. Randomised controlled trials (RCTs) comparing intraoperative use of dexmedetomidine with placebo, opioid, or usual care in adult patients requiring surgery under general anaesthesia were included. Study selection, data extraction, and risk of bias assessment were performed by two reviewers independently. We synthesised data using a random-effects Bayesian regression framework to derive effect estimates and the probability of a clinically important effect. For continuous outcomes, we pooled instruments with similar constructs using standardised mean differences (SMDs) and converted SMDs and credible intervals (CrIs) to their original scale when appropriate. We assessed the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Our primary outcome was quality of recovery after surgery. To guide interpretation on the original scale, the Quality of Recovery-15 (QoR-15) instrument was used (range 0-150 points, minimally important difference [MID] of 6 points).

RESULTS

We identified 49,069 citations, from which 44 RCTs involving 5904 participants were eligible. Intraoperative dexmedetomidine administration was associated with improvement in postoperative QoR-15 (mean difference 9, 95% CrI 4-14, n=21 RCTs, moderate certainty of evidence). We found 99% probability of any benefit and 88% probability of achieving the MID. There was a reduction in chronic pain incidence (odds ratio [OR] 0.42, 95% CrI 0.19-0.79, n=7 RCTs, low certainty of evidence). There was also increased risk of clinically significant hypotension (OR 1.98, 95% CrI 0.84-3.92, posterior probability of harm 94%, n=8 RCTs) and clinically significant bradycardia (OR 1.74, 95% CrI 0.93-3.34, posterior probability of harm 95%, n=10 RCTs), with very low certainty of evidence for both. There was limited evidence to inform other secondary patient-centred outcomes.

CONCLUSIONS

Compared with placebo or standard of care, intraoperative dexmedetomidine likely results in meaningful improvement in the quality of recovery and chronic pain after surgery. However, it might increase clinically important bradycardia and hypotension.

SYSTEMATIC REVIEW PROTOCOL

PROSPERO (CRD42023439896).

Personalised blood pressure management during major noncardiac surgery and postoperative neurocognitive disorders: a randomised trial

Background

It remains unknown whether there is a causal relationship between intraoperative hypotension and postoperative neurocognitive disorders. We tested the hypothesis that personalised-compared to routine-intraoperative blood pressure management reduces the incidence of postoperative neurocognitive disorders in patients having major noncardiac surgery.

Methods

In this single-centre trial, 328 elective major noncardiac surgery patients were randomly allocated to receive personalised blood pressure management (i.e. maintaining intraoperative mean arterial pressure [MAP] above preoperative baseline MAP from automated 24-h blood pressure monitoring) or routine blood pressure management (i.e. maintaining MAP above 65 mm Hg). The primary outcome was the incidence of neurocognitive disorders (composite of delayed neurocognitive recovery and delirium) between postoperative days 3 and 7.

Results

The primary outcome, neurocognitive disorders, occurred in 18 of 147 patients (12%) assigned to personalised and 21 of 148 patients (14%) assigned to routine blood pressure management (odds ratio [OR]=0.84, 95% confidence interval [CI]: 0.40-1.75, P=0.622). Delayed neurocognitive recovery occurred in 17 of 146 patients (12%) assigned to personalised and 17 of 145 patients (12%) assigned to routine blood pressure management (OR=0.99, 95% CI: 0.45-2.17, P=0.983). Delirium occurred in 2 of 157 patients (1%) assigned to personalised and 4 of 158 patients (3%) assigned to routine blood pressure management (OR=0.50, 95% CI: 0.04-3.53, P=0.684).

Conclusions

Personalised intraoperative blood pressure management maintaining preoperative baseline MAP neither reduced the incidence of the composite primary outcome neurocognitive disorders between postoperative days 3 and 7 nor the incidences of the components of the composite primary outcome-delayed neurocognitive recovery and delirium-compared to routine blood pressure management in patients having major noncardiac surgery.

Clinical trial registration

ClinicalTrials.gov (NCT03442907).

External validation of the CARDOT score for predicting respiratory complications after thoracic surgery

BACKGROUND

The CARDOT scores have been developed for prediction of respiratory complications after thoracic surgery. This study aimed to externally validate the CARDOT score and assess the predictive value of preoperative neutrophil-to-lymphocyte ratio (NLR) for postoperative respiratory complication.

METHODS

A retrospective cohort study of consecutive thoracic surgical patients at a single tertiary hospital in northern Thailand was conducted. The development and validation datasets were collected between 2006 and 2012 and from 2015 to 2021, respectively. Six prespecified predictive factors were identified, and formed a predictive score, the CARDOT score (chronic obstructive pulmonary disease, American Society of Anesthesiologists physical status, right-sided operation, duration of surgery, preoperative oxygen saturation on room air, thoracotomy), was calculated. The performance of the CARDOT score was evaluated in terms of discrimination by using the area under the receiver operating characteristic (AuROC) curve and calibration.

RESULTS

There were 1086 and 1645 patients included in the development and validation datasets. The incidence of respiratory complications was 15.7% (171 of 1086) and 22.5% (370 of 1645) in the development and validation datasets, respectively. The CARDOT score had good discriminative ability for both the development and validation datasets (AuROC 0.789 (95% CI 0.753-0.827) and 0.758 (95% CI 0.730-0.787), respectively). The CARDOT score showed good calibration in both datasets. A high NLR (≥ 4.5) significantly increased the risk of respiratory complications after thoracic surgery (P < 0.001). The AuROC curve of the validation cohort increased to 0.775 (95% CI 0.750-0.800) when the score was combined with a high NLR. The AuROC of the CARDOT score with the NLR showed significantly greater discrimination power than that of the CARDOT score alone (P = 0.008).

CONCLUSIONS

The CARDOT score showed a good discriminative performance in the external validation dataset. An addition of a high NLR significantly increases the predictive performance of CARDOT score. The utility of this score is valuable in settings with limited access to preoperative pulmonary function testing.

Triglyceride-glucose index-A novel metabolism disorder biomarker as a promising indicator for predicting postoperative 30-day infections in elderly patients undergoing gastrointestinal-related abdominal and pelvic surgery

BACKGROUND

The triglyceride-glucose index, a reliable surrogate biomarker of insulin resistance, has been reported to be associated with cardiovascular events and atherosclerosis. However, few studies have investigated the association of the triglyceride-glucose index with postoperative infections. This study aimed to study the clinical risk values of the preoperative triglyceride-glucose index in postoperative infection complications in elderly patients undergoing gastrointestinal-related abdominal and pelvic surgery.

METHODS

This retrospective cohort study included 3,225 older patients who underwent gastrointestinal-related abdominal and pelvic surgery between 2014 and 2019. The patients were divided into groups of triglyceride-glucose index ≤8.268 and triglyceride-glucose index >8.268 according to the optimal triglyceride-glucose index cut-off value. The outcome of interest was postoperative infections within 30 days after surgery. Primary and subgroup analyses were performed to confirm that preoperative triglyceride-glucose index qualifies as a reliable, independent risk indicator. Propensity score matching analysis was further applied to address covariates' potential residual confounding effect and test the robustness of the results.

RESULTS

In this study, the median age was 71 years (interquartile range, 67, 75 years), the proportion of male patients was 66.3%, and 1,058 (32.8%) were infected within 30 days after surgery. A triglyceride-glucose index >8.268 was associated with an increased risk of postoperative infections in multivariate regression analysis (odds ratio, 1.37; 95% confidence interval, 1.15-1.64; P < .001). The correlation between the triglyceride-glucose index and postoperative infections remained significantly robust (odds ratio, 1.52; 95% confidence interval, 1.21-1.92; P < .001) in the propensity score matching analysis.

CONCLUSIONS

The triglyceride-glucose index elevation determined by the optimal cutoff value of 8.268 was an independent risk factor for developing postoperative infections.

Identifying Early Risk Factors for Postoperative Pulmonary Complications in Cardiac Surgery Patients

Background and Objectives: Postoperative pulmonary complications (PPCs) are common in patients who undergo cardiac surgery and are widely acknowledged as significant contributors to increased morbidity, mortality rates, prolonged hospital stays, and healthcare costs. Clinical manifestations of PPCs can vary from mild to severe symptoms, with different radiological findings and varying incidence. Detecting early signs and identifying influencing factors of PPCs is essential to prevent patients from further complications. Our study aimed to determine the frequency, types, and risk factors significant for each PPC on the first postoperative day. The main goal of this study was to identify the incidence of pleural effusion (right-sided, left-sided, or bilateral), atelectasis, pulmonary edema, and pneumothorax as well as detect specific factors related to its development. Materials and Methods: This study was a retrospective single-center trial. It involved 314 adult patients scheduled for elective open-heart surgery under CPB. Results: Of the 314 patients reviewed, 42% developed PPCs within 12 h post-surgery. Up to 60.6% experienced one PPC, while 35.6% developed two PPCs. Pleural effusion was the most frequently observed complication in 89 patients. Left-sided effusion was the most common, presenting in 45 cases. Regression analysis showed a significant association between left-sided pleural effusion development and moderate hypoalbuminemia. Valve surgery was associated with reduced risk for left-sided effusion. Independent parameters for bilateral effusion include increased urine output and longer ICU stays. Higher BMI was inversely related to the risk of pulmonary edema. Conclusions: At least one PPC developed in almost half of the patients. Left-sided pleural effusion was the most common PPC, with hypoalbuminemia as a risk factor for effusion development. Atelectasis was the second most common. Bilateral effusion was the third most common PPC, significantly related to increased urine output. BMI was an independent risk factor for pulmonary edema development.

Prediction modeling of postoperative pulmonary complications following lung resection based on random forest algorithm

Postoperative pulmonary complications (PPCs) are a significant concern following lung resection due to prolonged hospital stays and increased morbidity and mortality among patients. This study aims to develop and validate a risk prediction model for PPCs after lung resection using the random forest (RF) algorithm to enhance early detection and intervention. Data from 180 patients who underwent lung resections at the Third Affiliated Hospital of the Naval Medical University between September 2022 and February 2024 were retrospectively analyzed. The patients were randomly allocated into a training set and a test set in an 8:2 ratio. An RF model was constructed using Python, with feature importance ranked based on the mean Gini index. The predictive performance of the model was evaluated through analyses of the receiver operating characteristic curve, calibration curve, and decision curve. Among the 180 patients included, 47 (26.1%) developed PPCs. The top 5 predictive factors identified by the RF model were blood loss, maximal length of resection, number of lymph nodes removed, forced expiratory volume in the first second as a percentage of predicted value, and age. The receiver operating characteristic curve and calibration curve analyses demonstrated favorable discrimination and calibration capabilities of the model, while decision curve analysis indicated its clinical applicability. The RF algorithm is effective in predicting PPCs following lung resection and holds promise for clinical application.

Impact and effect of preoperative short-term preoperative pulmonary-related training on patients with gastric cancer: a randomized controlled single center trial

PURPOSE

This study aimed is to evaluate the impact of pre- and postoperative pulmonary-related training, including respiratory and aerobic training, on postoperative pulmonary complications (PPCs) after radical resection of gastric cancer (GC).

METHODS

We conducted a randomized controlled trial of 121 participants who received a systematic, comprehensive, high-intensity pulmonary exercise regimen for 5 days preoperatively and at least 5 days postoperatively. The control group received standard preoperative care. We analyzed the occurrence of PPCs in both groups as the primary outcome RESULTS: A total of 43 of 121 participants (35.5%) were diagnosed as having PPCs, and the incidence of PPCs was markedly lower in the training group than in the control group (26.2% [16 of 61] vs 45.0% [27 of 60]; P = .031). Moreover, the duration of the postoperative hospital stay was shorter in the training group (8.69 ± 1.92 days) than the control group (9.57 ± 2.16 days; P = .020) and reduced hospitalization costs, amounting to €9605.1 ± €2556.26 in the training group and €10,594.6 ± €2560.7 in the control group (P = .035).

CONCLUSION

Our study established that a perioperative pulmonary-related training notably diminishes the incidence of PPCs, curtails the duration of hospitalization, and mitigates hospitalization expenses for patients undergoing GC surgery.

Criteria for continuous neuraxial analgesia associated with reduced mortality in patients undergoing thoracotomy

INTRODUCTION

Both thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia.

METHOD

1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates.

RESULTS

Continuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01).

CONCLUSIONS

Neuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.

Association of Previous Cardiac Surgery With Postoperative Pneumonia in Infants Undergoing Abdominal Operations: A Cohort Study

BACKGROUND

Children with congenital heart disease (CHD) often require other, non-cardiac related surgical procedures following their initial cardiac surgery. After full or partial CHD repair, they remain at increased risk of postoperative complications. We examined the association of previous cardiac intervention (surgery or percutaneous catheterization intervention) with postoperative pneumonia in infants undergoing abdominal general surgery.

METHODS

A 1:1 propensity score-matched study was conducted using a retrospective cohort of 104,820 infants (<12 months) who had general abdominal surgeries between 2012 and 2022 in U.S. hospitals participating in the National Surgical Quality Improvement Program. The primary outcome was postoperative pneumonia within 30 days. Secondary outcomes included unplanned reintubation, prolonged mechanical ventilation (>72 h), and extended hospital stay (>75th percentile for the study cohort).

RESULTS

Of the study cohort, 9736 infants (9.3%) had previous cardiac interventions. In the propensity score-matched sample, infants with previous cardiac surgery had increased risks of postoperative pneumonia (1.3% vs 0.8%; adjusted relative risk [RRadj]: 1.64, 95% CI: 1.22, 2.18, p = 0.001), unplanned reintubation (57.8% vs 32.6%; RRadj: 1.77, 95% CI: 1.77, 1.85, p < 0.001), prolonged mechanical ventilation (5.0% vs 2.3%; RRadj: 2.14, 95% CI: 1.83, 2.52, p < 0.001), and prolonged hospital stays (61.0% vs 53.8%; RRadj: 1.13, 95% CI: 1.10, 1.17, p < 0.001).

CONCLUSIONS

A history of previous cardiac intervention carries an increased risk of postoperative pneumonia, unplanned tracheal reintubation, prolonged mechanical ventilation, as well as longer hospital stays following intra-abdominal surgery. Clinicians should closely monitor these patients for respiratory complications after surgery.

LEVEL OF EVIDENCE

II.

Analysis of Perioperative Factors Leading to Postoperative Pulmonary Complications, Graft Injury and Increased Postoperative Mortality in Lung Transplantation

OBJECTIVES

Postoperative complications such as postoperative pulmonary complications (PPCs) and other organ complications are associated with increased morbidity and mortality after successful lung transplantation and have a detrimental effect on patient recovery. The aim of this study was to investigate perioperative risk factors for in-hospital mortality and postoperative complications with a focus on PPC and graft injury in patients undergoing lung transplantation DESIGN: Single-center retrospective cohort study of 173 patients undergoing lung transplantation SETTING: University Hospital, Medical Center Freiburg.

MAIN RESULTS

In the stepwise multivariate regression analysis, donor age >60 years (odds ratio [OR], 1.85; 95% confidence interval [CI], 1.27-2.81), intraoperative extracorporeal membrane oxygenation (OR, 2.4; 95% CI, 1.7-3.3), transfusion of >4 red blood cell concentrates (OR, 3.1; 95% CI, 1.82-5.1), mean pulmonary artery pressure of >30 mmHg at the end of surgery (OR, 3.5; 95% CI, 2-6.3), the occurrence of postoperative graft injury (OR, 4.1; 95% CI, 2.8-5.9), PPCs (OR, 2.1; 95% CI, 1.7-2.6), sepsis (OR, 4.5; 95% CI, 2.8-7.3), and Kidney disease Improving Outcome grading system stage 3 acute renal failure (OR, 4.3; 95% CI, 2.4-7.7) were associated with increased in hospital mortality, whereas patients with chronic obstructive pulmonary disease had a lower in-hospital mortality (OR, 1.6; 95% CI, 1.4-1.9). The frequency and number of PPCs correlated with postoperative mortality.

CONCLUSIONS

Clinical management and risk stratification focusing on the underlying identified factors that could help to improve patient outcomes.

Development and validation of a score for prediction of postoperative respiratory complications in infants and children (SPORC-C)

BACKGROUND

In infants and children, postoperative respiratory complications are leading causes of perioperative morbidity, mortality, and increased healthcare utilisation. We aimed to develop a novel score for prediction of postoperative respiratory complications in paediatric patients (SPORC for children).

METHODS

We analysed data from paediatric patients (≤12 yr) undergoing surgery in New York and Boston, USA for score development and external validation. The primary outcome was postoperative respiratory complications within 30 days after surgery, defined as respiratory infection, respiratory failure, aspiration pneumonitis, pneumothorax, pleural effusion, bronchospasm, laryngospasm, and reintubation. Data from Children's Hospital at Montefiore were used to create the score by stepwise backwards elimination using multivariate logistic regression. External validation was conducted using a separate cohort of children who underwent surgery at Massachusetts General Hospital for Children.

RESULTS

The study included data from children undergoing 32,187‬ surgical procedures, where 768 (2.4%) children experienced postoperative respiratory complications. The final score consisted of 11 predictors, and showed discriminatory ability in development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.85 (95% confidence interval: 0.83-0.87), 0.84 (0.80-0.87), and 0.83 (0.80-0.86), respectively.

CONCLUSION

SPORC is a novel validated score for predicting the likelihood of postoperative respiratory complications in children that can be used to predict postoperative respiratory complications in infants and children.

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study

BACKGROUND

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery.

METHODS

We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality.

RESULTS

Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone.

CONCLUSIONS

After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

Intraoperative dexamethasone is associated with a lower risk of respiratory failure in thoracic surgery: Observational cohort study (SURTHODEX)

BACKGROUND

Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery.

METHODS

We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect.

RESULTS

We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02).

CONCLUSIONS

Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.

Acute normovolemic hemodilution in cardiac surgery: Rationale and design of a multicenter randomized trial

BACKGROUND

Minimizing the use of blood component can reduce known and unknown blood transfusion risks, preserve blood bank resources, and decrease healthcare costs. Red Blood Cell (RBC) transfusion is common after cardiac surgery and associated with adverse perioperative outcomes, including mortality. Acute normovolemic hemodilution (ANH) may reduce bleeding and the need for blood product transfusion after cardiac surgery. However, its blood-saving effect and impact on major outcomes remain uncertain.

METHODS

This is a single-blinded, multinational, pragmatic, randomized controlled trial with a 1:1 allocation ratio conducted in Tertiary and University hospitals. The study is designed to enroll patients scheduled for elective cardiac surgery with planned cardiopulmonary bypass (CPB). Patients are randomized to receive ANH before CPB or the best available treatment without ANH. We identified an ANH volume of at least 650 ml as the critical threshold for clinically relevant benefits. Larger ANH volumes, however, are allowed and tailored to the patient's characteristics and clinical conditions.

RESULTS

The primary outcome is the percentage of patients receiving RBCs transfusion from randomization until hospital discharge, which we hypothesize will be reduced from 35% to 28% with ANH. Secondary outcomes are all-cause 30-day mortality, acute kidney injury, bleeding complications, and ischemic complications.

CONCLUSION

The trial is designed to determine whether ANH can safely reduce RBC transfusion after elective cardiac surgery with CPB.

STUDY REGISTRATION

This trial was registered on ClinicalTrials.gov in April 2019 with the trial identification number NCT03913481.

One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial

OBJECTIVE

Test the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection.

BACKGROUND

Constant tidal volume and respiratory rate ventilation can lead to atelectasis. Animal and human ARDS studies indicate that oxygenation improves with variable tidal volumes. Since one-lung ventilation shares characteristics with ARDS, we tested the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection.

DESIGN

Randomized trial.

SETTING

Operating rooms and a post-anesthesia care unit.

PATIENTS

Adults having elective open or video-assisted thoracoscopic lung resection surgery with general anesthesia were randomly assigned to intraoperative ventilation with fixed (n = 70) or with variable (n = 70) tidal volumes.

INTERVENTIONS

Patients assigned to fixed ventilation had a tidal volume of 6 ml/kgPBW, whereas those assigned to variable ventilation had tidal volumes ranging from 6 ml/kg PBW ± 33% which varied randomly at 5-min intervals.

MEASUREMENTS

The primary outcome was intraoperative oxygenation; secondary outcomes were postoperative pulmonary complications, mortality within 90 days of surgery, heart rate, and SpO2/FiO2 ratio.

RESULTS

Data from 128 patients were analyzed with 65 assigned to fixed-tidal volume ventilation and 63 to variable-tidal volume ventilation. The time-weighted average PaO2 during one-lung ventilation was 176 (86) mmHg in patients ventilated with fixed-tidal volume and 147 (72) mmHg in the patients ventilated with variable-tidal volume, a difference that was statistically significant (p < 0.01) but less than our pre-defined clinically meaningful threshold of 50 mmHg. At least one composite complication occurred in 11 (17%) of patients ventilated with variable-tidal volume and in 17 (26%) of patients assigned to fixed-tidal volume ventilation, with a relative risk of 0.67 (95% CI 0.34-1.31, p = 0.24). Atelectasis in the ventilated lung was less common with variable-tidal volumes (4.7%) than fixed-tidal volumes (20%) in the initial three postoperative days, with a relative risk of 0.24 (95% CI 0.01-0.8, p = 0.02), but there were no significant late postoperative differences. No other secondary outcomes were both statistically significant and clinically meaningful.

CONCLUSION

One-lung ventilation with variable tidal volume does not meaningfully improve intraoperative oxygenation, and does not reduce postoperative pulmonary complications.

Effect of postoperative intermittent boluses of subcostal quadratus lumborum block on pulmonary function recovery and analgesia after gastrectomy: a randomized controlled clinical trial

BACKGROUND

Following the gastrectomy, the reduction in pulmonary function is partly attributed to postoperative pain. Subcostal quadratus lumborum block (QLB) has recently emerged as a promising component in multimodal analgesia. We aimed to assess the impact of intermittent boluses of subcostal QLB on pulmonary function recovery and analgesic efficacy after gastrectomy.

METHODS

Sixty patients scheduled for gastrectomy were randomly assigned to either control group (multimodal analgesia) or intervention group (intermittent boluses of subcostal QLB plus multimodal analgesia). Two primary outcomes included the preservation of forced expiratory volume in the first second (FEV1) and the pain scores (0-10 cm visual analog score) on coughing 24 h postoperatively. We assessed the pulmonary function parameters, pain score, morphine consumption and number of rescue analgesia at a 24-h interval up to 72 h (Day1, Day2, Day3 respectively) as secondary outcomes.

RESULTS

59 patients were analyzed in a modified intention-to-treat set. The preservation of FEV1 (median difference: 4.0%, 97.5% CI: -5.7 to 14.9, P = 0.332) and pain scores on coughing (mean difference: 0.0 cm, 97.5% CI: -1.1 to 1.2, P = 0.924) did not differ significantly between two groups. In the intervention group, the recovery of forced vital capacity (FVC) was faster 72 h after surgery (interaction effect of group*(Day3-Day0): estimated effect (β) =0.30 L, standard error (SE) =0.13, P = 0.025), pain scores at rest were lower in the first 3 days (interaction effect of group*(Day1-Day0): β = - 0.8 cm, SE = 0.4, P = 0.035; interaction effect of group*(Day2-Day0): β = - 1.0 cm, SE = 0.4, P = 0.014; and interaction effect of group*(Day3-Day0): β = - 1.0 cm, SE = 0.4, P values = 0.009 respectively), intravenous morphine consumption was lower during 0-24 h (median difference: -3 mg, 95% CI -6 to -1, P = 0.014) and in total 72 h (median difference: -5 mg, 95% CI -10 to -1, P = 0.019), and the numbers of rescue analgesia was fewer during 24-48 h (median difference: 0, 95% CI 0 to 0, P = 0.043). Other outcomes didn't show statistical differences.

CONCLUSION

Postoperative intermittent boluses of subcostal QLB did not confer advantages in terms of the preservation of FEV1 or pain scores on coughing 24 h after gastrectomy. However, notable effects were observed in analgesia at rest and FVC recovery.

Cardiac index-guided therapy to maintain optimised postinduction cardiac index in high-risk patients having major open abdominal surgery: the multicentre randomised iPEGASUS trial

BACKGROUND

It is unclear whether optimising intraoperative cardiac index can reduce postoperative complications. We tested the hypothesis that maintaining optimised postinduction cardiac index during and for the first 8 h after surgery reduces the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery.

METHODS

In three German and two Spanish centres, high-risk patients having elective major open abdominal surgery were randomised to cardiac index-guided therapy to maintain optimised postinduction cardiac index (cardiac index at which pulse pressure variation was <12%) during and for the first 8 h after surgery using intravenous fluids and dobutamine or to routine care. The primary outcome was the incidence of a composite outcome of moderate or severe complications within 28 days after surgery.

RESULTS

We analysed 318 of 380 enrolled subjects. The composite primary outcome occurred in 84 of 152 subjects (55%) assigned to cardiac index-guided therapy and in 77 of 166 subjects (46%) assigned to routine care (odds ratio: 1.87, 95% confidence interval: 1.03-3.39, P=0.038). Per-protocol analyses confirmed the results of the primary outcome analysis.

CONCLUSIONS

Maintaining optimised postinduction cardiac index during and for the first 8 h after surgery did not reduce, and possibly increased, the incidence of a composite outcome of complications within 28 days after surgery compared with routine care in high-risk patients having elective major open abdominal surgery. Clinicians should not strive to maintain optimised postinduction cardiac index during and after surgery in expectation of reducing complications.

CLINICAL TRIAL REGISTRATION

NCT03021525.

Characteristics and outcomes for general anesthesia in Denmark

BACKGROUND

General anesthesia is common, but concerns regarding post-operative complications and mortality remain. No study has described the Danish patient population undergoing general anesthesia on a national level. The aim of this study was to describe the characteristics and outcomes of patients undergoing general anesthesia in Denmark.

METHODS

This study was a registry-based observational cohort study of adult patients (≥18 years) undergoing general anesthesia in Denmark during 2020 and 2021. Data from nationwide registries covering patient characteristics, anesthesia and procedure information, and patient outcomes were combined. Descriptive statistics were used to present findings, both overall and in subgroups based on the American Society of Anesthesiologists (ASA) classification.

RESULTS

We identified 453,133 cases of general anesthesia in 328,951 unique patients. The median age was 57 years (quartiles: 41, 71), and 242,679 (54%) were females. Data on ASA classification were missing for less than 1% of the population, and ASA II was the most prevalent ASA classification (49%). Among cases of general anesthesia, 0.1% experienced a stroke, 0.2% had in-hospital cardiac arrest, and 3.9% had a stay in the intensive care unit within 30 days. Mortality at 30 days and 1 year were 1.8% and 6.3%, respectively, increasing with a higher ASA classification.

CONCLUSION

This study offers the first comprehensive overview of adult patients undergoing general anesthesia in Denmark. Post-anesthesia complications were few and increased with ASA classification.

A systematic review and meta-analysis of thoracic epidural analgesia versus other analgesic techniques in patients post-oesophagectomy

BACKGROUND

Oesophageal cancer surgery represents a high perioperative risk of complications to patients, such as postoperative pulmonary complications (PPCs). Postoperative analgesia may influence these risks, but the most favourable analgesic technique is debated. This review aims to provide an updated evaluation of whether thoracic epidural analgesia (TEA) has benefits compared to other analgesic techniques in patients undergoing oesophagectomy surgery. Our hypothesis is that TEA reduces pain scores and PPCs compared to intravenous opioid analgesia in patients post-oesophagectomy.

METHODS

Electronic databases PubMed, Excerpta Medica Database (EMBASE) and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for randomised trials of analgesic interventions in patients undergoing oesophagectomy surgery. Only trials including thoracic epidural analgesia compared with other analgesic techniques were included. The primary outcome was a composite of respiratory infection, atelectasis and respiratory failure (PPCs), with pain scores at rest and on movement as secondary outcomes. Data was pooled using random effect models and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Data from a total of 741 patients in 10 randomised controlled trials (RCTs) from 1993 to 2023 were included. Nine trials were open surgery, and one trial was laparoscopic. Relative to intravenous opioids, TEA significantly reduced a composite of PPCs (risk ratio (RR) 3.88; 95% confidence interval (CI) 1.98-7.61; n = 222; 3 RCTs) and pain scores (0-100-mm visual analogue scale or VAS) at rest at 24 h (MD 9.02; 95% CI 5.88-12.17; n = 685; 10 RCTs) and 48 h (MD 8.64; 95% CI 5.91-11.37; n = 685; 10 RCTs) and pain scores on movement at 24 h (MD 14.96; 95% CI 5.46-24.46; n = 275; 4 RCTs) and 48 h (MD 16.60; 95% CI 8.72-24.47; n = 275; 4 RCTs).

CONCLUSIONS

Recent trials of analgesic technique in oesophagectomy surgery are restricted by small sample size and variation of outcome measurement. Despite these limitations, current evidence indicates that thoracic epidural analgesia reduces the risk of PPCs and severe pain, compared to intravenous opioids in patients following oesophageal cancer surgery. Future research should include minimally invasive surgery, non-epidural regional techniques and record morbidity, using core outcome measures with standardised endpoints.

TRIAL REGISTRATION

Prospectively registered on PROSPERO (CRD42023484720).

PPCRKB: a risk factor knowledge base of postoperative pulmonary complications

Postoperative pulmonary complications (PPCs) are highly heterogeneous disorders with diverse risk factors frequently occurring after surgical interventions, resulting in significant financial burdens, prolonged hospitalization and elevated mortality rates. Despite the existence of multiple studies on PPCs, a comprehensive knowledge base that can effectively integrate and visualize the diverse risk factors associated with PPCs is currently lacking. This study aims to develop an online knowledge platform on risk factors for PPCs (Postoperative Pulmonary Complications Risk Factor Knowledge Base, PPCRKB) that categorizes and presents the risk and protective factors associated with PPCs, as well as to facilitate the development of individualized prevention and management strategies for PPCs based on the needs of each investigator. The PPCRKB is a novel knowledge base that encompasses all investigated potential risk factors linked to PPCs, offering users a web-based platform to access these risk factors. The PPCRKB contains 2673 entries, 915 risk factors that have been categorized into 11 distinct groups. These categories include habit and behavior, surgical factors, anesthetic factors, auxiliary examination, environmental factors, clinical status, medicines and treatment, demographic characteristics, psychosocial factors, genetic factors and miscellaneous factors. The PPCRKB holds significant value for PPC research. The inclusion of both quantitative and qualitative data in the PPCRKB enhances the ability to uncover new insights and solutions related to PPCs. It could provide clinicians with a more comprehensive perspective on research related to PPCs in future. Database URL: http://sysbio.org.cn/PPCs.

Effects of individualised lung-protective ventilation with lung dynamic compliance-guided positive end-expiratory pressure titration on postoperative pulmonary complications of paediatric video-assisted thoracoscopic surgery: protocol for a randomised controlled trial

INTRODUCTION

Lung-protective ventilation strategies (LPVS) for one-lung ventilation (OLV) in paediatric patients pose greater challenges than in adults. Optimising LPVS for paediatric OLV to mitigate postoperative pulmonary complications (PPCs) has emerged as a current research focal point. However, there remains a divergence of opinions concerning the individualised setting and application of positive end-expiratory pressure (PEEP). Lung dynamic compliance (Cdyn) can serve as a reflection of the lung's physiological state in children during OLV and is a readily obtainable parameter. This study protocol is formulated to assess the effectiveness of Cdyn-guided PEEP titration on PPCs during paediatric OLV.

METHODS AND ANALYSIS

This study constitutes a single-centre, prospective, double-blind, randomised controlled trial. The trial aims to recruit 60 paediatric patients scheduled for video-assisted thoracoscopic surgery. These eligible patients will be randomly assigned to either the Cdyn-guided PEEP group or the conventional PEEP group during general anaesthesia for OLV. The primary outcome will involve assessing the incidence of PPCs at 7 days after surgery. Secondary outcomes will encompass the evaluation of the modified lung ultrasound score following surgery, as well as monitoring the oxygenation index, driving pressure and Cdyn during mechanical ventilation. Data collection will be performed by investigators who are kept blinded to the interventions.

ETHICS AND DISSEMINATION

The Clinical Trial Ethics Committee at Shenzhen Children's Hospital has conferred ethical approvals for this trial (approval number: 2022076). Results from this trial will be disseminated in peer-reviewed journals and presented at professional symposiums.

TRAIL REGISTRATION NUMBER

NCT05386901.

Risk stratification-based thromboprophylaxis does not affect mortality after fast-track hip and knee arthroplasty

BACKGROUND AND PURPOSE

Use of thromboprophylaxis effectively prevents pulmonary embolism (PE) and deaths after total hip and knee arthroplasty (THA and TKA). The optimum length of thromboprophylaxis is not known and has traditionally been based on the type of operation. Nowadays, a more individualized approach is preferred. This study analyzed if risk stratification-based planning of thromboprophylaxis has an association with the all-cause mortality after fast-track THA and TKA.

PATIENTS AND METHODS

We compared fast-track THAs and TKAs operated between 2015-2016 and 2020-2021. Between 2015 and 2016, all patients received a routine length of thromboprophylaxis. From 2020 onwards, thromboprophylaxis was planned by risk stratification, and patients at low risk for venous thromboembolism received thromboprophylaxis only during hospitalization. All causes of death within 90 days of surgery were identified and the incidence of mortality was calculated. Mortality rates between the two periods were then compared.

RESULTS

Between 2015 and 2016, 3192 arthroplasties were performed. A total of eight deaths occurred within 90 days of surgery, yielding an incidence of all-cause mortality of 0.3% (95% CI 0.1-0.5). Between 2020 and 2021, a total of 3713 arthroplasties were performed to patients who received risk stratification-based thromboprophylaxis. Thirteen of these patients died within 90 days of surgery, yielding an all-cause mortality incidence of 0.4% (95% CI 0.2-0.6). Cardiovascular diseases were the main cause of death during both study periods. None of the deaths were caused by PEs.

INTERPRETATION

Risk stratification-based thromboprophylaxis was not associated with increased all-cause mortality within 90 days of fast-track THA and TKA.

Real-world outcomes of lobectomy, segmentectomy and wedge resection for the treatment of stage c-IA lung carcinoma

OBJECTIVES

To determine safety and survival outcomes associated with lobectomy, segmentectomy and wedge resection for early-stage lung cancer by quiring the French population-based registry EPIdemiology in THORacic surgery (EPITHOR).

METHODS

Retrospective analysis of 19 452 patients with stage c IA lung carcinoma who underwent lobectomy, segmentectomy or wedge resection between 2016 and 2022 with curative-intent. Main outcome measures were 90-day mortality and 5-year overall survival estimates. Proportional hazards regression and propensity score matching were used to adjust outcomes for key patient, tumour and practice environment factors.

RESULTS

The treatment distribution was 72.2% for lobectomy, 21.5% for segmentectomy and 6.3% for wedge. Unadjusted 90-day mortality rates were 1.6%, 1.2% and 1.1%, respectively (P = 0.10). Unadjusted 5-year overall survival estimates were 80%, 78% and 70%, with significant inter-group survival curves differences (P < 0.0001). Multivariable proportional hazards regression showed that wedge was associated with worse overall survival [adjusted hazard ratio (AHR), 1.23 (95% confidence interval 1.03-1.47); P = 0.021] compared with lobectomy, while no significant difference was disclosed when comparing segmentectomy to lobectomy (1.08 [0.97-1.20]; P = 0.162). The three-way propensity score analyses confirmed similar 90-day mortality rate for wedge resection and segmentectomy compared with lobectomy (hazard ratio: 0.43; 95% confidence interval 0.16-1.11; P = 0.081 and 0.99; 0.48-2.10; P = 0.998, respectively), but poorer overall survival (1.45; 1.13-1.86; P = 0.003 and 1.31; 1-1.71; P = 0.048, respectively).

CONCLUSIONS

Wedge resection was associated with comparable 90-day mortality but lower overall survival when compared to lobectomy. Overall, all types of sublobar resections may not offer equivalent oncologic effectiveness in real-world settings.

Predictive modeling for identifying infection risk following spinal surgery: Optimizing patient management

Infection is known to occur in a substantial proportion of patients following spinal surgery and predictive modeling may provide a useful means for identifying those at higher risk of complications and poor prognosis, which could help optimize pre- and postoperative management strategies. The outcome measure of the present study was to investigate the occurrence of all-cause infection during hospitalization following scoliosis surgery. To meet this aim, the present study retrospectively analyzed 370 patients who underwent surgery at the Second Affiliated Hospital, Zhejiang University School of Medicine (Hangzhou, China) between January 2016 and October 2022, and patients who either experienced or did not experience all-cause infection while in hospital were compared in terms of their clinicodemographic characteristics, surgical variables and laboratory test results. Logistic regression was subsequently applied to data from a subset of patients in order to build a model to predict infection, which was validated using another subset of patients. All-cause, in-hospital postoperative infections were found to have occurred in 66/370 patients (17.8%). The following variables were included in a predictive model: Sex, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), diabetes mellitus, hypertension, preoperative levels of white blood cells and preoperative C-reactive protein (CRP) and duration of surgery. The model exhibited an area under the curve of 0.776 against the internal validation set. In conclusion, dynamic nomograms based on sex, ASA classification, BMI, diabetes mellitus, hypertension, preoperative levels of white blood cells and CRP and duration of surgery may have the potential to be a clinically useful predictor of all-cause infection following scoliosis. The predictive model constructed in the present study may potentially facilitate the real-time visualization of risk factors associated with all-cause infection following surgical procedures.

Postoperative intensive care allocation and mortality in high-risk surgical patients: evidence from a low- and middle-income country cohort

BACKGROUND

The escalation of surgeries for high-risk patients in Low- and Middle-Income Countries (LMICs) lacks evidence on the positive impact of Intensive Care Unit (ICU) admission and lacks universal criteria for allocation. This study explores the link between postoperative ICU allocation and mortality in high-risk patients within a LMIC. Additionally, it assesses the Ex-Care risk model's utility in guiding postoperative allocation decisions.

METHODS

A secondary analysis was conducted in a cohort of high-risk surgical patients from a 800-bed university-affiliated teaching hospital in Southern Brazil (July 2017 to January 2020). Inclusion criteria encompassed 1431 inpatients with Ex-Care Model-assessed all-cause postoperative 30-day mortality risk exceeding 5%. The study compared 30-day mortality outcomes between those allocated to the ICU and the Postanesthetic Care Unit (PACU). Outcomes were also assessed based on Ex-Care risk model classes.

RESULTS

Among 1431 high-risk patients, 250 (17.47%) were directed to the ICU, resulting in 28% in-hospital 30-day mortality, compared to 8.9% in the PACU. However, ICU allocation showed no independent effect on mortality (RR = 0.91; 95% CI 0.68‒1.20). Patients in the highest Ex-Care risk class (Class IV) exhibited a substantial association with mortality (RR = 2.11; 95% CI 1.54-2.90) and were more frequently admitted to the ICU (23.3% vs. 13.1%).

CONCLUSION

Patients in the highest Ex-Care risk class and those with complications faced elevated mortality risk, irrespective of allocation. Addressing the unmet need for adaptable postoperative care for high-risk patients outside the ICU is crucial in LMICs. Further research is essential to refine criteria and elucidate the utility of risk assessment tools like the Ex-Care model in assisting allocation decisions.

Postoperative Acute Kidney Injury After Intraoperative Hypotension in Major Risk Procedures

Background Reportedly prevalent, intraoperative hypotension (IOH) is linked to kidney injury and increased risk of mortality. In this study, we aimed to assess IOH incidence in high-risk non-cardiac surgery and its correlation with postoperative acute kidney injury (PO-AKI) and 30-day postoperative mortality. Methodology This retrospective cohort study included adult inpatients who underwent elective, non-cardiac, high-risk European Society of Anaesthesiology/European Society of Cardiology surgery from October to November of 2020, 2021, and 2022, excluding cardiac, intracranial, or emergency surgery. IOH was primarily defined by the 2022 Anesthesia Quality Institute. PO-AKI was defined as an increase in serum creatinine ≥0.3 mg/dL within 48 hours, the need for dialysis in dialysis-naïve patients, or the documentation of AKI in clinical records. For univariate analysis, the Mann-Whitney U test and chi-square or Fisher's exact tests were performed, as appropriate. Logistic regression was used to test risk factors for IOH in univariate analysis (p < 0.1). The significance level considered in multivariate analysis was 5%. Results Of the 197 patients included, 111 (56.3%) experienced IOH. After adjustment, surgical time >120 minutes remained associated with higher odds of IOH (odds ratio (OR) = 9.62, 95% confidence interval (CI) = 2.49-37.13), as well as combined general + locoregional (vs. general OR = 3.41, 95 CI% = 1.38-8.43, p = 0.008; vs. locoregional OR = 6.37, 95% CI = 1.48-27.47). No association was found between IOH and 30-day postoperative mortality (p = 0.565) or PO-AKI (p = 0.09). The incidence of PO-AKI was 14.9% (27 patients), being significantly associated with higher 30-day postoperative mortality (p = 0.018). Conclusions Our study highlights the high prevalence of IOH in high-risk non-cardiac surgical procedures. Its impact on PO-AKI and 30-day postoperative mortality appears less pronounced compared to the significant implications of PO-AKI, emphasizing the need for PO-AKI screening and renal protection strategies.

Incidence and risk factors of pulmonary complications after lung cancer surgery: A systematic review and meta-analysis

Postoperative pulmonary complications (PPCs) are associated with high mortality rates after lung cancer surgery. Although some studies have discussed the different risk factors for PPCs, the relationship between these factors and their impact on PPCs remains unclear. Hence, this study aimed to systematically summarize the incidence and determine the risk factors for PPCs. We conducted a systematic search of five English and four Chinese databases from their inception to April 1, 2023. A total of 34 articles (8 cohort studies and 26 case-control studies) (n = 31696, 5833 with PPCs) were included in the analysis. The primary outcome was the incidence of PPC. The secondary outcome was the odds ratio (OR) of PPCs based on the identified risk factors calculated by RevMan 5.4. A narrative descriptive summary of the study results was presented when pooling the results or conducting a meta-analysis was not possible. The pooled incidence of PPCs was 18.4 %. This meta-analysis demonstrated that TNM staging (OR 4.29, 95 % CI 2.59-7.13), chronic obstructive pulmonary disease (COPD) (OR 2.47, 95 % CI 1.80-3.40), smoking history (OR 2.37, 95 % CI 1.33-4.21), poor compliance with respiratory rehabilitation (OR 1.64, 95 % CI 1.17-2.30), male sex (OR 1.62, 95 % CI 1.28-2.04), diabetes (OR 1.56, 95 % CI 1.07-2.27), intraoperative bleeding volume (OR 1.44, 95 % CI 1.02-2.04), Eastern Cooperative Oncology Group score (ECOG) > 1 (OR 1.37, 95 % CI 1.04-1.80), history of chemotherapy and/or radiotherapy (OR 1.32, 95 % CI 1.03-1.70), older age (OR 1.18, 95 % CI 1.11-1.24), and duration of surgery (OR 1.07, 95 % CI 1.04-1.10) were significantly associated with a higher risk of PPCs. In contrast, the peak expiratory flow rate (PEF) (OR 0.99, 95 % CI 0.98-0.99) was a protective factor. Clinicians should implement targeted and effective interventions to prevent the occurrence of PPCs.

Norepinephrine weaning guided by the Hypotension Prediction Index in vasoplegic shock after cardiac surgery: protocol for a single-centre, open-label randomised controlled trial - the NORAHPI study

INTRODUCTION

Norepinephrine (NE) is the first-line recommended vasopressor for restoring mean arterial pressure (MAP) in vasoplegic syndrome (vs) following cardiac surgery with cardiopulmonary bypass. However, solely focusing on target MAP values can lead to acute hypotension episodes during NE weaning. The Hypotension Prediction Index (HPI) is a machine learning algorithm embedded in the Acumen IQ device, capable of detecting hypotensive episodes before their clinical manifestation. This study evaluates the clinical benefits of an NE weaning strategy guided by the HPI.

MATERIAL AND ANALYSIS

The Norahpi trial is a prospective, open-label, single-centre study that randomises 142 patients. Inclusion criteria encompass adult patients scheduled for on-pump cardiac surgery with postsurgical NE administration for vs patient randomisation occurs once they achieve haemodynamic stability (MAP>65 mm Hg) for at least 4 hours on NE. Patients will be allocated to the intervention group (n=71) or the control group (n=71). In the intervention group, the NE weaning protocol is based on MAP>65 mmHg and HPI<80 and solely on MAP>65 mm Hg in the control group. Successful NE weaning is defined as achieving NE weaning within 72 hours of inclusion. An intention-to-treat analysis will be performed. The primary endpoint will compare the duration of NE administration between the two groups. The secondary endpoints will include the prevalence, frequency and time of arterial hypotensive events monitored by the Acumen IQ device. Additionally, we will assess cumulative diuresis, the total dose of NE, and the number of protocol weaning failures. We also aim to evaluate the occurrence of postoperative complications, the length of stay and all-cause mortality at 30 days.

ETHICS AND DISSEMINATION

Ethical approval has been secured from the Institutional Review Board (IRB) at the University Hospital of Amiens (IRB-ID:2023-A01058-37). The findings will be shared through peer-reviewed publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05922982.

Methadone in combination with magnesium, ketamine, lidocaine, and dexmedetomidine improves postoperative outcomes after coronary artery bypass grafting: an observational multicentre study

BACKGROUND

An optimal pharmacological strategy for fast-track cardiac anesthesia (FTCA) is unclear. This study evaluated the effectiveness and safety of an FTCA program using methadone and non-opioid adjuvant infusions (magnesium, ketamine, lidocaine, and dexmedetomidine) in patients undergoing coronary artery bypass grafting.

METHODS

This retrospective, multicenter observational study was conducted across private and public teaching sectors. We studied patients managed by a fast-track protocol or via usual care according to clinician preference. The primary outcome was the total mechanical ventilation time in hours adjusted for hospital, body mass index, category of surgical urgency, cardiopulmonary bypass time and EuroSCORE II. Secondary outcomes included successful extubation within four postoperative hours, postoperative pain scores, postoperative opioid requirements, and the development of postoperative complications.

RESULTS

We included 87 patients in the fast-track group and 88 patients in the usual care group. Fast-track patients had a 35% reduction in total ventilation hours compared with usual care patients (p = 0.007). Thirty-five (40.2%) fast-track patients were extubated within four hours compared to 10 (11.4%) usual-care patients (odds ratio: 5.2 [95% CI: 2.39-11.08; p < 0.001]). Over 24 h, fast-track patients had less severe pain (p < 0.001) and required less intravenous morphine equivalent (22.00 mg [15.75:32.50] vs. 38.75 mg [20.50:81.75]; p < 0.001). There were no significant differences observed in postoperative complications or length of hospital stay between the groups.

CONCLUSION

Implementing an FTCA protocol using methadone, dexmedetomidine, magnesium, ketamine, lignocaine, and remifentanil together with protocolized weaning from a mechanical ventilation protocol is associated with significantly reduced time to tracheal extubation, improved postoperative analgesia, and reduced opioid use without any adverse safety events. A prospective randomized trial is warranted to further investigate the combined effects of these medications in reducing complications and length of stay in FTCA.

TRIALS REGISTRATION

The study protocol was registered in the Australian New Zealand Clinical Trials Registry ( https://www.anzctr.org.au/ACTRN12623000060640.aspx , retrospectively registered on 17/01/2023).

The exploration of perioperative hypotension subtypes: a prospective, single cohort, observational pilot study

Background

Hypotension is a risk factor for postoperative complications, but evidence from randomized trials does not support that a higher blood pressure target always leads to optimized outcomes. The heterogeneity of underlying hemodynamics during hypotension may contribute to these contradictory results. Exploring the subtypes of hypotension can enable optimal management of intraoperative hypotension.

Methods

This is a prospective, observational pilot study. Patients who were ≥ 45 years old and scheduled to undergo moderate-to-high-risk noncardiac surgery were enrolled in this study. The primary objective of this pilot study was to investigate the frequency and distribution of perioperative hypotension and its subtypes (hypotension with or without cardiac output reduction). The exposure of hypotension and its subtypes in patients with and without myocardial or acute kidney injury were also explored.

Results

Sixty patients were included in the analysis. 83% (50/60) of the patients experienced perioperative hypotension. The median duration of hypotension for each patient was 8.0 [interquartile range, 3.1-23.3] minutes. Reduced cardiac output was present during 77% of the hypotension duration. Patients suffering from postoperative myocardial or acute kidney injury displayed longer duration and more extensive exposure in all hypotension subtypes. However, the percentage of different hypotension subtypes did not differ in patients with or without postoperative myocardial or acute kidney injury.

Conclusion

Perioperative hypotension was frequently accompanied by cardiac output reduction in moderate-to-high-risk noncardiac surgical patients. However, due to the pilot nature of this study, the relationship between hypotension subtypes and postoperative myocardial or acute kidney injury still needs further exploration.

Clinical trial registration

https://www.chictr.org.cn/showprojEN.html?proj=134260, CTR2200055929.

Impact of enhanced recovery program implementation on postoperative outcomes after liver surgery: a monocentric retrospective study

INTRODUCTION

It is still unclear whether enhanced recovery programs (ERPs) reduce postoperative morbidity after liver surgery. This study investigated the effect on liver surgery outcomes of labeling as a reference center for ERP.

MATERIALS AND METHODS

Perioperative data from 75 consecutive patients who underwent hepatectomy in our institution after implementation and labeling of our ERP were retrospectively compared to 75 patients managed before ERP. Length of hospital stay, postoperative complications, and adherence to protocol were examined.

RESULTS

Patient demographics, comorbidities, and intraoperative data were similar in the two groups. Our ERP resulted in shorter length of stay (3 days [1-6] vs. 4 days [2-7.5], p = 0.03) and fewer postoperative complications (24% vs. 45.3%, p = 0.0067). This reduction in postoperative morbidity can be attributed exclusively to a lower rate of minor complications (Clavien-dindo grade < IIIa), and in particular to a lower rate of postoperative ileus, after labeling. (5.3% vs. 25.3%, p = 0.0019). Other medical and surgical complications were not significantly reduced. Adherence to protocol improved after labeling (17 [16-18] vs. 14 [13-16] items, p < 0.001).

CONCLUSIONS

The application of a labeled enhanced recovery program for liver surgery was associated with a significant shortening of hospital stay and a halving of postoperative morbidity, mainly ileus.

Rationale and study design for an Individualized PeriopeRative Open lung VEntilatory approach in Emergency Abdominal Laparotomy/scopy: study protocol for a prospective international randomized controlled trial

BACKGROUND

Postoperative pulmonary complications (PPC) are the most frequent postoperative complications, with an estimated prevalence in elective surgery ranging from 20% in observational cohort studies to 40% in randomized clinical trials. However, the prevalence of PPCs in patients undergoing emergency abdominal surgery is not well defined. Lung-protective ventilation aims to minimize ventilator-induced lung injury and reduce PPCs. The open lung approach (OLA), which combines recruitment manoeuvres (RM) and positive end-expiratory pressure (PEEP) titration, aims to minimize areas of atelectasis and the development of PPCs; however, there is no conclusive evidence in the literature that OLA can prevent PPCs. The purpose of this study is to compare an individualized perioperative OLA with conventional standardized lung-protective ventilation in patients undergoing emergency abdominal surgery with clinical signs of intraoperative lung collapse.

METHODS

Randomized international clinical trial to compare an individualized perioperative OLA (RM plus individualized PEEP and individualized postoperative respiratory support) with conventional lung-protective ventilation (standard PEEP of 5 cmH2O and conventional postoperative oxygen therapy) in patients undergoing emergency abdominal surgery with clinical signs of lung collapse. Patients will be randomised to open-label parallel groups. The primary outcome is any severe PPC during the first 7 postoperative days, including: acute respiratory failure, pneumothorax, weaning failure, acute respiratory distress syndrome, and pulmonary infection. The estimated sample size is 732 patients (366 per group). The final sample size will be readjusted during the interim analysis.

DISCUSSION

The Individualized Perioperative Open-lung Ventilatory Strategy in emergency abdominal laparotomy (iPROVE-EAL) is the first multicentre, randomized, controlled trial to investigate whether an individualized perioperative approach prevents PPCs in patients undergoing emergency surgery.

Surgical Outcomes in Different Age Cohorts Undergoing Abdominal Surgery: A Retrospective Study

PURPOSE

This study aimed to investigate and compare the surgical outcomes of younger and older patients after abdominal surgery and explore risk factors related to postoperative complications and in-hospital mortality in patients ≥65 years old.

DESIGN

A retrospective study on 540 adult patients who underwent abdominal surgery and stayed more than 48 hours in the hospital.

METHODS

The two groups of patients: younger than 65 years and ≥65 years old were compared related to postoperative complications, length of hospital stay, and mortality rates. The cohort of patients aged ≥65 years was selected to analyze risk factors for complications occurrence and in-hospital mortality.

FINDINGS

Patients ≥65 years old had poorer outcomes after abdominal surgery than younger patients. Pre-existence of comorbidities, American Society of Anesthesiologists physical status classification greater than two, emergency admission, and low preoperative serum albumin levels were risk factors for postoperative complications and mortality in elderly patients. Other risk factors for in-hospital mortality were the age ≥75 years, obesity, postoperative serum albumin level less than 30 g/L, presence of anemia before and after surgery, and occurrence of postoperative complications. Logistic regression revealed as independent risk factors for the postoperative complications the American Society of Anesthesiologists' physical status classification greater than two (odds ratio [OR]: 3.05, 95% confidence interval [CI]: 1.63-5.67, P = .0004) and preoperative serum albumin levels lower than 30 g/L (OR: 2.12, 95% CI: 1.08-4.17, P = .02), while for in-hospital postoperative mortality, independent risk factors were postoperative anemia (OR: 4.13; 95% CI: 1.22-13.97, P = .02) and obesity (OR: 7.65, 95% CI: 2.59-22.57, P = .0002).

CONCLUSIONS

Optimizing the preoperative conditions of older patients will improve their postoperative outcomes, especially for patients ≥75 years old, with obesity, comorbidities, anemia, severe nutritional risk, and emergency admission.

Prospective randomized double-blind study to evaluate the superiority of Vasopressin versus Norepinephrine in the management of the patient at renal risk undergoing cardiac surgery with cardiopulmonary bypass (NOVACC trial)

BACKGROUND

Cardiac surgery-associated acute kidney injury (CS-AKI) affects up to 30% of patients, increasing morbidity and healthcare costs. This condition results from complex factors like ischemia-reperfusion injury and renal hemodynamic changes, often exacerbated by surgical procedures. Norepinephrine, commonly used in cardiac surgeries, may heighten the risk of CS-AKI. In contrast, vasopressin, a noncatecholaminergic agent, shows potential in preserving renal function by favorably affecting renal hemodynamic. Preliminary findings, suggest vasopressin could reduce the incidence of CS-AKI compared to norepinephrine. Additionally, vasopressin is linked to a lower incidence of postoperative atrial fibrillation, another factor contributing to longer hospital stays and higher costs. This study hypothesizes that vasopressin could effectively reduce CS-AKI occurrence and severity by optimizing renal perfusion during cardiac surgeries.

STUDY DESIGN

The NOVACC trial (NCT05568160) is a multicenter, randomized, double blinded superiority-controlled trial testing the superiority of vasopressin over norepinephrine in patients scheduled for cardiac surgery with cardiopulmonary bypass (CPB). The primary composite end point is the occurrence of acute kidney injury and death. The secondary end points are neurological, cardiologic, digestive, and vasopressor related complications at day 7, day 30, day 90, hospital and intensive care unit lengths of stay, medico-economic costs at day 90.

CONCLUSION

The NOVACC trial will assess the effectiveness of vasopressin in cardiac surgery with CPB in reducing acute kidney injury, mortality, and medical costs.

CLINICAL TRIAL REGISTRATION

NCT05568160.

Dexmedetomidine Attenuates Inflammation in Elderly Patients Following Major Hepatobiliary and Pancreatic Surgery: A Randomized Clinical Trial

Background

Dexmedetomidine (Dex) may have anti-inflammatory properties and potentially reduce the incidence of postoperative organ injury.

Objective

To investigate whether Dex protects pulmonary and renal function via its anti-inflammatory effects in elderly patients undergoing prolonged major hepatobiliary and pancreatic surgery.

Design and Setting

Between October 2019 and December 2020, this randomized controlled trial was carried out at a tertiary hospital in Chongqing, China.

Patients

86 patients aged 60-75 who underwent long-duration (> 4 hrs) hepatobiliary and pancreatic surgery without significant comorbidities were enrolled and randomly assigned into two groups at a 1:1 ratio.

Interventions

Patients were given either Dex or an equivalent volume of 0.9% saline (Placebo) with a loading dose of 1 μg kg-1 for 10 min, followed by 0.5 μg kg-1 hr-1 for maintenance until the end of surgery.

Main Outcome Measures

The changes in serum concentrations of interleukin-6 (IL-6) and tumour necrosis factor-α (TNF-α) were primary outcomes.

Results

At one hour postoperatively, serum IL-6 displayed a nine-fold increase (P<0.05) in the Placebo group. Administration of Dex decreased IL-6 to 278.09 ± 45.43 pg/mL (95% CI: 187.75 to 368.43) compared to the Placebo group (P=0.019; 432.16 ± 45.43 pg/mL, 95% CI: 341.82 to 522.50). However, no significant differences in TNF-α were observed between the two groups. The incidence of postoperative acute kidney injury was twice as high in the Placebo group (9.30%) compared to the Dex group (4.65%), and the incidence of postoperative acute lung injury was 23.26% in the Dex group, lower than that in the Placebo group (30.23%), although there was no statistical significance between the two groups.

Conclusion

Dex administration in elderly patients undergoing major hepatobiliary and pancreatic surgery reduces inflammation and potentially protects kidneys and lungs.

Registration

Chinese Clinical Trials Registry, identifier: ChiCTR1900024162, on 28 June 2019.

The effect of an intraoperative patient-specific, surgery-specific haemodynamic algorithm in improving textbook outcomes for hepatobiliary-pancreatic surgery: a multicentre retrospective study

Background

The concept of a "textbook outcome" is emerging as a metric for ideal surgical outcomes. We aimed to evaluate the impact of an advanced haemodynamic monitoring (AHDM) algorithm on achieving a textbook outcome in patients undergoing hepatobiliary-pancreatic surgery.

Methods

This retrospective, multicentre observational study was conducted across private and public teaching sectors in Victoria, Australia. We studied patients managed by a patient-specific, surgery-specific haemodynamic algorithm or via usual care. The primary outcome was the effect of using a patient-specific, surgery-specific AHDM algorithm for achieving a textbook outcome, with adjustment using propensity score matching. The textbook outcome criteria were defined according to the International Expert Delphi Consensus on Defining Textbook Outcome in Liver Surgery and Nationwide Analysis of a Novel Quality Measure in Pancreatic Surgery.

Results

Of the 780 weighted cases, 477 (61.2%, 95% CI: 57.7%-64.6%) achieved the textbook outcome. Patients in the AHDM group had a higher rate of textbook outcomes [n = 259 (67.8%)] than those in the Usual care group [n = 218 (54.8%); p < 0.001, estimated odds ratio (95% CI) 1.74 (1.30-2.33)]. The AHDM group had a lower rate of surgery-specific complications, severe complications, and a shorter hospital length of stay (LOS) [OR 2.34 (95% CI: 1.30-4.21), 1.79 (95% CI: 1.12-2.85), and 1.83 (95% CI: 1.35-2.46), respectively]. There was no significant difference between the groups for hospital readmission and mortality.

Conclusions

AHDM use was associated with improved outcomes, supporting its integration in hepatobiliary-pancreatic surgery. Prospective trials are warranted to further evaluate the impact of this AHDM algorithm on achieving a textbook impact on long-term outcomes.

Association between mechanical power during one-lung ventilation and pulmonary complications after thoracoscopic lung resection surgery: a prospective observational study

BACKGROUND

The role of mechanical power on pulmonary outcomes after thoracic surgery with one-lung ventilation was unclear. We investigated the association between mechanical power and postoperative pulmonary complications in patients undergoing thoracoscopic lung resection surgery.

METHODS

In this single-center, prospective observational study, 622 patients scheduled for thoracoscopic lung resection surgery were included. Volume control mode with lung protective ventilation strategies were implemented in all participants. The primary endpoint was a composite of postoperative pulmonary complications during hospital stay. Multivariable logistic regression models were used to evaluate the association between mechanical power and outcomes.

RESULTS

The incidence of pulmonary complications after surgery during hospital stay was 24.6% (150 of 609 patients). The multivariable analysis showed that there was no link between mechanical power and postoperative pulmonary complications.

CONCLUSIONS

In patients undergoing thoracoscopic lung resection with standardized lung-protective ventilation, no association was found between mechanical power and postoperative pulmonary complications.

TRIAL REGISTRATION

Trial registration number: ChiCTR2200058528, date of registration: April 10, 2022.

Predicting the association of different levels of physical activity on postoperative pulmonary complications using the international physical activity questionnaire in patients undergoing thoracoscopic lung surgery under general anaesthesia: protocol for a prospective cohort study

INTRODUCTION

Postoperative pulmonary complications (PPCs) occur frequently in patients undergoing lung surgery under general anaesthesia and are strongly associated with longer postoperative hospital stays and increased mortality. The existing literature has shown that a higher level of preoperative physical activity (PA) plays a positive role in the low incidence of postoperative complications and the quality of life in patients undergoing lung surgery. However, the association between preoperative PA levels and the incidence of PPCs has rarely been studied, particularly in thoracoscopic lung surgery. This study aims to evaluate PA levels in patients undergoing thoracoscopic lung surgery using the International Physical Activity Questionnaire and to investigate the association between PA levels and the incidence of PPCs.

METHODS AND ANALYSIS

A total of 204 participants aged 18-80 years undergoing thoracoscopic lung surgery (thoracoscopic wedge resection, thoracoscopic segmentectomy and thoracoscopic lobectomy) will be included in the study. The primary outcome is the incidence of PPCs within the first 5 postoperative days. The secondary outcomes include the number of PPCs, the incidence of PPCs 1 month postoperatively, the arterial blood levels of inflammatory markers, the incidence of postoperative adverse events within the first 5 postoperative days, extubation time, unplanned admission to the intensive care unit, postoperative length of stay and mortality 1 month postoperatively.

ETHICS AND DISSEMINATION

The study was reviewed and approved by the Research Ethics Committee of the First Affiliated Hospital of Shandong First Medical University on 31 March 2022 (YXLL-KY-2022(014)) and is registered at ClinicalTrials.gov. We plan to disseminate the data and findings of this study in international and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

The trial has been prospectively registered at the clinicaltrials.gov registry (NCT05401253).

Risk factors for postoperative pulmonary complications in elderly patients undergoing video-assisted thoracoscopic surgery lobectomy under general anesthesia: a retrospective study

BACKGROUND

The objective of this study is to identify and evaluate the risk factors associated with the development of postoperative pulmonary complications (PPCs) in elderly patients undergoing video-assisted thoracoscopic surgery lobectomy under general anesthesia.

METHODS

The retrospective study consecutively included elderly patients (≥ 70 years old) who underwent thoracoscopic lobectomy at Xuanwu Hospital of Capital Medical University from January 1, 2018 to August 31, 2023. The demographic characteristics, the preoperative, intraoperative and postoperative parameters were collected and analyzed using multivariate logistic regression to identify the prediction of risk factors for PPCs.

RESULTS

322 patients were included for analysis, and 115 patients (35.7%) developed PPCs. Multifactorial regression analysis showed that ASA ≥ III (P = 0.006, 95% CI: 1.230 ∼ 3.532), duration of one-lung ventilation (P = 0.033, 95% CI: 1.069 ∼ 4.867), smoking (P = 0.027, 95% CI: 1.072 ∼ 3.194) and COPD (P = 0.015, 95% CI: 1.332 ∼ 13.716) are independent risk factors for PPCs after thoracoscopic lobectomy in elderly patients.

CONCLUSION

Risk factors for PPCs are ASA ≥ III, duration of one-lung ventilation, smoking and COPD in elderly patients over 70 years old undergoing thoracoscopic lobectomy. It is necessary to pay special attention to these patients to help optimize the allocation of resources and enhance preventive efforts.

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.

Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study

BACKGROUND

Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours.

METHODS

A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy).

RESULTS

Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001).

CONCLUSION

Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.