Identifying risk factors for poor multidimensional recovery after major surgery: A systematic review.

Traditional risk factors used for predicting poor postoperative recovery have focused on postoperative complications, adverse symptoms (nausea, pain), length of hospital stay, and patient quality of life. Despite these being traditional performance indicators of patient postoperative "status," they may not fully define the multidimensional nature of patient recovery. The definition of postoperative recovery is thus evolving to include patient-reported outcomes that are important to the patient. Previous reviews have focused on risk factors for the above traditional outcomes after major surgery. Yet, there remains a need for further study of risk factors predicting multidimensional patient-focused recovery, and investigation beyond the immediate postoperative period after patients are discharged from the hospital. This review aimed to appraise the current literature identifying risk factors for multidimensional patient recovery. METHODS: A systematic review without meta-analysis was performed to qualitatively summarize preoperative risk factors for multidimensional recovery 4-6 weeks after major surgery (PROSPERO, CRD42022321626). We reviewed three electronic databases between January 2012 and April 2022. The primary outcome was risk factors for multidimensional recovery at 4-6 weeks. A GRADE quality appraisal and a risk of bias assessment were completed. RESULTS: In total, 5150 studies were identified, after which 1506 duplicates were removed. After the primary and secondary screening, nine articles were included in the final review. Interrater agreements between the two assessors for the primary and secondary screening process were 86% (k = 0.47) and 94% (k = 0.70), respectively. Factors associated with poor recovery were found to include ASA grade, recovery tool baseline score, physical function, number of co-morbidities, previous surgery, and psychological well-being. Mixed results were reported for age, BMI, and preoperative pain. Due to the observational nature, heterogeneity, multiple definitions of recovery, and moderate risk of bias of the primary studies, the quality of evidence was rated from very low to low. CONCLUSION: Our review found that there were few studies assessing preoperative risk factors as predictors for poor postoperative multidimensional recovery. This confirms the need for higher quality studies assessing risk for poor recovery, ideally with a consistent and multi-dimensional definition of recovery.

Three Zone Scanning Protocol For Lung Ultrasound: An Anatomical Basis.

Lung ultrasound is rapidly gaining popularity based on point of care ease of use, diagnostic fidelity and lack of ionising radiation. This was particularly notable at the beginning of the COVID-19 pandemic, where concerns of contamination of the x-ray department led to a reluctance to order frequent chest x-rays. Early COVID-19 lung involvement is of a bronchopneumonia, and patches of consolidation adjacent to the chest wall were easily detectable by ultrasound. A large number of proposed scanning protocols were advocated and are often complex and largely based on traditional stethoscope examination or access points on the chest wall rather than the underlying lung anatomy. A surgical understanding of lung anatomy and related surface anatomy has led us to develop a simplified three zone scanning protocol in 2013. The anterior zone corresponds to the upper lobe, and the posterior zone is divided between upper lobe and lower lobe. The relationship between lung lobes and the surface of the chest wall provides the anatomical basis for a simple three scanning zone lung ultrasound protocol.

Comparison of Cardiac Output of Both 2-Dimensional and 3-Dimensional Transesophageal Echocardiography With Transpulmonary Thermodilution During Cardiac Surgery.

OBJECTIVES: To compare agreement and variability of cardiac output measurement of 2-dimensional (2D) and 3D transesophageal echocardiography (TEE) with thermodilution before and after bypass. DESIGN: Prospective observational study. SETTING: Two tertiary hospitals. INTERVENTIONS: Cardiac output (CO) was measured simultaneously with thermodilution and TEE by multiplying either the left ventricular outflow tract area (LVOTA) or aortic valve area (AVA), the velocity-time integral (VTI) of flow at the same site, and heart rate. The LVOTA was calculated using diameter for 2D TEE. Planimetry was used for 3D TEE. The AVA was measured using planimetry. PARTICIPANTS: The study comprised 82 adult patients undergoing coronary or valve surgery. MEASUREMENTS AND MAIN RESULTS: One hundred fifty-four complete sets of measurements were obtained (82 prebypass and 72 postbypass). All TEE methods had acceptable correlation and absence of proportional or fixed bias except for the left ventricular outflow tract (LVOT) VTI modal trace method, which had poor correlation and proportional but not fixed bias (regression coefficient [95% confidence interval], bias [percentage of mean CO]): 2D LVOT VTI modal trace 0.67 (0.54-0.80), -36.4%; 2D LVOT VTI outer edge trace 0.96 (0.80-1.12), -15.3%; 2D AVA planimetry 0.96 (0.75-1.18), +4.9%; 3D LVOT area planimetry 1.18 (0.96-1.41), +0.8%; 3D AVA planimetry 1.20 (0.93-1.46), +0.4%. All TEE methods had wide levels of agreement compared with thermodilution (-3.94 to +0.23 L/min, -2.83 to +1.28 L/min, -2.23 to +2.73 L/min, -2.35 to +2.42 L/min, and -2.57 to +2.61 L/min, respectively). Measurement variability was superior for all TEE methods compared with thermodilution before but not after bypass. CONCLUSIONS: Although limits of agreement of CO measurement with 3D TEE and thermodilution are wide, 2D planimetry of the AVA and continuous wave Doppler may be substituted for thermodilution before and after bypass.

RARAY Operation: Operative Description and Early Results for Achieving Total Arterial Coronary Revascularisation.

BACKGROUND: Total arterial revascularisation may prolong postoperative survival following coronary surgery due to avoidance of late saphenous vein graft (SVG) failure leading to ischaemic cardiac events. The left internal mammary artery (LIMA) is routinely used for CABG but harvest may adversely affect lung function and reduce sternal vascular supply. Early experience of a novel reconstruction with exclusive reliance on two radial arteries (RA) joined as a Y graft (RARAY) is presented. METHODS: One RA is anastomosed to the ascending aorta and used to revascularise the left anterior descending artery coronary territory; and a second RA is joined to the first 4-6 cm from the origin, approximating the lateral border of the pulmonary artery and used to revascularise the circumflex and right coronary territories. No LIMA is used. The radial artery was harvested open with diathermy and metal clips and since 2008, all patients received intravenous vasoconstrictors from the commencement of the anaesthetic. RESULTS: From 2002 to 2019, 28 patients underwent RARAY for specific indications of prior use or reasons to avoid LIMA harvest, preservation of lung function, minimisation of bleeding risk from antiplatelet agents and extra length of RA to graft distal coronary targets beyond usual reach for LIMA. There was no RA spasm, no in-hospital death and no patient returned with symptoms of angina. CONCLUSIONS: The early experience of the RARAY operation for three coronary territory revascularisations are satisfactory.

Patency When Grafted to Coronary Stenosis More Than 50% in LIMA-RA-Y Grafts.

BACKGROUND: Recent coronary surgery practice is to graft arterial conduits to more severely stenosed coronary targets than in the past. We aimed to investigate postoperative arterial graft patency with native coronary stenosis at the time of surgery, using the left internal mammary artery and radial artery (RA) as a composite Y graft (LIMA-RA-Y). In the study timeframe, it was routine clinical practice to graft coronary arteries with >50% stenosis. METHODS: Of 464 patients previously reported 1996-1999, 346 who underwent LIMA-RA-Y at the Royal Melbourne Hospital, 76 had postoperative angiograms at the same institution. Each anastomosis was considered separately. For arterial grafts a "string sign" was analysed as being occluded. Predictor of patency was performed with a generalised linear mixed model (GLMM). RESULTS: Seventy-six (76) patients had postoperative angiograms at 5.8±5.4 years (range 0.23-19.4; interquartile range 1.7-10.0) years postoperative; with age at operation 62.5±10.7 years and 3.4±0.8 grafts per patient, 82% were male. Of 256 anastomoses, 230 were to coronary targets >50% stenosis. Overall patency was 84.0% (214/256). For coronary stenosis >50%, patency was 88% (201/230) and varied by coronary territory left anterior descending (LAD) 94% (87/93), circumflex 90% (71/79) and right coronary artery (RCA) 74% (43/58). Interaction for coronary territory was significant (p=0.022). Higher preoperative coronary stenosis predicted higher patency; with odds ratio for improved patency of 1.83 (95% CI 1.51, 2.22), p<0.001 for each 10% increase in stenosis. CONCLUSIONS: Late patency of composite arterial grafts is acceptable when grafted to coronary arteries of greater than 50% stenosis.

Propofol Attenuates the Myocardial Protection Properties of Desflurane by Modulating Mitochondrial Permeability Transition.

BACKGROUND: Desflurane and propofol are cardioprotective, but relative efficacy is unclear. The aim was to compare myocardial protection of single, simultaneous, and serial administration of desflurane and propofol. METHODS: Sixty New Zealand White rabbits and 65 isolated Sprague Dawley rat hearts randomly received desflurane, propofol, simultaneous desflurane and propofol, or sequential desflurane then propofol. Rabbits were subdivided to receive either ischemia-reperfusion with temporary occlusion of the left anterior descending artery or a time-matched, nonischemic perfusion protocol, whereas rat hearts were perfused in a Langendorff model with global ischemia-reperfusion. End points were hemodynamic, functional recovery, and mitochondrial uptake of H-2-deoxy-D-glucose as an indicator of mitochondrial permeability transition. RESULTS: In rabbits, there were minimal increases in preload-recruitable stroke-work with propofol (P < .001), desflurane (P < .001), and desflurane-and-propofol (P < .001) groups, but no evidence of increases with pentobarbitone (P = .576) and desflurane-then-propofol (P = .374). In terms of end-diastolic pressure-volume relationship, there was no evidence of increase compared to nonischemic controls with desflurane-then-propofol (P = .364), a small but significant increase with desflurane (P < .001), and larger increases with pentobarbitone (P < .001), propofol (P < .001), and desflurane-and-propofol (P < .001).In rat hearts, there was no statistically significant difference in mitochondrial H-activity between propofol and desflurane-and-propofol (165 ± 51 × 10 vs 154 ± 51 × 10 g·mL·min/µmol; P = .998). Desflurane had lower uptake than propofol (65 ± 21 × 10 vs 165 ± 51 × 10 g·mL·min/µmol; P = .039), but there was no statistically significant difference between desflurane and desflurane-then-propofol (65 ± 21 × 10 vs 59 ± 11 × 10 g·mL·min/µmol; P = .999). CONCLUSIONS: Propofol and desflurane are cardioprotective, but desflurane is more effective than propofol. The added benefit of desflurane is lost when used simultaneously with propofol.

Transfusion Requirements in Cardiac Surgery III (TRICS III): Study Design of a Randomized Controlled Trial.

OBJECTIVES: To determine if a restrictive transfusion threshold is noninferior to a higher threshold as measured by a composite outcome of mortality and serious morbidity. DESIGN: Transfusion Requirements in Cardiac Surgery (TRICS) III was a multicenter, international, open-label randomized controlled trial of two commonly used transfusion strategies in patients having cardiac surgery using a noninferiority trial design (ClinicalTrials.gov number, NCT02042898). SETTING: Eligible patients were randomized prior to surgery in a 1:1 ratio. PARTICIPANTS: Potential participants were 18 years or older undergoing planned cardiac surgery using cardiopulmonary bypass (CPB) with a preoperative European System for Cardiac Operative Risk Evaluation (EuroSCORE I) of 6 or more. INTERVENTIONS: Five thousand patients; those allocated to a restrictive transfusion group received a red blood cell (RBC) transfusion if the hemoglobin concentration (Hb) was less than 7.5 g/dL intraoperatively and/or postoperatively. Patients allocated to a liberal transfusion strategy received RBC transfusion if the Hb was less than 9.5 g/dL intraoperatively or postoperatively in the intensive care unit or less than 8.5 g/dL on the ward. MEASUREMENTS AND MAIN RESULTS: The primary outcome was a composite of all-cause mortality, myocardial infarction, stroke, or new onset renal dysfunction requiring dialysis at hospital discharge or day 28, whichever comes first. The primary outcome was analyzed as a per-protocol analysis. The trial monitored adherence closely as adherence to the transfusion triggers is important in ensuring that measured outcomes reflect the transfusion strategy. CONCLUSION: By randomizing prior to surgery, the TRICS III trial captured the most acute reduction in hemoglobin during cardiopulmonary bypass.

Impact of Methylprednisolone on Postoperative Quality of Recovery and Delirium in the Steroids in Cardiac Surgery Trial: A Randomized, Double-blind, Placebo-controlled Substudy.

BACKGROUND: Inflammation after cardiopulmonary bypass may contribute to postoperative delirium and cognitive dysfunction. The authors evaluated the effect of high-dose methylprednisolone to suppress inflammation on the incidence of delirium and postoperative quality of recovery after cardiac surgery. METHODS: Five hundred fifty-five adults from three hospitals enrolled in the randomized, double-blind Steroids in Cardiac Surgery trial were randomly allocated to placebo or 250 mg methylprednisolone at induction and 250 mg methylprednisolone before cardiopulmonary bypass. Each completed the Postoperative Quality of Recovery Scale before surgery and on days 1, 2, and 3 and 1 and 6 months after surgery and the Confusion Assessment Method scale for delirium on days 1, 2, and 3. Recovery was defined as returning to preoperative values or improvement at each time point. RESULTS: Four hundred eighty-two participants for recovery and 498 participants for delirium were available for analysis. The quality of recovery improved over time but without differences between groups in the primary endpoint of overall recovery (odds ratio range over individual time points for methylprednisolone, 0.39 to 1.45; 95% CI, 0.08-2.04 to 0.40-5.27; P = 0.943) or individual recovery domains (all P > 0.05). The incidence of delirium was 10% (control) versus 8% (methylprednisolone; P = 0.357), with no differences in delirium subdomains (all P > 0.05). In participants with normal (51%) and low baseline cognition (49%), there were no significant differences favoring methylprednisolone in any domain (all P > 0.05). Recovery was worse in patients with postoperative delirium in the cognitive (P = 0.004) and physiologic (P < 0.001) domains. CONCLUSIONS: High-dose intraoperative methylprednisolone neither reduces delirium nor improves the quality of recovery in high-risk cardiac surgical patients.

A Pilot Assessment of 3 Point-of-Care Strategies for Diagnosis of Perioperative Lung Pathology.

BACKGROUND: Lung ultrasonography is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in the emergency and critical care setting and after cardiothoracic surgery in intensive care. Lung ultrasound may be useful before cardiothoracic surgery and after discharge from intensive care, but the proportion of significant respiratory pathology in this setting is unknown and may be too low to justify its routine use. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery. METHODS: In this prospective observational study, patients undergoing elective cardiothoracic surgery who received a CXR as part of standard care preoperatively or after discharge from the intensive care unit received a standardized clinical assessment and then a lung ultrasound examination within 24 hours of the CXR by 2 clinicians. The incidence of collapse/atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion, and pneumothorax were compared between clinical examination, CXR, and lung ultrasound (reference method) based on predefined diagnostic criteria in 3 zones of each lung. RESULTS: In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. With lung ultrasound as a reference, the sensitivity of the 5 different pathologies ranged from 7% to 69% (CXR), 7% to 76% (clinical examination), and 14% to 94% (combined); the specificity of the 5 different pathologies ranged from 91% to 98% (CXR), from 90% to 99% (clinical examination), and from 82% to 97% (combined). For clinical examination and lung ultrasound, intraobserver agreements beyond chance ranged from 0.28 to 0.70 and from 0.84 to 0.97, respectively. The agreements beyond chance of pathologic diagnoses between modalities ranged from 0.11 to 0.64 (CXR and lung ultrasound), from 0.08 to 0.7 (CXR and lung ultrasound), and from 0 to 0.58 (clinical examination and CXR). CONCLUSIONS: Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or postoperative cardiothoracic surgery participants with high estimate of interobserver agreement beyond that expected by chance, and we showed clinically significant diagnoses may be missed by the contemporary practice of clinical examination and CXR.

Assessment of Image Quality of Repeated Limited Transthoracic Echocardiography After Cardiac Surgery.

OBJECTIVES: The use of limited transthoracic echocardiography (TTE) has been restricted in patients after cardiac surgery due to reported poor image quality. The authors hypothesized that the hemodynamic state could be evaluated in a high proportion of patients at repeated intervals after cardiac surgery. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: The study comprised 51 patients aged 18 years or older presenting for cardiac surgery. INTERVENTIONS: Patients underwent TTE before surgery and at 3 time points after cardiac surgery. Images were assessed offline using an image quality scoring system by 2 expert observers. Hemodynamic state was assessed using the iHeartScan protocol, and the primary endpoint was the proportion of limited TTE studies in which the hemodynamic state was interpretable at each of the 3 postoperative time points. MEASUREMENTS AND MAIN RESULTS: Hemodynamic state interpretability varied over time and was highest before surgery (90%) and lowest on the first postoperative day (49%) (p<0.01). This variation in interpretability over time was reflected in all 3 transthoracic windows, ranging from 43% to 80% before surgery and from 2% to 35% on the first postoperative day (p<0.01). Image quality scores were highest with the apical window, ranging from 53% to 77% across time points, and lowest with the subcostal window, ranging from 4% to 70% across time points (p< 0.01). CONCLUSIONS: Hemodynamic state can be determined with TTE in a high proportion of cardiac surgery patients after extubation and removal of surgical drains.

Repeated Monitoring With Transthoracic Echocardiography and Lung Ultrasound After Cardiac Surgery: Feasibility and Impact on Diagnosis.

OBJECTIVES: Cardiorespiratory complications are common after cardiac surgery and current monitors used to diagnose these are invasive and have limitations. Transthoracic echocardiography and lung ultrasound are noninvasive and frequently improve diagnosis in critically ill patients but have not been reported for routine postoperative monitoring after coronary, valve, and aortic surgery. The aim was to determine whether both repeated postoperative transthoracic echocardiography and lung ultrasound revealed or excluded clinically important cardiac and respiratory disorders compared to conventional monitoring and chest x-ray. DESIGN: Prospective observational study. SETTING: Tertiary university hospital. PARTICIPANTS: Ninety-one patients aged older than 18 undergoing cardiac surgery INTERVENTIONS: Postoperative clinical patient assessment for significant cardiac and respiratory disorders by the treating physician was recorded at 3 time points (day after surgery, after extubation and removal of chest drains and at discharge) using conventional monitoring and chest x-ray. After each assessment, transthoracic echocardiography and lung ultrasound were performed, and differences in diagnosis from conventional assessment were recorded. MEASUREMENTS AND MAIN RESULTS: Transthoracic echocardiography was interpretable in at least 1 echocardiographic window in 99% of examinations. Transthoracic echocardiography and/or lung ultrasound changed the diagnosis of important cardiac and/or respiratory disorders in 61 patients (67%). New cardiac findings included cardiac dysfunction (38 patients), pericardial effusion (5), mitral regurgitation (2), and hypovolemia (1). New respiratory findings included pleural effusion (30), pneumothorax (4), alveolar interstitial syndrome (3) and consolidation (1). CONCLUSIONS: Routine repeated monitoring with cardiac and lung ultrasound after cardiac surgery is feasible and frequently alters diagnosis of clinically important cardiac and respiratory pathology.

The future of postoperative quality of recovery assessment: multidimensional, dichotomous, and directed to individualize care to patients after surgery.

PURPOSE OF REVIEW: Recovery after surgery is a complex interplay of the patient, the surgery, and the perioperative anaesthesia management. Assessment of recovery should address the needs of multiple stakeholders, including the institutions and healthcare providers, but primarily should be focused on the patients and their perception of quality of recovery and return to normalcy. This review will summarize the development of assessment of recovery to a multidimensional dichotomous construct that requires a real-time assessment tool validated for repeat measures and containing cognitive assessment. RECENT FINDINGS: Recovery is neither defined by a single composite number nor is it quantified at a single time point, but rather it is a continuum occurring in multiple domains and over periods of time from hours, to days to weeks or months after surgery. Recovery is often incomplete which may persist long term, leading to patient suffering, loss of work, and increased demands on family and healthcare providers long after apparently successful surgery. The important correlation between poor recovery, cognitive decline, institutional placement, and increased short and long-term mortality has been hampered by the heterogeneity of definitions and tools used and their assessment of recovery as a continuous vs. dichotomous score and at the group vs. individual level. Most research has been aimed at audit or group comparison rather than attempting to identify incomplete recovery at an early time period after surgery in specific patients and individualization of care based on the domain where recovery has failed. SUMMARY: Recovery is best defined as a multidimensional dichotomous construct encompassing nociceptive, emotive, functional, and cognitive domains. Its assessment tool should provide both real-time and restrospective recovery data, thus enabling clinical and research applications, and be validated for repeat measures over a breadth of multiple clinically relevant postoperative time points.

Transesophageal Echocardiography Guidance of Antegrade Cardioplegia Delivery for Cardiac Surgery.

OBJECTIVES: The initial volume of antegrade cardioplegia used to induce asystole during aortic cross-clamp still is based on empiric methods and may be excessive, potentially leading to hyperkalemia, myocardial edema, and acute left ventricular distention from aortic regurgitation. The objectives were to determine whether the volume of cardioplegia required to induce asystole is proportional to left ventricular mass, and whether the degree of left ventricular distention is proportional to the severity of aortic regurgitation. DESIGN: Prospective observational study. SETTING: Two tertiary university hospitals. INTERVENTIONS: Transesophageal echocardiography was used to estimate left ventricular mass (prolate ellipse revolution formula), quantify aortic regurgitation, and monitor for distention during initial antegrade cardioplegia delivery. The volume of cardioplegia required for asystole was recorded. PARTICIPANTS: Fifty-eight patients aged over 18 years scheduled for cardiac surgery requiring aortic cross-clamping. MEASUREMENTS AND MAIN RESULTS: There was a weak correlation of left ventricular mass and antegrade cardioplegia volume required for asystole (r = 0.35, p = 0.047). The degree of left ventricular distention correlated moderately with the severity of aortic regurgitation (r = 0.55, p = 0.007) and was excessive and stopped early (aborted) in 24% of all patients, including 18% of 39 patients without aortic regurgitation. An aortic regurgitation vena contracta of 0.3 cm predicted aborted cardioplegia with modest accuracy (AUC 0.81, 0.66-0.99, p = 0.02, sensitivity 71%, specifity 81%). CONCLUSIONS: Estimated left ventricular mass is not a useful predictor of the initial volume of antegrade cardioplegia required to induce asystole. However transesophageal echocardiography can predict and monitor for left ventricular distention, which is common.

Interatrial septum motion but not Doppler assessment predicts elevated pulmonary capillary wedge pressure in patients undergoing cardiac surgery.

BACKGROUND: Left atrial pressure and its surrogate, pulmonary capillary wedge pressure (PCWP), are important for determining diastolic function. The role of transthoracic echocardiography (TTE) in assessing diastolic function is well established in awake subjects. The objective was to assess the accuracy of predicting PCWP by TTE and transesophageal echocardiography (TEE) during coronary artery surgery. METHODS: In 27 adult patients undergoing on-pump coronary artery surgery, simultaneous echocardiographic and hemodynamic measurements were obtained immediately before anesthesia (TTE), after anesthesia and mechanical ventilation (TTE and TEE), during conduit harvest (TEE), and after separation from cardiopulmonary bypass (TEE). RESULTS: Twenty patients had an ejection fraction (EF) of 0.5 or greater. With the exception of E/e' and S/D ratios, echocardiographic values changed over the echocardiographic studies. In patients with low EF, E velocity, deceleration time, pulmonary vein D, S/D, and E/e' ratios correlated well with PCWP before anesthesia. After induction of anesthesia using TTE or TEE, correlations were poor. In normal EF patients, correlations were poor for both TEE and TTE at all five stages. The sensitivity and specificity of echocardiographic values were not high enough to predict raised PCWP except for a fixed curve pattern of interatrial septum (area under the curve 0.89 for PCWP ≥ 17, and 0.98 for ≥ 18 mmHg) and S/D less than 1 (area under the curve 0.74 for PCWP ≥ 17, and 0.78 for ≥ 18 mmHg). CONCLUSION: Doppler assessment of PCWP was neither sensitive nor specific enough to be clinically useful in anesthetized patients with mechanical ventilation. The fixed curve pattern of the interatrial septum was the best predictor of raised PCWP.

A human volunteer study to identify variability in performance in the cognitive domain of the postoperative quality of recovery scale.

BACKGROUND: The Postoperative Quality of Recovery Scale found lower than anticipated recovery in the cognitive domain. The definition of cognitive recovery did not allow for performance variability, and may have been too sensitive. This study aimed to examine variability in cognitive performance in volunteers. METHODS: One hundred forty-three volunteers completed the cognitive domain questions at baseline, after 15 min and 40 min, and on days 1 and 3. Delivery via face-to-face interview was conducted for the first three measurements, and then randomized for day 1 and 3 measurements (face-to-face only, telephone only, telephone then face-to-face, face-to-face then telephone). RESULTS: All volunteers answered orientation correctly. Mean change scores for other tests were positive, indicating a modest learning effect. There were no significant differences between methods of delivery (all P > 0.05). Due to variability in volunteers' performances, the authors propose a new scoring system to introduce a tolerance factor in scoring cognitive recovery. The proposed revised change from baseline scores are: orientation 0 or higher, digits forward -2 or higher, digits back -1 or higher, word recall -3 or higher, and word generation -3 or higher. This resulted in approximately 95% volunteers classed as "recovered" for each test item, and recovery for the domains ranged from 82.6 to 89.1%. The initial feasibility study was reanalyzed and cognitive recovery increased at all assessment times. At 3 days, cognitive recovery was found to increase from 33.5 to 86.4%. CONCLUSION: The authors recommend adoption of the new method for scoring cognitive recovery in the Postoperative Quality of Recovery Scale. Telephone or face-to-face delivery was equivalent and either method can be reliably applied.

Predictors of patient satisfaction with anaesthesia and surgery care: a cohort study using the Postoperative Quality of Recovery Scale.

CONTEXT: Previous research has shown that most patients are satisfied with their anaesthetic care. For those who are not the causes may be multifactorial including dissatisfaction with surgical outcomes. OBJECTIVES: We aimed to identify whether quality of recovery after anaesthesia and surgery measured in multiple domains affects patient satisfaction. DESIGN: Sub-group analysis of previously published observational cohort study of quality of recovery after surgery (using the Postoperative Quality of Recovery Scale) was used to identify predictors of incomplete satisfaction 3 days after surgery. SETTING: Multicentre perioperative surgery. PATIENTS: Patients ≥6 years old, undergoing a variety of operation types and all receiving general anaesthesia. OBSERVATIONS: Of 701 patients, 573 completed the satisfaction question on day 3. Satisfaction was rated by a single five-point rating question. Patients were divided into two groups: 477 (83%) were completely satisfied and 96 (17%) were not completely satisfied. Multivariable logistic regression analysis was performed on preoperative and patient characteristics and recovery in five domains as follows: physiological, nociceptive (pain and nausea), emotive (anxiety and depression), activities of daily living and cognition. Recovery was defined as return to baseline values or better for all questions within each domain. RESULTS: Incomplete satisfaction was predicted by persistent pain or nausea at day 3 [OR 8.2 (95% CI 2.5 to 27), P<0.01] and incomplete satisfaction at day 1 [OR 28 (95% CI 10 to 77), P<0.01]. Paradoxically, incomplete satisfaction was less likely to occur if pain or nausea was present 15 min after surgery [OR 0.34 (95% CI 0.11 to 0.99), P<0.05] or at day 1 [OR 0.30 (95% CI 0.10 to 0.91), P=0.03]. Incomplete recovery in the other domains did not influence satisfaction. CONCLUSION: Of the recovery domains measured using the Postoperative Quality of Recovery Scale, only nociception (pain or nausea) contributed to incomplete satisfaction.

Impact of focused cardiac and lung ultrasound screening performed by a junior doctor during admission to the surgical ward on patients before emergency non-cardiac surgery: A pilot prospective observational study.

Purpose: To assess whether pre-operative focused cardiac ultrasound and lung ultrasound screening performed by a junior doctor can change diagnosis and clinical management of patients aged ≥65 years undergoing emergency, non-cardiac surgery. Method: This pilot prospective observational study included patients scheduled for emergency, non-cardiac surgery. The treating team completed a diagnosis and management plan before and after focused cardiac and lung ultrasound, which was performed by a junior doctor. Changes to diagnosis and management after ultrasound were recorded. Ultrasound images were assessed for image and diagnostic interpretation by an independent expert. Results: There was a total of 57 patients at age 77 ± 8 years. Cardiopulmonary pathology was suspected after clinical assessment in 28% vs. 72% after ultrasound (including abnormal haemodynamic state in 61%, valvular lesions in 32%, acute pulmonary oedema/interstitial syndrome in 9% and bilateral pleural effusions in 2%). In 67% of patients, the perioperative management was changed. The changes were in fluid therapy in 30%, cardiology consultation in 7%, formal in- or out-patient, transthoracic echocardiography in 11% and 30% respectively. Discussion: The impact of pre-operative focused cardiac and lung ultrasound on diagnosis and management of patients on the hospital ward before emergency non-cardiac surgery by a junior doctor was comparable to previous studies of anaesthetists experienced in focused ultrasound. However, the ability to recognise when image quality is insufficient for diagnosis is an important consideration for novice sonographers. Conclusions: Focused cardiac and lung ultrasound examination by a junior doctor is feasible and may change preoperative diagnosis and management in patients of 65 years or older, admitted for emergency non-cardiac surgery.

Sevoflurane anesthesia does not impair acquisition learning or memory in the Morris water maze in young adult and aged rats.

BACKGROUND: Sevoflurane has been found to increase apoptosis and pathologic markers associated with Alzheimer disease, provoking concern over their potential contribution to postoperative cognitive dysfunction. METHODS: The effects of anesthesia with 1 minimum alveolar concentration of sevoflurane for 4 h or sham exposure on cognition were investigated in young adult and aged (20-24 months) rats at 1, 4, and 12 weeks postexposure. Spatial reference memory acquisition and retention were tested in the Morris water maze task. Latency to locate the hidden platform and swim speed were determined and compared between treatments. RESULTS: Sevoflurane anesthesia significantly reduced latency to find the hidden platform in both young adult (n = 10 per treatment, P < 0.0001) and aged rats (n = 7 per treatment, P < 0.0001) when tested 1 week after exposure. In young rats only, this improved acquisition learning was maintained at 4 (P = 0.003) but not at 12 weeks postexposure (P = 0.061). There were no differences in swim speed or in open field exploration between groups (no confounding effects of stress or locomotion). Retention memory measured using probe trials was not affected by exposure to sevoflurane in young adult or aged rats. CONCLUSION: Sevoflurane anesthesia did not impair acquisition learning and retention memory in young adult or aged rats.

Core review: physician-performed ultrasound: the time has come for routine use in acute care medicine.

The use of ultrasound in the acute care specialties of anesthesiology, intensive care, emergency medicine, and surgery has evolved from discrete, office-based echocardiographic examinations to the real-time or point-of-care clinical assessment and interventions. "Goal-focused" transthoracic echocardiography is a limited scope (as compared with comprehensive examination) echocardiographic examination, performed by the treating clinician in acute care medical practice, and is aimed at addressing specific clinical concerns. In the future, the practice of surface ultrasound will be integrated into the everyday clinical practice as ultrasound-assisted examination and ultrasound-guided procedures. This evolution should start at the medical student level and be reinforced throughout specialist training. The key to making ultrasound available to every physician is through education programs designed to facilitate uptake, rather than to prevent access to this technology and education by specialist craft groups. There is evidence that diagnosis is improved with ultrasound examination, yet data showing change in management and improvement in patient outcome are few and an important area for future research.

Isoflurane induces cognitive deficits in the Morris water maze task in rats.

BACKGROUND: Postoperative cognitive dysfunction has been reported in young, middle-aged and elderly patients with greater incidence with increasing age. Neurocognitive deficits are associated with anaesthetic exposure in aged rodents but in younger adult animals the findings are inconsistent and in middle-aged animals they are unknown. We aimed to compare the effects of moderate duration isoflurane anaesthesia in 100% oxygen on Morris water maze performance in young adult and middle-aged rats. We hypothesised that isoflurane would have greater effects on learning and memory in middle-aged compared with young rats. MATERIALS AND METHODS: Young adult (3 months, n = 25) and middle-aged (12 months, n = 20) male Sprague Dawley rats were assigned randomly to isoflurane exposure (1 minimum alveolar concentration, 4 h) or control conditions. Spatial learning (acquisition phase) and memory (probe trial) were tested in the Morris water maze 1 week after exposure. Middle-aged rats were retested in the probe trial 4 weeks after exposure for long-term memory retention. Latency to locate the hidden platform and time spent in the platform quadrant were compared between ages and treatments. RESULTS: Isoflurane did not affect acquisition of the water maze task in either age group. Isoflurane exposure induced a significant deficit in memory retention in young rats, but not middle-aged rats, in the probe trial 24 h after acquisition. Irrespective of treatment, middle-aged rats took longer to acquire the task than young rats. Four weeks after exposure, isoflurane-treated middle-aged rats showed no preference for target location, compared with sham-exposed rats which retained memory for previous platform location. CONCLUSION: Isoflurane exposure impaired retention memory for platform location 1 week after exposure in young adult rats and resulted in a delayed although weak impairment at 4 weeks in middle-aged rats. The great variation in reported effects of isoflurane suggests a complex effect of this agent on memory which warrants further investigation.