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Background: Critical incident reporting and analysis is one of the key components of patient safety in anesthesiology. The aim of this study was to determine the frequency and characteristics of critical incidents during anesthesia, main causes and factors involved, influence on patient outcomes, prevalence of incident reporting and further analysis. Methods: A multicenter prospective audit was conducted at the clinical departments of the Bogomolets National Medical University during the period from 1 to 2021 to 1 December 2021. 13 hospitals from different Ukrainian regions took part in the study. Anesthesiologists voluntarily submitted critical incident reports into a Google form as they occurred during the working shifts, reporting the details of the incident, and the incident registration routine in their hospital. The study design was approved by the Bogomolets National Medical University (NMU) ethics committee, protocol #148, 07.09.2021. Results: The incidence of critical incidents was 9.35 cases per 1000 anesthetic procedures. Most common incidents were related to the respiratory system: difficult airway (26.8%), reintubation (6.4%), oxygen desaturation (13.8%); cardiovascular system: hypotension (14.9%), tachycardia (6.4%), bradycardia (11.7%), hypertension (5.3%), collapse (3.2%); massive hemorrhage (17%). Factors associated with critical incidents were elective surgery (OR 4.8 [3.1–7.5]), age from 45 to 75 years (OR 1.67 [1.1–2.5]), ASA II (OR 38 [13–106]}, III (OR 34 [12–98]) or IV (3.7 [1.2–11]) compared to ASA I; regional anesthesia (OR 0.67 95 CI 0.5–0.9) or general anesthesia (GA) and regional anesthesia combination (OR 0.55 95 CI 0.3–0.9] decreased the risk of incidents compared to GA alone. Procedural sedation was associated with increased risk of a critical incident, compared to GA (OR 0.55 95 CI 0.3–0.9). The incidents occurred most commonly during the maintenance phase (75/113, 40%, OR compared to extubation phase 20 95 CI 8–48) or the induction phases of anesthesia (70/118, 37%, OR compared to extubation phase 18 95 CI 7–43). Among common reasons that could lead to the incident, the physicians have identified: individual patient features (47%), surgical tactics (18%), anesthesia technique (16%) and human factor (12%). The most frequent failings contributing to the incident occurrence were: insufficient preoperative assessment (44%), incorrect interpretation of the patients' state (33%), faulty manipulation technique (14%), miscommunication with a surgical team (13%) and delay in emergency care (10%). Furthermore, 48% of cases, as judged by participating physicians, were preventable and the consequences of another 18% could be minimized. The consequences of the incidents were insignificant in over a half of the cases, but in 24.5% have led to prolonged hospital stay, in 16% patients required an urgent transfer to the ICU and 3% of patients died during their hospital stay. The majority of the critical incidents (84%) were reported through the hospital reporting system, using mostly paper forms (65%), oral reports (15%) and an electronic database (4%). Conclusion: Critical incidents during anesthesia occur rather often, mainly during the induction or maintenance phases of anesthesia, and could lead to prolonged hospital stay, unplanned transfer to the ICU or death. Reporting and further analysis of the incident are crucial, so we should continue to develop the web-based reporting systems on both local and national levels. Study registration: NCT05435287, clinicaltrials.gov, 23/6/2022. [ABSTRACT FROM AUTHOR]

Background: Checklists are a common tool used in order to mitigate risks caused by human factors and can facilitate the safe induction of anesthesia as well as handovers. SBAR (Situation, Background, Assessment, Recommendation) is a checklist recommended by the WHO and DGAI for handovers, while SOAP-M (Suction, Oxygen, Airway, Pharmaceuticals, Monitoring) is a checklist for the induction of anesthesia. This study investigates the implementation and adoption of these two checklists. Methods: We conducted a single-center online survey one year after the implementation of SOAP-M and SBAR at a university hospital's anesthesiology department, using scales from three validated questionnaires to assess safety attitudes as well as the behavior of staff and the perceived usefulness of the checklists. Results: Staff with a high score in general attitude towards patient safety, as determined by the safety attitudes questionnaire, considered both checklists useful additions to their work environment. Nurses and physicians (p = 0.102) as well as groups divided according to work experience (p = 0.077) showed no significant differences in using SOAP-M and SBAR. Perceived usefulness was significantly higher (p < 0.001) among users of the checklists, and the same goes for positive reinforcement (p < 0.001), social cues (p = 0.0215) and goal cues (p = 0.0252). Conclusion: SOAP-M and SBAR are perceived as useful checklists for patient handovers and anesthesia induction by tertiary referral hospital's employees with high score in general safety attitude and were therefore commonly used one year after their introduction. No significant difference in checklist adoption between occupations as well as groups divided according to work experience could be found. Perceived usefulness is significantly higher among users of the checklist, who feel using the checklists provides more support. [ABSTRACT FROM AUTHOR]

Background: Emergence agitation is a transient confusional state of a child associated with consciousness from general anaesthesia, commonly occurs in the postoperative setting which delays their recovery and exposes them to traumas. The main objective of the current study was to investigate the magnitude of emergence agitation, its interventions and associated factors among paediatric surgical patients at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methods: Hospital based cross-sectional study with prospective follow-up framework was conducted on a paediatric surgical patients aged 2-14 years who underwent surgery under general anaesthesia between June 1 - October 30 2022. Stratified sampling method followed by simple random sampling technique was employed to reach study participants. Magnitude of emergence agitation and its interventions done at post-anaesthetic care units were recorded. Data analysis was carried out using a descriptive statistics method and the results were summarized using tables and diagrams. Bivariate analysis was done to identify causal relationship and multivariable analysis to assess the confounding effects of factors associated with emergence agitation. A p-value of less than 0.05 was considered statistically significant factor. Results: A total of 150 participants were included in the current study, where 107 (71.3%) were male and 97 (64.7%) were preschool aged. About 81 (54%) of care givers were female and majority of them have completed primary school. The mean (standard deviation) age of the participants was 6.4 (3.57) years. Around 42.7% of them developed emergence agitation with an average duration of 8.39 ± 4.45 minutes. Factors such as propofol administration at the end of procedure (OR of 0.104 with 95% CI [0.035, 0305]), Ear, nose, throat surgery and oral maxillofacial surgery (OR of 2.341 with 95% CI [1.051, 5.211]) and arrival of patient to recovery awake (OR of 0.456 95% CI [0.209, 0.994]) showed statistically significant association with emergence agitation. Conclusion: Almost half of the study participants experienced emergence agitation which is high magnitude. Ear, nose, throat surgery and oral maxillofacial surgeries were predictive factors of emergence agitation while propofol administration at the end of procedure and arrival of patient to recovery awake significantly decreased risk of emergence agitation. Therefore, anaesthesia personnel should have essential skills and knowledge to effectively care for children perioperatively including to minimize and treat emergence agitation. [ABSTRACT FROM AUTHOR]

Background: Intra-operative anaesthesia management should be optimised to reduce the occurrence of postoperative nausea and vomiting in high-risk patients; however, a single intervention may not effectively reduce postoperative nausea and vomiting in such patients. This study assessed the effect of an optimised anaesthetic protocol versus a conventional one on postoperative nausea and vomiting in patients who underwent laparoscopic sleeve gastrectomy. Methods: A single-centre randomised trial was conducted at Peking University Shenzhen Hospital from June 2021 to December 2022. Among 168 patients who underwent laparoscopic sleeve gastrectomy, 116 qualified, and 103 completed the study with available data. Patients were categorized into the conventional group (received sevoflurane and standard fluids) and the optimised group (underwent propofol-based anaesthesia and was administered goal-directed fluids). The primary endpoints were postoperative nausea and vomiting incidence and severity within 24 h. Results: Postoperative nausea and vomiting assessment at 0–3 h post-surgery revealed no significant differences between groups. However, at 3–24 h, the optimised anaesthetic protocol group showed lower postoperative nausea and vomiting incidence and severity than those of the conventional group (P = 0.005). In the conventional group, 20 (37.04%) patients experienced moderate-to-severe postoperative nausea and vomiting, compared to six (12.25%) patients in the optimised group (odds ratio = 0.237; 95% CI = 0.086, 0.656; P = 0.006). No significant differences were noted in antiemetic treatment, moderate-to-severe pain incidence, anaesthesia recovery, post-anaesthetic care unit stay, or postoperative duration between the groups. While the total intra-operative infusion volumes were comparable, the optimised group had a significantly higher colloidal infusion volume (500 mL vs. 0 mL, P = 0.014) than that of the conventional group. Conclusions: The incidence and severity of postoperative nausea and vomiting 3–24 h postoperatively in patients who underwent laparoscopic sleeve gastrectomy were significantly lower with propofol-based total intravenous anaesthesia and goal-directed fluid therapy than with sevoflurane anaesthesia and traditional fluid management. Total intravenous anaesthesia is an effective multimodal antiemetic strategy for bariatric surgery. Trial registration: This trial was registered with the Chinese Clinical Trial Registry (ChiCTR-TRC- 2,100,046,534, registration date: 21 May 2021). [ABSTRACT FROM AUTHOR]

Developing an anesthesia module in the operating room is one of the significant steps toward the implementation of electronic medical records (EMR) in health care centers. This study aimed to develop and evaluate the web based-anesthesia module of an electronic medical record Sciences, in the operating room of the Namazi Medical Training Center of Shiraz University of Medical Iran. This developmental and applied study was conducted in steps including determining the functional and non-functional requirements, designing and implementing the anesthesia module, and usability evaluation. 3 anesthesiologists, 3 anesthesiologist assistants, and 12 anesthetist nurses were included in the study as a research community. React.js, Node.js programming language to program this module, Mongo dB database, and Windows server for data management and USE standard questionnaire were used. In the anesthesia module, software quality features were determined as functional requirements and non-functional requirements included 286 data elements in 25 categories (demographic information, surgery information, laboratory results, patient graphs, consults, consent letter, physical examinations, medication history, family disease records, social record, past medical history, type of anesthesia, anesthesia induction method, airway management, monitoring, anesthesia chart, blood and fluids, blood gases, tourniquets and warmers, accessories, positions, neuromuscular reversal, transfer the patient from the operating room, complications of anesthesia and, seal/ signature). Also, after implementing the anesthesia module, results of the usability evaluation showed that 69.1% of the users agreed with the use of this module in the operating room and considered it user-friendly. [ABSTRACT FROM AUTHOR]

Background: Hypnosis can be a beneficial complementary anesthesia technique for a variety of surgical procedures. Despite favorable scientific evidence, hypnosis is still rarely used in the operating room. Obstacles to implementation could be a lack of interest or training, misconceptions, as well as limited knowledge amongst anesthesiology teams. Hence, this study aimed to assess the interest, training, beliefs, and knowledge about hypnosis in the operating room staff. Design: A questionnaire with 21-items, based on a prior survey, was set up on an online platform. The medical and nursing anesthesiology staff of four Swiss academic and large regional hospitals (N = 754) were invited to participate anonymously through e-mails sent by their hierarchy. Results were analyzed quantitatively. Results: Between June, 2020 and August, 2021 353 answers were collected (47% response rate). Most (92%) were aware that hypnosis needs specific training, with 14% trained. A large majority of the untrained staff wished to enroll for conversational hypnosis training. There was a strong agreement for hypnosis playing a role in anesthesia. Nevertheless, many of these professionals believed that hypnosis has a limited field of action (53%) or that it would be too time consuming (33%). The reduction of misconceptions was based more on exposure to hypnosis than on training. Conclusion: Overall, anesthesia providers' attitude was in favor of using hypnosis in the operating room. Misconceptions such as a prolongation of the procedure, alteration of consent, lack of acceptability for patients, and limited indications were identified as potential barriers. These deserve to be challenged through proper dissemination of the recent scientific literature and exposure to practice. [ABSTRACT FROM AUTHOR]

Background: Certain routine medication could result in post-induction hypotension (PIH), such as angiotensin axis blockades, which are frequently administered as a first-line therapy against hypertension. Remimazolam is reportedly associated with lesser intraoperative hypotension than propofol. This study compared the overall incidence of PIH following remimazolam or propofol administration in patients managed by angiotensin axis blockades. Methods: This single-blind, parallel-group, randomized control trial was conducted in a tertiary university hospital in South Korea. Patients undergoing surgery with general anesthesia were considered for enrollment if the inclusion criteria were met: administration of an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, 19 to 65 years old, American Society of Anesthesiologists physical status classification ≤ III, and no involvement in other clinical trials. The primary outcome was the overall incidence of PIH, defined as a mean blood pressure (MBP) < 65 mmHg or decrease by ≥ 30% of the baseline MBP. The time points of measurement were baseline, just before the initial intubation attempt, and 1, 5, 10, and 15 min following intubation. The heart rate, systolic and diastolic blood pressures, and bispectral index were also recorded. Groups P and R included patients administered propofol and remimazolam, respectively, as an induction agent. Results: A total of 81 patients were analyzed, of the 82 randomized patients. PIH was less frequent in group R than group P (62.5% versus 82.9%; t value 4.27, P = 0.04, adjusted odds ratio = 0.32 [95% confidence interval 0.10–0.99]). The decrease in the MBP from baseline was 9.6 mmHg lesser in group R than in group P before the initial intubation attempt (95% confidence interval 3.3–15.9). A similar trend was observed for systolic and diastolic blood pressures. No severe adverse events were observed in either group. Conclusion: Remimazolam results in less frequent PIH than propofol in patients undergoing routine administration of angiotensin axis blockades. Trial registration: This trial was retrospectively registered on Clinical Research Information Service (CRIS), Republic of Korea (KCT0007488). Registration date: 30/06/2022. [ABSTRACT FROM AUTHOR]

Background: This study used an epidural anesthesia practice kit (model) to evaluate the accuracy of epidural anesthesia using standard techniques (blind) and augmented/mixed reality technology and whether visualization using augmented/mixed reality technology would facilitate epidural anesthesia. Methods: This study was conducted at the Yamagata University Hospital (Yamagata, Japan) between February and June 2022. Thirty medical students with no experience in epidural anesthesia were randomly divided into augmented reality (-), augmented reality (+), and semi-augmented reality groups, with 10 students in each group. Epidural anesthesia was performed using the paramedian approach with an epidural anesthesia practice kit. The augmented reality (-) group performed epidural anesthesia without HoloLens2Ⓡ and the augmented reality (+) group with HoloLens2Ⓡ. The semi-augmented reality group performed epidural anesthesia without HoloLens2Ⓡ after 30 s of image construction of the spine using HoloLens2Ⓡ. The epidural space puncture point distance between the ideal insertion needle and participant's insertion needle was compared. Results: Four medical students in the augmented reality (-), zero in the augmented reality (+), and one in the semi-augmented reality groups failed to insert the needle into the epidural space. The epidural space puncture point distance for the augmented reality (-), augmented reality (+), and semi-augmented reality groups were 8.7 (5.7–14.3) mm, 3.5 (1.8–8.0) mm (P = 0.017), and 4.9 (3.2–5.9) mm (P = 0.027), respectively; a significant difference was observed between the two groups. Conclusions: Augmented/mixed reality technology has the potential to contribute significantly to the improvement of epidural anesthesia techniques. [ABSTRACT FROM AUTHOR]

Background: Hypoglycaemia and hyperglycaemia may develop during anaesthesia and surgery in children and can lead to severe adverse clinical outcomes. No study, as far as we know, has investigated glucose homeostasis in children undergoing surgery in Malawi. The aim of this study was to assess perioperative glucose levels of the children undergoing anaesthesia at Mercy James Centre (MJC) for Paediatric Surgery, Blantyre, Malawi. Methodology: This was an observational cross-sectional study. We looked at 100 children aged 1 day to 15 years anaesthetised at MJC. Data were analysed using SPSS 28. Student t test and Analysis of the variance (ANOVA) were used to compare means. The level of significance was 5%. Results: Male children represented 68%. The median age was 2.2 years. Sixten percents of patient were underweight. Fasting times were prolonged for 87%. Maintenance IV fluid with 2.5% dextrose was given to 14%. Overall, there was a significant increase of glycaemia from induction of anaesthesia to the end of the procedure. Hypoglycaemia was rare. The mean fasting glycaemia was 99.04 mg/dL ± 1.8, 116.95 mg/dL ± 34.2 at 30 min into the procedure and 127.62 mg/dL ± 46.8 at the end of the procedure. The differences in means were statistically significant (p < 0.001). Prolonged fasting times was associated with lower blood glucose means whereas nutrition status, type of the procedure, addition of dextrose in the fluid, and duration of procedure were associated with higher glycaemia means. Conclusion: Glycaemia increases under anaesthesia and surgery. Recommended fasting times, optimising nutritional status, when possible, no dextrose or lower than 2.5% dextrose in IV maintenance fluid are possible strategies to maintain blood sugar homeostasis during paediatric surgery and anaesthesia. [ABSTRACT FROM AUTHOR]

Background: Transversus abdominis plane (TAP) block can provide effective analgesia for abdominal surgery. However, it was questionable whether TAP had additional effect in the context of multimodal analgesia (MMA). Therefore, this study aimed to assess the additional analgesic effect of preoperative TAP block when added to MMA protocol in open gynecological surgery. Methods: In this prospective, randomized-controlled trial, 64 patients scheduled for open gynecological surgery were randomized to receive preoperative TAP block (Study group, n = 32) or placebo (Control group, n = 32) in addition to MMA protocol comprising dexamethasone, acetaminophen, flurbiprofen and celecoxib, and rescued morphine analgesia. The primary outcome was rescued morphine within 24 h after surgery. Secondary outcomes included pain scores, adverse effects, quality of recovery measured by 40-item quality of recovery questionnaire score (QoR-40) at 24 h, and quality of life measured with short-form health survey (SF − 36) on postoperative day (POD) 30. Results: The Study group had less rescued morphine than the control group within 24 h [5 (2–9) vs. 8.5 (5–12.8) mg, P = 0.013]. The Study group had lower pain scores at 1 h [3 (2–4) vs. 4 (3–5), P = 0.007], 2 h [3 (2–4) vs. 3.5 (3–5), P = 0.010] and 6 h [3 (2–3) vs. 3 (2.3–4), P = 0.028], lower incidence of nausea at 48 h (25.8% vs. 50%, P = 0.039), and higher satisfaction score [10 (10–10) vs. 10 (8–10), P = 0.041]. The SF-36 bodily pain score on POD 30 was higher in the Study group (59 ± 13 vs. 49 ± 16, P = 0.023). Conclusions: Preoperative TAP block had additional analgesic effect for open gynecological surgery when used as part of multimodal analgesia. Rescued morphine within 24 h was significantly reduced and the SF-36 bodily pain dimension at 30 days after surgery was significantly improved. Trial registration: www.chictr.org.cn (ChiCTR2000040343, on Nov 28 2020). [ABSTRACT FROM AUTHOR]

Background: Few interventions are known to reduce the incidence of respiratory failure that occurs following elective surgery (postoperative respiratory failure; PRF). We previously reported risk factors associated with PRF that occurs within the first 5 days after elective surgery (early PRF; E-PRF); however, PRF that occurs six or more days after elective surgery (late PRF; L-PRF) likely represents a different entity. We hypothesized that L-PRF would be associated with worse outcomes and different risk factors than E-PRF. Methods: This was a retrospective matched case-control study of 59,073 consecutive adult patients admitted for elective non-cardiac and non-pulmonary surgical procedures at one of five University of California academic medical centers between October 2012 and September 2015. We identified patients with L-PRF, confirmed by surgeon and intensivist subject matter expert review, and matched them 1:1 to patients who did not develop PRF (No-PRF) based on hospital, age, and surgical procedure. We then analyzed risk factors and outcomes associated with L-PRF compared to E-PRF and No-PRF. Results: Among 95 patients with L-PRF, 50.5% were female, 71.6% white, 27.4% Hispanic, and 53.7% Medicare recipients; the median age was 63 years (IQR 56, 70). Compared to 95 matched patients with No-PRF and 319 patients who developed E-PRF, L-PRF was associated with higher morbidity and mortality, longer hospital and intensive care unit length of stay, and increased costs. Compared to No-PRF, factors associated with L-PRF included: preexisiting neurologic disease (OR 4.36, 95% CI 1.81–10.46), anesthesia duration per hour (OR 1.22, 95% CI 1.04–1.44), and maximum intraoperative peak inspiratory pressure per cm H20 (OR 1.14, 95% CI 1.06–1.22). Conclusions: We identified that pre-existing neurologic disease, longer duration of anesthesia, and greater maximum intraoperative peak inspiratory pressures were associated with respiratory failure that developed six or more days after elective surgery in adult patients (L-PRF). Interventions targeting these factors may be worthy of future evaluation. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 first wave in France, the capacity of intensive care unit (ICU) beds almost doubled, mainly because of the opening of temporary ICUs with staff and equipment from anaesthesia. Objectives: We aim to investigate if the initial management in temporary ICU is associated with a change in ICU mortality and short-term prognosis. Design: Retrospective single-centre cohort study. Setting: Surgical ICU of the Bichat Claude Bernard University Hospital during the COVID-19 "first wave" (from 18 March to 10 April 2020). Patients: All consecutive patients older than 18 years of age with laboratory-confirmed SARS-CoV-2 infection and/or typical radiological patterns were included during their first stay in the ICU for COVID-19. Intervention: Patients were admitted to a temporary ICU if no room was available in the classical ICU and if they needed invasive mechanical ventilation but no renal replacement therapy or Extracorporeal Membrane Oxygenation (ECMO) in the short term. The temporary ICUs were managed by mixed teams (from the ICU and anaesthesiology departments) following a common protocol and staff meetings. Main outcome measure: ICU mortality Results: Among the 59 patients admitted, 37 (62.7%) patients had initial management in the temporary ICU. They had the same characteristics on admission and the same medical management as patients admitted to the classical ICU. ICU mortality was similar in the 2 groups (32.4% in temporary ICUs versus 40.9% in classical ICUs; p=0.58). SAPS-II and ECMO use were associated with mortality in multivariate analysis but not admission to the temporary ICU. Conclusion: In an overload context of the ICU of a geographical area, our temporary ICU model allowed access to intensive care for all patients requiring it without endangering them. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) is associated with neurocognitive impairment – a known risk factor for postoperative delirium. However, it is unclear whether OSA increases the risk of postoperative delirium and whether treatment is protective. The objectives of this study were to identify OSA with a home sleep apnea test (HSAT) and to determine whether auto-titrating positive airway pressure (APAP) reduces postoperative delirium in older adults with newly diagnosed OSA undergoing elective hip or knee arthroplasty. Methods: We conducted a multi-centre, randomized controlled trial at three academic hospitals in Canada. Research ethics board approval was obtained from the participating sites and informed consent was obtained from participants. Inclusion criteria were patients who were ≥ 6 0 years and scheduled for elective hip or knee replacement. Patients with a STOP-Bang score of ≥ 3 had a HSAT. Patients were defined as having OSA if the apnea–hypopnea index was ≥ 10/h. These patients were randomized 1:1 to either: 1) APAP for 72 h postoperatively or until discharge, or 2) routine care after surgery. The primary outcome was postoperative delirium, assessed twice daily with the Confusion Assessment Method for 72 h or until discharge or by chart review. The secondary outcome measures included length of stay, and perioperative complications occurring within 30 days after surgery. Results: Of 549 recruited patients, 474 completed a HSAT. A total of 234 patients with newly diagnosed OSA were randomized. The mean age was 68.2 (6.2) years and 58.6% were male. Analysis was performed on 220 patients. In total, 2.7% (6/220) patients developed delirium after surgery: 4.4% (5/114) patients in the routine care group, and 0.9% (1/106) patients in the treatment group (P = 0.21). The mean length of stay for the APAP vs. the routine care group was 2.9 (2.9) days vs. 3.5 (4.5) days (P = 0.24). On postoperative night 1, 53.5% of patients used APAP for 4 h/night or more, this decreased to 43.5% on night 2, and 24.6% on night 3. There was no difference in intraoperative and postoperative complications between the two groups. Conclusions: We had an unexpectedly low rate of postoperative delirium thus we were unable to determine if postoperative delirium was reduced in older adults with newly diagnosed OSA receiving APAP vs. those who did not receive APAP after elective knee or hip arthroplasty. Trial registration: This trial was retrospectively registered in clinicaltrials.gov NCT02954224 on 03/11/2016. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of lidocaine on the expression of voltage-dependent anion channel 1 (VDAC1) in breast invasive carcinoma (BRCA) and its impact on the apoptosis of breast cancer cells. Methods: We collected clinical data from patients with invasive breast cancer from 2010 to 2020 in the First affiliated hospital of Nanchang University, evaluated the prognostic value of VDAC1 gene expression in breast cancer, and detected the expression of VDAC1 protein in breast cancer tissues and paracancerous tissues by immunohistochemical staining of paraffin sections. Also, we cultured breast cancer cells (MCF-7) to observe the effect of lidocaine on the apoptosis of MCF-7 cells. Results: Analysis of clinical data and gene expression data of BRCA patients showed VDAC1 was a differentially expressed gene in BRCA, VDAC1 may be of great significance for the diagnosis and prognosis of BRCA patients. Administration of lidocaine 3 mM significantly decreased VDAC1 expression, the expression of protein Bcl-2 was significantly decreased (p < 0.05), and the expression of p53 increased significantly (p < 0.05). Lidocaine inhibited the proliferation of MCF-7 breast cancer cells, increased the percentage of G2 / M phase cells and apoptosis. Conclusion: Lidocaine may inhibit the activity of breast cancer cells by inhibiting the expression of VDAC1, increasing the apoptosis in breast cancer cells. [ABSTRACT FROM AUTHOR]

Background: Electrical impedance tomography (EIT) visualises alveolar overdistension and alveolar collapse and enables optimisation of ventilator settings by using the best balance between alveolar overdistension and collapse (ODCL). Besides, the global inhomogeneity index (GI), measured by EIT, may also be of added value in determining PEEP. Optimal PEEP is often determined based on the best dynamic compliance without EIT at the bedside. This study aimed to assess the effect of a PEEP trial on ODCL, GI and dynamic compliance in patients with and without ARDS. Secondly, PEEP levels from "optimal PEEP" approaches by ODCL, GI and dynamic compliance are compared. Methods: In 2015–2016, we included patients with ARDS using postoperative cardiothoracic surgery patients as a reference group. A PEEP trial was performed with four consecutive incremental followed by four decremental PEEP steps of 2 cmH2O. Primary outcomes at each step were GI, ODCL and best dynamic compliance. In addition, the agreement between ODCL, GI, and dynamic compliance was determined for the individual patient. Results: Twenty-eight ARDS and 17 postoperative cardiothoracic surgery patients were included. The mean optimal PEEP, according to best compliance, was 10.3 (±2.9) cmH2O in ARDS compared to 9.8 (±2.5) cmH2O in cardiothoracic surgery patients. Optimal PEEP according to ODCL was 10.9 (±2.5) in ARDS and 9.6 (±1.6) in cardiothoracic surgery patients. Optimal PEEP according to GI was 17.1 (±3.9) in ARDS compared to 14.2 (±3.4) in cardiothoracic surgery patients. Conclusions: Currently, no golden standard to titrate PEEP is available. We showed that when using the GI, PEEP requirements are higher compared to ODCL and best dynamic compliance during a PEEP trial in patients with and without ARDS. [ABSTRACT FROM AUTHOR]

Background: Acute kidney injury (AKI) is one of the most common postoperative complications in noncardiac surgical patients, has an important impact on prognosis and is difficult to predict. Whether preoperative N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations and left ventricular ejection fraction (LVEF) levels can predict postoperative AKI in noncardiac surgical patients is unclear. Methods: We included 3,314 patients who underwent noncardiac surgery and had measurements of preoperative NT-proBNP concentrations and LVEF levels at a tertiary academic hospital in China between 2008 and 2018. Multiple logistic regression analysis was used to construct a postoperative AKI risk prediction model for this cohort. Then, NT-proBNP concentrations and LVEF levels were included in the abovementioned model as independent variables, and the predictive ability of these two models was compared. Results: Postoperative AKI occurred in 223 (6.72%) patients within 1 week after surgery. Preoperative NT-proBNP concentrations and LVEF levels were independent predictors of AKI after adjustment for clinical variables. The area under the receiver operating characteristic curve (AUROC) of the AKI risk predictive model established with clinical baseline variables was 0.767 (95% CI: 0.732, 0.802). When NT-proBNP concentrations and LVEF levels were added to the base model, the AUROC was 0.811 (95% CI: 0.779, 0.843). The addition of NT-proBNP concentrations and LVEF levels improved reclassification by 22.9% (95% CI 10.5–34.4%) for patients who developed postoperative AKI and by 36.3% (95% CI 29.5–43.9%) for those who did not, resulting in a significant overall improvement in net reclassification (NRI: 0.591, 95% CI 0.437–0.752, P < 0.000). The integral discrimination improvement was 0.100 (95% CI: 0.075, 0.125, P < 0.000).The final postoperative AKI prediction model was constructed, and had a good discriminative ability and fitted to the dataset. Conclusions: Preoperative NT-proBNP concentrations and LVEF levels were independently associated with the risk of AKI after noncardiac surgery, and they could improve the predictive ability of logistic regression models based on conventional clinical risk factors. Trial registration: The protocol was preregistered in the Chinese Clinical Trial Registry (ChiCTR1900024056). [ABSTRACT FROM AUTHOR]

Background: Jcerity Endoscoper Airway is a new back-open endoscopic laryngeal mask airway device with a unique design. Our study sought to compare the implantation, ventilation quality and complications of JEA (Jcerity Endoscoper airway) versus LMA (Laryngeal Mask Airway) Supreme in the procedure of cerebral aneurysm embolization. Methods: In this prospective, randomised clinical trial, 182 adult patients with American Society of Anesthesiologists class Ι-II scheduled for interventional embolization of cerebral aneurysms were randomly allocated into the Jcerity Endoscoper airway group and the LMA Supreme group. We compared success rate of LMA implantation, ventilation quality, airway sealing pressure, peak airway pressure, degree of blood staining, postoperative oral hemorrhage, sore throat and other complications between the groups. Results: There were no significant differences between the groups in terms of one-time success rate of LMA implantation, ventilation quality, airway sealing pressure or airway peak pressure. However, LMA Supreme group showed a higher degree of blood staining than the JEA group when the laryngeal mask airway was removed (P = 0.04), and there were also more oral hemorrhages and pharyngeal pain than JEA group (P = 0.03, P = 0.02). No differences were observed between groups in terms of other airway complications related to the LMA. Conclusions: The JEA could not only achieve comparable one-time success rate of implantation and quality of ventilation as the LMA Supreme, but also have lower blood staining degree of mask and less sore throat in patients undergoing perioperative anticoagulation for cerebral aneurysm interventional embolization. Trial registration: Chinese Clinical Trial Registry, ChiCTR2100044133; Registered 11/03/2021. Statement: This study adheres to CONSORT guidelines. [ABSTRACT FROM AUTHOR]

Background: Preoperative anxiety is prevalent and has harmful effects on postoperative outcomes. However, to date, it is still unclear (i) to what extent patients perceive preoperative anxiety as emotionally distressful, (ii) whether patients would welcome support from anesthesiologists in coping with their anxiety, and (iii) whether anxiety scores are useful for everyday clinical practice to determine patients' need for support. Methods: 1082 patients scheduled to undergo elective procedures under general anesthesia were eligible for this cross-sectional study carried out at a university hospital. Preoperative anxiety, resulting in emotional distress, and patients' desire for anesthesiologists' support in coping with their anxiety were assessed dichotomously (no vs. yes) and analyzed descriptively. The intensity of anxiety was evaluated using the Amsterdam Preoperative Anxiety and Information Scale (range 4–20). Associations between the intensity of anxiety and the resulting desire for support were analyzed using logistic regression. Receiver operating characteristic analyses were performed to identify anxiety levels that best predict desire for support. Results: Among the 1000 (537 female; M (SD) 57 (18) years) subjects evaluated, 493 (318 (65 %) female) reported anxiety. Anxiety was associated with emotional distress in 320 (65 %) and desire for support in 291 (59 %) patients. Increased preoperative anxiety levels were associated with higher rates of desire for support (B= 0.270; odds ratio 1.31 [95 % CI 1.22–1.41]). An anxiety score > 9 was best to predict a desire for support (sensitivity 0.861, specificity 0.724). However, desire for support was even present in some patients with lowest anxiety scores (5 or 6). Conclusions: All patients undergoing surgery should be screened for preoperative anxiety and the resulting desire for support to be able to determine who would welcome support. Anxiety scoring tools do not seem to be useful to identify these patients. By helping patients experience less preoperative anxiety, anesthesiologists may not only reduce patients' emotional distress but also have a positive impact on postoperative outcome. Trial registration: German Clinical Trials Register (DRKS 00013319, 23 November 2017). [ABSTRACT FROM AUTHOR]

Background: Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. Methods: We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. Results: During the four-year period, 138 children (median age 21 months, minimum-maximum 9–101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3–11.3 g/dL) and 10.7 (7–13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. Conclusions: Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines. [ABSTRACT FROM AUTHOR]

Background: Postoperative pulmonary complications (PPCs) are important contributors to mortality and morbidity after surgery. The available predicting models are useful in preoperative risk assessment, but there is a need for validated tools for the early postoperative period as well. Lung ultrasound is becoming popular in intensive and perioperative care and there is a growing interest to evaluate its role in the detection of postoperative pulmonary pathologies. Objectives: We aimed to identify characteristics with the potential of recognizing patients at risk by comparing the lung ultrasound scores (LUS) of patients with/without PPC in a 24-h postoperative timeframe. Methods: Observational study at a university clinic. We recruited ASA 2–3 patients undergoing elective major abdominal surgery under general anaesthesia. LUS was assessed preoperatively, and also 1 and 24 h after surgery. Baseline and operative characteristics were also collected. A one-week follow up identified PPC+ and PPC- patients. Significantly differing LUS values underwent ROC analysis. A multi-variate logistic regression analysis with forward stepwise model building was performed to find independent predictors of PPCs. Results: Out of the 77 recruited patients, 67 were included in the study. We evaluated 18 patients in the PPC+ and 49 in the PPC- group. Mean ages were 68.4 ± 10.2 and 66.4 ± 9.6 years, respectively (p = 0.4829). Patients conforming to ASA 3 class were significantly more represented in the PPC+ group (66.7 and 26.5%; p = 0.0026). LUS at baseline and in the postoperative hour were similar in both populations. The median LUS at 0 h was 1.5 (IQR 1–2) and 1 (IQR 0–2; p = 0.4625) in the PPC+ and PPC- groups, respectively. In the first postoperative hour, both groups had a marked increase, resulting in scores of 6.5 (IQR 3–9) and 5 (IQR 3–7; p = 0.1925). However, in the 24th hour, median LUS were significantly higher in the PPC+ group (6; IQR 6–10 vs 3; IQR 2–4; p < 0.0001) and it was an independent risk factor (OR = 2.6448 CI95% 1.5555–4.4971; p = 0.0003). ROC analysis identified the optimal cut-off at 5 points with high sensitivity (0.9444) and good specificity (0.7755). Conclusion: Postoperative LUS at 24 h can identify patients at risk of or in an early phase of PPCs. [ABSTRACT FROM AUTHOR]

Intravenous lidocaine, a potent local anesthetic with analgesic and anti-inflammatory properties, has been shown to be an effective adjunct that reduces intra- and postoperative opioid consumption and facilitates pain management in adults. While it shows promise for use in the pediatric population, limited evidence is available. Objectives: To determine if general anesthesia with intraoperative intravenous lidocaine infusion versus general anesthesia without intravenous lidocaine infusion in children undergoing laparoscopic appendectomy decreased opioid requirements intra- and postoperatively. Design: A single-center parallel single-masked randomized controlled study. A computer-generated blocked randomization list was used to allocate participants. The study was conducted between March 2019 and January 2020. Setting: Pediatric teaching hospital in Poland. Participants: Seventy-four patients aged between 18 months and 18 years undergoing laparoscopic appendectomy. Seventy-one patients fulfilled the study requirements. Intervention: Intravenous lidocaine bolus of 1.5 mg/kg over 5 min before induction of anesthesia followed by lidocaine infusion at 1.5 mg/kg/h intraoperatively. The infusion was discontinued before the patients' transfer to the postanesthesia care unit (PACU). Primary outcome measure: The primary outcome measure was total nalbuphine requirement in milligrams during the first 24 h after surgery. Secondary outcome measures: The secondary outcome measures were intraoperative fentanyl consumption, intraoperative sevoflurane consumption, time to the first rescue analgesic request, incidence of postoperative nausea and vomiting during the first 24 h after surgery, frequency of side effects of lidocaine. Results: Children (n = 74) aged 5–17 randomly allocated to receive intraoperative lidocaine infusion (n = 37) or no intervention (n = 37). Seventy-one were included in the analysis (35 in the study group and 36 in the control group). There was no difference in the cumulative dose of nalbuphine in the first 24 h after removal of the endotracheal tube between groups [median of 0.1061 (IQR: 0.0962–0.2222) mg/kg in the lidocaine group, compared to the control group median of 0.1325 (IQR: 0.0899–0.22020) mg/kg, p = 0.63]. Intraoperative fentanyl consumption was lower in the lidocaine group [median of 5.091 (IQR: 4.848–5.714) μg/kg] than in the control group [median of 5.969 (IQR: 5.000–6.748), p = 0.03]. Taking into account the additional doses administered based on clinical indications, the reduction in the requirement for fentanyl in the lidocaine group was even greater [median of 0.0 (IQR: 0.0–0.952) vs 0.99 (IQR: 0.0–1.809) μg/kg, p = 0.01]. No difference was observed in the sevoflurane consumption between the two groups [median of 32.5 ml (IQR 25.0–43.0) in the lidocaine group vs median of 35.0 ml (IQR: 23.5–46.0) in the control group, p = 0.56]. The time to first analgesic request in the lidocaine group was prolonged [median of 55 (IQR: 40–110) min in the lidocaine group vs median of 40.5 (IQR: 28–65) min in the control group, p = 0.05]. There was no difference in the frequency of PONV between the two groups (48.57% in the lidocaine group vs 61.11% in the control group, p = 0.29). No lidocaine related incidence of anaphylaxis, systemic toxicity, circulatory disturbances or neurological impairment was reported, during anesthesia or postoperative period. Conclusions: Intraoperative systemic lidocaine administration reduced the intraoperative requirement for opioids in children undergoing laparoscopic appendectomy. This effect was time limited, and hence did not affect opioid consumption in the first 24 h following discontinuation of lidocaine infusion. Trial registration: NCT03886896. [ABSTRACT FROM AUTHOR]

Background: Major abdominal surgery is associated with endothelial glycocalyx disruption. The anti-inflammatory effects of lidocaine were recently associated with endothelial barrier protection. Methods: This was a single-centre, parallel group, randomized, controlled, double blind, pilot trial. Forty adult patients scheduled for major abdominal surgery were included between December 2016 and March 2017 in the setting of a University Hospital in Brussels (Belgium); reasons for non-inclusion were planned liver resection and conditions associated to increased risk of local anesthetics systemic toxicity. Patients were randomized to receive either lidocaine by continuous intravenous administration or an equivalent volume of 0.9% saline. The primary endpoint was the postoperative syndecan-1 concentration (difference between groups). Near-infrared spectroscopy of the thenar eminence in association with the vascular occlusion test, and contemporary analysis of flow-mediated dilation of the brachial artery were the secondary outcomes, along with haemodynamic data. Blood samples and data were collected before surgery (T0), and at 1–3 h (T1) and 24 h (T2) post-surgery. Results: Syndecan-1 concentration increased significantly post-surgery (P < 0.001), but without any difference between groups. The near-infrared spectroscopy-derived and flow-mediated dilation-derived variables showed minor changes unrelated to group assignment. Compared with the placebo group, the intervention group had a significantly lower peri-operative mean arterial pressure and cardiac index, despite equally conducted goal-directed haemodynamic management. Postoperative lactate concentrations were similar between groups. Conclusions: Lidocaine failed to have any effect on endothelial function. Since in comparisons to other types of clinical situations, syndecan-1 was only slightly upregulated, endothelial dysfunction after major abdominal surgery might be overestimated. Trial registration: « ISRCTN Registry » identifier: ISRCTN63417725. Date: 15/06/2020. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Peripheral perfusion index (PPI) is an indicator reflecting perfusion. Patients undergoing long time surgeries are more prone to hypoperfusion and increased lactate. Few studies focusing on investigating the association between PPI and surgical patients' prognoses. We performed this study to find it out. Methods: From January 2019 to September 2019, we retrospected all surgical patients who were transferred to ICU, Xinyang Central hospital, Henan province, China. Inclusive criteria: age ≥ 18 years old; surgical length ≥ 120 min. Exclusive criteria: died in ICU; discharging against medical advice; existing diseases affecting blood flow of upper limbs, for example, vascular thrombus in arms; severe liver dysfunction. We defined "prolonged ICU stay" as patients with their length of ICU stay longer than 48 h. According to the definition, patients were divided into two groups: "prolonged group" (PG) and "non-prolong group" (nPG). Baseline characteristics, surgical and therapeutic information, ICU LOS, SOFA and APACHE II were collected. Besides we gathered data of following parameters at 3 time points (T0: ICU admission; T1: 6 h after admission; T2: 12 h after admission): mean artery pressure (MAP), lactate, heart rate (HR), PPI and body temperature. Data were compared between the 2 groups. Multivariable binary logistic regression and ROC (receiver operating characteristic) curves were performed to find the association between perfusion indictors and ICU LOS. Results: Eventually, 168 patients were included, 65 in PG and 103 in nPG. Compared to nPG, patients in PG had higher blood lactate and lower PPI. PPI showed significant difference between two groups earlier than lactate (T0 vs T1). The value of PPI at two time points was lower in PG than nPG(T0: 1.09 ± 0.33 vs 1.41 ± 0.45, p = 0.001; T1: 1.08 ± 0.37 vs 1.49 ± 0.41, p < 0.001). Increased lactateT1(OR 3.216; 95% CI 1.253–8.254, P = 0.015) and decreased PPIT1 (OR 0.070; 95% CI 0.016–0.307, P < 0.001) were independently associated with prolonged ICU stay. The area under ROC of the PPIT1 for predicting ICU stay> 48 h was 0.772, and the cutoff value for PPIT1 was 1.35, with 83.3% sensitivity and 73.8% specificity. Conclusions: PPI and blood lactate at T1(6 h after ICU admission) are associated with ICU LOS in surgical patient. Compared to lactate, PPI indicates hypoperfusion earlier and more accurate in predicting prolonged ICU stay. [ABSTRACT FROM AUTHOR]

Background: Cannabis legalization may contribute to an increased frequency of chronic use among patients presenting for surgery. At present, it is unknown whether chronic cannabis use modifies the risk of postoperative nausea and vomiting (PONV). Methods: This study was a retrospective cohort study conducted at 2 academic medical centers. Twenty-seven thousand three hundred eighty-eight adult ASA 1–3 patients having general anesthesia for non-obstetric, non-cardiac procedures and receiving postoperative care in the Post Anesthesia Care Unit (PACU) were analyzed in the main dataset, and 16,245 patients in the external validation dataset. The main predictor was patient reported use of cannabis in any form collected during pre-anesthesia evaluation and recorded in the chart. The primary outcome was documented PONV of any severity prior to PACU discharge, including administration of rescue medications in PACU. Relevant clinical covariates (risk factors for PONV, surgical characteristics, administered prophylactic antiemetic drugs) were also recorded. Results: 10.0% of patients in the analytic dataset endorsed chronic cannabis use. Using Bayesian Additive Regression Trees (BART), we estimated that the relative risk for PONV associated with daily cannabis use was 1.19 (95 CI% 1.00–1.45). The absolute marginal increase in risk of PONV associated with daily cannabis use was 3.3% (95% CI 0.4–6.4%). We observed a lesser association between current, non-daily use of cannabis (RR 1.07, 95% CI 0.94–1.21). An internal validation analysis conducted using propensity score adjustment and Bayesian logistic modeling indicated a similar size and magnitude of the association between cannabis use and PONV (OR 1.15, 90% CI 0.98–1.33). As an external validation, we used data from another hospital in our care system to create an independent model that demonstrated essentially identical associations between cannabis use and PONV. Conclusions: Cannabis use is associated with an increased relative risk and a small increase in the marginal probability of PONV. [ABSTRACT FROM AUTHOR]

Background: The α2-adrenergic agonist dexmedetomidine (DEX) is a sedative and can be used as an adjunct to hypnotics. The study sought to evaluate the effects of different doses of DEX on the requirements for propofol for loss of consciousness (LOC) in patients monitored via the bispectral index (BIS). Methods: In this randomized, double-blind, three arm parallel group design and placebo-controlled trial, 73 patients aged between 18 and ~ 65 years with a BMI range of 18.0–24.5 kg·m− 2 and an American Society of Anesthesiologists (ASA) grade I or II who were scheduled for general anesthesia at the General Hospital of Ningxia Medical University were included in this study. Anesthesiologists and patients were blinded to the syringe contents. All patients were randomly assigned in a 1:1:1 ratio to receive a 0.5 μg·kg− 1 DEX infusion (0.5 μg·kg− 1 DEX group; n = 24), a 1.0 μg·kg− 1 DEX infusion (1.0 μg·kg− 1 DEX group; n = 25) or a saline infusion (control group; n = 24) for 10 min. Propofol at a concentration of 20 mg·kg− 1·h− 1 was then infused at the end of the DEX or saline infusion. The propofol infusion was stopped when the patient being infused lost consciousness. The primary endpoint were propofol requirements for LOC and BIS value at LOC. Results: The data from 73 patients were analyzed. The propofol requirements for LOC was reduced in the DEX groups compared with the control group (1.12 ± 0.33 mg·kg− 1 for the 0.5 μg·kg− 1 DEX group vs. 1.79 ± 0.39 mg·kg− 1 for the control group; difference, 0.68 mg·kg− 1 [95% CI, 0.49 to 0.87]; P = 0.0001) (0.77 ± 0.27 mg·kg− 1 for the 1.0 μg·kg− 1 DEX group vs. 1.79 ± 0.39 mg·kg− 1 for the control group; difference, 1.02 mg·kg− 1 [95% CI, 0.84 to 1.21]; P = 0.0001). The propofol requirements for LOC was lower in the 1.0 μg·kg− 1 DEX group than the 0.5 μg·kg− 1 DEX group (0.77 ± 0.27 mg·kg− 1 vs. 1.12 ± 0.33 mg·kg− 1, respectively; difference, 0.34 mg·kg− 1 [95% CI, 0.16 to 0.54]; P = 0.003). At the time of LOC, the BIS value was higher in the DEX groups than in the control group (67.5 ± 3.5 for group 0.5 μg·kg− 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.04 [95% CI, 4.85 to 9.23]; P = 0.0001) (68.4 ± 4.1 for group 1.0 μg·kg− 1 DEX vs. 60.5 ± 3.8 for the control group; difference, 7.58 [95% CI, 5.41 to 9.75]; P = 0.0001). Conclusion: The study showed that DEX (both 0.5 and 1.0 μg·kg− 1 DEX) reduced the propofol requirements for LOC. DEX pre-administration increased the BIS value for LOC induced by propofol. Clinical trial registration: The study was registered at ClinicalTrials.gov (trial ID: NCT02783846 on May 26, 2016). [ABSTRACT FROM AUTHOR]

Background: Cardiac surgery with extracorporeal circulation (ECC) can induce microvascular dysfunction and tissue hypoperfusion. We hypothesized that the alterations in near-infrared spectroscopy (NIRS)-derived parameters would be associated with post-operative complications in cardiac surgery patients. Methods: Prospective observational study performed at two University Hospitals. Ninety patients undergoing cardiac surgery with ECC were enrolled. The NIRS sensor was applied on the thenar eminence. A vascular occlusion test (VOT, 3-min ischemia) was performed at baseline (t0), at Intensive Care Unit (ICU) admission (t1), 3 (t2) and 6 (t3) hours later. Baseline tissue oxygen saturation (StO2), oxygen extraction rate and microvascular reactivity indices were calculated. Results: In the first hours after cardiac surgery, StO2 tended to increase (86% [80–89] at T3 versus 82% [79–86] at T0, p = ns), while both tissue oxygen extraction and microvascular reactivity tended to decrease, as indicated by increasing occlusion slope (− 8.1%/min [− 11.2 to − 7] at T3 versus − 11.2%/min [− 13.9 to − 7.9] at T0, p = ns) and decreasing recovery slope (1.9%/sec [1.1–2.9] at T3 versus 3.1%/sec [2.3–3.9] at T0, p = ns). No substantial differences were found in NIRS-derived variables and their changes over time between patients with complications and those without complications. Conclusions: Peripheral tissue oxygen extraction and microvascular reactivity were reduced during the first hours after cardiac surgery. NIRS-derived parameters were not able to predict complications in this population of cardiac surgery patients. [ABSTRACT FROM AUTHOR]

Background: Preoperative frailty predicts adverse postoperative outcomes. Despite the advantages of incorporating frailty assessment into surgical settings, there is limited research on surgical healthcare professionals' use of frailty assessment for perioperative care. Methods: Healthcare professionals caring for patients enrolled at a Canadian teaching hospital were surveyed to assess their perceptions of frailty, as well as attitudes towards and practices for frail patients. The survey contained open-ended and 5-point Likert scale questions. Responses were compared across professions using independent sample t-tests and correlations between survey items were analyzed. Results: Nurses and allied health professionals were more likely than surgeons to think frailty should play a role in planning a patient's care (nurses vs. surgeons p = 0.008, allied health vs. surgeons p = 0.014). Very few respondents (17.5%) reported that they 'always used' a frailty assessment tool. Results from qualitative data analysis identified four main barriers to frailty assessment: institutional, healthcare system, professional knowledge, and patient/family barriers. Conclusion: Across all disciplines, the lack of knowledge about frailty issues was a prominent barrier to the use of frailty assessments in practice, despite clinicians' understanding that frailty affects their patients' outcomes. Confidence in frailty assessment tool use through education and addressing barriers to implementation may increase use and improve patient care. Healthcare professionals agree that frailty assessments should play a role in perioperative care. However, few perform them in practice. Lack of knowledge about frailty is a key barrier in the use of frailty assessments and the majority of respondents agreed that they would benefit from further training. [ABSTRACT FROM AUTHOR]

Background: Shared decision-making (SDM) seeks to involve both patients and clinicians in decision-making about possible health management strategies, using patients' preferences and best available evidence. SDM seems readily applicable in anesthesiology. We aimed to determine the current level of SDM among preoperative patients and anesthesiology clinicians. Methods: We invited 115 consecutive preoperative patients, visiting the pre-assessment outpatient clinic of the department of Anesthesiology at the Academic Medical Center of Amsterdam. Inclusion criteria were patients who needed surgery in the arms, lower abdomen or legs, and in whom three anesthesia techniques were feasible. The SDM-level of the consultation was scored objectively by independent observers who judged audio-recordings of the consultation using the OPTION5-scale, ranging from 0% (no SDM) to 100% (optimum SDM), as well as subjectively by patients (using the SDM-Q-9 and CollaboRATE questionnaires) and clinicians (SDM-Q-Doc questionnaire). Objective and subjective SDM-levels were assessed on five-point and six-point Likert scales, respectively. Both scores were expressed as percentages. Results: Data of 80 patients could be analysed. Objective SDM-scores were low (30.5%). Subjective scores of the SDM-Q-9 and CollaboRATE were high among patients (91.7% and 96.3%, respectively) and among clinicians (SDM-Q-Doc; 84.3%). Apparently, they appreciated satisfaction rather than SDM, being poorly aware of what SDM entails. Conclusion: The level of SDM in an outpatient anesthesiology clinic where preoperative patients receive information about various possible anesthesia options, was found to be low. Thus, there is room for improving the level of SDM. Some suggestions are given how this can be achieved. [ABSTRACT FROM AUTHOR]

Background: Mortality from anaesthesia and surgery in many countries in Sub-Saharan Africa remain at levels last seen in high-income countries 70 years ago. With many factors contributing to these poor outcomes, the World Health Organization (WHO) launched the "Safe Surgery Saves Lives" campaign in 2007. This program included the design and implementation of the "Surgical Safety Checklist", incorporating ten essential objectives for safe surgery. We set out to determine the knowledge of and attitudes towards the use of the WHO checklist for surgical patients in national referral hospitals in East Africa. Methods: A cross-sectional survey was conducted at the main referral hospitals in Mulago (Uganda), Kenyatta (Kenya), Muhimbili (Tanzania), Centre Hospitalier Universitaire de Kigali (Rwanda) and Centre Hospitalo-Universitaire de Kamenge (Burundi). Using a pre-set questionnaire, we interviewed anaesthetists on their knowledge and attitudes towards use of the WHO surgical checklist. Results: Of the 85 anaesthetists interviewed, only 25 % regularly used the WHO surgical checklist. None of the anaesthetists in Mulago (Uganda) or Centre Hospitalo-Universitaire de Kamenge (Burundi) used the checklist, mainly because it was not available, in contrast with Muhimbili (Tanzania), Kenyatta (Kenya), and Centre Hospitalier Universitaire de Kigali (Rwanda), where 65 %, 19 % and 36 %, respectively, used the checklist. Conclusion: Adherence to aspects of care embedded in the checklist is associated with a reduction in postoperative complications. It is therefore necessary to make the surgical checklist available, to train the surgical team on its importance and to identify local anaesthetists to champion its implementation in East Africa. The Ministries of Health in the participating countries need to issue directives for the implementation of the WHO checklist in all hospitals that conduct surgery in order to improve surgical outcomes. [ABSTRACT FROM AUTHOR]

Background: In many countries, routine clinical anaesthesia does not always involve neuromuscular monitoring. In these clinical settings, the efficacy and safety of sugammadex use has not yet been confirmed. We investigated the efficacy and safety of sugammadex in the absence of neuromuscular monitoring. Methods: One hundred and forty patients who underwent laryngeal microsurgery with the use of rocuronium as a neuromuscular blocking agent, without the use of a neuromuscular monitoring device, were retrospectively investigated. The patients were randomly chosen among all the patients who met the inclusion criteria at a tertiary university hospital between July 2013 and February 2015 and were allocated to group S (sugammadex group) or group P (pyridostigmine group) according to the neuromuscular reversal agent administered. Five patients were excluded from analysis and 135 patients completed the study. Primary outcome was extubation time. Secondary outcomes were anaesthesia time, the correlation between anaesthesia time and extubation time, the total amount of rocuronium, and postoperative adverse events in the post-anaesthesia care unit (PACU). Results: Extubation time was significantly shorter in group S (6.3 ± 3.9 min) than in group P (9.0 ± 5.4 min). Anaesthesia time was also significantly shorter in group S (30.7 ± 10.3 min) than in group P (35.8 ± 12.6 min). In the patients with an anaesthesia time of 30 min or less, there was a positive correlation between anaesthesia time and extubation time in group P (r= 0.453), but there was no significant relationship in group S. The total amount of rocuronium used was higher in group S (0.62 ±0.11 mg kg-1) than in group P (0.38 ±0.14 mg kg-1). Postoperative adverse events in the PACU were comparable between the groups, except for tachycardia events: the incidence of tachycardia was significantly lower in group S (8.0 %) than in group P (17.3 %). Conclusions: Sugammadex could shorten anaesthesia and extubation times as well as recovery time in the PACU and reduce postoperative hemodynamic complications in a clinical setting in the absence of neuromuscular monitoring. This may enhance the patients' recovery in the operating room and PACU while improving the postoperative condition of patients. [ABSTRACT FROM AUTHOR]

Background: The benefits of an Acute Pain Service (APS) for pain management have been widely reported, but its diffusion is still limited. There are two APS models: anesthesiologist-based and a nurse-based model. Here we describe the development of a different APS model managed by anesthesia residents, and we report the first year of activity in a tertiary Italian university hospital (Careggi University Hospital, Florence, IT). Methods: Patients were included in the APS were those undergoing abdominal and urologic surgery causing moderate or severe postsurgical pain. The service was provided for patients, beginning upon their exit from the operating room, for 4, 12, 24 and 48 h for iv, and up to 72 h for epidural therapy. Vital signs, static/dynamic VAS, presence of nausea/vomiting, sedation level, and Bromage scale in case of epidural catheter, were monitored. Results: From September 2013 to April 2015, a total of 1054 patients who underwent major surgery were included in the APS: 542 from abdominal surgery and 512 from urological surgery. PCA and epidural analgesia were more adopted in general surgical patients than in urology (48 % vs 36 % and 15 % vs 2 %, respectively; P < 0.0001). Patients who underwent to abdominal surgery had a significantly higher self-administration of morphine (30.3 vs 22.7 mg; P = 0.0315). Elastomeric pump was the analgesic of choice in half of the urologic patients compared to a quarter of the general surgical patients (P < 0.0001). Among the different surgical techniques, epidural analgesia was used more in open (16.5 %) than in videolaparoscopic (1.9 %) and robotic technique (1.1 %), whereas PCA was predominant in videolaparoscopic (46.5 %) and robotic technique (55.5 %) than in open technique (31.4 %). Conclusions: The creation of APS, managed by anesthesia residents, may represent an alternative between specialist-based and nurse-based models. [ABSTRACT FROM AUTHOR]

Background: Despite being a commonly performed procedure, epidural catheter insertion has a significant failure rate. There is a lack of guidance as to how regularly the procedure should be performed in order to maintain competence. This study aimed to quantify whether increasing frequency of practice is associated with a reduction in failure rates. Methods: Data were collected prospectively on all patients undergoing intra-abdominal or thoraco-abdominal surgery who received epidural analgesia as part of their post-operative analgesic regimen over a 36 month period. Records were examined to identify the reason for epidural catheter removal, classified according to standardised definitions, the seniority of the inserting anaesthetist, and whether or not they were a permanent member of the anaesthetic department. Data were analysed using independent t tests, Mann-Whitney tests and Fisher's test. Results: 881 epidurals were inserted during the study period. 48 hour failure rate was 27.2%, whilst by 96 hours 33.9% of epidurals had failed. Increasing frequency of epidural insertion did not show a significant decrease in failure rate at either 48 (p = 0.36) or 96 hours (p = 0.28). However, long-term survival of epidurals at 96 hours was greater if inserted by permanent rather than temporary members of staff (non-permanent 60/141,42.6% vs permanent 228/715, 31.9%, OR 1.58 (CI 1.09-2.29) p = 0.02). Conclusion: This study demonstrates that failure rates for postoperative epidural analgesia in major surgery are not dependent upon the frequency with which practitioners insert epidural catheters. However, failure rates are dependent on permanency of anaesthetic staff. These findings are significant when placed in the context of the General Medical Council's requirements for clinicians to maintain competence in their clinical practice, suggesting that institutional factors may have greater bearing on epidural success or failure than frequency of task performance. [ABSTRACT FROM AUTHOR]

Background The elderly undergo cardiac surgery more and more frequently, often present multiple comorbidities, assume chronic therapies, and present a unique physiology. Aim of our study was to analyze the experience of a referral cardiac surgery center with all types of cardiac surgery interventions performed in patients ≥80 years old over a six years' period. Methods A retrospective observational study performed in a university hospital. 260 patients were included in the study (3.5% of the patients undergoing cardiac surgery in the study period). Results Mean age was 82 ± 1.8 years. Eighty-five percent of patients underwent elective surgery, 15% unplanned surgery and 4.2% redo surgery. Intervention for aortic valve pathology and coronary artery bypass grafting were performed in 51% and 46% of the patients, respectively. Interventions involving the mitral valve were the 26% of the total, those on the tricuspid valve were 13% and those on the ascending aortic arch the 9.6%. Postoperative low output syndrome was identified in 44 patients (17%). Mortality was 3.9% and most of the patients (91%) were discharged from hospital in good clinical conditions. Hospital mortality was lower in planned vs unplanned surgery: 3.8% vs 14% respectively. Chronic obstructive pulmonary disease (OR 9.106, CI 2.275 - 36.450) was the unique independent predictor of mortality. Conclusions Clinicians should be aware that cardiac surgery can be safely performed at all ages, that risk stratification is mandatory and that hemodynamic treatment to avoid complications is expected. [ABSTRACT FROM AUTHOR]

Background Postoperative pain management is of great importance in perioperative anesthetic care. Transversus abdominis plane (TAP) block has been described as an effective technique to reduce postoperative pain and morphine consumption after open lower abdominal operations. Meanwhile, local anesthetic infiltration (LAI) is also commonly used as a traditional method. However, the effectiveness of these two methods has not been compared before. Methods A meta-analysis of all relevant randomized controlled trials (RCTs) was conducted to compare the efficacy of single shot TAP block with that of single shot LAI for postoperative analgesia in adults. Major medical databases and trial registries were searched for published and unpublished RCTs. The endpoints include postoperative visual analog scale (VAS) pain score, morphine requirement, and rate of postoperative nausea and vomiting (PONV). For continuous data, weighted mean differences (WMDs) were formulated; for dichotomous data, risk ratios (RR) were calculated. Results were derived using a random-/fixed-effects model with 95% confidence interval (CI). Results Four RCTs, encompassing 96 TAP-block and 100 LAI patients, were included in the final analysis. Patients in the TAP-block group had lower VAS pain scores 24 hours postoperatively compared with the LAI group, both at rest (WMD [95% CI] = -0.67 [p < 0.01] and with movement (WMD = -0.89, p < 0.01). There were no significant between-group differences in 24-hour postoperative morphine requirements, the rates if PONV or VAS pain scores at 2 and 4 h postoperatively. Conclusion TAP block and LAI provide comparable short-term postoperative analgesia, but TAP block has better long-lasting effect. [ABSTRACT FROM AUTHOR]

Background In the context of infection, progressive illness resulting in acute organ dysfunction is thought to be secondary to inflammatory response. Our aims were to determine risk factors for progressive illness following infection in a low-risk hospitalised cohort, including the impact of prior stain therapy. Methods We performed a prospective observational cohort study on two adult acute medical wards of a single tertiary academic hospital. We screened drug prescription charts of all adult acute medical admissions for inclusion criteria of inpatient administration of antibiotics for more than 24 hours for a microbiologically confirmed or clinically suspected infection. Patients were followed until admission to a high dependency unit (HDU) or intensive care unit (ICU), discharge from hospital, or to a maximum of 10 days. Outcomes were evolution of systemic inflammatory response syndrome (SIRS) criteria, white cell count and C-reactive protein measurements, and adverse clinical outcomes. We constructed multivariable models accounting for repeated within-patient measurements to determine associations between a priori selected predictors (days since admission, age, gender, Charlson score, prior statin exposure) and selected outcomes. Results We enrolled 209 patients; 27.8% were statin users and the commonest infection was pneumonia (51.0%). Most (88.0%) had at least 1 SIRS criterion on admission, and 76 (37.3%) manifested additional SIRS criteria over time. Risks of admission to HDU/ICU (3.3%) and of 30-day mortality (5.7%) were low. The proportion of patients with at least 1 SIRS criterion, mean CRP, and mean WBC all decreased over time. Multivariable regression models identified days since hospital admission as the only variable associated with daily presence of SIRS criteria, WCC, or CRP (adjusted OR <1 and p < 0.0001 in all analyses). Statin exposure was not a significant predictor. Conclusions This cohort of ward patients treated for infection had a low risk of clinical deterioration, inflammatory markers improved over time, and statin exposure was not associated with any outcome. Future larger studies may identify risk factors for progression of illness in this population and plausible surrogate endpoints for evaluation in clinical trials. [ABSTRACT FROM AUTHOR]

Background The cricothyroid membrane (CTM) is the recommended site of access to the airway during cricothyrotomy to provide emergency oxygenation. We sought to compare the ability of physicians to correctly identify the CTM in male and female patients. Methods In a prospective observational study, anaesthetists were asked to locate the CTM by palpation which was then identified using ultrasound and the distance between the actual and estimated margin of the CTM was measured. Participants assessed the ease of CTM palpation using a visual analog scale. In a second series, the angulation of the posterior junction of the thyroid laminae was measured using ultrasound. 23 anaesthetists and 44 subjects participated. A total of 36 assessments were carried out in each gender. Incorrect identification of the CTM was more common in females (29/36 vs. 11/36, P < 0.001) and the distance from the CTM in the vertical plane was greater (11.0 [6.5-20.0] vs. 0.0 [0.0-10.0] mm, P < 0.001). In females distance from the CTM correlated positively with neck circumference (P = 0.005) and BMI (P = 0.00005) and negatively with subject height (P = 0.01). Posterior thyroid cartilage angulation was greater in females (118.6 ± 9.4° vs. 95.9 ± 12.9°, P < 0.001) and was lower in patients with correctly identified CTMs (100.0 ± 14.9° vs. 115.6 ± 15.9°, P = 0.02). VRS palpation correlated with decreased posterior thyroid cartilage angulation (P = 0.04). Conclusions CTM localisation is more difficult in female subjects irrespective of body habitus. It may be prudent to localize this structure by additional means (e.g. ultrasound) in advance of any airway manoeuvres or to modify the cricothyrotomy technique in the event that it is necessary in an emergency. [ABSTRACT FROM AUTHOR]

Background The variation in the rate of intraoperative respiratory events (IRE) over time under anesthesia and the influence of anesthesia-related factors have not yet been described. The objectives of this study were to describe the risk over time and the risk factors for IRE in children at a tertiary care hospital in southern Thailand. Methods The surveillance anesthetic database and chart review of IRE of 14,153 children who received surgery at Songklanagarind Hospital during January 2005 to December 2011 were used to obtain demographic, surgical and anesthesia-related data. Incidence density of IRE per person-time was determined by a Poisson modelling. Risk of IRE over time was displayed using Kaplan Meier survival and Nelson-Aalen curves. Multivariate Cox regression was employed to identify independent predictors for IRE. Adjusted hazard ratios (HR) and their 95% confidence intervals (CI) were obtained from the final Cox model. Results Overall, IRE occurred in 315 out of 14,153 children. The number (%) of desaturation, wheezing or bronchospasm, laryngospasm, reintubation and upper airway obstruction were 235 (54%), 101 (23%), 75 (17%), 21 (5%) and 4 (1%) out of 315 IRE, respectively. The incidence density per 100,000 person-minutes of IRE at the induction period (61.3) was higher than that in the maintenance (13.7) and emergence periods (16.5) (p < 0.001). The risk of desaturation, wheezing and laryngospasm was highest during the first 15, 20 and 30 minutes of anesthesia, respectively. After adjusting for age, history of respiratory disease and American Society of Anesthesiologist (ASA) classification, anesthesia-related risk factors for laryngospasm were assisted ventilation via facemask (HR: 18.1, 95% CI: 6.4-51.4) or laryngeal mask airway (HR: 12.5, 95% CI: 4.6-33.9) compared to controlled ventilation via endotracheal tube (p < 0.001), and desflurane (HR: 11.0, 95% CI: 5.1-23.9) compared to sevoflurane anesthesia (p < 0.001). Conclusions IRE risk was highest in the induction and early maintenance period. Assisted ventilation via facemask or LMA and desflurane anesthesia were anesthesia-related risk factors for laryngospasm. Therefore, anesthesiologists should pay more attention during the induction and early maintenance period especially when certain airway devices incorporated with assisted ventilation or desflurane are used. [ABSTRACT FROM AUTHOR]

Background: Methodologists have proposed the formation of a good research question to initiate the process of developing a research protocol that will guide the design, conduct and analysis of randomized controlled trials (RCTs), and help improve the quality of reporting such studies. Five constituents of a good research question based on the PICOT framing include: Population, Intervention, Comparator, Outcome, and Time-frame of outcome assessment. The aim of this study was to analyze if the presence a structured research question, in PICOT format, in RCTs used within a 2010 meta-analysis investigating the effectiveness of femoral nerve blocks after total knee arthroplasty, is independently associated with improved quality of reporting. Methods: Twenty-three RCT reports were assessed for the quality of reporting and then examined for the presence of the five constituents of a structured research question based on PICOT framing. We created a PICOT score (predictor variable), with a possible score between 0 and 5; one point for every constituent that was included. Our outcome variable was a 14 point overall reporting quality score (OQRS) and a 3 point key methodological items score (KMIS) based on the proper reporting of allocation concealment, blinding and numbers analysed using the intention-to-treat principle. Both scores, OQRS and KMIS, are based on the Consolidated Standards for Reporting Trials (CONSORT) statement. A multivariable regression analysis was conducted to determine if PICOT score was independently associated with OQRS and KMIS. Results: A completely structured PICOT score question was found in 2 of the 23 RCTs evaluated. Although not statistically significant, higher PICOT was associated with higher OQRS [IRR: 1.267; 95% confidence interval (CI): 0.984, 1.630; p = 0.066] but not KMIS (1.061 (0.515, 2.188); 0.872). These results are comparable to those from a similar study in terms of the direction and range of IRRs estimates. The results need to be interpreted cautiously due to the small sample size. Conclusions: This study showed that PICOT framing of a research question in anesthesia-related RCTs is not often followed. Even though a statistically significant association with higher OQRS was not found, PICOT framing of a research question is still an important attribute within all RCTs. [ABSTRACT FROM AUTHOR]

Background: The provision of Intensive Care (IC) can lead to a health care provider's physical, psychological and emotional exhaustion, which may develop into burnout. We notice the absence of specific studies regarding this syndrome in Portuguese Intensive Care Units (ICUs). Our main objective is to study the incidence and risk factors of burnout in Portuguese ICUs. Methods: A self-fulfilment questionnaire containing 3 items: (i) socio-demographic data of the study population; (ii) experiences in the workplace; (iii) Maslach Burnout Inventory (MBI) -- was applied to evaluate the influence of distinct factors on the prevalence of burnout among physicians and nurses working in ICUs. Results: Three hundred professionals (82 physicians and 218 nurses) from ten ICUs were included in the study, out of a total of 445 who were eligible. There was a high rate of burnout among professionals working in Portuguese ICUs, with 31% having a high level of burnout. However, when burnout levels among nurses and physicians were compared, no significant difference was found. Using multivariate analysis, we identified gender as being a risk factor, where female status increases the risk of burnout. In addition, higher levels of burnout were associated with conflicts and ethical decision making regarding withdrawing treatments. Having a temporary work contract was also identified as a risk factor. Conversely, working for another service of the same health care institution acts as a protective factor. Conclusions: A high rate of burnout was identified among professionals working in Portuguese ICUs. This study highlights some new risk factors for burnout (ethical decision making, temporary work contracts), and also protective ones (maintaining activity in other settings outside the ICU) that were not previously reported. Preventive and interventive programmes to avoid and reduce burnout syndrome are of paramount importance in the future organization of ICUs and should take the above results into account. [ABSTRACT FROM AUTHOR]

Background: Carbon monoxide (CO) poisoning can be a life threatening condition. Systemic hyperbaric oxygen (HBO) therapy is used to induce CO detoxification. However, little is known about the hemodynamic response to HBO in severely intoxicated patients. Methods: We retrospectively analyzed the medical records of 6 CO-poisoned patients treated with propofol, rocuronium bromide, and HBO. The HBO protocol comprised 3 HBO treatments (HBOT1 to HBOT3) within 24 hours. During all HBO sessions heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse blood pressure (ΔBP) were measured every five minutes. Non-parametric tests were used to compare data between HBO sessions. Results: HR increased significantly as the number of HBOT increased, from 68 beats per minute (bpm) during HBOT1 to 77 and 86 bpm during HBOT2 and HBOT3, respectively (p < 0.05). In addition, while no significant change was found for DBP, both SBP and ΔBP showed a transient and significant increase during HBOT2, compared to HBOT1, that did not return to basal values during HBOT3. Conclusion: Based on previous studies that have established the respective effects of rocuronium bromide, propofol, HBO, and CO alone on HR, SBP, and ΔBP, it is concluded that the hemodynamic responses observed in the present study are likely to be due to CO. If such, given that neither HR nor SBP and ΔBP returned to basal values by the end of HBOT3, it is suggested that more than 3 HBOT sessions could be necessary to provide full hemodynamic recovery in CO-poisoned patients. [ABSTRACT FROM AUTHOR]

Background: The role of recombinant activated protein C (aPC) during sepsis is still controversial. It showed antiinflammatory effect and improved the microvascular perfusion in experimental models of septic shock. The present study was aimed at testing the hypothesis that recombinant aPC therapy improves the microcirculation during severe sepsis. Methods: Prospective observational study on patients admitted in a 12-beds intensive care unit of a university hospital from July 2010 to December 2011, with severe sepsis and at least two sepsis-induced organ failures occurring within 48 hours from the onset of sepsis, who received an infusion of aPC (24 mcg/kg/h for 96 hours) (aPC group). Patients with contraindications to aPC administration were also monitored (no-aPC group). At baseline (before starting aPC infusion, T0), after 24 hours (T1a), 48 hours (T1b), 72 hours (T1c) and 6 hours after the end of aPC infusion (T2), general clinical and hemodynamic parameters were collected and the sublingual microcirculation was evaluated with sidestream dark-field imaging. Total vessel density (TVD), perfused vessel density (PVD), De Backer score, microvascular flow index (MFIs), the proportion of perfused vessels (PPV) and the flow heterogeneity index (HI) were calculated for small vessels. The perfused boundary region (PBR) was measured as an index of glycocalyx damage. Variables were compared between time points and groups using non parametric or parametric statistical tests, as appropriate. Results: In the 13 aPC patients mean arterial pressure (MAP), base excess, lactate, PaO2/FiO2 and the Sequential Organ Failure Assessment (SOFA) score significantly improved over time, while CI and ITBVI did not change. MFIs, TVD, PVD, PPV significantly increased over time and the HI decreased (p < 0.05 in all cases), while the PBR did not change. No-aPC patients (n = 9) did not show any change in the microcirculation over time. A positive correlation was found between MFIs and MAP. TVD, PVD and De Backer score negatively correlated with norepinephrine dose, and the SOFA score negatively correlated with MFIs, TVD and PVD. Conclusions: aPC significantly improves the microcirculation in patients with severe sepsis/septic shock. [ABSTRACT FROM AUTHOR]

Background: In trauma patients intubated in a physician-led pre-hospital trauma service we prospectively examined the rate of misplaced tracheal tubes, the presence and nature of gross airway contamination, and the value of ‘quick look’ airway assessment to identify patients with subsequent difficult laryngoscopy. Methods: Patients requiring pre-hospital intubation in a 16 month period were included. Intubation success rate, misplaced tracheal tube rate, Cormack and Lehane grade, and the presence and nature of gross airway contamination were recorded at laryngoscopy. Tube placement was verified with carbon dioxide detection and chest x-ray. After visual assessment physicians stated whether laryngoscopy was expected to be a straightforward or ‘difficult’. The assessment was compared to subsequent laryngoscopy grade. Results: 400 patients had attempted intubation and 399 were successfully intubated. 42 were in cardiac arrest and intubated without drugs. There were no oesophageal or misplaced tracheal tubes. Gross airway contamination was reported in 177 of 400 patients (44%), of which ¾ was from the upper airway. Unconscious patients had higher contamination rates (57%) than conscious patients (34%) (p ≤ 0.0001). As a test of difficult intubation, the ‘quick look’ generated sensitivity 0.597 and specificity 0.763 (PPV and NPV were 0.336 and 0.904 respectively). Conclusion: This study suggests that when physicians perform pre-hospital anaesthesia they have high intubation success rates and the use of ETCO2 monitoring reduces or eliminates undetected misplaced tracheal tubes. We found high rates of airway contamination; mostly blood from the upper airway. The ‘quick look’ airway assessment had some utility but is unreliable in isolation. [ABSTRACT FROM AUTHOR]

Background: Given the acknowledged problems in sepsis diagnosis, we use a novel way with the application of the latent class analysis (LCA) to determine the operative characteristics of C-reactive protein (CRP), D-dimer (DD) and Procalcitonin (PCT) as diagnostic tests for sepsis in patients admitted to hospital care with a presumptive infection. Methods: Cross-sectional study to determine the diagnostic accuracy of three biological markers against the gold standard of clinical definition of sepsis provided by an expert committee, and also against the likelihood of sepsis according to LCA. Patients were recruited in the emergency room within 24 hours of hospitalization and were follow-up daily until discharge. Results: Among 765 patients, the expert committee classified 505 patients (66%) with sepsis, 112 (15%) with infection but without sepsis and 148 (19%) without infection. The best cut-offs points for CRP, DD, and PCT were 7.8 mg/dl, 1616 ng/ml and 0.3 ng/ml, respectively; but, neither sensitivity nor specificity reach 70% for any biomarker. The LCA analysis with the same three tests identified a "cluster" of 187 patients with several characteristics suggesting a more severe condition as well as better microbiological confirmation. Assuming this subset of patients as the new prevalence of sepsis, the ROC curve analysis identified new cut-off points for the tests and suggesting a better discriminatory ability for PCT with a value of 2 ng/ml. Conclusions: Under a "classical" definition of sepsis three typical biomarkers (CRP, PCT and DD) are not capable enough to differentiate septic from non-septic patients in the ER. However, a higher level of PCT discriminates a selected group of patients with severe sepsis. [ABSTRACT FROM AUTHOR]

Background: The prognosis of hospitalized patients after emergent endotracheal intubation (ETI) remains poor. Our aim was to evaluate the 30-d hospitalization mortality of subjects undergoing ETI during daytime or off-hours and to analyze the possible risk factors affecting mortality. Methods: A single-center retrospective study was performed at a university teaching facility from January 2015 to December 2018. All adult inpatients who received ETI in the general ward were included. Information on patient demographics, vital signs, ICU (Intensive care unit) admission, intubation time (daytime or off-hours), the department in which ETI was performed (surgical ward or medical ward), intubation reasons, and 30-d hospitalization mortality after ETI were obtained from a database. Results: Over a four-year period, 558 subjects were analyzed. There were more male than female in both groups (115 [70.1%] vs 275 [69.8%]; P = 0.939). A total of 394 (70.6%) patients received ETI during off-hours. The patients who received ETI during the daytime were older than those who received ETI during off-hours (64.95 ± 17.54 vs 61.55 ± 17.49; P = 0.037). The BMI of patients who received ETI during the daytime was also higher than that of patients who received ETI during off-hours (23.08 ± 3.38 vs 21.97 ± 3.25; P < 0.001). The 30-d mortality after ETI was 66.8% (373), which included 68.0% (268) during off-hours and 64.0% (105) during the daytime (P = 0.361). Multivariate Cox regression analysis found that the significant factors for the risk of death within 30 days included ICU admission (HR 0.312, 0.176–0.554) and the department in which ETI was performed (HR 0.401, 0.247–0.653). Conclusions: The 30-d hospitalization mortality after ETI was 66.8%, and off-hours presentation was not significantly associated with mortality. ICU admission and ETI performed in the surgical ward were significant factors for decreasing the risk of death within 30 days. Trial registration: This trial was retrospectively registered with the registration number of ChiCTR2000038549. [ABSTRACT FROM AUTHOR]

Background: Inadvertent intravascular injection has been suggested as the most probable mechanism behind serious neurological complications during transforaminal epidural steroid injections. Authors believe a smaller gauge needle may lead to less intravascular uptake and less pain. Theoretically, there is less chance for a smaller gauge needle to encounter a blood vessel during an injection compared to a larger gauge needle. Studies have also shown smaller gauge needle to cause less pain. The aim of the study was to quantify the difference between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injection in regards to intravascular uptake and pain perception. Methods: This was a prospective single blind randomized clinical trial performed at outpatient spine practice locations of two academic institutions. One hundred sixty-two consecutive patients undergoing lumbosacral transforaminal epidural injections from February 2018 to June 2019 were recruited and randomized to each arm of the study – 84 patients were randomized to the 22-gauge needle arm and 78 patients to 25-gauge arm. Each transforaminal injection level was considered a separate incidence, hence total number of incidence was 249 (136 in 22-gauge arm and 113 in 25-gauge arm). The primary outcome measure was intravascular uptake during live fluoroscopy and/or blood aspiration. The secondary outcome measure was patient reported pain during the procedure on the numerical rating scale. Results: Fisher exact test was used to detect differences between 2 groups in regards to intravascular uptake and paired t-tests were used to detect differences in pain scores. The incidence of intravascular uptake for a 22-gauge needle was 5.9% (95% confidence interval: 1.9 to 9.8%) and for a 25-gauge needle, 7.1% (95% confidence interval: 2.4 to 11.8%) [p = 0.701]. Average numerical rating scale scores during the initial needle entry for 22-gauge and 25-gauge needle was 3.46 (95% confidence interval: 2.94 to 3.98) and 3.13 (95% confidence interval: 2.57 to 3.69) respectively [p = 0.375]. Conclusions: The study showed no statistically significant difference in intravascular uptake or pain perception between a 22-gauge needle and 25-gauge needle during lumbosacral transforaminal epidural steroid injections. Trial registration: ClinicalTrials.gov NCT04350307. Registered 4/17/2020. (Retrospectively registered). [ABSTRACT FROM AUTHOR]

Background: Volatile anesthetic agents used during surgery have immunomodulatory effects which could affect postoperative outcomes. Recognizing that regulatory T cells (Tregs) plays crucial roles in transplant tolerance and high peripheral blood Tregs associated with stable kidney graft function, knowing which volatile anesthetic agents can induce peripheral blood Tregs increment would have clinical implications. This study aimed to compare effects of desflurane and sevoflurane anesthesia on peripheral blood Tregs induction in patients undergoing living donor kidney transplantation. Methods: A prospective, randomized, double-blind trial in living donor kidney transplant recipients was conducted at a single center, tertiary-care, academic university hospital in Thailand during August 2015 – June 2017. Sixty-six patients were assessed for eligibility and 40 patients who fulfilled the study requirement were equally randomized and allocated to desflurane versus sevoflurane anesthesia during transplant surgery. The primary outcome included absolute changes of peripheral blood CD4+CD25+FoxP3+Tregs which measured by flow cytometry and expressed as the percentage of the total population of CD4+ T lymphocytes at pre-exposure (0-h) and post-exposure (2-h and 24-h) to anesthetic gas. P-value < 0.05 denoted statistical significance. Results: Demographic data were comparable between groups. No statistical difference of peripheral blood Tregs between desflurane and sevoflurane groups observed at the baseline pre-exposure (3.6 ± 0.4% vs. 3.1 ± 0.4%; p = 0.371) and 2-h post-exposure (3.0 ± 0.3% vs. 3.5 ± 0.4%; p = 0.319). At 24-h post-exposure, peripheral blood Tregs was significantly higher in desflurane group (5.8 ± 0.5% vs. 4.1 ± 0.3%; p = 0.008). Within group analysis showed patients receiving desflurane, but not sevoflurane, had 2.7% increase in peripheral blood Treg over 24-h period (p < 0.001). Conclusion: This study provides the clinical trial-based evidence that desflurane induced peripheral blood Tregs increment after 24-h exposure, which could be beneficial in the context of kidney transplantation. Mechanisms of action and clinical advantages of desflurane anesthesia based on Treg immunomodulation should be investigated in the future. Trial registration: ClinicalTrials.gov, NCT02559297. Registered 22 September 2015 - retrospectively registered [ABSTRACT FROM AUTHOR]

Background: Iatrogenic tracheal ruptures are rare but life-threatening airway complications that often require surgical repair. Data on perioperative vital functions and anesthetic regimes are scarce. The goal of this study was to explore comorbidity, perioperative management, complications and outcomes of patients undergoing thoracotomy for surgical repair. Methods: We retrospectively evaluated adult patients who required right thoracotomy for emergency surgical repair of iatrogenic posterior tracheal ruptures and were admitted to a university hospital over a 15-year period (2004–2018). The analyses included demographic, diagnostic, management and outcome data on preinjury morbidity and perioperative complications. Results: Thirty-five patients who met the inclusion criteria were analyzed. All but two patients (96%) presented with critical underlying diseases and/or emergency tracheal intubations. The median time (interquartile range) from diagnosis to surgery was 0.3 (0.2–1.0) days. The durations of anesthesia, surgery and one-lung ventilation (OLV) were 172 (128–261) min, 100 (68–162) min, and 52 (40–99) min, respectively. The primary airway management approach to OLV was successful in only 12 patients (34%). Major complications during surgery were observed in 10 patients (29%). Four patients (11%) required cardiopulmonary resuscitation, one of whom received extracorporeal membrane oxygenation, and another one of these patients died during surgery. Major complications were associated with significantly higher all-cause 30-day mortality (p = 0.002) and adjusted mortality (p = 0.001) compared to patients with minor or no complications. Conclusions: Surgical repair of iatrogenic tracheal ruptures requires advanced perioperative care in a specialized center due to high morbidity and potential complications. Airway management should include early anticipation of alternative OLV approaches to provide acceptable conditions for surgery. [ABSTRACT FROM AUTHOR]

Background: Goal Directed Fluid Therapy (GDFT) represents an objective fluid replacement algorithm. The effect of provider variability remains a confounder. Overhydration worsens perioperative morbidity and mortality; therefore, the impact of the calculated NPO deficit prior to the operating room may reach harm. Methods: A retrospective single-institution study analyzed patients at UC Irvine Medical Center main operating rooms from September 1, 2013 through September 1, 2015 receiving GDFT. The primary study question asked if GDFT suggested different fluid delivery after different NPO periods, while reducing inter-provider variability. We created two patient groups distinguished by 0715 surgical start time or start time after 1200. We analyzed fluid administration totals with either a 1:1 crystalloid to colloid ratio or a 3:1 ratio. We performed direct group-wise testing on total administered volume expressed as total ml, total ml/hr., and total ml/kg/hr. between the first case start (AM) and afternoon case (PM) groups. A linear regression model included all baseline covariates that differed between groups as well as plausible confounding factors for differing fluid needs. Finally, we combined all patients from both groups, and created NPO time to total administered fluid scatterplots to assess the effect of patient-reported NPO time on fluid administration. Results: Whether reported by total administered volume or net fluid volume, and whether we expressed the sum as ml, ml/hr., or ml/kg/hr., the AM group received more fluid on average than the PM group in all cases. In the general linear models, for all significant independent variables evaluated, AM vs PM case start did not reach significance in both cases at p = 0.64 and p = 0.19, respectively. In scatterplots of NPO time to fluid volumes, absolute adjusted and unadjusted R2 values are < 0.01 for each plot, indicating virtually non-existent correlations between uncorrected NPO time and fluid volumes measured. Conclusions: This study showed NPO periods do not influence a patient's volume status just prior to presentation to the operating room for surgical intervention. We hope this data will influence the practice of providers routinely replacing calculated NPO period volume deficit; particularly with those presenting with later surgical case start times. [ABSTRACT FROM AUTHOR]

Background: Extra Corporeal Membrane Oxygenation (ECMO) has become an accepted treatment option for severely ill patients. Due to a limited availability of ECMO support therapy, patients must often be transported to a specialised centre before or after cannulation. According to the ELSO guidelines, an ECMO specialist should be present for such interventions. Here we describe the safety and efficacy of a reduced team approach involving one anaesthesiologist, experienced in specialised intensive care medicine, and a specialised critical care nurse. Methods: This study is a 10 years retrospective, single institution analysis of all data collected between January 2007 and December 2016 from the medical records at the University Hospital Bonn, Germany. Results: The Bonner mobile ECMO team was deployed in 170 cases for on-site evaluation for ECMO support therapy. 4 (2.4%) patients died prior to arrival or during the implementation of ECMO support. Of the remaining 166 patients, 126 were cannulated at the referring site, 40 were transported without ECMO. Of those, 21 were subsequently cannulated out our centre. 19 patients never received ECMO treatment. The primary indication for ECMO treatment was ARDS (159/166 patients). Veno-venous ECMO was initiated in 137, whilst 10 patients received veno-arterial ECMO treatment. Mean transportation time was 75 ± 36 min, and mean transport distance was 56 ± 57 km. In total, 26 complications were observed, three being directly transport-related. The overall survival was 55%. Conclusions: Initiation of extracorporeal membrane oxygenation and subsequent transport can be safely and efficiently performed by a two-man team with good outcome. [ABSTRACT FROM AUTHOR]