Perioperatively Acquired Weakness

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

clinicaltrials.gov NCT03600454.

Anterior Quadratus Lumborum Block and Quadriceps Strength: A Prospective Cohort Study

The decrease in quadriceps strength after anterior quadratus lumborum block (AQLB) has not been quantified. This prospective cohort study investigated the incidence of quadriceps weakness after AQLB. We enrolled patients undergoing robot-assisted partial nephrectomy, and AQLB was performed at the L2 level with 30 mL of 0.375% ropivacaine. We evaluated each quadriceps' maximal voluntary isometric contraction using a handheld dynamometer preoperatively and postoperatively at 1 and 4 days. The incidence of muscle weakness was defined as a 25% reduction in muscle strength compared with the preoperative baseline, and "muscle weakness possibly caused by nerve block" was defined as a 25% reduction compared with the non-block side. We also assessed the numerical rating scale and quality of recovery-15 scores. Thirty participants were analyzed. The incidence of muscle weakness compared with preoperative baseline and the non-block side was 13.3% and 30.0%, respectively. Patients with a numerical rating scale ≥ 4 or quality of recovery-15 score < 122, which was classified as moderate or poor, had decreased muscle strength with relative risks of 1.75 and 2.33, respectively. All patients ambulated within 24 h after surgery. The incidence of quadriceps weakness possibly caused by nerve block was 13.3%; however, all patients could ambulate after 1 day.

Experimental Approach of Quadriceps Strength Measurement: Implications for Assessments in Critically Ill Survivors

(1) Background: The supine testing position is suitable for early quadriceps strength (QS) assessment in intensive care unit, while a seated position is more appropriate for survivors who have regained mobility. Acquiring consistent measurements is essential for longitudinal follow-up. We compared the QS generated in different settings in healthy volunteers. (2) Methods: Isometric QS was assessed using a MicroFet2 and standardised protocols comparing different modalities. Hip and knee flexion angles were, respectively, 45° and 40° (H45-K40) in the supine position, and both at 90° (H90-K90) in the seated position. Dynamometer was either handheld (non-fixed configuration, NFC), or fixed (FC) in a cubicle. (3) Results: QS in H90–K90 and H45-K40 positions were strongly correlated, but QS was higher in the later position regardless of the configuration. Compared to H45-K40, biases of 108.2N (or 28.05%) and 110.3N (27.13%) were observed in H90-K90 position, respectively, in the NFC and FC. These biases were independently and positively associated with QS (p < 0.001). For both position, there were no significant differences between QS measured in NFC or FC. (4) Conclusions: The quadriceps was less efficient in the seated position, compared to the supine position, in healthy volunteers. These findings have practical implications for further assessments and research in critically ill patients.

Pulmonary function decline in immediate postoperative period is not necessarily related to residual neuromuscular block: An observational study

BACKGROUND

Previous studies have reported an association between the use of neuromuscular blocking (NMB) agents and postoperative pulmonary complications. Postoperative pulmonary function is a key indicator for postoperative pulmonary complications. Several sites can be used to assess depth and recovery from NMB.

OBJECTIVES

To investigate postoperative pulmonary function change in relation to train-of-four measurements at the adductor pollicis and corrugator supercilii muscles, and anaesthesia-related variables in orthopaedic patients undergoing hip or knee arthroplasty.

DESIGN

Observational study.

SETTING

University hospital.

PATIENTS

Orthopaedic patients undergoing hip or knee arthroplasty.

MAIN OUTCOME MEASURES

Postoperative pulmonary function tests in the postanaesthesia care unit.

METHODS

Patients scheduled for elective hip or knee arthroplasty received simultaneous corrugator supercilii and adductor pollicis measurements during anaesthesia conducted according to clinical standards. Forced expiratory volume in 1 s and forced vital capacity (FVC) were measured at the time of inclusion and postoperatively on the postanaesthesia care unit. Linear regression analysis was performed for association between risk factors and pulmonary function change.

RESULTS

A total of 35 patients were included. After exclusions, 20 patients remained for final analysis. Corrugator supercilii showed earlier NMB recovery than adductor pollicis. FVC decreased significantly after surgery from 2.9 ± 1.0 to 2.3 ± 1.0 (P < 0.01) and forced expiratory volume in 1 s decreased from 2.3 ± 0.9 to 1.6 ± 0.8 l (P < 0.01). Patient age was the only factor significantly related to FVC decrease after surgery (P = 0.019) with a cut-off value of 65 years.

CONCLUSION

Both corrugator supercilii and adductor pollicis failed to indicate recovery of pulmonary function after NMB. Age seems to be a risk factor for postoperative decline in pulmonary function.

TRIAL REGISTRATION

German Clinical Trials registry, DRKS-ID: DRKS00014305.

Instruments to measure outcomes of post-intensive care syndrome in outpatient care settings - Results of an expert consensus and feasibility field test

Background

There is no consensus on the instruments for diagnosis of post-intensive care syndrome (PICS). We present a proposal for a set of outcome measurement instruments of PICS in outpatient care.

Methods

We conducted a three-round, semi-structured consensus-seeking process with medical experts, followed each by exploratory feasibility investigations with intensive care unit survivors (n₁ = 5; n₂ = 5; n₃ = 7). Fourteen participants from nine stakeholder groups participated in the first and second consensus meeting. In the third consensus meeting, a core group of six clinical researchers refined the final outcome measurement instrument set proposal.

Results

We suggest an outcome measurement instrument set used in a two-step process. First step: Screening with brief tests covering PICS domains of (1) mental health (Patient Health Questionnaire-4 (PHQ-4)), (2) cognition (MiniCog, Animal Naming), (3) physical function (Timed Up-and-Go (TUG), handgrip strength), and (4) health-related quality of life (HRQoL) (EQ-5D-5L). Single items measure subjective health before and after the intensive care unit stay. If patients report new or worsened health problems after intensive care unit discharge and show relevant impairment in at least one of the screening tests, a second extended assessment follows: (1) Mental health (Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder Scale-7 (GAD-7), Impact of Event Scale - revised (IES-R)); (2) cognition (Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), Trail Making Test (TMT) A and B); (3) physical function (2-Minute Walk Test (2-MWT), handgrip strength, Short Physical Performance Battery (SPPB)); and (4) HRQoL (EQ-5D-5L, 12-Item WHO Disability Assessment Schedule (WHODAS 2.0)).

Conclusions

We propose an outcome measurement instrument set used in a two-step measurement of PICS, combining performance-based and patient-reported outcome measures. First-step screening is brief, free-of-charge, and easily applicable by health care professionals across different sectors. If indicated, specialized healthcare providers can perform the extended, second-step assessment. Usage of the first-step screening of our suggested outcome measurement instrument set in outpatient clinics with subsequent transfer to specialists is recommended for all intensive care unit survivors. This may increase awareness and reduce the burden of PICS.

Trial registration

This study was registered at ClinicalTrials.gov (Identifier: NCT04175236; first posted 22 November 2019).

Functional ability and quality of life in critical illness survivors with intensive care unit acquired weakness: A secondary analysis of a randomised controlled trial

Introduction

Intensive care unit acquired weakness (ICUAW) may contribute to functional disability in ICU survivors, yet performance-based data for general ICU patients are lacking. This study explored functional outcomes of (1) and risk factors for (2) weakness at ICU discharge.

Methods

Data from a randomised controlled trial that investigated two early exercise regimes in previously independent, ventilated adults (n = 115) without any significant outcome-differences were used for the present analysis. ICUAW was clinically diagnosed in cooperative participants (n = 83) at ICU discharge with the Medical Research Council sum-score (MRC-SS) using a cut-off <48 for moderate or <36 for severe weakness. Primary outcomes were the 6-Minute Walk Test and Functional Independence Measure at hospital discharge. Secondary outcomes included health-related quality of life after six months. Risk factors during the ICU stay were explored for their effect on MRC-SS with linear regression.

Results

Functional outcomes and length of hospital stay significantly differed in patients with severe, moderate to no weakness (6-Minute Walk test: p = 0.013; 110m [IQR 75–240], 196m [90–324.25], 222.5m [129–378.75], Functional Independence Measure: p = 0.001; 91[IQR 68–101], 113[102.5–118.5], 112[97–123], length of stay after ICU discharge: p = 0.008; 20.9d [IQR 15.83–30.73], 16.86d [13.07–27.10], 11.16d [7.35–19.74]). However, after six months participants had similar values for quality of life regardless of their strength at ICU discharge (Short-Form 36 sum-scores physical health: p = 0.874, mental health: p = 0.908). In-bed immobilisation was the most significant factor associated with weakness at ICU discharge in the regression models (MRC-SS: -24.57(95%CI [-37.03 to -12.11]); p<0.001).

Conclusions

In this general, critically ill cohort, weakness at ICU discharge was associated with short-term functional disability and prolonged hospital length of stay, but not with quality of life, which was equivalent to the values for patients without ICUAW within six months. Immobilisation may be a modifiable risk factor to prevent ICUAW. Prospective trials are needed to validate these results.

Trial registration

German Clinical Trials Register (DRKS) identification number: DRKS00004347, registered on September 10, 2012.

Intraoperative hyperglycemia increases the incidence of postoperative delirium

BACKGROUND

Hyperglycemia frequently occurs during major surgery and is associated with adverse postoperative outcomes. This study aimed to investigate the influence of intraoperative hyperglycemia on incidences of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD).

METHODS

Eighty-seven patients aged ≥65 years undergoing elective surgery were included in this prospective observational subproject of the BioCog study. Blood glucose (BG) levels were measured every 20 minutes intraoperatively. Hyperglycemia was defined as BG levels ≥150 mg·dL-1. Patients were assessed for POD twice daily until postoperative day 7. The occurrence of POCD was determined three months after surgery. Multivariable logistic regression was used to identify associations between hyperglycemia and POD as well as POCD. Secondary endpoints comprised duration of hyperglycemia, maximum glucose level (Glucosemax) and differences between diabetic and non-diabetic patients.

RESULTS

POD occurred in 41 (47.1%), POCD in five (15.2%) patients. In two separate multivariable logistic regression models, hyperglycemia was significantly associated with POD (OR 3.86 [CI 95% 1.13, 39.49], P=0.044) but not POCD (3.59 [NaN, NaN], P=0.157). Relative duration of hyperglycemia was higher in POD patients compared to patients without POD (20 [0; 71] % versus 0 [0; 55] %, P=0.075), whereas the maximum glucose levels during surgery were similar between the two groups. Considering only non-diabetic patients, relative duration of hyperglycemia (P=0.003) and Glucosemax (P=0.015) were significantly higher in patients with POD.

CONCLUSIONS

Intraoperative hyperglycemia was independently associated with POD but not POCD. Relative duration of hyperglycemia appeared thereby to also play a role. Especially hyperglycemic non-diabetic patients might be at high risk for POD.

[Early mobilisation on the intensive care unit : What we know]

BACKGROUND

Early mobilization is defined as intervention within the first 72 h after intensive care unit (ICU) admission. According to the current state of relevant studies, evidence on early mobilization in critically ill patients is still inconsistent. This leads to insecurity in caretakers and subsequently to incomplete implementation in German ICUs.

OBJECTIVES

What type of intervention is suitable for certain patient groups? Which issues remain unresolved?

RESULTS

To obtain best possible outcomes, early mobilization should be initiated during the first 72 h after ICU admission. Implementation of early mobilization improves clinical outcome and should be integrated in a patient-centered bundle (such as ABCDEF). Mechanical ventilation is not a contraindication to intervention. Evidence in neurocritical care as well as functionally dependent patients is still low. Mode of intervention and dosage of early mobilisation remain unclear.

CONCLUSION

Early mobilization is safe and feasible, resulting in improved outcomes in surgical and medical ICU patients. Further studies are necessary to evaluate the optimal dosage and duration of intervention, especially in neurocritical care patients.