Successful fast track protocol implementation for patients undergoing transapical transcatheter aortic valve implantation

The Influence of Audiovisual Distraction on Pain Reduction During Transcatheter Aortic Valve Implantation Under Monitored Anesthesia Care: A Prospective Randomized Trial

OBJECTIVES

To investigate the effect of an audiovisual distraction system on the dose of remifentanil for perioperative sedation during transcatheter aortic valve implantation under monitored anesthesia care.

DESIGN

Single-center prospective randomized nonblinded study.

SETTING

Tertiary referral academic hospital.

PARTICIPANTS

Ninety patients who underwent transfemoral transcatheter aortic valve implantation between July 2019 and July 2021.

INTERVENTIONS

Patients were randomized to use either a novel audiovisual distraction system during the intervention (n = 45) or standard care without an audiovisual distraction system (n = 45).

MEASUREMENTS AND MAIN RESULTS

Standardized questionnaires were given to each patient at admission and before and after the intervention to assess their levels of anxiety. Primary endpoints were the average and peak infusion rates of remifentanil. All patients were considered for the final analysis according to an intention-to-treat design. No relevant differences in pre- and postinterventional anxiety status were observed between the groups. Similarly, there were no significant differences in reported pain scores (p = 0.364). The average infusion rate (p = 0.028) and peak infusion rate (p = 0.025) of remifentanil were lower in the group with an audiovisual distraction system.

CONCLUSIONS

Audiovisual distraction is a useful adjunct to reduce the dose of remifentanil under monitored anesthesia care during transcatheter aortic valve implantation. Larger studies are needed to evaluate potential positive effects on patient satisfaction, incidence of delirium, and possible economic benefits.

On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery

OBJECTIVES

Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery.

METHODS

Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home.

RESULTS

Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7.

CONCLUSIONS

Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.

Indicators and predictors modifiable by the nursing department during the preoperative period: A scoping review

AIM AND OBJECTIVES

The aim of this study is to identify preoperative indicators and/or predictors of complications or inefficiencies in the surgical process that can be modified within nursing practice.

BACKGROUND

Due to rapid sociodemographic and technological change, the global demand for surgical attention is rising exponentially, requiring new strategies for optimisation and sustainability in perioperative care.

DESIGN

We conduced the scoping review using the methodology recommended by the Joanna Briggs Institute supported with The PAGER framework and guided by the PRISMA-ScR Checklist.

METHODS

Four databases (CINAHL, MEDLINE, SCOPUS and PUBMED) were examined to extract relevant published results for elective surgery on adult patients during the period 2011-2021. This process identified 609 records. Exclusion criteria were applied, and the sample was then evaluated with the Quality Assessment Tool for Studies with Diverse Designs (QATSDD), after which 15 studies remained.

RESULTS

The following preoperative indicators and/or predictors were considered: (1) Anxiety; (2) Pain; (3) Health education, knowledge and training; (4) Satisfaction; (5) Management/organisation (including costs, resources used/available, organisational issues, hospital stay (preoperative), standardisation and protocolisation.

CONCLUSION

The identification of five indicators and/or predictors of complications or inefficiencies in the surgical process, which can be modified by nursing, allows the effective application of interventions in the preoperative phase, optimising care and improving health outcomes.

RELEVANCE TO CLINICAL PRACTICE

The development and implementation of specific nursing skills in the preoperative phase are essential to optimise the surgical process.

Comparison effects of two muscle relaxant strategies on postoperative pulmonary complications in transapical transcatheter aortic valve implantation: a propensity score-matched analysis

BACKGROUND

Prior studies have reported conflicting results on the effect of sugammadex on postoperative pulmonary complications (PPCs) and research on this topic in transapical-transcatheter aortic valve implantation (TA-TAVI) was sparse. The current study aimed to investigate whether there were differences in the incidence of PPCs between two muscle relaxant strategies (rocuronium/sugammadex vs. cisatracurium/neostigmine) in patients undergoing TA-TAVI.

METHODS

This retrospective observational study enrolled 245 adult patients underwent TA-TAVI between October 2018 and January 2021. The patients were grouped according to the type of muscle relaxant strategies (115 with rocuronium/sugammadex in the R/S group and 130 with cisatracurium/neostigmine in the C/N group, respectively). Pre- and intraoperative variables were managed by propensity score match (PSM) at a 1:2 ratio. PPCs (i.e., respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm and aspiration pneumonitis) were evaluated from the radiological and laboratory findings.

RESULTS

After PSM, 91 patients in the R/S group were selected and matched to 112 patients in the C/N group. Patients in the R/S group showed lower PPCs rate (45.1% vs. 61.6%, p = 0.019) compared to the C/N group. In addition, the R/S group showed significant shorter extubation time (7.2 ± 6.2 vs. 10.3 ± 8.2 min, p = 0.003) and length of hospital stay (6.9 ± 3.3 vs. 8.0 ± 4.0 days, p = 0.034).

CONCLUSION

The rocuronium/sugammadex muscle relaxant strategy decreases the incidence of PPCs in patients undergoing TA-TAVI when compared to cisatracurium/neostigmine strategy. Trial registration ChiCTR, ChiCTR2100044269. Registered March 14, 2021-Prospectively registered, http://www.Chictr.org.cn .

Extubation in the Operating Room After Transapical Transcatheter Aortic Valve Implantation Safely Improves Time-Related Outcomes and Lowers Costs: A Propensity Score-Matched Analysis

OBJECTIVE

The experience of safe extubation in the operating room (OR) after transcatheter aortic valve implantation (TAVI) procedure remains not well established. The authors conducted this study to assess the effect of OR extubation in comparison with extubation in the intensive care unit (ICU) on the outcomes and cost in patients undergoing transapical-TAVI.

DESIGN

A propensity score-matched analysis.

SETTING

A single major urban teaching and university hospital.

PARTICIPANTS

A total of 266 patients undergoing transapical TAVI under general anesthesia between June 2015 and March 2020.

INTERVENTIONS

Propensity matching on pre- and intraoperative variables was used to identify 99 patients undergoing extubation in the OR versus 72 undergoing extubation in the ICU for outcome analysis.

MEASUREMENTS AND MAIN RESULTS

After matching, extubation in the OR showed significant reductions of length of stay (LOS) in ICU (38.8 ± 17.4 v 58.0 ± 70.0 h, difference -19.2, 95% confidence interval [CI] -35.7 to -2.7, p = 0.009) and postoperative LOS in hospital (7.1 ± 3.9 v 10.1 ± 4.6 d, difference -3.0, 95% CI -4.3 to -1.7, p < 0.0001) compared with ICU extubation, but did not significantly affect the composite incidence of any postoperative complications (46.5% [46 of 99] v 52.8% [38 of 72], difference -6.3%, 95% CI -21.5 to 8.9, p = 0.415). Also, extubation in the OR led to significant reduction of total hospital cost compared with extubation in the ICU (¥303.5 ± 17.3 v ¥329.9 ± 52.3 thousand, difference -26.2, 95% CI -38.8 to -13.7, p < 0.0001).

CONCLUSIONS

The current study provided evidence that extubation in the OR could be performed safely without increases in morbidity, mortality, or reintubation rate and could provide cost-effective outcome benefits in patients undergoing transapical-TAVI.