Current concepts of perioperative monitoring in high-risk surgical patients: a review

Versatility of Impella® Ventricular Assist Devices in High-risk Cardiac Patients During Complex Procedures: A Case Series

High-risk cardiac patients undergoing complex electrophysiology procedures face potential hemodynamic instability, necessitating effective mechanical circulatory support. The catheter-based Impella® ventricular assist device (Abiomed, Danvers, MA, USA) is crucial to stabilizing hemodynamics by improving the flow of blood from the left ventricle to the aorta. Its automated controller ensures cerebral hemodynamic stability, allowing for bedside adjustments. Herein, we present a case series illustrating the versatility of the Impella® device in managing patients during complex electrophysiology procedures and highlighting its role in mitigating hemodynamic compromise.

Impact of the American Society of Anesthesiologists (ASA) classification on hip fracture surgery outcomes: insights from a retrospective analysis

BACKGROUND

The American Society of Anesthesiologists (ASA) classification is the most used system to assess patient health status before surgery, ranging from I to V levels. This study aims to explore the impact of different ASA risk classes (ASA II [mild risk] and ASA III [severe risk]) on clinical outcomes following hip fracture surgery, including all-cause mortality and postoperative complications.

METHODS

A retrospective analysis from 2019 to 2021 across three Jordanian centers was conducted. The study included patients aged 65 and above who underwent hip fracture repair surgeries. Preoperative measures, intraoperative management protocols, and postoperative care were collected. Clinical data were extracted from electronic medical records, including demographics, fracture type, intraoperative data, and postoperative outcomes.

RESULTS

The analysis included 1033 patients, with 501 (48.5%) in the mild anesthetic risk group (ASA I-II) and 532 (51.5%) in the severe anesthetic risk group (ASA III-V). The mean age was 73 years, with a higher prevalence of males in the severe risk group. Patients in the severe risk group had more comorbidities, higher ICU admissions (15.23% vs. 6.18%), longer hospital stays (median 7 vs. 6 days), and higher rates of postoperative thromboembolic complications (3.39% vs. 1.39%) compared to the mild risk group. Additionally, the severe risk group showed higher mortality rates both in-hospital mortality (3.38% vs. 1.39%) and all-cause mortality (16.92% vs. 10.36%). Multivariate analysis identified higher ASA score as independent risk factors for increased all-cause mortality (HR = 1.64 95%CI 1.51-2.34) and thromboembolic complications (OR = 2.85 95%CI 1.16-7). Length of hospital stay was significantly associated with higher ASA score (OR = 1.04 95%CI 0.96-1.11).

CONCLUSION

The study underscores the significant impact of anesthetic risk on the outcomes of hip fracture surgeries. Patients with higher ASA scores associated with severe systemic diseases may have at increased risk of adverse outcomes.

Comparative Retrospective Assessment of the Effectiveness and Risk Factors of Fluoroquinolones, Cephalosporines, and Selective Antibiotic Prophylaxis for Transrectal Prostate Biopsy

INTRODUCTION

Despite increasing resistance of enterobacteria against fluoroquinolones (FLU), they are still widely used during transrectal prostate biopsy (TRPB). This study was designed to analyse infectious complications and risk factors between FLU, cephalosporines (CEPH) and selective other antibiotics (O-AB) used during TRPB.

METHODS

664 patients were included retrospectively (152 FLU, 452 CEPH and 60 O-AB). Infectious complications were defined as fever >38.0°C, the in-house definition of complicated urinary tract infection (cUTI) (if all applied: fever >38.0°C, leucocytosis >11.000/µL and positive urine dipstick) or postinterventional bacteriuria. Hospitalisation rate, duration and comorbidities were also assessed. χ2 and Fisher's exact test were used for group comparison. Multivariate regression analysis assessed the association of comorbidities with infectious complications.

RESULTS

FLU and CEPH were indifferent regarding infectious complications, however in the O-AB group significantly more common compared to FLU and CEPH (11.6, 13.3, 25%, p < 0.05). Duration of hospital stay in CEPH was significantly shorter compared to FLU and O-AB (4.1 vs. 6.3 vs. 8.2 days, p < 0.05). Arterial hypertension showed increased association with fever (OR 6.002 (1.178; 30.597) p = 0.031) and cUTI (OR 6.006 (1.207; 29.891) p = 0.029).

CONCLUSION

Infectious complications were low and indifferent between FLU and CEPH but significantly more frequent in O-AB. Arterial hypertension was significantly associated with postinterventional fever and cUTI.

Navigating Abdominal Volvulus: A Comprehensive Review of Management Strategies

Abdominal volvulus represents a critical condition characterized by the abnormal twisting of the GI tract, potentially leading to obstruction and vascular compromise. Prompt recognition and appropriate management are essential to prevent complications and improve patient outcomes. This comprehensive review examines the anatomy, pathophysiology, clinical presentation, and diagnostic evaluation of, and management strategies for abdominal volvulus. Non-operative techniques, including detorsion and decompression, as well as surgical interventions, such as laparoscopic and open approaches, are discussed. Additionally, the importance of multidisciplinary collaboration and postoperative care is emphasized. Despite significant advancements, unresolved issues remain, necessitating further research to refine diagnostic and therapeutic approaches. Future directions, including exploring emerging technologies, offer promise for enhancing the management of this challenging condition. Overall, this review provides clinicians with valuable insights into the optimal management of abdominal volvulus, aiming to improve patient outcomes and enhance clinical practice.

A Cross-Sectional Study of Anesthesia Safety in Wad Medani, Sudan: A Pre-war Status Indicating a Post-war Crisis

BACKGROUND

As the surgical burden grows, increasing patient safety during anesthesia and surgery becomes a major global public health priority. Anesthesia can be safely administered in higher-income countries, yet it is more challenging in third-world countries. This study focuses on Sudan, a third-world country, and its unmet anesthetic needs before the current war and how these needs might compromise the post-war status.

AIM

The aim of this study is to compare Sudan's outstanding anesthesia requirements to the World Health Organization's safe anesthesia practice standards in terms of workforce, medications, equipment, and anesthesia conduct.

METHODS

This study was carried out in four hospitals (Wad Medani Teaching Hospital, Wad Medani Maternity Hospital, Gezira Centre for Renal and Urological Surgeries, and the National Centre for Pediatric Surgeries) in Wad Medani, two of which were referral and two were state-run. Each hospital from every category was identified using a convenience sampling technique. The World Health Organization-World Federation of Societies of Anesthesiologists International Standard and earlier regional African publications were used to determine the minimum predicted safe anesthesia needs.

RESULTS

The results of our study demonstrate that overall, the hospitals surveyed fulfilled the minimum standards set by the World Health Organization and the World Federation of Societies of Anesthesiologists (WHO-WFSA) for safe anesthesia practice by 73% with no significant difference in the safety of anesthesia practice between state and referral hospitals.

CONCLUSIONS

The state of safe anesthesia care in Wad Medani hospitals surveyed fell well short of the expected minimal criteria due to important requirements such as patient monitoring indicators, the inaccessibility of life-saving facilities such as defibrillators, and difficult intubation instruments. More importantly, the conduct of anesthesia was far below the standard.

Preoperative admission is non-essential in most patients receiving elective laparoscopic cholecystectomy: A cohort study

We evaluated conventional overnight-stay laparoscopic cholecystectomy, focusing on the preoperative admission day, to assess the feasibility of implementing daycare laparoscopic cholecystectomy, which is currently underutilized in developing and some Asian countries. We retrospectively reviewed elective laparoscopic cholecystectomy data from March 2020 to February 2022 at a 700-bed tertiary hospital in Thailand. Variables included age, sex, body mass index, comorbidities, American Society of Anesthesiologists status, presence of preoperative anesthesiology visit, laparoscopic cholecystectomy indications, additional intraoperative cholangiography, and surgery cancellations. The primary focus was on preoperative treatment and monitoring needs; secondary outcomes included morbidity, mortality within 30 days, and prolonged hospital stay (>48 hours). Statistical analysis was conducted using the Fisher exact test, t-test, and logistic regression. The study included 405 patients. Of these, 65 (16.1%) received preoperative treatment, with 21 unnecessary (over) treatments and six under-treatments. Based on the results, approximately 12.1% (n = 49) of patients may have theoretically required preoperative admission and treatment. Multivariable analysis showed that the increasing of comorbidities was significantly associated with preoperative management (odds ratio [95% Confidence interval]: 7.0 [2.1, 23.1], 23.9 [6.6, 86.6], 105.5 [17.5, 636.6]) for one, two, and three comorbidities, respectively), but factors such as age, obesity, and American Society of Anesthesiologists status were not. The cohort had 4.2% morbidity (2.2% medical complications), with no mortality. Surgery cancellations occurred in 0.5%. In conclusion, on the basis of our data, a small proportion (12.1%) of patients undergoing elective laparoscopic cholecystectomy may require preoperative admissions to receive the necessary treatment, and most (87.9%) preoperative admissions may not provide treatment benefit. The traditional admission approach was safe but required re-evaluation for optimal resource management.

Outpatient compared to inpatient thyroidectomy on 30-day postoperative outcomes: a national propensity matched analysis

BACKGROUND

To address the postoperative outcomes between outpatient and inpatient neck surgery involving thyroidectomy procedures.

METHODS

A cohort analysis of surgical patients undergoing primary, elective, total thyroidectomy from multiple United States medical institutions who were registered with the American College of Surgeons National Surgical Quality Improvement Program from 2015 to 2018. The primary outcome was a composite score that included any 30-day postoperative adverse event.

RESULTS

A total of 55,381 patients who underwent a total thyroidectomy were identified comprising of 14,055 inpatient and 41,326 outpatient procedures. A cohort of 13,496 patients who underwent outpatient surgery were propensity matched for covariates with corresponding number of patients who underwent inpatient thyroidectomies. In the propensity matched cohort, the occurrence of any 30-day after surgery complications were greater in the inpatient group, 424 out of 13,496 (3.1%) compared to the outpatient group, 150 out of 13,496 (1.1%), P < 0.001. Moreover, death rates were greater in the inpatient group, 22 out 13,496 (0.16%) compared to the outpatient group, 2 out of 13,496 (0.01%), P < 0.001. Similarly, hospital readmissions occurred with greater frequency in the inpatient group, 438 out of 13,496 (3.2%) compared to the outpatient group, 310 out of 13,496 (2.3%), P < 0.001.

CONCLUSION

Thyroidectomy procedures performed in the outpatient setting had less rates of adverse events, including serious postoperative complications (e.g., surgical site infection, pneumonia, progressive renal insufficiency). In addition, patients who had thyroidectomy in the outpatient setting had less 30-day readmissions and mortality. Surgeons should recognize the benefits of outpatient thyroidectomy when selecting disposition of patients undergoing neck surgery.

Intraoperative Hypotension Prediction—A Proactive Perioperative Hemodynamic Management—A Literature Review

Intraoperative hypotension (IH) is a frequent phenomenon affecting a substantial number of patients undergoing general anesthesia. The occurrence of IH is related to significant perioperative complications, including kidney failure, myocardial injury, and even increased mortality. Despite advanced hemodynamic monitoring and protocols utilizing goal directed therapy, our management is still reactive; we intervene when the episode of hypotension has already occurred. This literature review evaluated the Hypotension Prediction Index (HPI), which is designed to predict and reduce the incidence of IH. The HPI algorithm is based on a machine learning algorithm that analyzes the arterial pressure waveform as an input and the occurrence of hypotension with MAP <65 mmHg for at least 1 min as an output. There are several studies, both retrospective and prospective, showing a significant reduction in IH episodes with the use of the HPI algorithm. However, the level of evidence on the use of HPI remains very low, and further studies are needed to show the benefits of this algorithm on perioperative outcomes.

Hemodynamic Instability during Surgery for Pheochromocytoma: A Retrospective Cohort Analysis

BACKGROUND

Perioperative hemodynamic instability is one of the most common adverse events in patients undergoing adrenalectomy for pheochromocytoma. The aim of this study was to analyze the impact of perioperative severe hemodynamic instability.

METHODS

We present a retrospective, single-center analysis in a major tertiary hospital of all consecutive patients undergoing elective adrenalectomy from 2005 to 2019 for pheochromocytoma. Severe perioperative hypertension and hypotension were evaluated, defined as changes in blood pressure larger than 30% of the preoperative patient-specific mean arterial pressure (MAP).

RESULTS

Unilateral adrenalectomy was performed in 67 patients. Intraoperative episodes of hemodynamic instability occurred in 97% of all patients (n = 65), severe hypertension occurred in 24 patients (36%), and severe hypotensive episodes occurred in 62 patients (93%). Patients with more than five severe hypotensive episodes (n = 29) received higher preoperative alpha-adrenergic blockades (phenoxybenzamine 51 ± 50 mg d^-1 vs. 29 ± 27 mg d^-1; p = 0.023) and had a longer mean ICU stay (39.6 ± 41.5 h vs. 20.6 ± 19.1 h, p = 0.015).

CONCLUSION

Intraoperative hypotensive, rather than hypertensive, episodes occurred during adrenalectomy. The occurrence of more than five hypotensive episodes correlated well with a significantly longer hospital stay and ICU time.

Continuous non-invasive remote automated blood pressure monitoring with novel wearable technology: A Validation Study

Background

Wearable continuous monitoring biosensor technologies have the potential to transform postoperative care with early detection of impending clinical deterioration.

Objective

Our aim was to validate the accuracy of Cloud DX Vitaliti continuous vital signs monitor (CVSM) continuous noninvasive blood pressure (cNIBP) measurements in postsurgical patients. A secondary aim was to examine user acceptance of the Vitaliti CVSM with respect to comfort, ease of application, sustainability of positioning, and aesthetics.

Methods

Included participants were ≥18 years old and recovering from surgery in a cardiac intensive care unit (ICU). We targeted a maximum recruitment of 80 participants for verification and acceptance testing. We also oversampled to minimize the effect of unforeseen interruptions and other challenges to the study. Validation procedures were according to the International Standards Organization (ISO) 81060-2:2018 standards for wearable, cuffless blood pressure (BP) measuring devices. Baseline BP was determined from the gold-standard ICU arterial catheter. The Vitaliti CVSM was calibrated against the reference arterial catheter. In static (seated in bed) and supine positions, 3 cNIBP measurements, each 30 seconds, were taken for each patient with the Vitaliti CVSM and an invasive arterial catheter. At the conclusion of each test session, captured cNIBP measurements were extracted using MediCollector BEDSIDE data extraction software, and Vitaliti CVSM measurements were extracted to a secure laptop through a cable connection. The errors of these determinations were calculated. Participants were interviewed about device acceptability.

Results

The validation analysis included data for 20 patients. The average times from calibration to first measurement in the static position and to first measurement in the supine position were 133.85 seconds (2 minutes 14 seconds) and 535.15 seconds (8 minutes 55 seconds), respectively. The overall mean errors of determination for the static position were –0.621 (SD 4.640) mm Hg for systolic blood pressure (SBP) and 0.457 (SD 1.675) mm Hg for diastolic blood pressure (DBP). Errors of determination were slightly higher for the supine position, at 2.722 (SD 5.207) mm Hg for SBP and 2.650 (SD 3.221) mm Hg for DBP. The majority rated the Vitaliti CVSM as comfortable. This study was limited to evaluation of the device during a very short validation period after calibration (ie, that commenced within 2 minutes after calibration and lasted for a short duration of time).

Conclusions

We found that the Cloud DX’s Vitaliti CVSM demonstrated cNIBP measurement in compliance with ISO 81060-2:2018 standards in the context of evaluation that commenced within 2 minutes of device calibration; this device was also well-received by patients in a postsurgical ICU setting. Future studies will examine the accuracy of the Vitaliti CVSM in ambulatory contexts, with attention to assessment over a longer duration and the impact of excessive patient motion on data artifacts and signal quality.

Trial Registration

ClinicalTrials.gov NCT03493867; https://clinicaltrials.gov/ct2/show/NCT03493867

The current state of anesthesia safety in a third world country: a cross-sectional survey among anesthesia providers in Ethiopia

BACKGROUND

Improving patient safety during anesthesia and surgery becomes a major global public health issue due to the increasing in surgical burden. Anesthesia is delivered safely in developed countries, but its safety is hampered by complex problems in third world countries. This survey assesses the unmet anesthesia needs of one of a third world country, Ethiopia.

METHODS

A cross-sectional survey was conducted in Amhara region of Ethiopia from 15/12/2019 to 30/1/2020. All 81 hospitals of the region were stratified by their level as district, general, and referral hospital. The study was conducted in 66 hospitals. The number of hospitals from each strata were calculated by proportional sampling technique resulting; five referral, three general, and fifty eight primary hospitals. Each hospital from each strata was selected by convenience. Each anesthesia provider for the survey was selected randomly from each hospital and questionnaires were distributed. The minimum expected safe anesthesia requirements were taken from World Health Organization-World Federation of Societies of Anesthesiologists International Standard and Ethiopian Hospitals Standard. Anesthesia practice was expected safe if the minimum requirements were practiced always (100%) in each hospital. P < 0.05 with 95% confidence interval were used to compare the safety of anesthesia between higher and lower level hospitals.

RESULTS

Seventy eight (88.6%) anesthesia providers working in 62 hospitals responded to the survey. On aggregate, 36 (58%) hospitals from the total 62 hospitals have met the minimum expected safe anesthesia requirements. Among the different variables assessed; professional aspects 32 (52.45%), medication and intravenous fluid 33 (53.36%), equipment and facilities 33 (52.56%), patient monitoring 43(68.88%), and anesthesia conduct 38 (62.1%) of surveyed hospitals have met the minimum requirements. Anesthesia safety is relatively higher in higher level hospitals (general and referral) 6 (75%) when compared to district hospitals 30 (55.5%), P < 0.001.

CONCLUSION

Anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. Patient monitoring and anesthesia conduct are relatively good, but World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.

Performance of the Parasympathetic Tone Activity (PTA) index to assess the intraoperative nociception using different premedication drugs in anaesthetised dogs

The dynamic variations of the Parasympathetic Tone Activity (PTA) index were evaluated to assess nociception in dogs undergoing anaesthetic protocols with different premedication drugs. Sixty-six dogs, divided into three groups of 22 dogs each, were given different premedication drugs “morphine” (0.2 mg/kg), “morphine + medetomidine (5 μg/kg)”, “morphine + acepromazine (0.03 mg/kg)”, then similarly induced and maintained under general anaesthesia. The PTA, HR (heart rate) and MAP (mean arterial pressure) were assessed at S (steady-state), Cut (cutaneous incision), PTA_E (PTA Event, assessed 1 min before a significant PTA decrease), HDR (Haemodynamic reaction, assessed 5 min before an increase of ≥ 20% in HR and/or MAP). For each group, the dynamic variation of PTA (ΔPTA) was calculated and a Receiver Operating Characteristics (ROC) curve was performed to detect if any of the premedication drugs may alter the performance of PTA index to predict intraoperative haemodynamic reactions. In all groups, a haemodynamic reaction was detected after Cut, PTA_E and HDR and was preceded with a significant decrease of PTA, except for “morphine + medetomidine” group which showed a significant drop of PTA only at PTA_E and HDR. The ΔPTA showed a fair performance in all groups (a mean [95% CI] AUC of 0.73 [0.62–0.82], 0.70 [0.59–0.79] and 0.71 [0.59–0.80] respectively in morphine, morphine + ACP and morphine + medetomidine). Although ΔPTA was rather altered by the premedication drug, it was able to predict, to a certain extent, haemodynamic reactions in all groups.