Epidemiology of perioperative RV dysfunction: risk factors, incidence, and clinical implications

In this edition of the journal, the Perioperative Quality Initiative (POQI) present three manuscripts describing the physiology, assessment, and management of right ventricular dysfunction (RVD) as pertains to the perioperative setting. This narrative review seeks to provide context for these manuscripts, discussing the epidemiology of perioperative RVD focussing on definition, risk factors, and clinical implications. Throughout the perioperative period, there are many potential risk factors/insults predisposing to perioperative RVD including pre-existing RVD, fluid overload, myocardial ischaemia, pulmonary embolism, lung injury, mechanical ventilation, hypoxia and hypercarbia, lung resection, medullary reaming and cement implantation, cardiac surgery, cardiopulmonary bypass, heart and lung transplantation, and left ventricular assist device implantation. There has however been little systematic attempt to quantify the incidence of perioperative RVD. What limited data exists has assessed perioperative RVD using echocardiography, cardiovascular magnetic resonance, and pulmonary artery catheterisation but is beset by challenges resulting from the inconsistencies in RVD definitions. Alongside differences in patient and surgical risk profile, this leads to wide variation in the incidence estimate. Data concerning the clinical implications of perioperative RVD is even more scarce, though there is evidence to suggest RVD is associated with atrial arrhythmias and prolonged length of critical care stay following thoracic surgery, increased need for inotropic support in revision orthopaedic surgery, and increased critical care requirement and mortality following cardiac surgery. Acute manifestations of RVD result from low cardiac output or systemic venous congestion, which are non-specific to the diagnosis of RVD. As such, RVD is easily overlooked, and the relative contribution of RV dysfunction to postoperative morbidity is likely to be underestimated.We applaud the POQI group for highlighting this important condition. There is undoubtedly a need for further study of the RV in the perioperative period in addition to solutions for perioperative risk prediction and management strategies. There is much to understand, study, and trial in this area, but importantly for our patients, we are increasingly recognising the importance of these uncertainties.

A multicentre survey investigating the knowledge, behaviour, and attitudes of surgical healthcare professionals to frailty assessment in emergency surgery: DEFINE(surgery)

PURPOSE

Screening for frailty in people admitted with emergency surgical pathology can initiate timely referrals to enhanced perioperative services such as intensive care and geriatric medicine. However, there has been little research exploring surgical healthcare professionals' opinions to frailty assessment, or accuracy in identification. This study aimed to assess the knowledge, behaviour, and attitudes of healthcare professionals to frailty assessment in emergency surgical admissions.

METHODS

We designed a cross-sectional multicentre study developed by a multiprofessional team of surgeons, geriatricians, and supported by patients. A semi-structured survey examined attitudes and behaviours. Knowledge was assessed by comparing respondents' accuracy in scoring twenty-two surgical case vignettes using the Clinical Frailty Scale.

RESULTS

Eleven hospitals across England, Wales, and Scotland participated. Two hundred and eleven clinicians responded-20.4% junior doctors, 43.6% middle grade doctors, 24.2% senior doctors, 11.4% nurses and physician associates. Respondents strongly supported perioperative frailty assessment. Most were already assessing for frailty, although frequently not using a standardised tool. There was a strong call for more frailty education. Participants scored 2175 vignettes with 55.4% accurately meeting the gold standard; accuracy improved to 87.3% when categorised into "not frail/mildly frail/severely frail" and 94% when dichotomised to "not frail/frail".

CONCLUSION

Frailty assessment is well supported by healthcare professionals working in surgery. However, standardised tools are not routinely being used, and only half of respondents could accurately identify frailty. Better education around frailty assessment is needed for healthcare professionals working in surgery to improve perioperative pathway for people living with frailty.

Knowledge-based, computerized, patient clinical decision support system for perioperative pain, nausea and constipation management: a clinical feasibility study

Opioid administration is particularly challenging in the perioperative period. Computerized-based Clinical Decision Support Systems (CDSS) are a promising innovation that might improve perioperative pain control. We report the development and feasibility validation of a knowledge-based CDSS aiming at optimizing the management of perioperative pain, postoperative nausea and vomiting (PONV), and laxative medications. This novel CDSS uses patient adaptive testing through a smartphone display, literature-based rules, and individual medical prescriptions to produce direct medical advice for the patient user. Our objective was to test the feasibility of the clinical use of our CDSS in the perioperative setting. This was a prospective single arm, single center, cohort study conducted in Strasbourg University Hospital. The primary outcome was the agreement between the recommendation provided by the experimental device and the recommendation provided by study personnel who interpreted the same care algorithm (control). Thirty-seven patients were included in the study of which 30 (81%) used the experimental device. Agreement between these two care recommendations (computer driven vs. clinician driven) was observed in 51 out 54 uses of the device (94.2% [95% CI 85.9-98.4%]). The agreement level had a probability of 86.6% to exceed the 90% clinically relevant agreement threshold. The knowledge-based, patient CDSS we developed was feasible at providing recommendations for the treatment of pain, PONV and constipation in a perioperative clinical setting.Trial registration number & date The study protocol was registered in ClinicalTrial.gov before enrollment began (NCT05707247 on January 26th, 2023).

Accuracy and clinical utility of heart rate variability derived from a wearable heart rate monitor in patients undergoing major abdominal surgery

Low heart rate variability (HRV) can potentially identify patients at risk of intraoperative hypotension. However, it is unclear whether cheaper, readily accessible consumer heart rate (HR) monitors can provide similar utility to clinical Holter electrocardiograph (ECG) monitors. The objectives of this study were (1) to assess the validity of using the Polar H10 HR monitor as an alternative to a clinical Holter ECG and (2) to test total power (TP) as a predictor of intraoperative hypotension. The primary outcome was the level of agreement between Polar H10 and Holter ECG. Twenty-three patients undergoing major abdominal surgery with general anesthesia had 5-minute HR recordings taken concurrently with both devices during a pre-anesthetic consultation. Agreement between Polar H10 and Holter ECG was compared via Bland-Altman analysis and Lin's Concordance Correlation Coefficient. Patients were divided into groups based on TP <  500 m s 2 and TP >  500 m s 2 . Intraoperative hypotension was defined as MAP < 60 mmHg, systolic blood pressure < 80 mmHg, or 35% decrease in MAP from baseline. There was substantial agreement between Polar H10 and Holter ECG for average R-R interval, TP and other HRV indices. Reduced TP (< 500 ms 2 ) had a high sensitivity (80%) and specificity (100%) in predicting intraoperative hypotension. Patients with reduced TP were significantly more likely to require vasoactive drugs to maintain blood pressure.The substantial agreement between Polar H10 and Holter ECG may justify its use clinically. The use of preoperative recordings of HRV has the potential to become part of routine preoperative assessment as a useful screening tool to predict hemodynamic instability in patients undergoing general anesthesia.

Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review

"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design.

Funding

None.

Wearable devices for postoperative monitoring in surgical ward and the chain of liability

Perioperative medicine is undergoing many changes with the introduction of new technologies. Wearable devices are among them. These novel tools are providing an additional possibility for perioperative monitoring. However, in order to ensure that the introduction of wearable device in surgical wards does not lead to additional challenges for healthcare professionals, a careful implementation plan should be drawn up by a multidisciplinary team. In addition, a chain of liability should also be established a priori to facilitate their use and avoid ambiguity in the occurrence of a critical event.

Value-Based Health Care in Perioperative Medicine: Process Maps and Costing to Determine Best Practices

Perioperative care in the United States is largely based on current fee-for-service models. Fee-for-service models are not based on the true cost of services provided, charges do not equal costs, and reimbursement varies based on insurer. Value-based health care is defined as patient-centered outcomes over cost of providing these services. Process mapping and time-driven activity-based costing can be used to define actual cost of services provided. Outcomes after discharge can be measured, so that the overall value of care provided can be assessed and improved based on the outcomes and costs identified.

Preoperative Patient Evaluation: Newer Hypoglycemic Agents

New medications in the treatment of diabetes are an active area of research and drug development. Although many hypoglycemic therapies have been in use for decades, new evidence continues to emerge highlighting benefits of these medications for other indications. In this article, the authors review the classes of newer hypoglycemic agents and summarize medications currently in phase 2 and 3 clinical trials. The literature to support specific recommendations for perioperative management is scant, however, where it exists, we have included it. In other instances, the authors have noted a reasonable approach based on pharmacokinetics and principles of perioperative medication management.

Pregnancy reference intervals and exertion and breathlessness ratings for the six minute walk test in healthy nulliparous people

Background

The Six Minute Walk Test (6MWT) is a simple, non-invasive, well-validated test that assesses cardiorespiratory fitness however is rarely used in pregnant people. It may have clinical utilization to assess fitness, breathing and exertion in pregnancy however no reference intervals exist for people 14+0 to 35+6 weeks gestation. We determined the reference intervals for distance walked for the 6MWT, including exertional and breathlessness ratings for this group.

Method

We conducted a prospective observational cohort study of 196 healthy nulliparous pregnant people in earlier pregnancy (EP) 14+0 to 23+6 weeks, and middle pregnancy (MP) 24+0 to 35+6 gestation, who performed a standardized 6MWT protocol including rating exertion and breathlessness (Rating Perceived Exertion (RPE) scale (1 none -15 maximal) and Modified Borg Dyspnea (MBD) scale (0 none - 10 maximal)).

Results

The mean ± SD distance walked was 548 ± 80.9 (EP) versus 547 ± 87.3 (MP) meters (m) P = 0.928. 6MWT reference intervals for the distance walked for the 6MWT were 392-704 m (EP) and 376-718 m (MP). Median (IQR) exertion and breathlessness ratings with exercise for the EP and MP group were 6 (4,7) and 0.5 (0,1) and 6 (4,8) and 0.5 (0,1) respectively. There were no adverse events.

Conclusion

The 6MWT is safe, feasible and acceptable in pregnant people. The reference intervals for the 6MWT are 392-704 m in people 14+0 to 23+6 weeks gestation and 376-718 m for people 24+0 to 35+6 weeks gestation. Exertion was light and breathlessness was just noticeable with the 6MWT.

Randomized controlled trial of the effect of general anesthetics on postoperative recovery after minimally invasive nephrectomy

BACKGROUND

General anesthetic techniques can affect postoperative recovery. We compared the effect of propofol-based total intravenous anesthesia (TIVA) and desflurane anesthesia on postoperative recovery.

METHODS

In this randomized trial, 150 patients undergoing robot-assisted or laparoscopic nephrectomy for renal cancer were randomly allocated to either the TIVA or desflurane anesthesia (DES) group. Postoperative recovery was evaluated using the Korean version of the Quality of Recovery-15 questionnaire (QoR-15K) at 24 h, 48 h, and 72 h postoperatively. A generalized estimating equation (GEE) was performed to analyze longitudinal QoR-15K data. Fentanyl consumption, pain severity, postoperative nausea and vomiting, and quality of life three weeks after discharge were also compared.

RESULTS

Data were analyzed for 70 patients in each group. The TIVA group showed significantly higher QoR-15K scores at 24 and 48 h postoperatively (24 h: DES, 96 [77, 109] vs. TIVA, 104 [82, 117], median difference 8 [95% CI: 1, 15], P = 0.029; 48 h: 110 [95, 128] vs. 125 [109, 130], median difference 8 [95% CI: 1, 15], P = 0.022), however not at 72 h (P = 0.400). The GEE revealed significant effects of group (adjusted mean difference 6.2, 95% CI: 0.39, 12.1, P = 0.037) and time (P < 0.001) on postoperative QoR-15K scores without group-time interaction (P = 0.051). However, there were no significant differences in other outcomes, except for fentanyl consumption, within the first 24 h postoperatively.

CONCLUSIONS

Propofol-based TIVA showed only a transient improvement in postoperative recovery than desflurane anesthesia, without significant differences in other outcomes.

American society of anesthesiologists physical status classification significantly affects the performances of machine learning models in intraoperative hypotension inference

STUDY OBJECTIVE

To explore how American Society of Anesthesiologists (ASA) physical status classification affects different machine learning models in hypotension prediction and whether the prediction uncertainty could be quantified.

DESIGN

Observational Studies SETTING: UofL health hospital PATIENTS: This study involved 562 hysterectomy surgeries performed on patients (≥ 18 years) between June 2020 and July 2021.

INTERVENTIONS

None MEASUREMENTS: Preoperative and intraoperative data is collected. Three parametric machine learning models, including Bayesian generalized linear model (BGLM), Bayesian neural network (BNN), a newly proposed BNN with multivariate mixed responses (BNNMR), and one nonparametric model, Gaussian Process (GP), were explored to predict patients' diastolic and systolic blood pressures (continuous responses) and patients' hypotensive event (binary response) for the next five minutes. Data was separated into American Society of Anesthesiologists (ASA) physical status class 1- 4 before being read in by four machine learning models. Statistical analysis and models' constructions are performed in Python. Sensitivity, specificity, and the confidence/credible intervals were used to evaluate the prediction performance of each model for each ASA physical status class.

MAIN RESULTS

ASA physical status classes require distinct models to accurately predict intraoperative blood pressures and hypotensive events. Overall, high sensitivity (above 0.85) and low uncertainty can be achieved by all models for ASA class 4 patients. In contrast, models trained without controlling ASA classes yielded lower sensitivity (below 0.5) and larger uncertainty. Particularly, in terms of predicting binary hypotensive event, for ASA physical status class 1, BNNMR yields the highest sensitivity of 1. For classes 2 and 3, BNN has the highest sensitivity of 0.429 and 0.415, respectively. For class 4, BNNMR and GP are tied with the highest sensitivity of 0.857. On the other hand, the sensitivity is just 0.031, 0.429, 0.165 and 0.305 for BNNMR, BNN, GBLM and GP models respectively, when training data is not divided by ASA physical status classes. In terms of predicting systolic blood pressure, the GP regression yields the lowest root mean squared errors (RMSE) of 2.072, 7.539, 9.214 and 0.295 for ASA physical status classes 1, 2, 3 and 4, respectively, but a RMSE of 126.894 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. RMSEs are 2.175, 13.861, 17.560 and 22.426 for classes 1, 2, 3 and 4 respectively for the BGLM. In terms of predicting diastolic blood pressure, the GP regression yields the lowest RMSEs of 2.152, 6.573, 5.371 and 0.831 for ASA physical status classes 1, 2, 3 and 4, respectively; RMSE of 8.084 if model is trained without controlling the ASA physical status class. The RMSEs for other models are far higher. Finally, in terms of the width of the 95% confidence interval of the mean prediction for systolic and diastolic blood pressures, GP regression gives narrower confidence interval with much smaller margin of error across all four ASA physical status classes.

CONCLUSIONS

Different ASA physical status classes present different data distributions, and thus calls for distinct machine learning models to improve prediction accuracy and reduce predictive uncertainty. Uncertainty quantification enabled by Bayesian inference provides valuable information for clinicians as an additional metric to evaluate performance of machine learning models for medical decision making.

[Structured implementation of fast-track pathways to enhance recovery after elective colorectal resection : First results from five German hospitals]

BACKGROUND

Multimodal optimized perioperative management (mPOM, fast-track, enhanced recovery after surgery, ERAS) leads to a significantly accelerated recovery of patients with elective colorectal resections. Nevertheless, fast-track surgery has not yet become established in everyday clinical practice in Germany. We present the results of a structured fast-track implementation in five German hospitals.

METHODS

Prospective data collection in the context of a 13-month structured fast-track implementation. All patients ≥ 18 years undergoing elective colorectal resection and who gave informed consent were included. After 3 months of preparation (pre-FAST), fast-track treatment was initiated and continued for 10 months (FAST). Outcome criteria were adherence to internationally recommended fast-track elements, postoperative complications, functional recovery, and postoperative hospital stay.

RESULTS

Data from 192 pre-FAST and 529 FAST patients were analyzed. Age, sex, patient risk, location, and type of disease were not different between both groups. The FAST patients were more likely to have undergone minimally invasive surgery (82% vs. 69%). Fast-track adherence increased from 52% (35-65%) under traditional treatment to 83% (65-96%) under fast-track treatment (p < 0.01). The duration until the end of infusion treatment, removal of the bladder catheter, first bowel movement, oral solid food, regaining autonomy, suitability for discharge and postoperative length of stay were significantly lower in the FAST group. Complications, reoperations, and readmission rates did not differ.

CONCLUSION

Fast-track adherence rates > 75% can also be achieved in German hospitals through structured fast-track implementation and the recovery of patients can be significantly accelerated.

Multidisciplinary prehabilitation to improve frailty and functional capacity in high-risk elective surgical patients: a retrospective pilot study

BACKGROUND

Frailty is associated with worse outcomes and higher healthcare costs. The long waiting time for surgery is a potential 'teachable' moment. We examined the feasibility and safety of a pilot prehabilitation programme on high-risk frail patients undergoing major elective surgery.

METHODS

A single-centre, retrospective pilot study (Dec 2020-Nov 2021) on a one-stop prehabilitation programme (structured exercise training, nutritional counselling/therapy, and psychological support) in collaboration with geriatricians and allied health professionals. At least 4 weeks before surgery, patients at high risk of frailty or malnutrition, or undergoing major hepatectomy, esophagectomy, pancreaticoduodenectomy, or radical cystectomy, were referred for prehabilitation (2-3 sessions/week). The primary outcomes were the feasibility and safety of prehabilitation. The secondary outcomes were changes in functional, emotional, and nutritional status and days alive and at home within 30 days after surgery (DAH30) associated with prehabilitation.

RESULTS

Over a 12-month period, 72 out of 111 patients (64.9%) from the Perioperative Medicine Clinic were eligible for prehabilitation, of which 54 (75%) were recruited. The mean (standard deviation) age was 71.9 (6.9) years. The adherence rate to 3 weeks of prehabilitation was high in 52 (96.3%) participants. Prehabilitation improved exercise capacity (P = 0.08), enhanced some functional mobility measures (P = 0.02), and increased nutritional energy (P = 0.04) and protein intakes (P < 0.01). However, prehabilitation-related changes in muscle strength, cognitive function, and emotional resilience were minimal. The median (interquatile range) DAH30 was 19 (14-23) days. No adverse events were reported.

CONCLUSIONS

This outpatient-based, one-stop multidisciplinary prehabilitation programme was feasible, safe, and improved several measures of patient's physiological reserve and functional capacity.

CLINICAL TRIAL REGISTRATION

NCT05668221.

The impact of anticholinergic burden on clinical outcomes in older hospitalised surgical patients

Polypharmacotherapy is an ever-increasing issue with an ageing patient population. Anticholinergic medications make up a large proportion of patient medication but cause significant side effects, contributing to well-documented issues within the older population and in hospital medicine. This review explores the documented impact of anticholinergic burden in older surgical patients on postoperative delirium, infection, length of stay and readmission, urinary retention, ileus and mortality. It also highlights the need for further high-quality research into anticholinergic burden management among older surgical patients to further impact practice and policy in the area.

Challenging issues of implementing enhanced recovery after surgery programs in South Korea

This review discusses the challenges of implementing enhanced recovery after surgery (ERAS) programs in South Korea. ERAS is a patient-centered perioperative care approach that aims to improve postoperative recovery by minimizing surgical stress and complications. While ERAS has demonstrated significant benefits, its successful implementation faces various barriers such as a lack of manpower and policy support, poor communication and collaboration among perioperative members, resistance to shifting away from outdated practices, and patient-specific risk factors. This review emphasizes the importance of understanding these factors to tailor effective strategies for successful ERAS implementation in South Korea's unique healthcare setting. In this review, we aim to shed light on the current status of ERAS in South Korea and identify key barriers. We hope to encourage Korean anesthesiologists to take a leading role in adopting the ERAS program as the standard for perioperative care. Ultimately, our goal is to improve the surgical outcomes of patients using this proactive approach.

Implementation of Ireland's first state-funded day-case total hip arthroplasty programme

BACKGROUND

Over the last two decades, many elective procedures have transitioned to day-case surgery thanks to the introduction of 'enhanced recovery' protocols. Only recently has total hip arthroplasty been considered a candidate for day-case surgery, as it was once associated with significant pain, mobility impairment and prolonged postoperative recovery. The National Orthopaedic Hospital Cappagh became the first public hospital in Ireland to set up a day-case total hip arthroplasty service in June 2018, and since then has performed over 109 such cases.

AIMS

We outline our day-case total hip arthroplasty pathway, with specific focus on anaesthetic considerations. We report rates of failed discharge and readmission.

RESULTS

We achieved successful same-day discharge in 90.8% of our first 109 cases. Readmission rate was 4.6%.

CONCLUSION

Our experience of implementing a day-case total hip arthroplasty pathway was highly positive and congruent with expectations from the literature. With appropriate patient selection and education, day-case total hip arthroplasty is not just safe, but of benefit to both patients and healthcare systems.

Comparing preoperative fasting and ultrasound-measured intravascular volume status in elective surgery, enhanced recovery patients versus inpatient, urgent surgery patients and the ability of IVC collapsibility to predict post-induction hypotension

Hypotension following induction of general anaesthesia has been shown to result in increased complications and mortality postoperatively. Patients admitted to the hospital undergoing urgent surgery are often fasted from fluids for significant periods compared to elective patients subject to Enhanced Recovery After Surgery protocols despite guidelines stating that a two-hour fast is sufficient. The aim of this prospective, observational study was to compare fasting times and intravascular volume status between elective surgery patients subject to enhanced recovery protocols and inpatient, urgent surgery patients and to assess differences in the incidence of post-induction hypotension. Fasting data was obtained by questionnaire in the preoperative area in addition to inferior vena cava collapsibility index, a non-invasive measure of intravascular volume. Blood pressure readings and drug administration for the ten minutes following induction were obtained from patients' charts. Inpatients undergoing urgent surgery were fasted significantly longer than enhanced recovery patients and had lower intravascular volume. However, no difference was found in the incidence of post-induction hypotension.

Perioperative medicine: challenges and solutions for global health

The emerging field of perioperative medicine has the potential to make significant contributions to global health. Perioperative medicine aims to help reduce unmet surgical need, decrease variation in quality and systematically improve patient outcomes. These aims are also applicable to key challenges in global health, such as limited access to surgical care, variable quality and workforce shortages. This article describes the areas in which perioperative medicine can contribute to global health using case studies of successful care pathways, risk prediction tools, strategies for effective grassroots research and novel workforce approaches aimed at effectively using limited resources.

Pediatric perioperative fluid management

The purpose of perioperative fluid management in children is to maintain adequate volume status, electrolyte level, and endocrine system homeostasis during the perioperative period. Although hypotonic solutions containing glucose have traditionally been used as pediatric maintenance fluids, recent studies have shown that isotonic balanced crystalloid solutions lower the risk of hyponatremia and metabolic acidosis perioperatively. Isotonic balanced solutions have been found to exhibit safer and more physiologically appropriate characteristics for perioperative fluid maintenance and replacement. Additionally, adding 1-2.5% glucose to the maintenance fluid can help prevent children from developing hypoglycemia as well as lipid mobilization, ketosis, and hyperglycemia. The fasting time should be as short as possible without compromising safety; recent guidelines have recommended that the duration of clear fluid fasting be reduced to 1 h. The ongoing loss of fluid and blood as well as the free water retention induced by antidiuretic hormone secretion are unique characteristics of postoperative fluid management that must be considered. Reducing the infusion rate of the isotonic balanced solution may be necessary to avoid dilutional hyponatremia during the postoperative period. In summary, perioperative fluid management in pediatric patients requires careful attention because of the limited reserve capacity in this population. Isotonic balanced solutions appear to be the safest and most beneficial choice for most pediatric patients, considering their physiology and safety concerns.

Multidisciplinary perioperative management in dilatation and evacuation for a giant hydatidiform mole: A case report

Gestational trophoblastic disease (GTD) is an abnormal pregnancy caused by the placenta, which can potentially metastasise. Suction evacuation is recommended for diagnosis and treatment, and dilatation and evacuation (D&E) is usually performed under intravenous anaesthesia due to the short operation time and minimal blood loss. We refer to the guidelines produced by the Japan Society of Obstetrics and Gynaecology (JSOG), and acknowledge that practices vary globally. However, to the best of our knowledge, there is no evidence on perioperative management and arrangements in D&E required for managing giant hydatidiform moles, such as preventing massive haemorrhage, respiratory dysfunction with a pathogenesis like ovarian hyperstimulation syndrome (OHSS), or intensive care needs. This case report describes perioperative considerations for managing a giant hydatidiform mole using D&E in a uterus enlarged to the third-trimester pregnancy size. A 28-year-old multiparous woman was clinically diagnosed with a hydatidiform mole after a spontaneous miscarriage due to abnormal genital bleeding, systemic oedema, and abdominal distention. Ultrasound and computed tomography showed a ballooning uterus with a third-trimester pregnancy size, a robust intrauterine mass, and ascites. Serum hCG levels were extremely high (>3,000,000 mIU/mL), confirming the clinical diagnosis of a hydatidiform mole. Emergency D&E was safely performed under multidisciplinary perioperative management, with careful preparation and support. This is a rare experience-based case report and valuable documentation detailing multidisciplinary perioperative management under general anaesthesia. To the best of our knowledge, this is the first report describing the considerations, details, and innovations required in the perioperative management of giant hydatidiform moles using D&E.

Systems of Care Delivery and Optimization in the Preoperative Arena

Key elements of an effective preoperative process include the following: history-taking, risk assessment, shared decision making, effective interdisciplinary communication, preoperative optimization of modifiable conditions, longitudinal care coordination, contribution to population health aims, and collection of outcomes-driven metrics. Perioperative medicine tenets can be applied by health systems of all sizes and demographics to improve quality and safety.

Trail making test B in postoperative delirium: a replication study

Background

The Trail Making Test B (TMT-B) is indicative of cognitive flexibility and several other cognitive domains. Previous studies suggest that it might be associated with the risk of developing postoperative delirium, but evidence is limited and conflicting. We therefore aimed to replicate the association of preoperative TMT-B results with postoperative delirium.

Methods

We included older adults (≥65 yr) scheduled for major surgery and without signs of dementia to participate in this binational two-centre longitudinal observational cohort study. Presurgical TMT-B scores were obtained. Delirium was assessed twice daily using validated instruments. Logistic regression was applied and the area under the receiver operating characteristic curve calculated to determine the predictive performance of TMT-B. We subsequently included covariates used in previous studies for consecutive sensitivity analyses. We further analysed the impact of outliers, missing or impaired data.

Results

Data from 841 patients were included and of those, 151 (18%) developed postoperative delirium. TMT-B scores were statistically significantly associated with the incidence of postoperative delirium {odds ratio per 10-s increment 1.06 (95% confidence interval [CI] 1.02-1.09), P=0.001}. The area under the receiver operating characteristic curve was 0.60 ([95% CI 0.55-0.64], P<0.001). The association persisted after removing 21 outliers (1.07 [95% CI 1.03-1.07], P<0.001). Impaired or missing TMT-B data (n=88) were also associated with postoperative delirium (odds ratio 2.74 [95% CI 1.71-4.35], P<0.001).

Conclusions

The TMT-B was associated with postoperative delirium, but its predictive performance as a stand-alone test was low. The TMT-B alone is not suitable to predict delirium in a clinical setting.

Clinical trial registration

NCT02265263. (https://clinicaltrials.gov/ct2/show/results/NCT02265263).

Mismatch of populations between randomised controlled trials of perioperative interventions in major abdominal surgery and current clinical practice

BACKGROUND

Demographics of patients undergoing major abdominal surgery are changing. External validity of relevant RCTs may be limited by participants not resembling patients encountered in clinical practice. We aimed to characterise differences in age, weight, BMI, and ASA grade between participants in perioperative trials in major abdominal surgery and patients in a reference real-world clinical practice sample. The secondary aim was to investigate whether time since trial publication was associated with increasing mismatch between these groups.

METHODS

MEDLINE and Embase were searched for multicentre RCTs from inception to September 2022. Studies of perioperative interventions in adults were included. Studies that limited enrolment based on age, weight, BMI, or ASA status were excluded. We compared trial cohort age, weight, BMI, and ASA distribution to those of patients undergoing major abdominal surgery at our tertiary referral hospital during September 2021 to September 2022. We used a local, single-institution reference sample to reflect the reality of clinical practice (i.e. patients treated by a clinician in their own hospital, rather than averaged nationally). Mismatch was defined using comparison of summary characteristics and ad hoc criteria based on differences relevant to predicted mortality risk after surgery.

RESULTS

One-hundred and six trials (44,499 participants) were compared to a reference cohort of 2792 clinical practice patients. Trials were published a median (IQR [range]) 13.4 (5-20 [0-35]) years ago. A total of 94.3% of trials were mismatched on at least one characteristic (age, weight, BMI, ASA). Recruitment of ASA 3 + participants in trials increased over time, and recruitment of ASA 1 participants decreased over time (Spearman's Rho 0.58 and - 0.44, respectively).

CONCLUSIONS

Patients encountered in our current local clinical practice are significantly different from those in our defined set of perioperative RCTs. Older trials recruit more low-risk than high-risk participants-trials may thus 'expire' over time. These trials may not be generalisable to current patients undergoing major abdominal surgery, and meta-analyses or guidelines incorporating these trials may therefore be similarly non-applicable. Comparison to local, rather than national cohorts, is important for meaningful on-the-ground evidence-based decision-making.

Clinical triggers and vital signs influencing crisis acknowledgment and calls for help by anesthesiologists: A simulation-based observational study

STUDY OBJECTIVE

In a perioperative emergency, anesthesiologists must acknowledge the unfolding crisis promptly, call for timely assistance, and avert patient harm. We aimed to identify vital signs and qualitative factors prompting crisis acknowledgment and to compare responses between observers and participants in simulation.

DESIGN

Prospective, simulation-based, observational study.

SETTING

An anesthesia crisis resource management course at a freestanding simulation center.

SUBJECTS

Sixty attending anesthesiologists from a variety of practice settings.

INTERVENTIONS

In each case, a primary anesthesiologist in charge (PAIC) managed a simulated patient undergoing a uniformly scripted sequence of perioperative anaphylaxis and called for help from another anesthesiologist when a crisis began. Anesthesiologist observers (AOs) viewed the case separately and recorded times of crisis onset.

MEASUREMENTS

Simulation footage was reviewed by investigators for patient vital signs and participant behaviors at times of crisis acknowledgment, with the call for help as an explicit proxy for PAIC crisis acknowledgment. These factors were categorized, and group-level data were compared.

RESULTS

Nineteen PAICs and 41 AOs were included. Clinicians acknowledged crises around a mean arterial pressure (MAP) of 65 mmHg and oxygen saturation of 94% as anaphylactic shock progressed. PAICs acknowledged crises at a higher respiratory rate than AOs (20 vs. 18 breaths/min, p = 0.038). Other vitals and timing of crisis acknowledgment did not differ between PAICs and AOs. Nearly half of all participants (45%) identified crises at MAP <65 mmHg. Timing of crisis acknowledgment varied widely (range: 421 s).

CONCLUSIONS

Despite overall heterogeneity in clinical performance, anesthesiologists acknowledged crises per standard definitions of hypotension. Thresholds for crisis acknowledgment did not significantly differ between PAICs and AOs, suggesting minimal effect from active care responsibility. Many indicated crises at MAP <65 mmHg or after significant deterioration, risking failure-to-rescue events. We suggest that crisis management instruction should address triggers for requesting help.

Development of an automated, general-purpose prediction tool for postoperative respiratory failure using machine learning: A retrospective cohort study

STUDY OBJECTIVE

Postoperative respiratory failure is a major surgical complication and key quality metric. Existing prediction tools underperform, are limited to specific populations, and necessitate manual calculation. This limits their implementation. We aimed to create an improved, machine learning powered prediction tool with ideal characteristics for automated calculation.

DESIGN, SETTING, AND PATIENTS

We retrospectively reviewed 101,455 anesthetic procedures from 1/2018 to 6/2021. The primary outcome was the Standardized Endpoints in Perioperative Medicine consensus definition for postoperative respiratory failure. Secondary outcomes were respiratory quality metrics from the National Surgery Quality Improvement Sample, Society of Thoracic Surgeons, and CMS. We abstracted from the electronic health record 26 procedural and physiologic variables previously identified as respiratory failure risk factors. We randomly split the cohort and used the Random Forest method to predict the composite outcome in the training cohort. We coined this the RESPIRE model and measured its accuracy in the validation cohort using area under the receiver operating curve (AUROC) analysis, among other measures, and compared this with ARISCAT and SPORC-1, two leading prediction tools. We compared performance in a validation cohort using score cut-offs determined in a separate test cohort.

MAIN RESULTS

The RESPIRE model exhibited superior accuracy with an AUROC of 0.93 (95% CI, 0.92-0.95) compared to 0.82 for both ARISCAT and SPORC-1 (P-for-difference < 0.0001 for both). At comparable 80-90% sensitivities, RESPIRE had higher positive predictive value (11%, 95% CI: 10-12%) and lower false positive rate (12%, 95% CI: 12-13%) compared to 4% and 37% for both ARISCAT and SPORC-1. The RESPIRE model also better predicted the established quality metrics for postoperative respiratory failure.

CONCLUSIONS

We developed a general-purpose, machine learning powered prediction tool with superior performance for research and quality-based definitions of postoperative respiratory failure.

Anesthetic management of thoracotomy for massive intrathoracic solitary fibrous tumor of the pleura: a case report

BACKGROUNDS

Solitary fibrous tumor of the pleura (SFTP) is a rare thoracic tumor and usually asymptomatic. Massive SFTP may affect adjacent organs and tissues including pulmonary vasculature, bronchus and heart. A thoracotomy for massive SFTP is necessary in severe case. Therefore, it is important for anesthesiologists to understand the condition of patients with massive SFTP and develop an appropriate anesthetic management strategy. A 76-year-old woman with massive SFTP presented to our clinical center and was evaluated as requiring thoracotomy. She received multidisciplinary cooperation treatment from the radiology, cardiac, thoracic surgery and anesthetic teams. The perioperative management of anesthesiologists played a crucial role in the great prognosis of this woman.

CONCLUSIONS

This case report demonstrates the importance of comprehensive and meticulous perioperative management and provides guidance to the multidisciplinary team on the potential risk and the rational treatment strategy of patients with massive SFTP during the perioperative period.

Machine Learning of Physiologic Waveforms and Electronic Health Record Data: A Large Perioperative Data Set of High-Fidelity Physiologic Waveforms

Perioperative morbidity and mortality are significantly associated with both static and dynamic perioperative factors. The studies investigating static perioperative factors have been reported; however, there are a limited number of previous studies and data sets analyzing dynamic perioperative factors, including physiologic waveforms, despite its clinical importance. To fill the gap, the authors introduce a novel large size perioperative data set: Machine Learning Of physiologic waveforms and electronic health Record Data (MLORD) data set. They also provide a concise tutorial on machine learning to illustrate predictive models trained on complex and diverse structures in the MLORD data set.

From Big Data's 5Vs to clinical practice's 5Ws: enhancing data-driven decision making in healthcare

The use of AI-based algorithms is rapidly growing in healthcare, but there is still an ongoing debate about how to manage and ensure accountability for their clinical use. While most of the studies focus on demonstrating a good algorithm performance it is important to acknowledge that several additional steps are needed for reaching an effective implementation of AI-based models in daily clinical practice, with implementation being one of the main key factors. We propose a model characterized by five questions that can guide in this process. Additionally, we believe that a hybrid intelligence, human and artificial respectively, is the new clinical paradigm that offer the most benefits for developing clinical decision support systems for bedside use.

Postoperative Critical Care Admission Was Not Associated with Improved Postoperative Outcomes in Elective Colorectal Surgery: Secondary Analysis Of POWER Trial

BACKGROUND

The efficacy of routine admission of high-risk patients to a critical care unit after surgery is not clear. The aim of our study was to investigate the association between critical care admission after scheduled colorectal surgery and postoperative complications, 30-day mortality, and length of stay in hospital.

METHODS

A pre-defined secondary substudy of POWER study was performed. POWER study was a prospective multicenter observational study of patients undergoing elective primary colorectal surgery during a single period of two months of recruitment between September and December 2017.

RESULTS

A total of 2084 patients from 80 Spanish hospitals were included, of which 722 (34.6%) were admitted to critical care unit (CCU) after elective surgery. After adjusting for confounding factors in the multivariate analysis, postoperative CCU admission was independently associated with a higher incidence of moderate-to-severe postoperative complications (adjusted OR 1.951, 95% CI 1.570, 2.425; p < 0.001). Regarding secondary outcomes, postoperative critical care admission was independently associated with higher 30-day mortality (adjusted OR 6.736; 95% CI 2.507, 18.101; p < 0.001) and independently associated with an increased hospital length of stay (adjusted OR 1.143, 95% CI 1.112, 1.175; p < 0.001).

CONCLUSIONS

Direct admission to CCU after scheduled colorectal surgery was not associated with a reduction in moderate-to-severe postoperative complications.

Implementation of an Un-Pairing Passport to Improve the Transition From Intern to Resident During a Critical Period of Anesthesiology Residency Training

Background

The transition from intern year to the first year of clinical anesthesiology residency (CA-1) is a challenging period for residents and their supervisors. Orientation methods and instructional material targeting this transition vary across U.S. residency programs. An un-pairing passport was implemented during the 2021-2022 transition to guide and provide expectations for interns, senior residents, and staff. The objective of this quality improvement project was to assess the effectiveness of the passport in improving the transition period and overall preparedness of the new CA-1s.

Methods

We surveyed 3 groups (CA-1s, CA-2s/CA-3s, and staff anesthesiologists) 6 months after the completion of passport implementation to retrospectively assess the 2021-2022 CA-1 class's preparedness across 7 domains compared with those who transitioned before passport implementation. Mann-Whitney U statistics and median effect sizes were used to compare pre- and postintervention.

Results

Self-reflected preparedness scores of the CA-1s were higher across all domains compared with the senior resident group (r = 0.328-0.548). Overall level of comfort and preparedness for the start of the CA-1 year was higher in the postintervention group (r = 0.162- 0.514). Staff anesthesiologists' perceived preparedness of the residents was also higher across all domains for the postintervention group (r = 0.197-0.387).

Conclusion

The un-pairing passport improved residents' and staff anesthesiologists' subjective assessments of the readiness of new CA-1 residents after a critical transition in their training. Similar tools can be more broadly applied to other anesthesiology residency and possibly fellowship programs as well as subspecialty rotations within those programs.

Perioperative advanced haemodynamic monitoring of patients undergoing multivisceral debulking surgery: an observational pilot study

BACKGROUND

Patients undergoing high-risk surgery show haemodynamic instability and an increased risk of morbidity. However, most of the available data concentrate on the intraoperative period. This study aims to characterise patients with advanced haemodynamic monitoring throughout the whole perioperative period using electrical cardiometry.

METHODS

In a prospective, observational, monocentric pilot study, electrical cardiometry measurements were obtained using an Osypka ICON™ monitor before surgery, during surgery, and repeatedly throughout the hospital stay for 30 patients with primary ovarian cancer undergoing multivisceral cytoreductive surgery. Severe postoperative complications according to the Clavien-Dindo classification were used as a grouping criterion.

RESULTS

The relative change from the baseline to the first intraoperative timepoint showed a reduced heart rate (HR, median - 19 [25-quartile - 26%; 75-quartile - 10%]%, p < 0.0001), stroke volume index (SVI, - 9.5 [- 15.3; 3.2]%, p = 0.0038), cardiac index (CI, - 24.5 [- 32; - 13]%, p < 0.0001) and index of contractility (- 17.5 [- 35.3; - 0.8]%, p < 0.0001). Throughout the perioperative course, patients had intraoperatively a reduced HR and CI (both p < 0.0001) and postoperatively an increased HR (p < 0.0001) and CI (p = 0.016), whereas SVI was unchanged. Thoracic fluid volume increased continuously versus preoperative values and did not normalise up to the day of discharge. Patients having postoperative complications showed a lower index of contractility (p = 0.0435) and a higher systolic time ratio (p = 0.0008) over the perioperative course in comparison to patients without complications, whereas the CI (p = 0.3337) was comparable between groups. One patient had to be excluded from data analysis for not receiving the planned surgery.

CONCLUSIONS

Substantial decreases in HR, SVI, CI, and index of contractility occurred from the day before surgery to the first intraoperative timepoint. HR and CI were altered throughout the perioperative course. Patients with postoperative complications differed from patients without complications in the markers of cardiac function, a lower index of contractility and a lower SVI. The analyses of trends over the whole perioperative time course by using non-invasive technologies like EC seem to be useful to identify patients with altered haemodynamic parameters and therefore at an increased risk for postoperative complications after major surgery.

Perioperative Fluid Management

The medical complexity of the geriatric patients has been steadily rising. Still, as outcomes of surgical procedures in the elderly are improving, centers are pushing boundaries. There is also a growing appreciation of the importance of perioperative fluid management on postoperative outcomes, especially in the elderly. Optimal fluid management in this cohort is challenging due to the combination of age-related physiological changes in organ function, increased comorbid burden, and larger fluid shifts during more complex surgical procedures. The current state-of-the-art approach to fluid management in the perioperative period is outlined.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

Enhanced recovery after surgery: comes out to the Sun

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

Head cooling wrap could suppress the elevation of core temperature after cardiac surgery during forced-air warming in a pediatric intensive care unit: a randomized clinical trial

PURPOSE

The main aim of the current trial was to explore our hypothesis that cooling head wraps lower the core temperature more effectively than ice packs on the head during forced-air warming after pediatric cardiac surgeries.

METHODS

This study was a single-center Randomized Controlled Trial. Participants were children with a weight ≤ 10 kg and hyperthermia during forced-air warming after cardiac surgeries. When the core temperature reached 37.5 °C, ice packs on the head (group C) or a cooling head wrap (group H) were used as cooling devices to decrease the core temperature. The primary outcome was the core temperature. The secondary outcomes were the foot surface temperature and heart rate. We measured all outcomes every 30 min for 240 min after the patient developed hyperthermia. We conducted two-way ANOVA as a pre-planned analysis and also the Bonferroni test as a post hoc analysis.

RESULTS

Twenty patients were randomly assigned to groups C and H. The series of core temperatures in group H were significantly lower than those in group C (p < 0.0001), and post hoc analysis showed that there was no significant difference in core temperatures at T0 between the two groups and statistically significant differences in all core temperatures at T30-240 between the two groups. There was no difference between the two groups' surface temperatures and heart rates.

CONCLUSIONS

Compared to ice packs on the head, head cooling wraps more effectively suppress core temperature elevation during forced-air warming after pediatric cardiac surgery.

Long-term disease interactions amongst surgical patients: a population cohort study

BACKGROUND

The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described.

METHODS

We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations.

RESULTS

We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs.

CONCLUSION

One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.

Open datasets in perioperative medicine: a narrative review

With the growing interest of researchers in machine learning and artificial intelligence (AI) based on large data, their roles in medical research have become increasingly prominent. Despite the proliferation of predictive models in perioperative medicine, external validation is lacking. Open datasets, defined as publicly available datasets for research, play a crucial role by providing high-quality data, facilitating collaboration, and allowing an objective evaluation of the developed models. Among the available datasets for surgical patients, VitalDB has been the most widely used, with the Medical Informatics Operating Room Vitals and Events Repository recently launched and the Informative Surgical Patient dataset for Innovative Research Environment expected to be released soon. For critically ill patients, the available resources include the Medical Information Mart for Intensive Care, the eICU Collaborative Research Database, the Amsterdam University Medical Centers Database, and the High time Resolution ICU Dataset, with the anticipated release of the Intensive Care Network with Million Patients' information for the AI Clinical decision support system Technology dataset. This review presents a detailed comparison of each to enrich our understanding of these open datasets for data science and AI research in perioperative medicine.

Human-centered visualization technologies for patient monitoring are the future: a narrative review

Medical technology innovation has improved patient monitoring in perioperative and intensive care medicine and continuous improvement in the technology is now a central focus in this field. Because data density increases with the number of parameters captured by patient-monitoring devices, its interpretation has become more challenging. Therefore, it is necessary to support clinicians in managing information overload while improving their awareness and understanding about the patient's health status. Patient monitoring has almost exclusively operated on the single-sensor-single-indicator principle-a technology-centered way of presenting data in which specific parameters are measured and displayed individually as separate numbers and waves. An alternative is user-centered medical visualization technology, which integrates multiple pieces of information (e.g., vital signs), derived from multiple sensors into a single indicator-an avatar-based visualization-that is a meaningful representation of the real-world situation. Data are presented as changing shapes, colors, and animation frequencies, which can be perceived, integrated, and interpreted much more efficiently than other formats (e.g., numbers). The beneficial effects of these technologies have been confirmed in computer-based simulation studies; visualization technologies improved clinicians' situation awareness by helping them effectively perceive and verbalize the underlying medical issue, while improving diagnostic confidence and reducing workload. This review presents an overview of the scientific results and the evidence for the validity of these technologies.

Preoperative assessment and optimisation prior to planned aortic aneurysm repair: a UK survey examining current practice and attitudes of vascular surgeons and vascular anaesthetists

BACKGROUND

The majority of those diagnosed with aortic aneurysm in the UK are older, multi-morbid patients. Decision-making as to who may benefit from intervention (open or endovascular aneurysm repair) is highly variable across the NHS (as is the mode of intervention), in part because there are no detailed guidelines or consensus on preoperative assessment. Thus, there is likely to be significant variation in the pre-operative assessment and optimisation of these patients.

METHODS

A survey was designed to understand current practice and attitudes of vascular surgeons and vascular anaesthetists in the UK regarding preoperative assessment and optimisation of patients undergoing elective aortic aneurysm repair. The survey was reviewed and validated by an expert panel, then distributed electronically to all vascular surgical and vascular anaesthetic leads in the UK.

RESULTS

Overall, the response rate was 68%. The responses were varied between surgeons and anaesthetists, with differences reported in the preoperative assessment and optimisation of patients, the approach to shared decision-making, and the perioperative pathway.

CONCLUSIONS

Despite initiatives such as Getting It Right First Time (GIRFT) and National Institute for Health and Care Excellence (NICE) guidelines, variation still exists between centres with some differences in opinion observed between surgeons and anaesthetists. These differences may be leading to duplication of work in the perioperative pathway, inconsistencies in how risk is assessed and communicated with consequent variation in patient care. Addressing these issues requires awareness and implementation of existing guidelines, transdisciplinary working, efficient data-driven pathways, and structured aortic aneurysm multi-disciplinary team to promote meaningful shared decision-making.

Preoperative characterization of baseline EEG recordings for risk stratification of post-anesthesia care unit delirium

STUDY OBJECTIVE

Delirium in the post-anesthesia care unit (PACU-D) presents a serious condition with a high medical and socioeconomic impact. In particular, PACU-D is among common postoperative complications of elderly patients. As PACU-D may be associated with postoperative delirium, early detection of at-risk patients and strategies to prevent PACU-D are important. We characterized EEG baseline signatures of patients who developed PACU-D following surgery and general anesthesia and patients who did not.

DESIGN AND SETTING

We conducted a post-hoc analysis of preoperative EEG recordings between patients with and without PACU-D, as indicated by positive bCAM scores post general anesthesia and surgery.

PATIENTS AND MEASUREMENTS

Preoperative baseline EEG recordings from 89 patients were recorded at controlled eyes-open (focused wakefulness) and eyes-closed (relaxed wakefulness) conditions. We computed power spectral densities, permutation entropy, spectral entropy and spectral edge frequency to see if these parameters can reflect potential baseline EEG differences between PACU-D (31.5%) and noPACU-D (68.5%) patients. Wilcoxon's Rank Sum Test as well as AUC values were used to determine statistical significance.

MAIN RESULTS

Baseline EEG recordings showed significant differences between PACU-D and noPACU-D patients preoperatively. Compared to the noPACU-D group, PACU-D patients presented with lower power in higher frequencies during relaxed and focused wakefulness alike. These differences in power led to AUC values of 0.73 [0.59;0.85] (permutation entropy) and 0.72 [0.61;0.83] (spectral edge frequency) indicative of a "fair" performance to separate patients with and without PACU-D.

CONCLUSIONS

The baseline EEG of relaxed wakefulness as well as focused wakefulness may be used to assess the risk of developing PACU-D following surgery under general anesthesia. Moreover, routinely used monitoring parameters capture these differences as well, potentially allowing an easy transfer to clinical settings.

CLINICAL TRIAL NUMBER

NCT03775356.

On the Horizon: Specific Applications of Automation and Artificial Intelligence in Anesthesiology

Purpose of Review

The purpose of this review is to summarize the current research and critically examine artificial intelligence (AI) technologies and their applicability to the daily practice of anesthesiologists.

Recent Findings

Novel AI tools are developed using data from electronic health records, imaging, waveforms, clinical notes, and wearables. These tools can accurately predict the perioperative risk for adverse outcomes, the need for blood transfusion, and the risk of difficult intubation. Intraoperatively, AI models can assist with technical skill augmentation, patient monitoring, and management. Postoperatively, AI technology can aid in preventing complications and discharge planning. While further prospective validation is needed, these early applications demonstrate promise in every area of perioperative care.

Summary

The practice of anesthesiology is at a precipice fueled by technological innovation. The clinical AI implementation would enable personalized and safer patient care by offering actionable insights from the wealth of perioperative data.

Effect of surgical delay on 30-day mortality in patients receiving direct oral anticoagulants and admitted for hip fracture

BACKGROUND

Early hip fracture surgery is recommended to decrease mortality, however the impact of a delay in surgery due to previous treatment with direct oral anticoagulants (DOA) is unknown. Our objective was to determine if early surgery, defined as surgery within 48 h of hospital admission is associated with decreased postoperative mortality. We tested the hypothesis that early surgery was beneficial with regard for mortality in patients treated with direct oral anticoagulants.

METHODS

Retrospective cohort study in a French University Hospital including patient admitted for Hip fracture. The main exposure was wait time for surgery defined as the total time, in hours, between hospital admission and surgery. The main outcome was mortality within 30 days after hip fracture surgery.

RESULTS

In 3429 patients, the overall 30-day mortality was 4.1% (95% CI 3.5%; 4.9%). In DOA + patients, the 30-day mortality rates in the early and delayed surgery groups were 1.2% and 5.9%, respectively, with estimated risk difference of -4.4 (with a 2% probability of this difference is > 0). In the DOA + group, early surgery tended to be associated with a higher percentage receiving red-blood cells (64.6% vs 54.8%, respectively, estimated risk difference of 9.9% with a 93% probability of this difference is > 0) and lower risk of pneumonia (1.2% vs 8.2%, respectively; estimated difference of -6.7% with 0.3% probability of superiority).

CONCLUSION

Early hip fracture surgery was associated with improved survival in patients previously treated with DOAs.

Geriatric care for surgical patients: results and reflections from a cross-sectional survey in acute Belgian hospitals

PURPOSE

To explore geriatric care for surgical patients in Belgian hospitals and geriatricians' reflections on current practice.

METHODS

A web-based survey was developed based on literature review and local expertise, and was pretested with 4 participants. In June 2021, the 27-question survey was sent to 91 heads of geriatrics departments. Descriptive statistics and thematic analysis were performed.

RESULTS

Fifty-four surveys were completed, corresponding to a response rate of 59%. Preoperative geriatric risk screening is performed in 25 hospitals and systematically followed by geriatric assessment in 17 hospitals. During the perioperative hospitalisation, 91% of geriatric teams provide non-medical and 82% provide medical advice. To a lesser extent, they provide geriatric protocols, geriatric education and training, and attend multidisciplinary team meetings. Overall, time allocation of geriatric teams goes mainly to postoperative evaluations and interventions, rather than to preoperative assessment and care planning. Most surgical patients are hospitalised on surgical wards, with reactive (73%) or proactive (46%) geriatric consultation. In 36 hospitals, surgical patients are also admitted on geriatric wards, predominantly orthopaedic/trauma, abdominal and vascular surgery. Ninety-eight per cent of geriatricians feel that more geriatric input for surgical patients is needed. The most common reported barriers to further implement geriatric-surgical services are shortage of geriatricians and geriatric nurses, and unadjusted legislation and financing.

CONCLUSION

Geriatric care for surgical patients in Belgian hospitals is mainly reactive, although geriatricians favour more proactive services. The main opportunities and challenges for improvement are to resolve staff shortages in the geriatric work field and to update legislation and financing.

Perioperative outcomes in intermediate and high-risk patients after major surgery following introduction of a dedicated perioperative medicine team: A single centre cohort study

Intermediate and high-risk patients undergoing surgery are often managed on a surgical ward in the absence of haemodynamic or ventilatory support requirements necessitating intensive care unit or high dependency unit admission. We describe a model of care for the multidisciplinary management of selected postoperative patients and the epidemiology of patients managed using this model at a tertiary Australian hospital.Of 25,139 patients undergoing inpatient surgery at our institution over a two-year period, 506 (2%) were referred to the Perioperative Medicine team. The median age of patients referred was 74 years; 85% had an American Society of Anesthesiologists physical status ≥3, and 44% underwent emergency surgery. Major complication or death within 30 days was 44.2% (213/482). The most common complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program were transfusion within 72 h (17.4%), pneumonia/aspiration pneumonitis (11.3%), and acute renal failure (10.6%); median time to Medical Emergency Team call was 146 (interquartile range 77-279) h.Sixty-six percent of referred patients (280/423) required an intervention during their time under the service. This high incidence indicates that this population of patients merits closer attention, including routine measurement and reporting of postoperative outcomes to monitor and improve quality of care at our institution as part of an integrated perioperative service. We believe that with so much current focus on perioperative medicine, it is important we translate this to clinical care by evolving traditional models of management into more innovative strategies to meet the complex demands of today's surgical patients.

Publishing quality improvement studies: learning to share and sharing to learn

This editorial welcomes the decision of BJA Open to publish quality improvement (QI) studies. It summarises the current problems with conducting, evaluating, and publishing QI studies. It highlights existing guidance for prospective authors to follow regarding the reporting of QI interventions, their context(s), underlying theories, and evaluation. In so doing, we hope to encourage the publication of more QI studies of sufficient quality to facilitate learning or replication elsewhere.

Triage and outcomes for a whole cohort of patients presenting for major emergency abdominal surgery including the No-LAP population: a prospective single-center observational study

PURPOSE

This study aimed to characterize 252 consecutive patients with an indication for major emergency abdominal surgery including patients not proceeding to surgery (No-Lap). Patients who do not proceed to major emergency abdominal surgery and their clinical outcomes are not well characterized in the existing literature. Triage criteria may vary between centers, potentially impacting reported outcomes.

METHODS

A single-center prospective observational study in a high-volume Danish surgical center including 252 patients presenting with an indication for major emergent abdominal surgery was conducted from the 15th of October 2020 to the 15th of August 2021. The primary outcome was to estimate the prevalence of No-Lap patients.

RESULTS

Overall, 21 patients (8.3%) of our total study cohort did not proceed to surgery. These patients were significantly older, more comorbid with higher ASA scores, poorer performance status, and were more likely to have bowel ischemia. Poor functional performance and surgeons' consideration of futile intervention were the main reasons for deferring surgery in all 21 patients. Overall, 30-day mortality was 95% for the No-LAP cohort, 9% for the LAP cohort, and 16% for the whole cohort, respectively.

CONCLUSIONS

The No-LAP group selection process could be one of the main determinants of reported postoperative outcomes. Prospective international multi-center studies to characterize the entire cohort of patients eligible for emergency laparotomy including the No-LAP population are needed, as large variations in triage criteria and culture seem to exist. Trial registration Retrospectively registered.

Preoperative Evaluation and Cardiac Risk Assessment in Vascular Surgery

We summarize epidemiologic trends, outcomes, and preoperative guidelines for vascular surgery patients from 2010 to 2022. Vascular surgery continues to evolve in technology and engineering to treat a surgical population that suffers from a high prevalence of comorbidities. Preoperative optimization seeks to characterize the burden of disease and to achieve medical control in the timeline available before surgery. Risk assessment, evaluation, optimization, and prediction of major adverse cardiac events is an evolving science where the Vascular Surgery Quality Initiative has made an impact. Ongoing investigation may demonstrate value for preoperative echocardiography, functional capacity, frailty, and mobility assessments.

Low Preoperative Prealbumin Levels Are a Strong Independent Predictor of Postoperative Cerebrospinal Fluid Leak Following Endoscopic Endonasal Skull Base Surgery

OBJECTIVE

Prealbumin levels correlate with overall nutritional status, and low values are associated with poor wound healing. We investigated whether low preoperative prealbumin levels predict risk of endoscopic endonasal skull base surgery (EESBS) reconstruction failure, as demonstrated by postoperative cerebrospinal fluid (CSF) leak and/or infection.

METHODS

Between October 2018 and February 2020, 98 patients with documented preoperative prealbumin levels were prospectively followed. The incidence of CSF leak and infection in patients with low prealbumin levels (≤20 mg/dL) was compared with those with normal prealbumin levels (>20 mg/dL). Numerous factors previously shown to influence CSF leak rates were assessed. Both univariate and multivariable analyses were performed to identify independent predictive factors.

RESULTS

Within this prospectively gathered patient cohort composed of >95% "high-risk" expanded EESBS, 14 of 98 patients (14.3%) experienced a postoperative CSF leak. Factors univariately associated with postoperative complications at the 0.2 level of significance were used in a multivariable model. Low prealbumin levels (≤20 mg/dL) proved to be a strong independent predictive factor associated with a 5-fold increased risk of postoperative CSF leak (odds ratio 5.01, P = 0.01), and postoperative surgical-site infection (P = 0.0009). These associations remained after controlling for multiple other factors, including body mass index, surgical pathology, previous EESBS, risk assessment index, and high- versus low-flow intraoperative CSF leaks.

CONCLUSIONS

Preoperative prealbumin levels are an independent predictor of EESBS associated CSF leak and infection. Future studies are needed to investigate the utility of screening and correcting prealbumin levels to limit postoperative complications.

What Do Orthopedic Trauma Surgeons Want and Expect from Anesthesiologists?

From the orthopedic trauma surgeon's perspective, successful injury management hinges on fracture fixation and restoration of patient mobility in a safe and expeditious manner. Management of critically injured polytrauma patients and shared decisions regarding regional anesthetics presents a myriad of challenges for orthopedic trauma surgeons and anesthesiologists alike. As the populations age, the typical patient sustaining traumatic orthopedic injuries are increasingly frail and elderly. This trend in demographics has mandated that care for orthogeriatric patients is coordinated by multidisciplinary teams working in concert on medically complex cases to a common end. In this article, we highlight opportunities for improved communication and care integration between orthopedic trauma surgeons and anesthesiologists.